Notice2026-06500
Medicare and Medicaid Programs; Approval of Application by the Accreditation Commission for Health Care Inc. (ACHC) for Continued CMS-Approval of its Hospice Accreditation Program
Primary source
Metadata and text below are from the Federal Register, a public-domain U.S. government work. Always verify the official published version before relying on it for any legal matter.
Published
April 3, 2026
Issuing agencies
Health and Human Services DepartmentCenters for Medicare & Medicaid Services
Abstract
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.
Full Text
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<title>Federal Register, Volume 91 Issue 64 (Friday, April 3, 2026)</title>
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[Federal Register Volume 91, Number 64 (Friday, April 3, 2026)]
[Notices]
[Pages 16947-16949]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2026-06500]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-3473-FN]
Medicare and Medicaid Programs; Approval of Application by the
Accreditation Commission for Health Care Inc. (ACHC) for Continued CMS-
Approval of its Hospice Accreditation Program
AGENCY: Centers for Medicare & Medicaid Services, (CMS), HHS.
ACTION: Notice.
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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
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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 Sec.
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 Sec. 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:
<bullet> 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.
<bullet> A comparison of ACHC's Medicare hospice accreditation
program standards to our current Medicare hospice CoPs.
<bullet> 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 Sec. 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:
<bullet> Section 418.52(c)(5), to address the requirement regarding
confidential clinical records.
<bullet> Section 418.54(b), to include reference to Sec. 418.24.
<bullet> Section 418.54(c), to address comfort or well-being as
part of the comprehensive assessment focus.
<bullet> Section 418.54(c)(1), to address the patient's well-being
and comfort as part of the comprehensive assessment and
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the presence or lack of objective data and subjective complaints
requirement.
<bullet> Section 418.58(c)(2), to address the requirement of
tracking adverse patient events and analyzing their cause.
<bullet> Section 418.100(f)(2), to address the requirements of
subparts A and C of this section.
<bullet> Section 418.104(a)(2), to include references to Sec.
418.52 and Sec. 418.24.
<bullet> Section 418.104(a)(4), to include reference to Sec.
418.54(e).
<bullet> Section 418.104(a)(5), to include references to Sec.
418.25, Sec. 418.102(b), and Sec. 418.102(c).
<bullet> Section 418.52(a)(6), to include reference to Sec.
418.52(a)(2).
<bullet> Section 418.112(b), to address the requirement to make any
arrangements necessary for hospice-related inpatient care.
<bullet> Section 418.112 (c), to require an agreement that
specifies the provision of hospice services in the facility.
<bullet> Section 418.112(f), to address the usage of appropriate
forms.
<bullet> Section 418.114(b)(3)(i)(A), to address the Master of
Social Work (MSW) requirement.
<bullet> 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:
<bullet> 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.
<bullet> 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.
<bullet> 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 Sec. 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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</html>Indexed from Federal Register on April 3, 2026.
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