Annual ACHC Standard Updates

On an annual basis, ACHC reviews the standards for each accreditation program to ensure relevancy. Generally the revisions are minor and include additions, deletions, and clarifications. The 2019 revisions were released February 1. All deletions and clarifications became effective February 1. New standards and additions to standards become effective June 1.

Below is a partial list of revisions, by program:

Home Health

Standard  Change Effective Date
HH1-8A Added the word organization/organizations to the standard regarding the written agreement requirements. February 1, 2019
HH2-6B.02 Clarified in the standard that a written policy and procedure regarding providing the patient with information about advance directives. February 1, 2019
HH4-1B.01 Clarified direct patient care to be the care of a patient provided personally by a staff member or contracted individual/organization in a patient’s residence or healthcare facility. Direct patient care may involve any aspects of the health care of a patient, including treatments, counseling, self-care, patient education, and administration of medication. February 1, 2019
HH4-2H.01 Replaced the word “contact” with “care” as it related to criminal background checks. February 1, 2019


Standard  Change Effective Date
HSP1-8A Added the word organization/organizations to the standard to be consistent with the Medicare Conditions of Participation §418.100(e) regarding the written agreement requirements. February 1, 2019
HSP4-1B.01 Clarified direct patient care to be the care of a patient provided personally by a staff member or contracted individual/organization in a patient’s residence or healthcare facility. Direct patient care may involve any aspects of the health care of a patient, including treatments, counseling, self-care, patient education, and administration of medication. February 1, 2019
HSP4-2H Replaced the word “contact” with “care” as it related to criminal background checks. February 1, 2019
HSP4-14A Added physician assistants as an allowable individual that the interdisciplinary group may confer with regarding the patient’s medication management. February 1, 2019
HSP5-1B Decreased the retention of medical records to six years from the date of the most recent discharge of death of the patient from seven years. February 1, 2019
HSP6-3A Removed the requirement that the annual QAPI report is included in the hospice’s annual evaluation. February 1, 2019
HSP7-4F Changed the Hospice standards referenced in the interpretation to the correct Hospice standards; HSP7-3A to HSP7-4B, HSP7-3B to HSP7-4C, HSP7-3C toHSP7-4D, and HSP7-3D to HSP7-4E, respectively. February 1, 2019

Private Duty

Standard  Change Effective Date
HH1-8A Added the word organization/organizations to the standard regarding the written agreement requirements. February 1, 2019
HH2-6B.02 Clarified in the standard that a written policy and procedure regarding providing the patient with information about advance directives. February 1, 2019
HH4-1B.01 Clarified direct patient care to be the care of a patient provided personally by a staff member or contracted individual/organization in a patient’s residence or healthcare facility. Direct patient care may involve any aspects of the health care of a patient, including treatments, counseling, self-care, patient education, and administration of medication. February 1, 2019
HH4-2H.01 Replaced the word “contact” with “care” as it related to criminal background checks. February 1, 2019


 Standard Change Effective Date
 DRX3-4B Added clarification regarding the requirements for notifying clients/patients of their financial responsibilities  February 1, 2019
 DRX4-7A Added requirement for annual competency assessment to be conducted for personnel who clean, test and/or repair equipment  June 1, 2019


Standard Change Effective Date
 DRX3-4B Added clarification regarding the requirements for notifying clients/patients of their financial responsibilities  February 1, 2019
DRX7-8J.01 New standard for IRX, SRX, and SRXOnly that adds quality control measures to assure proper medication labeling  June 1, 2019


Standard Change Effective Date
SLC4-6A Added clarification that all technicians scoring sleep studies must be credentialed as required by standard  February 1, 2019


Standard Change Effective Date
TCRX7-A & B Changed the requirement for the submission of continued compliance data from annual submission to submission during the mid-point in the accreditation cycle  June 1, 2019

ACHC has posted a complete list of updated standards, for each program, in the 2019 Standards Update Reference Guides. Access the Standards Update Reference Guides in your Customer Central account by selecting the “Resources” tab, then choosing the “Education Library” dropdown, then choosing your program within the “Educational Tools” section, and then clicking on the 2019 update.

If you have any questions regarding these changes, please contact your Account Advisor.

CMS Lifts Home Health Moratoria in FL, TX, MI & IL

According to the Centers for Medicare & Medicaid Services (CMS), “As of January 30, 2019, there are no active Medicare Provider Enrollment Moratoria in any State or U.S. territories.”  CMS announced Wednesday that the provider enrollment moratoria on home health agencies in Illinois, Michigan, Texas, and Florida have expired. The notice from CMS can be read here.

ACHC is able to expeditiously conduct an Initial Medicare Certification Survey for home health agencies (HHAs) in these states. An organization may apply for accreditation if the following eligibility requirements are met.

The organization must:

  1. Be currently operating within the United States and/or its territories.
  2. Be licensed according to applicable state and federal laws and regulations and maintain all current legal authorization to operate.
  3. Have completed the Medicare Enrollment Application Form CMS-855A and had this form verified by the assigned Medicare Administrative Contractor (MAC), if applicable.
  4. Have established policies and procedures.
  5. Have successfully completed a test Outcome and Assessment Information Set (OASIS) transmission to the state repository, if applicable.
  6. Have met capitalization requirements, if applicable.
  7. Occupy a building in which services are provided/coordinated that is identified, constructed, and equipped to support such services.
  8. Clearly define the services it provides directly or under contract.
  9. Submit all required documents and fees to ACHC within specified time frames.
  10. Be providing home health nursing and at least one qualifying therapeutic service.
    1. The qualifying therapeutic services include physical therapy, speech therapy, occupational therapy, medical social services, and home health aide (Reference in Centers for Medicare and Medicaid Services (CMS) 42 CFR 484.105(f).
    2. A Distinction is a non-qualifying therapeutic service.
  11. Have provided care to a minimum of 10 patients requiring skilled care (not required to be Medicare patients). At least seven of the 10 required patients are receiving skilled care from the Home Health Agency (HHA) at the time of the initial Medicare survey. If the HHA is not able to meet the minimum number of patients required, the initial survey will not be conducted. If the HHA is located in a medically underserved area, they can contact the CMS Regional Office (RO). If the CMS RO determines that the HHA is located in a medically underserved area, the CMS RO may reduce the minimum number of patients from 10 to five. At least two of the five required patients should be receiving skilled care from the HHA at the time of the initial Medicare survey. It is the organization’s responsibility to notify ACHC if it is located in an underserved area.


For more information call (855) 937-2242 ext. 457

Partial Shutdown Not Expected to Hamper Providers, ACHC

As the new year begins with the continuation of a partial federal government shutdown, we are keeping our attention focused on what this may mean for our providers and their patients. Essentially, we are able to deliver good news, with little to no impacts foreseen.

We have been in contact with CMS and they have assured us that there will be no impact to their operations as they are funded through the end of their fiscal year, September 30, 2019. This means there will be no effect on payments to healthcare providers through the federal government payment system, and no changes with state-level survey and certification operations.

As for accreditation, ACHC is not a federal agency and our operations will not be affected by the shutdown. All surveys, reviews, and support services performed by ACHC and its affiliates will be provided according to normal schedules.

We will continue to stay abreast of any impact the shutdown may have at both federal and state levels and make you aware of any noteworthy developments as soon as we become aware of them. In the meantime, if you have any questions about your accreditation or would like to bring our attention to any issues, please do not hesitate to contact your Account Advisor or call ACHC at (855) 937-2242.

Thank you for your continued dedication to serving your patients with excellence and distinction and may 2019 bring you and your loved ones good health, happiness and success.


Barbara Sylvester, RN, BBA, MSOLQ
Director, Regulatory Affairs and Quality

Mapping Community Palliative Care

Palliative care is well established in U.S hospitals, with seventy-five percent of those with fifty beds or more reporting a palliative care program. Recognizing the needs of seriously ill patients and their families in all care settings, many palliative care programs are working to extend services in their communities – either by expanding existing hospital programs to other settings, or building new programs in non-hospital settings.  These programs provide palliative care in patient’s homes, nursing homes, doctor’s offices, and outpatient clinics, and are vital in reaching a patient population that would otherwise not be served through traditional hospital palliative care. However, little is known about the locations or extent of this community reach, or how these community palliative care services are staffed and structured to meet patient and family need.

To fill this gap, the Center to Advance Palliative Care (CAPC), in collaboration with the National Coalition for Hospice and Palliative Care (NCHPC), launched Mapping Community Palliative Care.  The goal of this initiative is to develop a comprehensive inventory of community palliative care programs and estimate their prevalence nationwide.

The three-year project, funded by the Gordon and Betty Moore Foundation, will catalog palliative care programs in the community and analyze palliative care access across settings. By completing a short eight-question survey, community palliative care programs nationwide can put their program “on the map,” identifying themselves, where their services are provided, and what services they offer. Mapping Community Palliative Care is committed to increasing access to palliative care services for patients, families, caregivers, and providers. Programs participating in Mapping Community Palliative Care will have the option to be listed in the Provider Directory on, the leading online resource for palliative care information for people with serious illness and their families. Anyone looking for palliative care resources will be able to search the directory by location and service type (hospital, home, nursing home, and office/clinic). As more and more programs add their profiles to the directory, patients and families will be able to find local resources and programs to meet their specific needs.

Mapping participants are also invited to participate in the National Palliative Care Registry™ – by providing annual aggregate data on program structure and operations, participants receive reports comparing their palliative care programs to their peers. Mapping Community Palliative Care and the National Palliative Care Registry™ are both free and open to programs across all care settings.

Mapping Community Palliative Care is working to bring the field of palliative care one step closer to a comprehensive national profile of palliative care services across care settings.

To participate, please visit and “make your mark” today!

If you are interested in learning more about Mapping Community Palliative Care, please contact Rachael Heitner, MA, CHPCA, Research Associate at CAPC, at

Don’t let a natural disaster interrupt your patients’ oxygen supply

How prepared are you and your staff for an emergency? Do you have a solid plan for your patients?

Anything that impacts service for your patients should be addressed in your plan

ACHC corporate surveyor Cynthia Gray breaks it down: What to do when nature wreaks havoc on the supply line for oxygen-dependent patients (as recently published in the August edition of AARC Times)

By Cynthia Gray, BS, RRT-RPFT

Cindy Gray

“Providing oxygen tanks for a short amount of time is reasonable. Most home medical equipment companies provide the patient with three times the maximum response time. When a power outage is extended to days, weeks, or even months, alternative plans must be initiated. RTs can be a key resource for patients if that should occur. Patients and their caregivers can plan ahead and be prepared for alternative living arrangements if an extended outage is a possibility.

… In an emergency, a documented plan is easier to follow than trying to remember what was discussed.

… RTs have a great opportunity to help patients understand that early action is imperative. If your institution is alerted about an impending disaster, act early.”


Key Steps to Opening a Medicare-Certified Home Health Agency

While starting a new skilled home health agency (HHA) can be exciting and rewarding, it can also be a long and time-intensive process. Although there is a growing need for HHAs with the population of people age 65 and older expected to reach 19.6 percent by 2030, CMS in recent years has imposed significant financial and operational barriers that HHAs must navigate.

Because ACHC was created by home care providers, we understand these unique challenges that you face. Our goal as your partner in accreditation is to offer resources and education to help you through this process and fully prepare you for accreditation. One of these resources that ACHC has recently developed is a free On-Demand Home Health Start-Up Webinar that walks you through the process of starting an HHA in more detail. This webinar can be found on

Below we have outlined some of the key steps to opening a Medicare-Certified HHA.

  1. Determine your states requirements concerning a Certificate of Need (CON)
  2. Determine if state licensure is required in the state where you want to operate
  3. Must meet requirements of CMS State Operations Manual, Chapter 2, Section 2180C
    • Provide Skilled Nursing services and other therapeutic services
    • These services are supervised by a physician or RN
    • Have established policies & procedures
    • Maintain clinical records on all patients
    • Have an overall plan and budget
    • Meet the Medicare Conditions of Participation (CoPs)
    • Meet capitalization requirements
  4. Complete and submit an 855A application to CMS
    • Once approved, submit approval letter to ACHC
  5. Complete a successful test OASIS transmission
  6. Develop patient caseload
    • Must have 10 patients served with 7 active at the time of survey
    • Must meet the definition of CMS skilled care per the Medicare Benefits Policy Manual Chapter 7
  7. Download and review ACHC Accreditation Standards
  8. Submit your ACHC Accreditation application and Preliminary Evidence Report (PER) Checklist
  9. ACHC will complete an on-site survey within 60 days of HHA’s stated readiness


IACHC_Certified-Consultant_Sealf you would like more help with getting your agency off the ground, or preparing for accreditation, you may be interested in reaching out to an ACHC Certified Consultant. Our Certified Consultants have been trained in ACHC Accreditation Standards, survey approach, and processes to better prepare healthcare clients for the accreditation survey. Find a Certified Consultant on

ACHC Approved for Ongoing Home Health and Hospice Licensure Surveys by State of Maryland

In a recent press release, Accreditation Commission for Health Care (ACHC) announced its approval by the Maryland Department of Health, to perform accreditation surveys in lieu of ongoing state licensure surveys for Home Health agencies and Hospices, in accordance with state law.

“This approval from the Maryland Department of Health means that home health agencies and hospices who are accredited by ACHC will no longer receive ongoing state licensure surveys,” said Teresa Harbour, ACHC’s Program Director for Home Health, Hospice, and Private Duty programs. “We appreciate the value Maryland
Department of Health sees in accreditation and we applaud their willingness to work with us to offer ACHC accredited agencies an alternative to ongoing licensure surveys.”

The Maryland Department of Health has reviewed ACHC’s Accreditation Standards and survey process and confirmed that they meet the state’s licensure requirements. On December 12, 2017, Dr. Patricia Tomsko Nay announced that home health agencies and hospices accredited by ACHC are deemed to comply with Maryland State licensure requirements and are exempt from routine licensure surveys conducted by the Department.

To remain licensed, deemed Home Health agencies and Hospices must continue to submit a renewal application and comply with applicable Maryland Health Care Commission requirements. With the application, the licensee seeking deemed status for state licensure proposes, must submit its currently applicable ACHC inspection results and all supporting documentation.

For more information on ACHC accreditation in-lieu of ongoing licensure surveys in Maryland, contact us at

ACHC Accreditation – A New Option for California Home Health Licensure

With more than 500 initial licensure applications pending approval in California, home health agencies are being forced to wait up to two years before receiving their license. To help combat this delay, the California Department of Public Health (CDPH) has given home health agencies the option of working with a CMS-deemed accreditation organization to obtain an initial licensure survey. CDPH is encouraging home health agencies to take advantage of this new option in order to expedite their licensure approval process.

The Accreditation Commission for Health Care (ACHC), a nationally recognized accreditation organization known for providing value, integrity, and the industry’s best customer service, is one of the approved accreditors.

“ACHC is ready to immediately accept applications and assist start-up agencies seamlessly through the licensure process,” said Teresa Harbour, ACHC’s Program Director for Home Health, Hospice, and Private Duty.  “Meeting the needs of California providers is essential to ACHC, so we have created accreditation prep tools and resources specific for these providers.”

Faina Neveleva, Administrator of Signature Home Health Care, was grateful for the training and support her agency received from ACHC. She attended the ACHC Home Health workshop in preparation for her agency’s recent accreditation survey.

“The workshops were so educational. Lisa [ACHC Clinical Compliance Educator] was very patient and answered all of our questions,” added Neveleva. “The free ACHC Accreditation Guide to Success workbook tells you exactly what the Surveyors are looking for. We rely on this so much.”

ACHC is accepting applications for home health licensure and accreditation in California and has already started surveying agencies. Once the application is completed, ACHC guarantees agencies will be surveyed within 25 days.

“We were impressed with how simple and straightforward the ACHC application process was and how quickly we were surveyed,” said Neveleva. “Throughout the whole process, our Account Advisor was very knowledgeable and helpful, returning calls usually within an hour and making sure all our questions were answered.”

Partnering with ACHC not only provides a faster route to licensure, it also allows agencies to reap the benefits of accreditation – ensuring compliance with the Medicare Conditions of Participation (CoPs) and the highest quality standards.

VNA Hospice & Palliative Care of Southern California has been accredited for over 20 years and recently switched to ACHC. Paula Natale, Director of Regulatory Affairs, said the organization switched because the ACHC Accreditation Standards are easy to understand and are more applicable to the home health and hospice services provided by the agency.

“It is a way for us to show our patients, payors, and referral sources that we have achieved a higher standard above and beyond the Medicare CoPs and that we are committed to continuously improving the care we provide,” Natalesaid, reflecting on the value of accreditation.

With more than 1,200 accredited home health agencies across the country, ACHC prides itself on the fact that 98 percent of customers say they would recommend ACHC – and Natale agrees.

“I have recommended ACHC to several colleagues,” she said. “Having experience with other accrediting organizations, I can say that the knowledge, professionalism, and customer service from ACHC Account Advisors, Surveyors, and Clinical team is unmatched in the industry.”

This article was published on Home Health Care News on December 20, 2017.

The Changing Healthcare Environment: An Interview with Kim Bradley, Nurse Executive of Sentara Enterprises

On Behalf of ACHC, the Remington Report interviewed Kim Bradley, Sentara Enterprises, to get insights into the changing healthcare environment and how her organization is handling the challenges. For more than a decade, Sentara has been ranked as one of the nation’s top integrated healthcare systems.  Their not-for-profit system includes advanced imaging centers, nursing and assisted-living centers, outpatient campuses, physical therapy and rehabilitation services, home health and hospice agency, a 3,800-provider medical staff and four medical groups.


Remington Report: The move toward value-based care and a rapidly changing healthcare delivery system are just a few of the challenges weighing heavily on the minds of today’s healthcare executives. Explain your organization’s five top challenges.

Bradley: You have accurately identified one of the greatest challenges that we face at Sentara, as in many organizations – and that is, transitioning to a value based mindset while continuing to live, largely, in a fee for service reimbursement environment.  We view this as both a challenge and an opportunity because as patients move through the continuum at a faster pace, we have the opportunity to touch more patients.  Patients come to us earlier and with higher acuities than we’ve seen in the past.

This leads to additional challenges – recruiting, retaining, and training top talent to care for our growing patient population.  Another challenge that we balance is timely and effective communication among multiple business lines in an integrated delivery network.

Remington Report: If you take one of your challenges, what solution (s) would make it possible to make a difference?

Bradley: I believe that tight processes, efficient workflows, evidenced based care protocols, reliable technology that support the clinicians in the field that avoids duplicative documentation are critical. That is a tremendous amount of work that we have committed to performing which allows us to provide excellent care to our high acuity patient population.

Remington Report: In the midst of change, explain the ways your organization is pushing innovation.

Bradley: We are seeking efficient ways to utilize our EMRs.  We are also seeking enhanced and innovative ways to utilize telehealth and virtual visits.

Remington Report: Explain how ACHC’s partnership is providing solutions to your organization.

Bradley: ACHC has proven to be a wonderful partner to Sentara Enterprises throughout our accreditation journey as well as through opening new providers for home health.  They have offered to assist us with review of new policies and procedures for the upcoming CoPs as well as the new Emergency Preparedness guidelines that impact all of our business lines.

ACHC has partnered with us to identify and share best practices.  By doing so, it not only elevates our organization but our industry as a whole.

National Home Care & Hospice Month – Stories from Hospice in the Pines’ We Honor Veterans Program

November is National Home Care & Hospice Month, and the National Hospice and Palliative Care Organization’s (NHPCO) theme for this year is “It’s about how you live!”

ACHC asked agencies to submit stories honoring the lives of the patients they serve. We are excited to share two stories we received from Hospice in the Pines in Lufkin Texas. These two stories are about men this organization serves through their We Honor Veterans program. This program was founded by the National Hospice and Palliative Care Organization in collaboration with the Department of Veteran Affairs that partners with hospice organizations around the nation. We are proud of Hospice of the Pines’ commitment to our veterans and the way they honor the lives of these heroes!


Bill Fortune

At 91 years old, Colonel Bill Fortune is an exceptional American hero who served in the United States Air Force during World War II.

This impressive and decorated serviceman is one of two siblings in his family to serve in the United States Military. Collectively his immediate family members and himself have served a total of over 120 years in the military.  Colonel Bill Fortune was one of the first air pilots to fly into an active hurricane.

Today he displays several pictures within his bedroom, above his bed, of the B-29 airplanes which he flew in the war. These images bring such great joy to his mind and heart when reminisced upon. Colonel Fortune was a co-pilot, and served for a total number of 36 years in the United States Military.  Colonel Bill Fortune is a native of Lufkin and has been active until his diagnosis with cancer, yet his lovely and beautiful spirit truly remains ever cheerful to all.

Hospice in the Pines had the honor of recognizing his dedicated service through the We Honor Veterans pinning ceremony. On Friday September 15, 2017, three team members from Hospice in the Pines joined the Fortune family in their home to celebrate the life and servitude of Colonel Fortune. It was a ceremony that doubled as a small family reunion and will forever be a memory in the legacy of Colonel Fortune’s beautiful life. What an honor it was to play a part in showing appreciation to such a dedicated veteran.


Tommy Solomon

Tommy Solomon is a United States Veteran who served during the Vietnam War.

Mr. Solomon was stationed in Lackland Airforce Base, he was selected to be a mechanic for his expertise and knowledge of repairing and assembling airplanes. In Mr. Solomon’s home, you will find numerous models of planes decorated with the traditional colors of the F104-Fighter planes and the Douglas DC3 planes, all which Mr. Solomon had assembled, dissembled, fixed, cleaned. Mr. Solomon worked on planes such as the C124, C118, P38 Fighter, and the C121 which he stated, “this was the most beautiful plane ever built”. Mr. Solomon said he will never forget his fellow comrades and the unification they all shared to take care of one another; to always provide servitude, dignity, shared values and most importantly faith and unity with one another.

Mr. Solomon’s spirit, strength and humor can still be felt and seen every day. His art and Greek mythological statues and images that can be found in his home, remind him of living in Greece for a short duration of his life.  Mr. Solomon loves to spend his time with his family and his many pets.

Hospice in the Pines was honored to acknowledge his service to our country through the We Honor Veterans pinning ceremony. Mr. Solomon’s dedicated service is a glimpse at the wonderful and beautiful life he has lived. We are forever grateful for his service.