ALERT: HHS advises providers take note of cyber security risks

May 12, 2017. The US Department of Health and Human Services (HHS) is monitoring a significant cyber attack that has focused primarily on health systems in Europe. At this point the agency is assessing impact to US health systems and providers as some information suggests this attack may have spread to other industries and regions. Until more is known ACHC advises all to remind their associates and staff of safe and robust cyber security practices. The agency has provided some resources to assist in recognizing threats as well as how to handle suspicious activity. Monitor ACHC’s Twitter page ( for current information affecting health care providers. Below is the advisory sent by HHS.

Dear HPH Sector Colleagues,
HHS is aware of a significant cyber security issue in the UK and other international locations affecting hospitals and healthcare information systems. We are also aware that there is evidence of this attack occurring inside the United States. We are working with our partners across government and in the private sector to develop a better understanding of the threat and to provide additional information on measures to protect your systems. We advise that you continue to exercise cyber security best practices – particularly with respect to email.
Laura Wolf,
Critical Infrastructure Protection Lead
Additional information on ransomware provided by HHS Office for Civil Rights can be found at:
Cyber Newsletters:
Ransomware Guidance:

A Conversation with Bryan Prince about USP 800

Bryan Prince knows that USP can be a bitter pill for the independent pharmacist to swallow. The owner of Lab·Red Pharmacy Consultants who is an expert in cleanroom design, chemical handling and workflow understands the challenges pharmacy owners face as they try to balance a commitment to worker safety with the realities of running a business.

Prince also lent his expertise to the recently released Hazardous Drug Consensus Statement, a joint effort of the Pharmacy Compounding Accreditation Board (PCAB) and industry leaders on the handling of hazardous drugs per USP guidelines.

Set to become official – i.e., enforceable by a regulatory entity such as a state board of pharmacy – on July 1, 2018, USP describes practice and quality standards for handling hazardous drugs (as identified by National Institute for Occupational Safety and Health, or NIOSH) in healthcare settings.

“The reality is it’s a huge financial investment,” Prince said about USP , noting that many pharmacists are wondering where they will find the space and/or the money to redesign or expand their cleanrooms/storage areas to meet requirements.

“We’ve got four different aspects of compounding,” Prince explained, “which equals four different rooms: USP , non-sterile, nonhazardous; USP sterile nonhazardous. Now we’re going to add on USP , non-sterile hazardous, and USP , sterile hazardous.

Think of it from the independent pharmacy owner’s perspective, he said: “You’re telling me I’ve got to have four separate rooms? Where am I going to find that space?”

From a broader perspective, though, can’t one assume that pharmacists already understand the risks and thus are doing the right things when it comes to HD handling?

“I’ve heard this: ‘Bryan, I’ve been doing this (HD compounding) for 20 years, and I’m OK.’ Then I’ve heard the flip side: The gentleman who said ‘After 20 years of doing this, I had some tumors removed.’ He couldn’t pinpoint it, but he felt like it was exposure to chemicals.

“At a conference, I met a young woman who said, ‘I’ve had three miscarriages. Do you think that’s because I work in a compounding pharmacy and I handle chemicals?’ And I told her ‘I can’t make that determination for you.’

“But the reality is, I think this is the next ‘mesothelioma’ waiting to happen,” Prince said, adding that he wonders why there aren’t yet legal ads on TV to the tune of: ‘If you’ve been working in a compounding pharmacy for X number of years and suffer from Y or Z …”

While Prince believes that USP is long overdue, he believes the need for it is stronger than ever. “Where we are today is different from where we were five years ago. There are more and more stories of exposure. The whole meningitis outbreak (scores of deaths traced to contaminated steroid injections from New England Compounding Center) kicked this thing off full throttle. The government took it and went to the next level with it.

“Did the independent pharmacy industry need some sort of regulatory change as it relates to chemical handling? Absolutely. I’m always going to be on the side of the fence that says this has been a long time coming,” which may be in opposition to the pharmacy owner, he acknowledged.

“But we have to get to a place where we understand that chemicals are dangerous.”

Bryan Prince will be presenting during a workshop sponsored by ACHC’s Accreditation University on July 25-26 at Fairleigh Dickinson University School of Pharmacy and Health Sciences in Teaneck, NJ. This PCAB Sterile and Non-Sterile Compounding and USP Compliance Workshop will provide pharmacy personnel with a comprehensive overview of the accreditation process and a standard-by-standard review of the requirements for each, along with a detailed examination of USP and guidelines. For more information and to register, visit or contact Chelsie Rigsbee at 919-785-1214 or

Need to Make Updates to Your Accreditation?

At ACHC it’s our goal to be a partner throughout the entire process – before, during, and after accreditation. ACHC knows that once in your 3-year accreditation cycle, business operations adjust for market demands. Your company could move locations, add branch offices, adjust the services provided, or even purchase another entity. If anything changes with your business operations in your accreditation cycle, it is important to notify ACHC.

Updating your information while in your 3-year accreditation cycle is even easier now with Customer Central. You can begin the notification process online. Log into your Customer Central account and navigate to the ”MY ACCOUNT + » Edit Company Info” page.

01. Edit Company Info

Click on the “[Expand]” button to view the section that you wish to explore. For this example, we’ll look at “CHANGE OF OWNERSHIP”.

02. Select Change of Ownership


Select the correct change of ownership form to download the PDF. The form should be completed in Adobe Reader. Don’t have Adobe Reader? Get it here »

03. FIll out PDF


Complete all of the corresponding questions, save the file, and email it to your Account Advisor with any required documentation (specified in the PDF). If you have any questions while in the process, always feel free to reach out to your company’s Account Advisor.

Customer Central allows you to complete the entire process online – from account creation to accreditation! With direct access to your accreditation team and valuable new resources, achieving and maintaining accreditation has never been easier.

Ready for accreditation? Contact ACHC at (855) 937-2242 to learn more.

Home Health | Hospice | DMEPOS | Private Duty
Pharmacy | Sleep  | Behavioral Health

ACHC | Brand Guidelines 2015

The ACHC brand is more than just a logo; it is a broad representation of our essence, used to signify the exceptional quality of our healthcare provider clients. Achieving ACHC Accreditation is a notable accomplishment that your company should be proud to display. The ACHC and PCAB  Accreditation “seals” show your organization’s adherence to a rigorous set of standards, and demonstrates your commitment to providing the highest quality health care to those you serve.

Visit Customer Central at or contact the ACHC Marketing Department for digital files of the logos. The kit downloaded with this document contains all of the logo variations, a sample press release, and suggested website text.

For more information, contact the ACHC Marketing Department at (855) 937-2242. Thank you for your support.

Ready for accreditation? Contact ACHC at (855) 937-2242 to learn more.

Home Health | Hospice | DMEPOS | Private Duty
Pharmacy | Sleep  | Behavioral Health

Behavioral Health Home Care

Behavioral Health Home Care integrates behavioral health interventions into home care services for patients whose mental illness, substance abuse, intellectual/developmental disabilities make it difficult, or otherwise prevent them from receiving care outside of their homes. Services are provided by a psychiatric nurse and other home care personnel, as ordered by a physician.

Watch the above video to learn more about ACHC’s Behavioral Health Home Care service.

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Ready for accreditation? Contact ACHC at (855) 937-2242 to learn more.

Home Health | Hospice | DMEPOS | Private Duty
Pharmacy | Sleep  | Behavioral Health

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Advisor Tips: On-Site Survey

In this Advisor Tips video with Danny Hupp, one of ACHC’s DMEPOS and Pharmacy Accreditation Advisors, he discusses three tips to help you prepare for your survey.

  1. Complete your Preliminary Evidence Report (PER) Checklist
    • The PER Checklist will be submitted on Customer Central
  2. Organize your patient and personnel files
    • ACHC’s Surveyors will review a random selection of files for compliance
  3. Conduct a mock survey with your staff members
    • This will help your team get in the survey-ready mindset

Learn more by watching the video above.

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Ready for accreditation? Contact ACHC at (855) 937-2242 to learn more.

Home Health | Hospice | DMEPOS | Private Duty
Pharmacy | Sleep  | Behavioral Health


CMS Moratoria Extension

18 Feb 2014_CMS extension

In response to recent high profile instances of fraud, waste, and abuse, the Centers for Medicare and Medicaid Services (CMS) released Survey and Certification letter 14-10-HHA on February 4, 2014, extending the moratoria on home health agency enrollment. These moratoria are phase two of the original release in July, 2013 that curtailed the enrollment of any new home health agency in Chicago, IL (Cook, DuPage, Kane, Lake, McHenry, and Will counties) and Miami, FL (Miami-Dade and Monroe counties). CMS reports that these areas were chosen due to high risk for fraud, high utilization, and a disproportionately large number of new providers.

In this new phase, CMS has extended the moratoria in the above areas, and has also added four additional targeted areas – Fort Lauderdale, FL (Broward county), Detroit, MI (Macomb, Monroe, Oakland, Washtenaw, and Wayne counties), Dallas, TX (Collin, Dallas, Denton, Ellis, Kaufman, Rockwell, and Tarrant counties) and Houston, TX (Brazoria, Chambers, Fort Bend, Galveston, Harris, Liberty, Montgomery, and Waller counties).

The moratoria will affect any home health agency located in the above areas that has applied for, or is in the process of obtaining a Medicare provider number, but has not been approved by the Medicare Administrative Contractor (MAC) as of January 30, 2014.  In order for a home health agency’s application to be considered complete, CMS requires that the following steps must be fully completed:

  1. The agency’s initial Medicare certification survey must have been completed
  2. The second MAC review has been completed
  3. CMS regional office sent the tie-in notice to the MAC
  4. The MAC performed a site visit
  5. The MAC switched the agency’s Provider Enrollment Chain Organization System (PECOS) record to approved

If all of these steps were not completed prior to the implementation date of the moratoria, the agency’s application will be denied. If an organization’s status is denied, they will be notified by the MAC. Once the moratorium is lifted, the agency will need to complete a new enrollment application if it continues to seek a Medicare provider number. In addition, the MAC will deny any application for a branch addition location in the above areas as well. Agencies affected will have the right to appeal by following information found in the denial letter issued by the MAC.

Unfortunately, home health surveys conducted by an accrediting organization in these targeted areas for initial deeming purposes will not be accepted by CMS and will not be accepted as a valid survey during the moratoria. ACHC can continue to process prospective home health agency’s application for accreditation only. For more information, contact your Accreditation Advisor at (855) 937-2242.

Download the survey and certification letters, and the FAQs issued by CMS ››

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Ready for accreditation? Contact ACHC at (855) 937-2242 to learn more.

Home Health | Hospice | DMEPOS | Private Duty
Pharmacy | Sleep  | Behavioral Health

Maintaining Survey Readiness

ACHC Survey Readiness

As we embark into  2014, many of us set New Year’s Resolutions only to break our well-intentioned goals and ideals a few short weeks or months later as the daily hustle and bustle of life and work resumes. One New Year’s Resolution that should be established and kept is maintaining survey readiness. We know that we should always be “survey ready” but maintaining that on a daily basis becomes difficult as more pressing issues arise.

A few key points in maintaining survey readiness are:

  • Ensure you have the most current ACHC Standards for Accreditation and your policy and procedure manuals are consistent with ACHC Standards as well as any additional federal and/or local regulations.
  • Stay current with the monthly Did You Know publications sent by ACHC.
  • Audit medical and personnel records on a continuous basis to identify issues of non-compliance early and develop an internal Plan of Correction for any issues of non-compliance found.
  • Access ACHC’s Customer Central portal frequently for the latest information and resources to assist you in maintaining survey readiness.

ACHC has created tools to assist you with this endeavor. These tools coincide with key time frames; at 6, 12, and 24 months post-survey as well as 6 months prior to renewal.

For example, some annual requirements including program evaluation, staff education, and personnel evaluations are often overlooked or not completed on time. The tools ACHC has created provide you with checklists to help you to stay on track in between surveys. ACHC conducts surveys every three years, but as we know, random, unannounced surveys by any regulatory body could happen at any time and staying current is the key to a successful survey outcome.

Download the Continued Compliance documents by logging into your Customer Central Account and navigate to ‘After Accreditation’ -> ‘Continued Compliance’.

Home Health | Hospice | DMEPOS | Private Duty
Pharmacy | Sleep  | Behavioral Health

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Lisa MeadowsAbout the Author: Lisa Meadows

As Clinical Compliance Educator for Home Health, Hospice and Private Duty, Lisa brings over 20 years of medical social work experience to the classroom, including acute care hospitalization and home and hospice health care.  Previously an ACHC Hospice Surveyor, Lisa currently travels across the U.S. as a Presenter and an Educator, speaking on accreditation and other relevant health care topics.

ACHC Whiteboard Sessions – Needs Assessment Survey

In this Whiteboard Session ACHC’s CEO, José Domingos, discusses the results from the 2013 Needs Assessment Survey. The data collected consisted of more than 2,000 respondents, including new and existing customers. ACHC identified three common trends among the responses:

1. Customers were satisfied with ACHC’s level of customer service

  • Average a 4.7 out of 5.0 for the last six months

2. Providers desired more educational resources. ACHC now offers:

3. Providers want a more streamlined accreditation process

  • Reduced required files submitted for the PER
  • Updated online customer portal: Customer Central

Learn more by watching the video above.

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Ready for accreditation? Contact ACHC at (855) 937-2242 to learn more.

Home Health | Hospice | DMEPOS | Private Duty
Pharmacy | Sleep  | Behavioral Health

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Survey The Expert Podcast: Episode 11 “Behavioral Health Integration”

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[iOS Users]

In today’s Survey The Expert podcast, we’ll be joined by Britt Welch, ACHC’s Behavioral Health Manager. He has over twenty-five years of experience in the behavioral health field and offers his knowledge of clinical practice, community mental health services, and state government.

Episode Highlights:
Behavioral Health integration positively affects patient care

  • Helps to manage patient’s disability
  • Reduces costs
  • Leads to better outcomes

ACHC’s Behavioral Health standards were developed with the integration of care framework

  • 5 services are currently available for accreditation
  • 10 services launching in 2014

Learn more by visiting or by contacting Britt Welch at (855) 937-2242 ext. 235

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Home Health | Hospice | DMEPOS | Private Duty
Pharmacy | Sleep  | Behavioral Health