ACHC Hospice Accreditation — Frequently Asked Questions
What is ACHC Hospice Accreditation?
ACHC Hospice Accreditation is a CMS-approved accreditation program that grants hospice organizations deemed status under the Medicare Conditions of Participation for Hospice Care (42 CFR Part 418). An accredited hospice is deemed compliant with the Medicare CoPs without a separate routine CMS survey. ACHC is one of a small number of accrediting bodies with CMS deeming authority for hospice.
Is ACHC Hospice Accreditation required?
ACHC accreditation is not required to operate a Medicare-certified hospice — organizations can remain subject to standard CMS state agency surveys. However, many hospices pursue ACHC accreditation to obtain CMS deemed status, satisfy managed care network requirements, and signal quality to referral sources including hospitals and palliative care programs.
What is the interdisciplinary group (IDG) requirement for hospice?
The Medicare CoPs (42 CFR 418.56) require that a hospice's IDG include at minimum a physician, registered nurse, social worker, and pastoral or other counselor. The IDG develops and reviews the patient's plan of care. ACHC standards require documented IDG meeting records with signatures from all participating disciplines.
What are the bereavement program requirements for hospice accreditation?
Bereavement services must be provided for at least 13 months following the patient's death. ACHC standards require documented bereavement risk assessments for all bereaved families, scheduled follow-up contacts, and tracking of all decedents through the 13-month period. This is one of the most frequently cited deficiency areas in hospice surveys.
What is the volunteer hours requirement for hospice?
The Medicare CoPs (42 CFR 418.78) require that volunteers provide a minimum of 5% of total patient care hours furnished by all paid hospice employees and contractors. This must be tracked and documented continuously. Failure to meet the 5% threshold or inadequate documentation is a common survey deficiency.
How long does ACHC Hospice Accreditation take?
Most organizations can achieve initial accreditation in 9-15 months. The key constraints are the bereavement tracking requirement and the look-back period for IDG and care plan documentation. Organizations with existing documentation systems can often compress to 6-9 months.
What are the four levels of hospice care?
Medicare recognizes four levels: (1) Routine Home Care — the standard level; (2) Continuous Home Care — intensive nursing during crisis, minimum 8 hours in 24; (3) Inpatient Respite Care — short-term inpatient to relieve caregiver, maximum 5 days; (4) General Inpatient Care — inpatient for unmanageable symptoms. Each level has distinct documentation requirements evaluated in ACHC surveys.
What is the difference between core and non-core hospice services?
Core services — nursing, medical social services, physician services, and counseling — must be provided directly by hospice employees. Non-core services may be contracted. ACHC surveys verify that core services are provided directly and that contracted service agreements meet required standards.
How much does ACHC Hospice Accreditation cost?
ACHC application and survey fees are based on organization size and census and are not publicly published — contact ACHC directly. IHS consulting engagement fees are scoped per engagement — contact IHS for a tailored proposal.
What are the most common ACHC Hospice survey deficiencies?
Common deficiencies include: bereavement program gaps (13-month tracking incomplete, risk assessments missing), IDG documentation failures, care plans not current, inadequate aide supervision, volunteer hours below the 5% threshold, nominal QAPI programs, and continuous home care documentation insufficient to support that level of care.
What happens if a hospice receives a Preliminary Denial of Accreditation?
A Preliminary Denial notifies the organization that denial is being considered. The organization may respond with documentation demonstrating correction. If the response is accepted, accreditation may be awarded. If not, the denial becomes final and the organization must re-apply after a waiting period. IHS has experience navigating Preliminary Denial responses across multiple ACHC program types.
How does IHS help hospice organizations prepare for ACHC accreditation?
IHS provides end-to-end consulting: gap analysis, IDG documentation audit, bereavement program review, policy development, QAPI design, mock survey, day-of support, and post-survey RFI response. IHS is led by Thomas G. Goddard, JD, PhD, former Chief Operating Officer and General Counsel of URAC.
Have More Questions?
Schedule a free discovery session to discuss your hospice's specific accreditation questions and situation.
Schedule a Free Discovery Session