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Hospice Program Accreditation Process

1. Create a Customer Central Account

Your first step in the accreditation process is to create your Customer Central Account, where you will have access to all of the tools needed to achieve and maintain ACHC accreditation. Once you have registered your account, you will have the ability to select ACHC standards, complete an online application, and access all of ACHC’s accreditation resources. Your organization will also receive a personal Account Advisor who will serve as your consistent point of contact throughout the entire process.

2. Download ACHC Standards

The next step in the process is to download the ACHC standards relevant to the programs and services you provide. Your Customer Central account will provide you access to preview and purchase ACHC standards. By purchasing, you will gain unlimited access to ACHC standards.

3. Submit the Required Documents

ACHC requires the following five items to be completed before scheduling your survey:
  • Online Application
    The online application is found on your Customer Central account. Here, you have the ability to complete the entire application process in one, easy-to-use interface.

  • Deposit
    Quickly and securely submit your accreditation deposit through Customer Central.

  • Accreditation Agreement
    Review and return your signed Accreditation Agreement (contract) to ACHC.

  • Payment Method
    Schedule your payments by selecting the payment method of choice for the remaining accreditation balance.

  • Preliminary Evidence Report (PER)
    The PER allows your organization to submit select documentation to ACHC for review prior to the accreditation survey. This step provides supporting evidence to demonstrate your organization’s understanding of, and compliance with, ACHC standards.

4. Scheduling the Survey

Surveys are scheduled once the Accreditation Agreement (contract) is signed and the PER is submitted. Please note that all surveys are unannounced (with the exception of initial licensure surveys for Home Health agencies). You will have the opportunity to select 10 blackout dates on your application. ACHC will not conduct surveys on your blackout dates or major holidays (as defined in the ACHC Policies and Procedures). Surveyors are selected based on the services your organization provides, and are expertly qualified through professional experience and continuous ACHC training.

5. On-Site Survey

ACHC will notify customers by phone within one or two hours on the day of the survey with identification information about their ACHC Surveyor. The on-site survey consists of the following:
  • A. Opening Conference
  • B. Tour of the Organization
  • C. Data Collection
    • • Personnel record review
    • • Patient record review
    • • Financial/billing records
    • • Service contracts
    • • Risk management
    • • Performance Improvement (PI) activities
    • • Policies and Procedures (P&P)
    • • On-site observations
    • • Personnel and patient interviews
  • D. Closing Conference

6. Post Survey

Following the conclusion of the on-site survey, the ACHC Surveyor submits all of the data collected to the organization’s Account Advisor for processing. The information is entered into an electronic tool that provides data for determining the decision.

Preparing the Summary of Findings

The Summary of Findings (SOF) is prepared, detailing all ACHC standards and corresponding Medicare Conditions of Participation (CoPs) that were marked as a deficiency during the on-site survey. Each ACHC standard marked as a deficiency contains an “Action Required” statement. This assists the organization in preparing a Plan of Correction (POC) to meet the ACHC requirements. Surveyors may include any best practice suggestions in their summary as additional education. These best practice suggestions are not mandatory for the organization, but are recommendations for improvement.

Accreditation Review Committee
All SOFs are analyzed by the appropriate Clinical Manager or designee, and are evaluated by the Accreditation Review Committee to ensure accuracy before a final decision is rendered. The Accreditation Review Committee consists of a minimum of three experts.

7. Accreditation Decisions

There are four possible outcomes for an accreditation decision.

There are no deficiencies found. The organization is compliant with all ACHC standards. Accreditation is granted for three years.

Accreditation Pending
The organization is found to be faulty in one or more standards. The organization submits a Plan of Correction (POC) for all standards that are deficient, and the POC will be reviewed by the Accreditation Review Committee. When a POC is approved, ACHC can issue accreditation to the organization.

The organization is found to be deficient in a number of ACHC standards and/or at least one Medicare Condition of Participation (CoP). The organization submits a Plan of Correction (POC) for all standards that are deficient, and the POC will be reviewed by the Accreditation Review Committee. ACHC will schedule a Dependent survey at the company's expense. Based on the findings of the Dependent survey, a final decision will be made by the Accreditation Review Committee.

The number, scope, and/or severity of deficiencies demonstrate substantial noncompliance with standards. If accreditation is denied, the company has the opportunity to re-apply for Accreditation at any time they believe they are ready for survey.

8. Accreditation Status

Once accreditation is achieved, the organization’s Account Advisor will send an accreditation approval letter and an accreditation certificate by mail. The provider will also have access to the certificate and letter on their Customer Central website. Additionally, the ACHC marketing material and branding standards are available on Customer Central.

If you are seeking initial Medicare certification, ACHC will submit the appropriate paperwork to CMS with a recommendation of Deemed status to the CMS Central Office, CMS Regional Office, and the state in which the organization is located. Your Account Advisor is available to answer any questions you have throughout the entire process.

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Hospice Testimonials

Show All Testimonials
  • “I would be willing to share our experience with ACHC, as it has been very positive”

    Hospice of Randolph County
    Asheboro, NC
  • "Our Surveyors were thorough, intelligent, and informative. They were very helpful in explaining findings as well as allowing opportunity for us to produce the required information. We did not feel they were here to look for problems but to help us become a better hospice."

    Niagara Hospice, Inc.

  • "I want to express that our experience with ACHC has been exceptional and the information, advice as well as guidance demonstrates true quality.  We have worked well with all ACHC associates and desire to continue to attain true success. The survey was good and the two associate surveyors provided good insight and performance scales to enhance the service of our program…the process was extremely thorough and well collaborated!"

    Hospice in the Pines
    Lufkin, TX

  • "It was an absolute pleasure to work with ACHC. The surveyors were so gracious and awesome. They both were very kind and informative. Their approach positively welcomed us to participate in the survey. Our staff members were very anxious with the survey practice initially and trying to escape from it. But it was totally opposite to what we expected out of a survey. The whole process went with ease because of the surveyor’s approach. My Account Advisor corresponded frequently with me.  I’m extremely satisfied with your service and absolutely recommend your people to other industry associates. It was a delight to work with ACHC."

    Amedisys Hospice, L.L.C. 
  • “My experience with the survey was very positive. Sheryl, Julie, and Janice were very professional and knowledgeable during the survey process.  The surveyors promoted an environment of ease and encouragement during the survey. They praised the operations of our agency and were very helpful and positive in discussing ways to improve our processes. Thanks to the ACHC team for exceeding my expectations.  I look forward to a partnership for years.”

    Forrest General Home Care and Hospice
  • "WOW! We can’t thank you enough. We have never had such congenial, knowledgeable and gracious surveyors in our years and years of having other accreditors. We just finished our first day-end conference – and I’m happy to say that I’m going to sleep very well tonight! Words are not enough to express our deepest gratitude to you."

    Laura Reyher, BSN, RN, Director
    BSA Home Care and Hospice

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