2025 ANNUAL REPORT
2025 ANNUAL REPORT
CONVERSATIONS THAT MATTER
IMPROVEMENT OPPORTUNITIES
behavioral health
Our report of the most frequently-cited standards can be reviewed in the program- specific Quality Review editions of Surveyor, Vol. 2025, No. 2 .
0%
100%
The charts that follow illustrate the weighted distribution of deficiency findings, by program. This high-level overview indicates where focused improvement efforts can have positive impact for an organization across a group of functionally-related standards.
7%
15%
4%
21%
12%
9%
Organization & Administration Provision of Care and Record Management represents the biggest improvement opportunity for behavioral health organizations. The focus of these standards is how treatment and interventions are planned, delivered, and evaluated. At each step, complete and accurate documentation authenticates service delivery and supports continuity of client care. Program/ Service Operations Fiscal Management Human Resource Management Provision of Care & Record Management Quality Outcomes/ Performance Improvement Risk Management: Infection & Safety Control
community care programs The categories identified in the legend reflect the sections into which ACHC standards are organized. The sections are defined as follows:
1. Organization and Administration ■ Leadership structure including governing body, advisory committees, management, and employee responsibilities, conflicts of interest, and reporting relationships ■ Business licensure, program goals, and regulatory compliance 2. Program/Service Operations ■ Patient and organizational rights and responsibilities, complaints, incidents, management of Protected Health Information, cultural diversity, and compliance with fraud and abuse laws 3. Fiscal Management ■ Annual budgeting process, business practices, accounting procedures, and financial processes 4. Human Resource Management ■ Requirements for personnel records, including training and competency assessments
5. Provision of Care and Record Management ■ Documentation and requirements for the
dmepos
service recipient/client/patient record ■ Operational aspects of care/services provided
0%
100%
3%
8%
19%
22%
13%
14%
21%
6. Quality Outcomes/Performance Improvement ■ Plan and implementation of a
Performance Improvement (PI) program ■ Program responsibilities, data collection, analysis, corrective measures developed from the data, and outcomes achieved
Organization & Administration DMEPOS opportunities for improvement are distributed across categories with HR Management and Risk Management: Infection and Safety Control showing slightly higher percentages of aggregate standard deficiencies. Fiscal Management Human Resource Management Provision of Care & Record Management Program/ Service Operations
Quality Outcomes/ Performance Improvement
Risk Management: Infection & Safety Control
7. Risk Management: Infection and Safety Control
■ Surveillance, identification, prevention, control, and investigation of infections and safety risks ■ Fire safety, hazardous material handling, and disaster and crisis preparation
Section 3: Fiscal Management
Section 4: Human Resource Management
Section 2: Program/Service Operations
Section 1: Organization & Administration
Section 5: Provision of Care and Record Management
Section 6: Quality Outcomes/ Performance Improvement
Section 7: Risk Management: Infection and Safety Control
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