The Surveyor Newsletter a resource for news about ACHC programs.
SURVEYOR Volume 2025 | No. 1
SURVEYOR
CORNER VIEW Reflections from José Domingos, ACHC President and CEO
TABLE OF CONTENTS
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EMBRACING INCLUSION
My career as a nerd began as I studied mechanical engineering technology. As an engineer whose work focused on instrumentation and medical connectors, I was exposed to the diverse field of health care. Engineering provided a foundation of systematic, logical, problem solving. Health care provided the opportunity to have positive impact on thousands of human lives. New roles over the years led to time spent in hospital and laboratory settings. By following varied interests as they arose, I worked in many roles and industries, but health care was a recurring theme. Thirteen years ago, I arrived at ACHC. The ACHC human resources team lives by the slogan “we only hire the best.” Nerdiness isn’t a prerequisite; it can be developed. Our staff members start with bright, curious minds but often come to ACHC with little exposure to accreditation. I am thrilled to observe those who develop into deeply committed leaders, eager to share their passion for healthcare excellence, going above and beyond in their service to our customers.
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JOINING THE “IN” CROWD
08
ACCREDITATION PROGRAMS
15
DISTINCTION PROGRAMS
16
CERTIFICATION PROGRAMS
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YOUR EDUCATIONAL RESOURCE
In the following pages, you’ll read more about why being an “Accreditation Nerd” is so important to us at ACHC and you’ll meet a few staff members you might not otherwise know.
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STRATEGIC PARTNERS
For those accreditation nerds who work in the organizations we serve, greetings from the tribe. And for those of you who have not yet embraced the title, no worries. We’ll mentor you whenever you’re ready!
BOARD OF COMMISSIONERS
LEADERSHIP TEAM
Brock Slabach, MPH, FACHE Chair CHIEF OPERATIONS OFFICER, NATIONAL RURAL HEALTH ASSOCIATION Maria (Sallie) Poepsel, PhD, MSN, CRNA, APRN Vice Chair OWNER AND CEO, MSMP ANESTHESIA SERVICES, LLC
Leonard S. Holman, Jr., RPh Treasurer HEALTHCARE EXECUTIVE AND CONSULTANT
Jennifer Burch, PharmD OWNER, CENTRAL PHARMACY, CENTRAL COMPOUNDING CENTERS
José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER Patrick Horine, MHHA VICE PRESIDENT, ACUTE CARE SERVICES
José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER, ACCREDITATION COMMISSION FOR HEALTH CARE Richard A. Feifer, MD, MPH, FACP CHIEF MEDICAL OFFICER, INNOVAGE
John Barrett, MBA Officer-at-Large SENIOR CONSULTANT, QUALITY SYSTEMS ENGINEERING Roy G. Chew, PhD Immediate Past Chair PAST PRESIDENT, KETTERING HEALTH NETWORK Gregory Bentley, Esq. PRINCIPAL, THE BENTLEY WASHINGTON LAW FIRM
Matt Hughes VICE PRESIDENT, COMMUNITY CARE SERVICES Jonathan Kennedy, CPA, MBA VICE PRESIDENT, FINANCE AND CORPORATE SERVICES
Mark S. Defrancesco, MD, MBA, FACOG Secretary WOMEN’S HEALTH CONNECTI CUT/PHYSICIANS FOR WOMEN’S HEALTH (RETIRED)
Denise Leard, Esq. ATTORNEY, BROWN & FORTUNATO
Marshelle Thobaben, RN, MS, PHN, APNP, FNP PROFESSOR, HUMBOLDT STATE UNIVERSITY
SURVEYOR
accreditation nerds unite
Just call us Accreditation Nerds The enthusiasm of accreditation nerds was revealed at ACHCU Academy this March. The five content tracks of the program—hospital clinical/administrative, hospital facilities, hospice, home health, and pharmacy—gave us five categories for a game we called “Not Immediate Jeopardy.” We planned to encourage Academy registrants to play our game with accreditation nerd t-shirts. We learned quickly that the game was fun, but the t-shirts were treasure! Individuals tasked to help their organizations achieve and maintain ACHC accreditation are deeply invested . They take enormous pride in that effort and in their knowledge of accreditation requirements. The demand for t-shirts outstripped the supply! Academy presents a unique opportunity to gather with other members of the ACHC “nerd nation” to learn and exchange ideas. “ In -person” takes on a double meaning: Connection is one of the best parts of the annual event and as Academy grows, more and more healthcare nerds are “in the know!”
Embracing Inclusion: ACHC Accreditation Nerds
There are math nerds and science nerds, film nerds and Shakespeare nerds, gaming nerds, music nerds; the list goes on. There are subgenres within categories: What is a civil war reenactor but a history enthusiast with a niche focus? In other words, a nerd.
Nursing Nerd
Nerds are highly engaged in a specialized area of knowledge. And with that working definition, many now adopt for themselves what was once a negative label. The evolution of “nerd” from an insult to a badge of honor is the result of an important change—a mindset shift from a perspective of exclusivity to one that embraces inclusion .
Rather than being received as a criticism calling out an “uncool” interest, today’s nerds are proud of their passions, open to others who share them, and totally fine with those who don’t. Recognize someone’s intensity of focus by saying, “you’re a nerd!” and you’ll likely be met with enthusiastic agreement and an invitation for you to learn more.
After nursing school I started on a surgical floor, later moving to a surgical ICU. I thrived in those high-intensity environments, but when my hospital faced closure, a PRN nurse I worked with suggested I give home health (HH) a try. At the time, I had my doubts—HH was often seen as where nurses went when they couldn’t “hang” in the hospital. But from my very first day 30 years ago, I was hooked. Home health opened my eyes to a different kind of patient care, one that went beyond the hospital’s clinical focus. Success demanded more than just hands-on skills—it required a keen understanding of regulations and standards, which I found incredibly compelling. When OASIS was introduced to home health in 1999, I jumped at the chance to volunteer and lead its implementation at my agency. That experience ignited a passion for quality and regulatory work, and I transitioned into a role as a regional quality coordinator. While in that position, my company made the decision to shift from state oversight to pursue ACHC accreditation. I found the transition process absolutely fascinating—digging into the details, aligning policies, and ensuring compliance was right up my alley. That experience inspired me to take a leap and apply for a surveyor position 16 years ago, and I can honestly say it’s been the
ACHCU ACADEMY CLASS OF 2025
most rewarding role of my career. The constant evolution of rules and regulations keeps me on my toes, and I thrive on staying ahead of the curve in this ever- changing field. I definitely live and breathe accreditation.
Accreditation nerd pride on display as many attendees wore their shirts on the last day of the conference.
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accreditation nerds unite
Beginning with onboarding, organizations seeking accreditation or certification from ACHC experience a process that builds trust. Questions are encouraged and the open exchange of information creates a high level of involvement between provider and supplier organizations and ACHC. In volvement Drives In vention This trust-based collaboration can lead to invention. When discussion reveals gaps in established regulations or emerging trends in healthcare services, ACHC looks to build a bridge. Moving from an identified problem to an improved practice may require further clarification of existing requirements, or additional standards. Sometimes the answer is a completely new accreditation, certification, or distinction program. Creating something new is never accomplished without significant partnership. Subject matter experts contribute and review proposed standards. Organizations agree to be surveyed as beta-test sites for the standards. Feedback is evaluated, changes made, and programs launched. Integrity is embedded in this process of invention. The result? A growing portfolio of programs dedicated to improving safety and healthcare quality for those ready to join ACHC.
Joining the “In” Crowd
ACHC’s staff of accreditation nerds focus on in tegrity and in volvement.
Discerning In tegrity
Integrity applied to an object or organization describes the cohesion or wholeness of the components parts. An organization of integrity works to minimize flaws in its structure and processes, so that reliability becomes a defining characteristic. Integrity applied to a person indicates a strong sense of moral purpose. These individuals can be relied on to do the right thing with dependable consistency. Integrity is a corporate value for ACHC. It
while simultaneously ensuring full compatibility with a high level of
quality. Getting to know organizations well also allows us to share relevant guidance for best practices to maximize each organization’s potential for excellence. Then, after every onsite visit, organizations are asked for feedback about the experience from
ACHC NERDS SPAN OUR TEAMS
application to survey. Responses undergo
detailed analysis by our Quality team, serving as a measurement that we rely on for the continuous internal improvement that is foundational to maintaining our own organizational consistency. From initial contact through accreditation decision, a process of
guides us to deliver a better accreditation experience. Individually and collectively, we aim to align who we say we are as an organization with what we do.
Teneisha Chambers Customer Experience Manager
Brittanica Cooper Account Advisor II
José Domingos President and CEO
Angela FitzSimmons Associate Director, Corporate Communications
Erica Cox Customer Care Specialist
When we talk about ACHC, we often speak of the benefits of our flexibility. This means we look at each applicant organization as a distinct entity. We ask about the scope of services provided, the populations served, and the organization’s business structure. This critical information brings each organization into sharp focus, allowing ACHC to accept variety in how standards compliance is achieved
Mary Lou Flemming Associate Director, Regulatory Affairs
Bob Gardner Associate Director, Strategy & Technology
Sheryl Miller Customer Experience Manager
Susan Mills Program Director
discovery engages applicant organizations with a host of ACHC employees—a customer care representative, an account advisor, a clinical educator, the regulatory team, and surveyors. Accreditation with integrity benefits all parties.
Barb Sylvester Director, Regulatory Affairs & Quality
Maggie Poulson Project Manager
Richard Parker Associate Director, Life Safety & Physical Environment
Jillian Piccicuto Senior Project Manager
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achc programs
Accreditation Programs
ASCs are often the preferred location for outpatient procedural care. ACHC’s expertise can position new organizations for success and existing surgery centers for ongoing quality and sustainability. Our program holds deeming authority from CMS and our approach is practical, educational, and collaborative. Certification offers recognition of an orthopaedic specialty within the ASC. associated certification: » Advanced Joint Replacement ambulatory surgery center
In -depth describes ACHC’s offerings.
Our accreditation programs address the continuum of care from organizations providing supplies and support for activities of daily living to facility-based acute care and long-term residential care. ACHC Standards for each program are selected to align with the scope and acuity of services provided.
Assisted living communities focus on quality of care and quality of life. Accreditation supports staff education on methods for strategic improvement that confirm consistent, ongoing quality— across all of your services. Accreditation is your announcement to residents and prospective residents that your community is a thriving, supportive care provider. assisted living
acute care hospital
ACHC’s hospital program celebrates its 80th birthday in 2025, but we’re just getting started. Our legacy of superior customer support throughout the term of accreditation is augmented regularly with a growing list of tools and resources to address the challenges that hospitals face when meeting regulatory requirements. Certifications add tiered recognition for specialized programs, represents quality to your community, and acknowledging excellence in your teams. And new certifications are coming soon! associated certifications: » Cardiac Care — COMING SOON » Joint Replacement
With 20 distinct service options under this program, each organization can craft a highly relevant and meaningful accreditation solution. Standards are designed to increase safety, emergency preparedness, treatment continuity, and HIPAA compliance. The optional Distinction in Telehealth recognizes the trend toward virtual patient/client interactions that extend access across and beyond communities. associated distinction: » Telehealth behavioral health
» Stroke Care » Wound Care
Convenient care clinics can be free-standing or located in retail stores, supermarkets, or pharmacies. Accreditation represents quality for these settings delivering non-emergency care. A Distinction adds recognition for those that offer virtual visits. associated distinction: » Telehealth ambulatory care
clinical laboratory
Laboratory accreditation encompasses all specialties and testing complexities from waived tests to pathology. ACHC’s goal is to help laboratories achieve superior patient outcomes through testing, training, and documentation. A streamlined approach to accreditation offers unparalleled clarity and efficiency, saving resources
and adding value. CE credits and QC support tools are just a few of the educational offerings associated with ACHC Laboratory Accreditation.
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Operations Nerd I started amassing nerd credentials early. I was a proud mathlete in middle school. I attended midnight book releases for the Harry Potter series. I am embarrassingly familiar with Lord of the Rings movie marathons. My undergrad degree is in mechanical engineering with a minor in math. I question any decision made without data. (As W. Edwards Deming said, “Without data, you’re just another person with an opinion.”) Before my senior year in college, I interned as a project engineer. I sat in a cubicle, surrounded by cubicles, and during that summer the man across from me retired. From his cubicle. So, I finished college and joined the United States Air Force. After officer training, aviator training, and specialty training, I spent six years flying 1,100 hours of reconnaissance through five deployments to four countries. Then I became a trainer for new graduates coming into the Air Force after college. Ten years in, my husband and I felt it was time to consider new opportunities. We used an algorithm to decide what and where. Housing, schools, and employment opportunities brought us to the Research Triangle. I joined ACHC in 2024 as a project manager. As I manage the launch of new
critical access hospital
Small but mighty, a CAH is often the heart of its community. ACHC’s accreditation program has 80 years’ experience in supporting these special hospitals, including those seeking initial CAH status. With limited resources, imagine what an accessible partner with deep regulatory, clinical, and operational expertise can mean for your organization.
associated certifications: » Cardiac Care — COMING SOON » Joint Replacement
» Stroke Care » Wound Care
Businesses of all sizes benefit from ACHC’s deep experience with medical equipment services. Standards align with the focus of each organization’s business. Expert surveyors bring integrity to the process. Distinctions add recognition for those that specialize beyond basic accreditation. associated distinction: » Clinical Respiratory Patient Management dmepos » Custom Mobility ACHC’s program focuses on mobile dentistry that provides access to dental services outside a typical dental office. Accreditation of this innovative service scrutinizes the quality of services delivered by a licensed dentist or dental hygienist working under the supervision of a dentist using specially equipped vehicles or portable equipment to bring care to the patient. dentistry
programs, my mind is very focused on issues in health care. My goal is to set ACHC up for the future in this increasingly data-driven world. Finding answers using applied mathematics and data science fit with my biggest interests: service and solutions.
Maggie Poulson Project Manager
home health
Agencies seeking approval to bill Medicare for nursing and other skilled services on an intermittent basis are eligible for this accreditation. Distinctions offer recognition for specialty services and provide additional validation of quality and a marketing differentiator for these agencies. associated distinction:
home care
» Outcomes » Palliative Care
» Telehealth
» Age-Friendly Care » Behavioral Health
Agencies offering “private duty” care provided hourly or by shift that may be covered by third party payors but is not eligible for Medicare reimbursement are eligible for this program. Distinctions add recognition for those that specialize beyond basic accreditation.
Home Care vs Home Health All home health is home care but not all home care is home health. Home health offers a broad set of services that are reimbursable by Medicare, ordered by a licensed provider, and usually include skilled nursing. Home Care Accreditation focuses on services provided hourly or by shift that may be covered by various payors, but is not covered by Medicare.
Organizations that employ registered nurses to administer infused medications in the patient’s home under the supervision of an RN or pharmacist, must have Home Infusion Therapy Accreditation to bill Medicare for this service. This accreditation also requires periodic physician review of the plan of care. home infusion therapy
associated distinction: » Palliative Care
» Telehealth
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Agencies providing care for terminally ill patients using an interdisciplinary approach to meet the physical, psychosocial, spiritual, and emotional needs of the patient and their family may apply for hospice accreditation. Distinctions offer additional recognition for agencies that go beyond the basic requirements for accreditation with specific expertise in an aspect of care delivery. hospice
pcab accreditation (compounding pharmacy)
PCAB, a brand of ACHC since 2014, is the recognized benchmark for excellence in pharmaceutical compounding practice. ACHC standards ensure compliance with USP for sterile and nonsterile compounding in 503A pharmacies. And our in-house experts create unparalleled educational resources.
associated distinctions: » Age-Friendly Care » Palliative Care
Are you nerd-level knowledgeable about pharmacy accreditation?
» Telehealth
Do you know the difference between 503A pharmacies and 503B pharmacies? PCAB Nerds will tell you that 503A pharmacies are compounding medications for a specific patient in a pharmacy eligible for recognition under ACHC’s PCAB program. These organizations may be working with sterile, nonsterile, and/or hazardous drugs and they are adhering to the relevant USP requirements that form the basis of PCAB standards. (They may go on to explain that 503B facilities are entirely different because they manufacture in bulk and must be registered under the FDA; accreditation is not an option.) Do you wonder if ACHC can accredit an infusion pharmacy for both an ambulatory infusion suite (AIS) and an ambulatory infusion center (AIC)? What about hazardous drug handling? Pharmacy Nerds will say yes, yes, and yes! And then they’ll go on to ask more about your pharmacy model to make sure all aspects are addressed in the accreditation solution they help you craft.
in-home hospital care
This program validates quality for organizations providing high acuity care in the patient’s home that would typically default to inpatient admission. Hospitals that outsource “hospital-at-home” care and home-based providers with the staffing, experience, and commitment to home visits that support this level of care are eligible for accreditation.
office-based surgery
We call it office-based surgery, but you probably just refer to it as your practice. Whatever your specialty, if you are offering procedural services under minimal to moderate sedation, ACHC accreditation will help you identify and mitigate safety risks and improve your business efficiency (and sustainability!). Accreditation demonstrates the safety and quality of the care you provide, creating a valuable differentiator for your practice.
pharmacy
Pharmacy Inspection Services
From individual businesses to corporate entities with hundreds of sites, ACHC’s deep experience in pharmacy services means you’ll gain a partner that adds value far beyond your accreditation certificate. The range of services allow for a uniquely relevant accreditation solution. Distinctions add recognition for those that specialize beyond basic accreditation. associated distinctions: » Infectious Disease Specific to HIV » Nutrition Support » Oncology » Rare Diseases and Orphan Drugs
Your state board of pharmacy (BOP) may mandate a nonresident pharmacy inspection prior to approving delivery of compounded drugs across state lines. ACHC is authorized by some states to conduct this inspection and prepare a report for the BOP which has jurisdiction over licensure. Pharmacy Inspection Services are specific to each state’s BOP and are not the same as PCAB Accreditation requirements.
palliative care
This program recognizes organizations that provide physical, intellectual, emotional, social, and spiritual support based on the individual patient’s needs (regardless of age or stage of illness), not on their prognosis. Eligibility requires an existing, ongoing, standalone palliative program and a current caseload of at least three patients. Palliative Care is also available as a Distinction under Home Care, Home Health, and Hospice Accreditation. The choice of accreditation or distinction is based on the scope and independence of the palliative program. associated distinction: » Telehealth
RX
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Distinction Programs
renal dialysis
This program focuses on safety, quality, and patient comfort. Our deeply experienced staff understands the range of organizational structures under which dialysis services are delivered – including the unique requirements of long-term care settings. Our goal is to serve as your partner in continuous quality improvement. distinction opportunity: » Telehealth certification opportunity: » Long-Term Care Dialysis
Distinctions are added recognition for ACHC-accredited organizations with expertise in a focused area of special service. Distinction must be earned in conjunction with accreditation.
For agencies that integrate behavioral health intervention into home care services for patients whose mental illness, substance abuse, or intellectual/developmental disabilities that make it difficult for them to receive care outside of their homes. Services are provided by a psychiatric nurse and other home care personnel, as ordered by a physician. eligibility: » ACHC Home Health Accreditation behavioral health For care by licensed respiratory care practitioners (RCPs) or other qualified healthcare professionals of patients with acute or chronic respiratory conditions that can be monitored and managed outside a hospital environment. Emphasis is on a collaborative, team-based approach to assessment and ongoing treatment, disease management, and education. eligibility: » ACHC DMEPOS Accreditation clinical respiratory patient management Older adults may have goals and priorities that differ from those of other age groups. Age-friendly care is intentional with regard to safety and reduction of harm and confusion. It focuses on the use of four evidence-based best practices in geriatric care: What Matters, Medication, Mentation, and Mobility. eligibility: » ACHC Home Health Accreditation age-friendly care » ACHC Hospice Accreditation
sleep
ACHC standards meet Medicare requirements relevant to sleep centers that offer services in the lab or in the home. A second option confers accreditation for sleep testing that is exclusively home-based.
Regulatory Nerd
When ACHC achieved its first state-level approval to accredit sleep labs in 2009, I felt such a sense of accomplishment. I had joined the staff as Regulatory and Government Affairs Liaison (quite a mouthful) and after months of writing letters and making phone calls, getting that acceptance felt like a triumph.
I worked in DME for more than 20 years—in billing, as a certified fitter, as a site manager for a large DME company, and with my state association lobbying for the industry—then I became a DME surveyor for ACHC. Knowledge is never wasted. Before settling into DME, I trained to be an air traffic controller. It wasn’t for me, but those simulations where we had to imagine multilevel highways in the sky are like the levels of regulation that healthcare organizations have to meet. There are federal requirements, state requirements, licensure, payor requirements. I like what I do. I like working in operations. Years ago, I had a boss who said I never seemed happier than when I was rearranging things to be better organized. She was referencing a retail job, but it’s still the same. I like to understand the rules and then set up systems that work.
For providers of custom mobility products. Emphasis is on improved service and responsive care to clients/patients with conditions requiring mobility support, including 24/7 access to support. eligibility: » ACHC DMEPOS Accreditation, including Complex Rehabilitation and Assistive Technology Supplier (RTS) services. custom mobility
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For infusion providers to demonstrate their expertise in the delivery of parenteral and enteral nutrition products, with a focus on nutrition-specific pharmacy operations and provision of care. eligibility: » ACHC Pharmacy Accreditation, including Infusion Pharmacy service nutrition support For delivery of medications for the treatment of cancer-specific conditions; the ability to identify the toxic nature of these medications; and collaboration between the physician, pharmacist, and client/ patient to optimize the client’s/patient’s plan of care, cost containment, and client/patient outcomes. eligibility: » ACHC Pharmacy Accreditation oncology For pharmacies able to demonstrate a clear, delineated dispensing and purchasing methodology for medications to treat HIV. Standards focus on the ability to clearly manage client/patient adherence to these medications; collaboration between the physician, pharmacist, and client/patient to optimize the plan of care; cost containment; and outcomes. eligibility: » ACHC Pharmacy Accreditation infectious disease specific to hiv
Is a Distinction in Palliative Care right for my organization? Do you offer palliative care as a complement to your primary services, for example as a bridge to hospice care? Then yes, the distinction is the right choice. Do you have an existing, standalone palliative care program with a current, ongoing caseload? Then you are ready to apply for accreditation!
palliative care
Patient- and family-centered care that optimizes quality of life throughout the continuum of illness by addressing physical, intellectual, emotional, social, and spiritual needs and facilitating patient autonomy, access to information, and choice. eligibility:
» ACHC Hospice Accreditation
» ACHC Home Care Accreditation » ACHC Home Health Accreditation
For pharmacies with processes and procedures to bring medications for rare diseases into market from FDA approval to patient management, employee education, and medication handling and dispensing. There must be a clear, and agreed upon, collaboration between the pharmacy and the manufacturer to provide optimal patient care with the ability to collect, analyze, report, and act on data collected during the patient treatment journey. eligibility: » ACHC Pharmacy Accreditation rare diseases and orphan drugs
This Distinction recognizes agencies that use data across a range of domains to evaluate the quality of their care and guide continuous quality improvement. Data are used in create benchmarks and identify opportunities to improve processes, services, and operations for better overall care and outcomes. eligibility: » ACHC Home Health Accreditation and top 25% of CMS cohort outcomes
I’m a nerd because I get excited about projects that build structure, clarity, and consistency. By helping internal and external teams. I know my work connects directly to patient care.
telehealth
This additional recognition focuses on the provision of care to clients/patients with acute or chronic conditions, using telehealth technology that allows monitoring in the clinical or home environment. This technology creates disease management empowerment and independence, improved access to care, increased collaboration among healthcare providers, and improved client/patient outcomes. eligibility:
Jillian Piccicuto, PMP Senior Project Manager
» ACHC Palliative Care Accreditation » ACHC Renal Dialysis Accreditation
» ACHC Home Care Accreditation » ACHC Home Health Accreditation » ACHC Hospice Accreditation
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Certification Programs Certification confirms quality in specific programs within an organization. These are programs treating a subset of the organization’s patient population. Generally, the program is of sufficient scope to require formal support from the organization’s governing body. The certification survey is limited to review of the specialty service and how it integrates into the organization as whole.
stroke
Hospitals seeking stroke certification can demonstrate to their community, local EMS, and/or state regulators the level of care that they can provide to stroke patients. options: » Stroke Ready Care is for centers that collaborate with community emergency services to meet the initial needs of stroke patients. » Primary Stroke Care programs can stabilize and treat acute stroke through the administration of tPA and other therapies. » Thrombectomy Stroke Care programs have the capacity to perform this procedure for ischemic stroke patients. » Comprehensive Stroke Care programs offer advanced treatment through neurology, neurosurgery, and neuroradiology.
healthcare staffing services
This program confirms that your staffing agency meets recognized standards for credentialing, training, and evaluating competencies of healthcare professionals prior to placement, and tracking those placements. In an era of staffing shortages, third-party validation demonstrates your commitment to providing a solution.
long-term care dialysis
Unlike other ACHC Certification programs, Long-Term Care Dialysis requires ACHC Renal Dialysis Accreditation. Standards are designed to promote an elevated care model that delivers optimal patient safety and enhances the continuum of care and collaboration between the dialysis facility and the long-term care facility (SNF/NF).
Joint replacement programs seeking certification can demonstrate commitment to a multidisciplinary approach to continuous quality improvement in patient care. options: Advanced Joint Replacement is for organizations performing partial joint procedures with no or controlled comorbidities. Advanced Joint Replacement with Distinction is for organizations performing partial or total joint procedures on outpatients or inpatients. Comprehensive Joint Replacement is for organizations that perform high complexity, high acuity total joint replacements or revision procedures on inpatients. eligibility: » Advanced Joint Replacement - ASCs or HOPDs » Advanced Joint Replacement with Distinction – ASCs, hospitals » Comprehensive Joint Replacement - hospitals joint replacement Providers of noninvasive therapy for kidney stones and stones and masses in other organs use ACHC certification externally as verification of their standard of care and internally to ensure the consistency of practice and documentation that drive quality outcomes. options: » Advanced Lithotripsy lithotripsy » Comprehensive Lithotripsy
telehealth
Organizations that focus on delivering care and services through technology-based patient contact are eligible for Telehealth Certification. Telehealth is also available as a Distinction under Ambulatory Care, Behavioral Health, Home Care, Home Health, Hospice, Palliative Care, and Renal Dialysis Accreditation. The choice of certification or distinction is based on whether the program stands alone or is a considered a service within an accreditation-eligible organization.
wound care
Treatment of nonhealing, complex, and chronic wounds requires multidisciplinary care. It can be delivered in outpatient or inpatient settings. Wound Care Certification signals quality to your community and offers recognition for your team’s skill, experience, and collaborative approach. eligibility: » Advanced Wound Care programs provide care for nonhealing, complex, and chronic wounds on an outpatient basis, including through mobile services provided in multiple locations through a corporate management structure. » Advanced Wound Care with Distinction is offered for hospitals providing inpatient wound care that may include hyperbaric oxygen therapy and/or outpatient wound services.
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education for success
Your Educational Resource
certified accreditation professionals (cap)
I’m a nerd because I’ve climbed the ladder to oversee our organizational compliance. About 15 years ago, I took a leader-personality test and the results said I was “too compliant.” That’s when I said, “Then I’m in the right role!”
Organization-based nerds can earn the CAP credential. It means you have participated in a rigorous training program and passed an exam demonstrating your knowledge of ACHC’s process and standards. As a professional credential, it speaks to your pride in the ability to guide your organization to a successful survey outcome and to your ability to promote a culture of excellence within your organization.
The Questioning Nerd, ACHCU edition We meet the needs of a diverse range of healthcare settings by embracing the nerd mindset. ACHCU builds resources by asking:
Barbara Sylvester, RN Director, Regulatory Affairs & Quality
quality nerd
» What more is there to know? » How does this concept connect to other settings? » What skills or tools would deepen understanding? » What are the most common misconceptions about this subject?
» How do these standards apply to real- world scenarios? » How can we optimize this approach? » What patterns do we see emerging? » What community or network can help grow this knowledge?
product certification
Many home care, home health, and hospice
I’m a nerd because I find it incredibly rewarding to watch a customer shift from “where do we even begin?” to “we’re ready!” Accreditation might not be everyone’s passion, but helping providers feel confident, supported, and prepared? That’s absolutely mine.
organizations hope to streamline compliance efforts by purchasing vendor resources like Policy and Procedure sets, QAPI Programs, Emergency Preparedness Programs, Admission Packets, and more. However, it remains the responsibility of the organization seeking accreditation to ensure that these products fulfill ACHC requirements. By achieving ACHCU Product Certification, vendors can demonstrate their understanding of the requirements and validate their product’s compliance.
ACHCU enhances educational offerings, embraces collaboration with experts, asks for feedback, and acts for improvement with webinars, master classes, workshops, workbooks, tools, and certification offerings.
Brittanica Cooper Account Advisor II preparation nerd
certified consultants
Many organizations seek the guidance of an experienced consultant when seeking accreditation. ACHCU provides focused, in-depth training for consultants to build expertise and maintain up-to-date knowledge of ACHC’s survey process and/or standards.
Nerds Plan Ahead AMELIA ISLAND, FL | March 2 – 4, 2026
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accreditation nerds unite
vendors These organizations offer products that support compliance with ACHC accreditation standards, data management, and regulatory requirements.
Strategic Partners
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
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.
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.
I’m a nerd because I love an oxford comma. I embrace the idea that I’m a creative person, but my definition of creativity is expansive. My own version is expressed through words and pictures intended to solve business problems.
I’m a nerd because I love hearing from companies that go through the accreditation process that ACHC is awesome to work with. To me, that means the team I lead is getting it right.
Angela FitzSimmons Associate Director, Corporate Communications
Teneisha Chambers Customer Experience Manager
feedback nerd
grammar nerd
22 | Volume 2025 | No. 1
achc.org | (855) 937-2242 | 23
The Unpretentious Nerd, ACHC edition Healthcare accreditation is a serious business, and we take our work seriously.
ACHC knows that surveying healthcare organizations is an important responsibility. Each initial and renewal application represents an invitation to evaluate the quality, safety, and effectiveness of an organization. Applicants may need accreditation, or they may choose to be recognized without a regulatory mandate. In either case, the trust placed in us means that, in addition to a rigorous evaluation, ACHC owes each organization relevant feedback reflecting a deep understanding of its purpose, mission, and business model.
Being serious about our work doesn’t require us to be humorless. Or punitive. We hope you enjoy the irreverent take on ACHC accreditation in this issue of Surveyor . For information about any of our programs, or to get your start as an official ACHC Accreditation Nerd, contact us:
customerservice@achc.org
(855) 937-2242
Cary, NC | achc.org ©2025 Accreditation Commission for Health Care, Inc.
SURVEYOR
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