ACHC Reapproved as Accrediting Organization for Another 4 Years

By A.J. Plunkett

Expect surveyors from the Accreditation Commission for Health Care (ACHC) to pay more attention to the Life Safety Code® survey and to consider possibly more severe deficiencies involving the LSC after a review by CMS.

CMS approved ACHC as a hospital accrediting organization (AO) for another four years but only after a few adjustments to survey processes and standards, according to a notice set to be published in the Federal Register September 6.

The approval lasts through September 25, 2027.

Among other changes CMS required to approve ACHC’s application for reapproval:

  • Ensured ACHC standards required assessment of a patient after registration but before surgery or procedures, both inpatient and outpatient, as outlined under the Medical Staff Condition of Participation, Section 482.22 (c)(5), including:
    • Patient age
    • Diagnoses
    • Type and number of surgeries and procedures scheduled to be performed
    • Comorbidities
    • The level of anesthesia required for the surgery or procedure
    • Meeting nationally established standards as well as local and state patient safety standards
  • Updated standards to address the requirements regarding LSC waivers.
  • Revised standards to “to address the requirements regarding alcohol-based hand rub (ABHR) dispensers”
  • Revised complaint response policies and processes to align with the State Operations Manual, Chapter 5 guidance, including revising “its Administrative Review Offsite Investigation process to align with CMS’ triage process to track and trend for potential focus areas during the next onsite survey or complete an onsite complaint investigation.”
  • Revised accreditation policies to include the applicable sections of NFPA 99 Health Care Facilities Code
  • Ensured that “all hospital LSC surveyors have received comparable and adequate training or have sufficient experience to make them qualified to survey health care facilities for compliance with both the 2012 LSC and 2012 NFPA 99 requirements”
  • And will provide “guidance and instruction to surveyors on determining the appropriate level of citation for LSC deficiencies”

CMS has been concerned about physical environment deficiencies from all the hospital AOs for years. And it recently also told AOs to more closely adhere to CMS regulations about complaint investigations and conducting surveys without prior notice.