ACHC Annual Report - 2024

2024 ANNUAL REPORT

BUILDING BRIDGES

2024 Annual Report building bridges

to improve healthcare

2024 ANNUAL REPORT 2023 ANNUAL REPORT REDESIGNING ACCREDITATION

2024 ANNUAL REPORT

BUILDING BRIDGES

ACHC advocates partnership. We seek to affiliate with organizations that share our vision of inclusion and excellence. Whether it’s helping a hospice agency improve interdisciplinary care, guiding a compounding pharmacy to meet rigorous safety standards, collaborating with a healthcare system to improve consistency across locations, or partnering with a vendor to offer discounted resources to mutual customers, our focus is on practical solutions that empower organizations to deliver better patient outcomes. We believe accreditation should be inclusive, collaborative, and forward-thinking. It should foster innovation by bridging diverse perspectives and equipping organizations with the tools and

our mission

WE AIM TO DELIVER THE BEST POSSIBLE EXPERIENCE AND TO PARTNER WITH ORGANIZATIONS AND HEALTHCARE PROFESSIONALS THAT SEEK ACCREDITATION AND RELATED SERVICES.

resources they need to succeed. This is why our approach is based on coalition-building rather than exclusivity. We work with a broad range of stakeholders – from providers and associations to product and service vendors – to cultivate a community that elevates quality for all. In late 2024, two organizations that serve a set of constituents similar to ACHC’s announced that they were establishing a partnership. This would be unremarkable except that their announcement used terms like “locking arms” and “mutually beneficial strategic alliance.” It went on to state that the relationship would remain in place in perpetuity, to extend mutual endorsements, and to confirm a board seat for each organization’s CEO on the other’s Board of Directors. At a time when issues of healthcare equity and access are hot topics, this relationship strikes me as out of step. Exclusive partnerships that shut out other voices risk reinforcing silos at a time when collaboration is more critical than ever. Accreditation should act as a bridge, connecting stakeholders across the continuum of care and creating space for innovation, shared learning, and collective growth. ACHC has spent the past year engaged in the process of building. Our expanded headquarters is rapidly taking shape. It will expand our ability to host external organizations and collaborate more broadly. Simultaneously, our new cloud-based customer platform is in the testing phase. ACHC Navigator will provide closer connection among all users: customers, staff, and surveyors. By building bridges instead of barriers, everyone benefits – providers, patients and the broader healthcare system. Exclusivity may create an illusion of prestige, but that illusion is fleeting. It doesn’t drive progress. Healthcare is not a monolith. It’s a complex ecosystem with varying needs, challenges and strengths. The challenges facing healthcare today, including rising costs, workforce shortages and health inequities, demand inclusive, collaborative solutions. At ACHC, we’re committed to working with all stakeholders to create a more equitable and innovative future for healthcare. Together, we can elevate standards, drive innovation and ensure that every patient receives the high-quality care they deserve.

CONTENTS 1 CEO Message

BRIDGES TO INNOVATION | Accreditation, Certification, Distinctions

BRIDGES TO CONFIDENCE | Education, Training, Tools

BRIDGES TO EXPERTISE | Decoding Complexity

BRIDGES TO COLLABORATION | Strategic Partnerships

ACHC is ready to help your organization thrive. Let’s build a stronger, more inclusive future for healthcare – together.

BRIDGES TO IMPROVEMENT | 2024 Survey Trends by Program

Board of Commissioners/Leadership Team

2024 ANNUAL REPORT

BUILDING BRIDGES

BRIDGES TO INNOVATION ACCREDITATION, CERTIFICATION, DISTINCTION Myths about innovation abound. “Innovation equals invention.” “Innovation requires creative genius.” These two examples are refuted by research showing that most innovation is incremental, based on finding a new way to use or adjust an existing thing or process (curved shower rods and mobile ordering, anyone?). In fact, most innovation is born from constraint. Clear boundaries serve to stimulate creative problem solving. ACHC programs provide structure that allows innovation to thrive. Where relevant, we embed federal regulations within our standards, and we publish the criteria we use to evaluate compliance. Within these guidelines, we help each organization flourish. Each organization is a unique entity and ACHC expects to see policies and procedures to serve a particular scope of service, patient population, and staffing structure. We know there is more than one way to meet the intent of a standard. And customer innovations have led to new accreditation, certification, and distinctions as we build the bridges that spread good ideas.

APPROVALS In 2024, ACHC received renewal of CMS deeming authority for Home Infusion Therapy Accreditation through April 2031.

NEW ACCREDITATION PROGRAM

In-Home Hospital Care Accreditation launched in November to evaluate quality in organizations offering advanced home-based care. This model brings care for higher acuity or chronic conditions into patients’ home as a treatment option that reduces inpatient admissions and addresses patient preference. This program resulted from the collaborative effort of ACHC’s hospital and home health teams. Eligible providers come from both sides of this care continuum.

NEW CERTIFICATION PROGRAMS Long-Term Care Dialysis Certification represents innovating for excellence. Accredited organizations that coordinate dialysis treatment for residents of skilled nursing or long-term care facilities are eligible. Standards address communication and training for the LTC staff and stress

ACCREDITATION PROGRAMS 21

Healthcare Staffing Services Certification addresses the urgent need across healthcare settings for contract clinical staff. Staffing agencies can use the certification to validate their ability to provide credentialed candidates with demonstrated competencies. This ensures smooth onboarding for their client organizations and supports seamless compliance with accreditation standards.

A Recognized Accreditor 10 CMS Programs

The Centers for Medicare and Medicaid Services (CMS) grants “deeming authority” to accreditation organizations (AO) that have been rigorously assessed and confirmed to meet or exceed federal requirements for specific provider or supplier programs. When a healthcare organization achieves accreditation with “deemed status,” that award comes with a recommendation for initial or continuing Medicare certification—a condition for billing for services rendered to Medicare/Medicaid beneficiaries. ACHC is recognized by CMS for acute care hospitals, ambulatory surgery centers, critical access hospitals, clinical laboratories, DMEPOS, Home Infusion Therapy, Home Health, Hospice, Renal Dialysis, and Sleep.

infection prevention in the communal living setting that is akin to approaches used for in-center dialysis. This certification bridges an existing gap in quality requirements for these higher acuity patients by addressing effective management of medically fragile patients with complex care requirements. Avoiding the need for frequent transportation outside the care facility can reduce hospital admissions with improved clinical outcomes while simultaneously providing a better patient experience.

DISTINCTION PROGRAMS

13 CERTIFICATION PROGRAMS

2024 ANNUAL REPORT

BUILDING BRIDGES

NEW DISTINCTION OFFERINGS Home health and hospice care providers can now be recognized by a Distinction in Age-Friendly Care . Agencies that seek this distinction must demonstrate adherence to evidence-based best practices in geriatric care known as the 4Ms*: What Matters, Medication, Mentation, and Mobility. Medicare-certified home health agencies are routinely evaluated on domains including patient outcomes, patient satisfaction, and healthcare utilization. Medicare annually ranks agency performance within peer cohorts. ACHC-accredited agencies that score in the top 25% of their cohort are eligible for the new Distinction in Outcomes , a marketable signifier of quality care. *The 4Ms represent elements of the Age-Friendly Health Systems initiative developed by The John A. Hartford Foundation and the Institute for Healthcare Improvement, in collaboration with the American Hospital Association and the Catholic Health Association of the United States.

MYTH BUSTING Accreditation is the subject of many myths—stories passed from person to person over time—and these stories take on a life of their own. As ACHC has expanded into acute care settings and engaged with leaders in hospital settings, the stickiness of these myths has become apparent. In 2024, we sponsored a webinar with Becker’s Healthcare to address some of these myths. Two physician leaders with direct experience of accreditation joined the conversation. As they became aware that their initial beliefs were untrue, they were happy to help us “myth-bust” for a wider audience.

Accreditations

acute care hospital

ambulatory care

ambulatory surgery center

assisted living

behavioral health

MYTH vs .

FACT

clinical laboratory

compounding pharmacy

myth: There is only one government-approved hospital accreditor. fact: Healthcare accreditation is by independent for profit and nonprofit organizations. ACHC is a nonprofit organization with a hospital accreditation program approved by CMS since 1965. myth: Accreditation varies in prestige. fact: CMS-approved AOs must apply specific federal requirements in evaluating hospitals. The resulting accreditation is the same, regardless of the AO. Differences abound however, in extra requirements and in the AO’s approach. ACHC standards align closely with CMS and follow a PDSA process. Our approach embeds education as a key component. myth: A survey is an exercise in fear and intimidation. fact: ACHC surveyors are selected and trained for knowledge of the standards and the ability to offer consistent, meaningful interpretation and education for healthcare staff. myth: Asking questions is a bad idea. fact: ACHC believes questions represent curiosity and a desire to learn and improve. Questions are encouraged. myth: Magnet status (or other accolades) are tied to a specific AO. fact: Magnet status, like Leapfrog ratings, Medicare star ratings, and other quality awards are independent of AO. If not, be suspicious of a self-serving relationship that doesn’t benefit your organization!

critical access hospital

dentistry

dmepos

Entering New Markets

home care

home health

Healthcare organizations outside the U.S. seek accreditation through ACHC International to demonstrate leadership that raises the bar for their region. Others are looking to expand their access to the market for medical tourism. In every case, accreditation by ACHC International raises an organization’s profile world-wide. ACHC International Hospital Accreditation launched in 2024 with surveys conducted in Honduras and in Saudi Arabia.

home infusion therapy

hospice

in-home hospital care

office-based surgery

palliative care

pharmacy

International quality standards for compounded medications were introduced in Europe with the launch of the PCAB Program in Italy.

renal dialysis

sleep

To watch the webinar, visit https://go.beckershospitalreview.com/asc/myth-busting-learn-the-truth-about- hospital-accreditation-options

2024 ANNUAL REPORT

BUILDING BRIDGES

BRIDGES TO CONFIDENCE EDUCATION, TRAINING, TOOLS Education is foundational to ACHC’s philosophy.

FOCUSED FLUENCY

In 2024, ACHCU’s Master Class catalog grew to include subject matter for compounding pharmacies and hospitals. On-demand access was added for past programs.

INDIVIDUAL CAP CREDENTIAL LAUNCHED

Access to program and clinical expertise is built into our process. A library of additional learning resources to support accreditation and organizational success is offered through ACHCU, our educational division. These offerings are curated to be relevant, refreshed to be current, and delivered by a wide range of experienced, enthusiastic faculty. Key resources on-demand More than a decade ago, ACHC offered an accreditation workshop in conjunction with a national DME conference. The concept of an intensive preparatory course proved so popular that additional programs were established by ACHCU and a quarterly schedule adopted. In 2024, ACHC piloted the inclusion of accreditation workshops as an added value for home health, hospice, pharmacy (including

ACHC accreditations, distinctions, and certifications are awarded to organizations, but we know that the task of guiding preparation is usually assigned to a specific individual. Now, those working in DMEPOS, hospice,

and specialty pharmacy can enhance their expertise and personal professional development with a new credential: Certified Accreditation Professional (CAP). Earning the CAP credential equips individuals with advanced knowledge of ACHC’s process and standards. CAP is awarded through ACHCU after completion of training and an exam to validate knowledge retention. CAP is valid for three years, renewable, and earns continuing education credits.

compounders), and DMEPOS contracts. These organizations can access the material when preparing for survey or whenever new staff are onboarded throughout their term of accreditation.

68 Free Workshops

17,966 Webinar Registrants

HealthTrainU 45,103

Tests taken through

Save the Date March 2 - 4 , 2026 Amelia Island, FL

1,717

430 Labs Using IQCP E-Optimizer

Participants in hospital Coffee Chats

2024 ANNUAL REPORT

BUILDING BRIDGES

BRIDGES TO EXPERTISE DECODING COMPLEXITY Mastery is a concept near and dear to ACHC. Overwhelmingly, individuals join the ACHC staff directly from work in healthcare settings. The move to accreditation often is the result of a strong desire to share knowledge for a bigger impact on patient care. In 2024, ACHC experts wrote, reviewed, and revised countless standards, spoke at conferences, led education events and Master Classes, were interviewed on podcasts, and authored dozens of blog posts and articles for healthcare publications. Here are some examples.

Cyndi Newman , MSHL, BSN, RN, Senior Clinical Review Specialist Is Anesthesia Part of your Safe Medication Practices?, OR Today

Richard Parker , MBA, CHRM, Associate Director, Life Safety & Physical Environment

What Every OR Manager Should Know about Construction in the OR, OR Today What is the Life Safety Surveyor Looking for in the OR?, OR Today Managing Water Quality for Medical Device Processing, OR Today Humidity in ORs: How Low Can You Go?, OR Today Water Quality Standards Boost Healthcare Industry, Canadian Facility Management & Design Managing Water Quality for Medical Device Processing, Facility Executive Building a Resilient Emergency Preparedness Program, NRHA newsletter Sherry Poulos , MSN, RN, RNC-NIC, CNL, Senior Standards Interpretation Specialist Safe Storage of Supplies, OR Today Megan Reed , LPhT, CPhT, HDDP, Program Lead The Puzzle of Home and Ambulatory Infusion Accreditation , Infusion, Vol. 30, No. 2 Julie Vandenbark , MLS, BSN, RN, Senior Standards Interpretation Specialist Before and After: Activate your Quality Program, Use Root Cause Analysis for Better QAPI in Surgical Services, OR Today

Teresa Hoosier , RN, CDN, Associate Clinical Director

Amy Antonacci , MSN, RN, Standards Interpretation Specialist The Pre-Anesthesia Evaluation: Make it Meaningful, OR Today

28 BLOG POSTS

Enhancing Dialysis Care in Long-Term Care Facilities: A Focus on Certification Standards, Patient Safety and Quality HealthCare Patrick Horine , MHA, Vice President, Acute Care Services Opportunity Uncovered: How COVID-19 Accelerated Healthcare Transformation,

José Domingos , President & CEO

102,000 NEWSLETTER SUBSCRIBERS + 44 CONFERENCES AND EXHIBITS

Leading the Charge in Health Accreditation and Continuous Improvement, Global Healthcare Magazine Tricia Dixon-Thomas , MSN, RN, Clinical Review Specialist Improving Discharge Instructions in ASCs and HOPDs , OR Today Donna Gorby , MLD, BSN, RN, Standards Interpretation Specialist Exams under Anesthesia Require Specific Consent, OR Today Detecting Blind Spots in Your Restraint Process , NRHA guest blog

Managed Healthcare Executive Beyond Compliance , OR Today

Rommie Johnson , MPH, PMP, Program Director Setting Staff Standards for Office-Based Surgery, OR Today Navigating Compliance in ASCs: Avoid Immediate Jeopardy, OR Today

2024 ANNUAL REPORT

BUILDING BRIDGES

BRIDGES TO COLLABORATION STRATEGIC PARTNERS ACHC welcomes associations and vendors who seek formalized partnerships. These partnerships are not intended to promote exclusivity, but to equip ACHC customers with increased awareness of and access to relevant advocacy organizations and product offerings. In many cases, we share discount offers with members and clients of our partnering organizations. Visit achc.org for links to each of our partners.

vendors These organizations offer products that support compliance with ACHC accreditation standards, data management, and regulatory requirements.

52 Weeks Marketing Accredited Home Healthcare Directory Accurate Accreditation AmerisourceBergen Drug Corporation AndHealth Axxess BetterRX

Clearway Health Comprehensive Pharmacy Solutions CPS Azina Expedited Accreditations Fairview Pharmacy Solutions Health Recovery Solutions Home Options Network, LLC HospiceMatch, Inc. KanTime Managed Health Care Associates, Inc. McKesson Corporation Maxor Pharmacy Management MedForms NGA Healthcare NikoHealth

Partner Plus Media PowerDMS, Inc. ProTek QAPIplus, a product of Health Forum

Plus, Inc. Omnicell QPI Healthcare Services, LLC Qualis RLDatix SimiTree Shields Health Solutions Surglogs STACK Trellis Rx Visante Worldview

Bluesight (formally SafeQual Sectyr) Cardinal Health VitalSource GPO Cardinal Health Specialty Pharmacy Services Care Pharmacies Cooperative, Inc. Careficient CarepathRx Specialty Pharmacy & Infusion Solutions

associations These organizations offer valuable resources and advance legislative agendas for the benefit of their constituents.

Alliance for Pharmacy Compounding American Association for Homecare American Association of Sleep Technologists American College of Apothecaries American Mobile & Teledentistry Alliance Arizona Association for Home Care Arizona Hospice & Palliative Care Organization Association for Home & Hospice Care of North Carolina Atlantic Coast Medical Equipment Services Association California Ambulatory Surgery Association California Association for Health Services at Home California Hospice and Palliative Care Association Community Oncology Pharmacy Association Connecticut Association for Healthcare at Home Florida Alliance for Health Care Services Health System Owned Specialty Pharmacy Alliance Home Care Alliance of Massachusetts, Inc. Home Care & Hospice Association of New Jersey Home Care Association of America

Home Care Association of Florida Home Care Association of New York State Illinois Homecare & Hospice Council Immunoglobulin National Society Indiana Association for Home & Hospice Care, Inc. Kansas Home Care & Hospice Association Kentucky Home Care Association Louisiana-Mississippi Hospice & Palliative Care Michigan HomeCare & Hospice Association National Association of Specialty Pharmacy National Rural Health Association Ohio Council for Home Care & Hospice Pennsylvania Homecare Association Tennessee Association for Home Care Texas Association for Home Care & Hospice Texas-New Mexico Hospice & Palliative Care Organization The US Oncology Network Virginia Association for Home Care and Hospice

Bold indicates a new partnership in 2024.

Since its inception in 2016, ACHC’s annual charity golf event has brought the North Carolina Triangle-based community—our corporate neighbors—and our nation-wide community of healthcare partners together for a fundraiser benefiting organizations focused on children and family well-being. BRIDGES TO COMMUNITY CHIPPING IN FOR CHARITY

In 2024, ACHC’s Chipping in for Charity made a $40,000 donation to Big Brothers Big Sisters of the Triangle and SAFEchild.

2024 ANNUAL REPORT

BUILDING BRIDGES

BRIDGES TO IMPROVEMENT ACUTE CARE PROGRAMS Survey findings identify where to focus for improvement.

acute care hospitals

100%

13%

36%

10% 11%

29%

Administrative The proportion of deficiencies under Facilities Management decreased in 2024 compared to the prior year. Quality and Risk Management deficiencies increased correspondingly. All other categories were unchanged. Facilities Management Direct Patient Care Ancillary Patient Care Services Quality & Risk Management

ACHC reviews the most frequently-cited standards in our annual Surveyor – Quality Review Editions . Here, we take a bird’s-eye view of compliance trends for services and operational functions by category. Charts on the following pages show how the total deficiencies were distributed for a specific setting. Legends identify which chapters are included in each category. You may want to consider a QAPI focus on a high-percentage category. Beyond correcting individual standard deficiencies, this approach encourages more cross-departmental collaboration to meet goals for quality.

Facilities Management Chapters 9, 11, 13

Direct Patient Care Chapters 16, 17, 18, 20, 26, 27, 30, 31, 33, 34

Administrative Chapters 1, 2, 3, 4, 6

Ancillary Patient Care Services Chapters 14, 19, 21, 22, 23, 24, 25, 32

Quality & Risk Management Chapters 7, 12, 15

ambulatory surgery centers

100%

31%

24%

17%

18%

Administrative Administration and Facilities Management standards continue to represent the biggest opportunities in ASCs but standards related to patient care (direct and ancillary) grew from 25% to 35% in 2024). Quality & Risk Management represented a significantly smaller share of overall deficiencies in 2024. Facilities Management Direct Patient Care Ancillary Patient Care Services Quality & Risk Management

Facilities Management Chapters 7, 15, 16

Direct Patient Care Chapters 9, 10, 11

Administrative Chapters 1, 2, 3, 8

Ancillary Patient Care Services Chapters 12, 13, 14

Quality & Risk Management Chapters 4, 5, 6

2024 ANNUAL REPORT

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critical access hospitals

clinical laboratory

100%

10%

47%

21%

18%

15%

11%

12%

36%

5% 12%

Administrative The distribution of deficiencies across CAHs was mostly unchanged from 2023 to 2024. The biggest opportunities remain in Facilities Management. Direct Patient Care

Analytic Systems remains the most challenging group of standards and the biggest opportunity for laboratory improvement.

Facilities Management

Ancillary Patient Care Services

Quality & Risk Management

General Laboratory

Laboratory Personnel

Provider Performed Microscopy &

Proficiency Testing

General Systems

Analytic Systems

Specialty- Subspecialty Specific

Immuno- hematology & Transfusion Services

Pathology

Waived Testing

Facilities Management Chapters 3, 14, 17

Direct Patient Care Chapters 2, 6, 8, 12, 13

Administrative Chapters 1, 4, 5, 7

Ancillary Patient Care Services Chapters 10, 11, 19

Quality & Risk Management Chapters 9, 16, 18

office-based surgery

100%

25%

35%

20%

14%

Administrative Office settings that provide procedural care are most likely to find challenges with Administrative and Facilities Management standards. These are areas worth focus for their connection to patient and staff experience and satisfaction. Facilities Management Direct Patient Care Ancillary Patient Care Services Quality & Risk Management

Visit achc.org/resources/publications to review Surveyor – Quality Review Edition, Vol. 2024, No. 2 for detail on individual standards cited in 2024.

Facilities Management Chapters 7, 15, 16

Direct Patient Care Chapters 9, 10, 11

Administrative Chapters 1, 2, 3, 8

Ancillary Patient Care Services Chapters 12, 13, 14

Quality & Risk Management Chapters 4, 5, 6

2024 ANNUAL REPORT

BUILDING BRIDGES

BRIDGES TO IMPROVEMENT COMMUNITY CARE PROGRAMS ACHC standards are designed to create a culture of quality and continuous improvement. ACHC reviews the most frequently-cited standards in our annual Surveyor – Quality Review Edition . Here we offer a high-level overview of where improvement efforts can have positive impact on an entire set of services or operational functions.

behavioral health

100%

14%

26%

31%

16%

Organization & Administration Percentages for behavioral health organizations are largely unchanged from last year with the exception of improvement in Quality Outcomes/Performance Improvement from 8% of deficiencies in 2023 to 3% in 2024. Sections 1, 2, 4, and 5 each increased slightly in response. Fiscal Management

Program/ Service Operations

Human Resource Management

Provision of Care & Record Management

Quality Outcomes/ Performance Improvement

Risk Management: Infection & Safety Control

dmepos

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

100%

service recipient/client/patient record ■ Operational aspects of care/services provided

11%

14%

23%

15%

25%

6. Quality Outcomes/Performance Improvement ■ Plan and implementation of a

DME deficiencies were stable from 2023 to 2024 with negligible shifts of one or two percent in sections 1, 2, 5, 6, and 7. Human Resources and Risk Management offer the greatest opportunity for improvement.

Organization & Administration

Program/ Service Operations

Fiscal Management

Human Resource Management

Provision of Care & Record Management

Quality Outcomes/ Performance Improvement

Risk Management: Infection & Safety Control

Performance Improvement (PI) program ■ Program responsibilities, data collection, analysis, corrective measures developed from the data, and outcomes achieved

home care

7. Risk Management: Infection and Safety Control

100%

■ Surveillance, identification, prevention, control, and investigation of infections and safety risks ■ Fire safety, hazardous material handling, and disaster and crisis preparation

17%

21%

34%

12%

Provision of Care deficiencies that saw a significant drop from 2022 to 2023 made further incremental improvement (2 percent) in 2024. This is good news for home care service recipients.

Organization & Administration

Program/ Service Operations

Fiscal Management

Human Resource Management

Provision of Care & Record Management

Quality Outcomes/ Performance Improvement

Risk Management: Infection & Safety Control

Section 3: Fiscal Management

Section 4: Human Resource Management

Section 5: Provision of Care and Record Management

Section 6: Quality Outcomes/ Performance Improvement

Section 7: Risk Management: Infection and Safety Control

Section 2: Program/Service Operations

Section 1: Organization & Administration

2024 ANNUAL REPORT

BUILDING BRIDGES

home health

pharmacy

100%

6% 14%

15%

23%

10%

33%

4% 7%

8% 11%

60%

Organization & Administration Most home health deficiencies come from standards within the Provision of Care and Records Management section. Initiating a quality project related to complete and accurate documentation of orders and care delivered could be a great starting point to lower the frequency of issues in this category. Fiscal Management

Organization & Administration Pharmacy deficiencies were stable from 2023 to 2024 with negligible shifts of one or two percent in sections 4, 6, and 7. Risk Management: Infection and Safety Control remains the most frequent opportunity for improvement. Fiscal Management

Program/ Service Operations

Human Resource Management

Provision of Care & Record Management

Quality Outcomes/ Performance Improvement

Risk Management: Infection & Safety Control

Program/ Service Operations

Human Resource Management

Provision of Care & Record Management

Quality Outcomes/ Performance Improvement

Risk Management: Infection & Safety Control

renal dialysis

home infusion therapy

100%

3% 11% 7%

36%

35%

3% 13%

3% 12%

59%

Organization & Administration Provision of Care and Record Management standards were the most likely to be found noncompliant in 2024 and at a higher rate than in 2023 (59% vs. 53%). Documentation deficiencies are the most frequent issue across standards in this section. Fiscal Management

Organization & Administration The percentage of Provision of Care and Record Management deficiencies increased in 2024 and Risk Management: Infection and Safety Control deficiencies decreased but these remain the areas with the biggest opportunities for dialysis providers to improve their services. Program/ Service Operations Fiscal Management Human Resource Management Provision of Care & Record Management

Quality Outcomes/ Performance Improvement

Risk Management: Infection & Safety Control

Program/ Service Operations

Human Resource Management

Provision of Care & Record Management

Quality Outcomes/ Performance Improvement

Risk Management: Infection & Safety Control

sleep

hospice

100%

3% 13% 4%

26%

19%

23%

12%

6% 10%

21%

53%

Organization & Administration Hospice deficiencies were stable from 2023 to 2024 with negligible shifts of one or two percent in sections 5 and 6. Documentation deficiencies remain the most frequent issue across Provision of Care and Record Management standards. Fiscal Management

Organization & Administration In 2024, sleep testing saw small changes in the percentages in sections 5, 6, and 7, with Provision of Care and Record Management and Risk Management: Infection and Safety Control nudged upward by a declining percentage of deficiencies in Quality Outcomes/Performance Improvement. Fiscal Management Provision of Care & Record Management Program/ Service Operations Human Resource Management

Quality Outcomes/ Performance Improvement

Risk Management: Infection & Safety Control

Program/ Service Operations

Human Resource Management

Provision of Care & Record Management

Quality Outcomes/ Performance Improvement

Risk Management: Infection & Safety Control

Fiscal Management Section 3

Human Resource Management Section 4

Provision of Care and Record Management Section 5

Quality Outcomes/Performance Improvement Section 6

Risk Management: Infection and Safety Control Section 7

Program/Service Operations Section 2

Organization & Administration Section 1

2024 ANNUAL REPORT

BUILDING BRIDGES

pcab pharmacy

BOARD OF COMMISSIONERS

100%

13%

25%

50%

Brock Slabach, MPH, FACHE chair Chief Operating Officer, National Rural Health Association Maria (Sallie) Poepsel, PhD, MSN, CRNA, APRN vice chair Owner and CEO, MSMP Anesthesia Services, LLC Mark S. DeFrancesco, MD, MBA, FACOG secretary Women’s Health Connecticut/Physicians for Women’s Health (retired)

Leonard S. Holman, Jr, RPh treasurer Healthcare Executive and Consultant

John Barrett, BSEE, MBA officer-at-large Senior Consultant, Quality Systems Engineering Roy G. Chew, PhD immediate past chair Past President, Kettering Health Network

Standards for compounders align closely with USP and section titles vary from other Community Care Services. Prior to 2024, PCAB standards were in six sections. In 2024, a seventh section was added to reflect the addition of Hazardous Drug Handling as an element of accreditation relevant to the majority of compounding pharmacies. The most frequent deficiencies—in Provision of Care and Record Management— decreased in frequency from 57% in 2023 to 50% in 2024.

Program/Service Operations Section 2

Organization & Administration Section 1

Personnel Training and Competency Section 3

Patient Communications Section 4

Quality Outcomes/Performance Improvement Section 5

Provision of Care and Record Management Section 6

Gregory Bentley, Esq. Principal, The Bentley Washington Law Firm

Richard A. Feifer, MD, MPH, FACP Chief Medical Officer, Innovage

Jennifer Burch, PharmD, RPH, CDCES, FNCAP, FAPC Owner, Central Pharmacy, Central Compounding Centers José Domingos President and CEO, Accreditation Commission for Health Care

Denise Leard, Esq. Attorney, Brown & Fortunato

Marshelle Thobaben, RN, MS, PHN, APNP, FNP Professor, Humboldt State University

LEADERSHIP TEAM

Visit achc.org/resources/publications to review Surveyor – Quality Review Edition, Vol. 2024, No. 2 for detail on individual standards cited in 2024.

José Domingos President and CEO

Matt Hughes Vice President, Community Care Services

Patrick Horine, MHHA Vice President, Acute Care Services

Jonathan Kennedy, CPA, MBA Vice President, Finance and Corporate Services

2024 ANNUAL REPORT

achc.org

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