ACHC Accreditation Checklist

Select the ACHC program being surveyed.

Record the survey type.

Confirm whether CMS deemed status applies to this program.

Record the edition of the ACHC standards the organization is preparing against.

List every location and branch included in the survey scope.

Confirm the state license for each location is current and displayed or on file.

Check that permits, registrations and any certificates of need are current for the services provided.

Confirm the Medicare and Medicaid enrollment details match the current ownership, address and services.

Record the expiry date of each license and who is responsible for renewal.

Confirm the governing body membership and its responsibilities are documented.

Check that governing body meeting minutes show review of quality, complaints and financial performance.

Confirm the administrator and clinical director roles are filled and their qualifications are on file.

Confirm an alternate is named to act when the administrator is absent.

Check that the organizational chart is current and shows lines of authority.

Confirm policies cover every service the program provides.

Check that each policy shows an approval date and a review date within the organization's review cycle.

Confirm staff can locate current policies and that superseded versions are withdrawn.

Confirm policies reflect current state and federal requirements for the program.

Confirm the services offered match those described in marketing materials and admission documents.

Check admission, transfer and discharge processes against written policy.

Confirm care or service plans are developed, followed and updated when the client's needs change.

Check that after-hours contact and on-call arrangements work as described to clients.

Confirm clients receive a written statement of rights and responsibilities at admission.

Check that signed consent and acknowledgement forms are in the client record.

Confirm clients are told how to make a complaint and how to contact the state agency and ACHC.

Check privacy practices for client information, including the notice of privacy practices.

Sample personnel files and confirm each holds a job description signed by the employee.

Confirm current licenses or certifications are verified for every clinical role.

Check that background checks and health screening are completed before staff start work.

Confirm orientation, initial competency and ongoing competency assessments are documented.

Check that annual performance evaluations and required in-service training are complete.

Sample active and discharged client records and confirm each is complete and signed.

Confirm physician or practitioner orders are signed and dated within the required timeframe.

Check that assessments, care plans, visit notes and coordination of care are documented.

Confirm records are stored securely and retained for the required period.

Record any documentation gap found and the record it was found in.

Confirm a written performance improvement plan exists and is approved by leadership.

Check that quality indicators are measured, analyzed and reported to the governing body.

Confirm at least one current improvement project shows data before and after the change.

Check that client satisfaction results are collected and acted on.

Confirm every complaint is logged with the date received, investigation and resolution.

Check that complaints are resolved within the timeframe set in policy and the client is informed.

Confirm incidents and adverse events are reported, investigated and trended.

Check that complaint and incident trends feed into the performance improvement program.

Confirm the infection prevention program covers hand hygiene, PPE and staff illness reporting where applicable.

Check that equipment used with clients is cleaned, maintained and tracked.

Confirm client home or site safety assessments are completed where the program requires them.

Check that workplace safety training and hazard reporting are in place for staff.

Confirm an emergency preparedness plan exists and is based on a documented risk assessment.

Check that the communication plan includes contact details for staff, clients and outside agencies.

Confirm client emergency plans or priority levels are recorded where the program requires them.

Confirm emergency preparedness training and exercises are completed and documented.

List every contracted service and confirm a signed, current contract is on file.

Confirm business associate agreements are in place wherever client information is shared.

Check that contracted staff meet the same qualification and competency requirements as employees.

Confirm contracted services are monitored for quality.

Carry out a mock survey or internal audit covering each section of this checklist.

Record the readiness status for each finding.

Assign an owner and a target date to every gap found.

Record the corrective action and the evidence that will show the gap is closed.

Confirm corrective actions are completed and verified before the survey window opens.

After the survey, confirm any plan of correction is submitted on time and each item is tracked to verified closure.