ACHC Hospice Accreditation Program Reapproved by CMS

Content

ACTION:

Notice.

SUMMARY:

This notice acknowledges the approval of an application from the Accreditation Commission for Health Care Inc., for continued
CMS approval as a national accrediting organization for hospice programs that wish to participate in the Medicare or Medicaid
programs.

DATES:

The decision announced in this notice is applicable from November 27, 2025, through November 27, 2031.

FOR FURTHER INFORMATION CONTACT:

Lillian Williams, (410) 786-8636.

Kristin Shifflett, (410) 786-4133.

SUPPLEMENTARY INFORMATION:

I. Background

Under the Medicare program, eligible beneficiaries may receive covered services from a hospice provided certain requirements
are met. Section 1861(dd) of the Social Security Act (the Act) establishes distinct definitions relating to hospices. Regulations
concerning provider agreements are at 42 CFR part 489 and those pertaining to activities relating to the survey and certification
of facilities are at 42 CFR part 488. The regulations at 42 CFR part 418 specify the conditions that a hospice must meet in
order to participate in the Medicare program, the scope of covered services, and the conditions for Medicare payment for hospices.

Generally, to enter into an agreement with Medicare, a hospice must first be certified as complying with the

  conditions of participation (CoPs) set forth in part 418, subparts C and D, and recommended to the Centers for Medicare &
  Medicaid (CMS) for participation by a State survey agency. Thereafter, the hospice is subject to periodic surveys by a State
  survey agency to determine whether it continues to meet these conditions. However, there is an alternative to certification
  surveys by state agencies. Accreditation by a nationally recognized Medicare accreditation program approved by CMS may substitute
  for both initial and ongoing state review.

Section 1865(a)(1)(A) of the Act provides that, if the Secretary of the Department of Health and Human Services (the Secretary)
finds that accreditation of a provider entity by an approved national Accrediting Organization (AO) meets or exceeds all applicable
Medicare conditions, the Secretary shall treat the provider entity as having met those conditions; that is, CMS will “deem”
the provider entity to be in compliance. Accreditation by an AO is voluntary and is not required for Medicare participation.

If an AO is recognized by the Secretary as having standards for accreditation that meet or exceed Medicare requirements, any
provider entity accredited by the national accrediting organization's approved program may be deemed to meet the Medicare
conditions. A national AO applying for CMS approval or re-approval of their accreditation program under 42 CFR part 488, subpart
A, must provide CMS with reasonable assurance that the AO requires the accredited provider entities to meet requirements that
are at least as stringent as the Medicare conditions. Our regulations concerning the approval of AOs are set forth at § 488.5.
Section 488.5(e)(2)(i) permits CMS to grant a term of approval of up to 6 years, and an accrediting organization must reapply
for continued approval of its Medicare accreditation program . The Accreditation Commission for Health Care Inc. (ACHC) currently
has a term of approval as a recognized accreditation program for its hospice accreditation program that expires November 27,
2025.

II. Application Approval Process

Section 1865(a)(3)(A) of the Act provides a statutory timetable to ensure that our review of applications for CMS-approval
of an accreditation program is conducted in a timely manner. The Act provides us 210 days after the date of receipt of a complete
application, with any documentation necessary to make the determination, to complete our application review process. Within
60 days after receiving a complete application, we must publish a notice in the
Federal Register
that identifies the national accrediting body making the request, describes the request, and provides no less than a 30-day
public comment period. At the end of the 210-day period, we must publish a notice in the
Federal Register
approving or denying the application.

III. Provisions of the Proposed Notice

In the June 25, 2025,
Federal Register
(90 FR 27020 and 27021), we published a proposed notice with request for comment announcing ACHC's request for continued approval
of its Medicare hospice accreditation program. In the June 25, 2025, proposed notice, we detailed our evaluation criteria.
Under section 1865(a)(2) of the Act and in our regulations at § 488.5, we conducted a review of ACHC's Medicare hospice accreditation
application in accordance with the criteria specified by our regulations, which include, but are not limited to the following:

• A virtual administrative review of ACHC's: (1) Corporate policies; (2) financial and human resources available to accomplish the proposed surveys; (3) procedures for training, monitoring, and evaluation of its hospice surveyors; (4) ability to investigate and respond appropriately to complaints against accredited hospices; and (5) survey review and decision-making process for accreditation.
• A comparison of ACHC's Medicare hospice accreditation program standards to our current Medicare hospice CoPs.
• A documentation review of ACHC's survey process to— ++ Determine the composition of survey teams, surveyor qualifications, and ACHC's ability to provide continuing surveyor training.

++ Compare ACHC's processes to those we require of state survey agencies, including periodic resurvey and the ability to investigate
and respond appropriately to complaints against accredited hospices.

++ Evaluate ACHC's procedures for monitoring hospices it has found to be out of compliance with ACHC's program requirements.
(This pertains only to monitoring procedures when ACHC identifies non-compliance. If noncompliance is identified by a state
survey agency through a validation survey, the state survey agency monitors corrections as specified at § 488.9(c)).

++ Assess ACHC's ability to report deficiencies to the surveyed hospice and respond to the hospice's plan of correction in
a timely manner.

++ Establish ACHC's ability to provide CMS with electronic data and reports necessary for effective validation and assessment
of the organization's survey process.

++ Determine the adequacy of ACHC's staff and other resources.

++ Confirm ACHC's ability to provide adequate funding for performing required surveys.

++ Confirm ACHC's policies with respect to surveys being unannounced.

++ Confirm ACHC's policies and procedures to avoid conflicts of interest, including the appearance of conflicts of interest,
involving individuals who conduct surveys or participate in accreditation decisions.

++ Obtain ACHC's agreement to provide CMS with a copy of the most current accreditation survey together with any other information
related to the survey as we may require, including corrective action plans.

IV. Analysis of and Responses to Public Comments on the Proposed Notice

In accordance with section 1865(a)(3)(A) of the Act, the June 25, 2025, proposed notice with request for comment, we also
solicited public comments regarding whether ACHC 's requirements met or exceeded the Medicare CoPs for hospice. We received
several comments. All comments were in favor of ACHC's hospice renewal application. We thank the commenters for their input
and have considered it when making our decision.

V. Provisions of the Final Notice

A. Differences Between ACHC's Standards and Requirements for Accreditation and Medicare Conditions and Survey Requirements

We compared ACHC's hospice accreditation requirements and survey process with the Medicare CoPs of part 418, and the survey
and certification process requirements of parts 488 and 489. Our review and evaluation of ACHC's hospice application, which
were conducted as described in section III. of this final notice, yielded the following areas where, as of the date of this
notice, ACHC has completed revising its standards and certification processes in order to meet the requirements at:

• Section 418.52(c)(5), to address the requirement regarding confidential clinical records.
• Section 418.54(b), to include reference to § 418.24.

• Section 418.54(c), to address comfort or well-being as part of the comprehensive assessment focus.
  • Section 418.54(c)(1), to address the patient's well-being and comfort as part of the comprehensive assessment and

  the presence or lack of objective data and subjective complaints requirement.

• Section 418.58(c)(2), to address the requirement of tracking adverse patient events and analyzing their cause.

• Section 418.100(f)(2), to address the requirements of subparts A and C of this section.

• Section 418.104(a)(2), to include references to § 418.52 and § 418.24.

• Section 418.104(a)(4), to include reference to § 418.54(e).

• Section 418.104(a)(5), to include references to § 418.25, § 418.102(b), and § 418.102(c).

• Section 418.52(a)(6), to include reference to § 418.52(a)(2).

• Section 418.112(b), to address the requirement to make any arrangements necessary for hospice-related inpatient care.

• Section 418.112 (c), to require an agreement that specifies the provision of hospice services in the facility.

• Section 418.112(f), to address the usage of appropriate forms.

• Section 418.114(b)(3)(i)(A), to address the Master of Social Work (MSW) requirement.

• Section 418.116(a), to require a hospice to have a license in accordance with State licensure laws.
  In addition to the standards review, CMS also reviewed ACHC's comparable survey processes, which were conducted as described
  in section III. of this notice, and yielded the following areas where, as of the date of this notice, ACHC has completed revising
  its survey processes in order to demonstrate that it uses survey processes that are comparable to state survey agency processes
  by:

• Revising ACHC's survey process documentation to include both the 2012 editions of Life Safety Code (LSC) and Health Care
  Facilities Code (HCFC), and 2013 edition of the Fire Safety Evaluation System (FSES) NFPA 101A Fire Safety for Health Care
  Occupancies.

• Ensuring that all new ACHC LSC surveyors complete LSC Preceptor Evaluations in accordance with ACHC's surveyor training policy
  and have supporting records on file.

• Providing additional survey training to hospice surveyors on citing levels as it relates to the initial comprehensive assessment,
  for example standard versus conditional level to ensure compatibility with § 488.26(b).

B. Term of Approval

Based on our review and observations described in section III. and V. of this final notice, we find that ACHC has provided
reasonable assurance that hospices accredited under the program will meet or exceed the applicable Medicare conditions or
requirements. Therefore, we approve ACHC as a national accreditation organization for hospices that request participation
in the Medicare program, effective from November 27, 2025 through November 27, 2031.

VI. Collection of Information Requirements

This document does not impose information collection requirements, that is, reporting, recordkeeping or third-party disclosure
requirements. Consequently, there is no need for review by the Office of Management and Budget under the authority of the
Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.).

The Administrator of the Centers for Medicare & Medicaid Services (CMS), Mehmet Oz, having reviewed and approved this document,
authorizes Vanessa Garcia, who is the Federal Register Liaison, to electronically sign this document for purposes of publication
in the
Federal Register
.

Vanessa Garcia, Federal Register Liaison, Centers for Medicare & Medicaid Services. [FR Doc. 2026-06500 Filed 4-2-26; 8:45 am] BILLING CODE 4120-01-P

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