2024 ANNUAL REPORT
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
0%
100%
5%
14%
26%
31%
3%
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
0%
100%
service recipient/client/patient record ■ Operational aspects of care/services provided
11%
14%
23%
9%
15%
25%
2%
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
0%
100%
■ Surveillance, identification, prevention, control, and investigation of infections and safety risks ■ Fire safety, hazardous material handling, and disaster and crisis preparation
6%
17%
21%
34%
12%
7%
2%
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
16
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