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University of Phoenix
NSG/468 Influencing Quality within Healthcare
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Date
Regulation and accreditation serve different purposes in home health and hospice care. Regulation consists of legally enforceable requirements that providers must follow, while accreditation is an independent quality assessment used to determine whether an organization meets established standards. For Medicare-certified providers, accreditation can also play a role in demonstrating compliance with federal requirements when an accrediting organization has CMS-approved deeming authority.
In home health and hospice care, the distinction is particularly important because organizations must meet the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs) to participate in Medicare. Organizations may also pursue accreditation through an approved accrediting organization such as the Community Health Accreditation Partner (CHAP) to demonstrate adherence to recognized quality and performance standards.
Although regulation and accreditation are closely related, they are not interchangeable.
Regulation refers to laws, rules, and mandatory requirements established and enforced by government agencies. Healthcare providers must comply with applicable regulations to operate legally and, when applicable, participate in government healthcare programs.
Accreditation is a formal evaluation performed by an independent accrediting organization. During accreditation, surveyors assess whether an organization meets defined standards related to quality, patient safety, leadership, clinical practices, documentation, and organizational performance.
Regulations generally establish the minimum requirements for legal and program participation, whereas accreditation can provide a framework for organizations to demonstrate quality and pursue continuous improvement. Accreditation standards may incorporate regulatory requirements while also addressing practices that go beyond basic compliance.
The CMS Conditions of Participation (CoPs) establish federal health and safety requirements that Medicare-certified healthcare providers must satisfy. Home health agencies and hospice organizations must comply with the applicable CoPs to participate in the Medicare program.
The requirements address areas such as patient rights, quality assessment and performance improvement, clinical services, organizational responsibilities, personnel qualifications, and other aspects of safe patient care.
The primary goals of the CMS Conditions of Participation include:
Protecting patient health and safety
Establishing consistent standards for healthcare delivery
Supporting quality and evidence-based care
Promoting quality assessment and performance improvement
Establishing requirements for Medicare participation
Failure to comply with applicable CMS requirements can result in corrective action and may jeopardize an organization’s Medicare certification or participation.
Community Health Accreditation Partner (CHAP) is an independent accrediting organization that evaluates home health, hospice, and other community-based healthcare organizations against established quality standards.
CHAP accreditation evaluates more than basic regulatory compliance. The process examines how an organization delivers care, manages operations, protects patients, maintains documentation, supports employees, and implements quality improvement activities.
For organizations that qualify, accreditation by a CMS-approved accrediting organization can provide an alternative pathway for demonstrating compliance with applicable Medicare requirements through deemed status.
CMS deemed status means that CMS recognizes an approved accrediting organization’s determination that a healthcare provider meets applicable Medicare Conditions of Participation.
In practical terms, an organization accredited by an accrediting body with CMS-approved deeming authority may be able to use accreditation to demonstrate compliance with applicable Medicare requirements rather than relying exclusively on a direct CMS certification survey.
Deemed status does not eliminate the provider’s responsibility to comply with federal requirements. The organization must continue meeting applicable CMS standards and maintaining the requirements associated with its accreditation and Medicare participation.
CHAP has a long history in home and community-based healthcare. It was established in 1965 through a collaboration involving the American Public Health Association and the National League for Nursing and became an early accrediting organization focused specifically on home and community-based services.
CHAP’s role has evolved as home health, hospice, and community-based healthcare have become increasingly important components of the U.S. healthcare system.
The history of CMS recognition is also significant. CHAP received CMS deeming authority for home health agencies in 1992 and later for hospice organizations in 1999, allowing qualifying accredited organizations to use CHAP accreditation as a means of demonstrating compliance with applicable Medicare requirements.
CHAP accreditation can help healthcare organizations create systems that support quality, safety, accountability, and continuous improvement. The accreditation process encourages providers to examine not only whether they meet requirements but also how effectively their policies and procedures work in everyday practice.
Accreditation promotes consistent clinical processes and encourages organizations to identify opportunities to improve patient safety and outcomes.
Healthcare organizations can use accreditation standards to evaluate performance, identify gaps, implement corrective strategies, and monitor whether improvements are sustained over time.
The review process can identify opportunities to improve leadership, clinical workflows, documentation, staff education, quality management, and compliance systems.
For organizations using an accrediting organization with applicable CMS deeming authority, accreditation can support the process of demonstrating compliance with Medicare Conditions of Participation.
Accreditation can also provide an external indication that an organization has undergone an independent assessment against established healthcare standards. This may help strengthen confidence among patients, families, referral partners, and other stakeholders.
The exact process and requirements can vary depending on the type and scope of services provided. Generally, accreditation involves preparation, assessment, review, and ongoing compliance.
Organizations typically begin by reviewing their policies, procedures, clinical practices, documentation, leadership processes, and quality improvement activities against applicable CHAP standards.
This self-assessment helps identify gaps before the formal survey.
CHAP surveyors evaluate the organization against applicable standards. Depending on the services and accreditation program, the evaluation may involve reviewing records and documentation, observing operations, interviewing staff, and examining patient care processes.
The objective is to determine whether the organization’s actual practices align with its policies and applicable standards.
Survey findings are reviewed as part of CHAP’s accreditation decision-making process. The organization may be required to address identified deficiencies or areas of noncompliance before accreditation is granted or maintained.
Accreditation is not simply a one-time achievement. Healthcare organizations must continue meeting applicable standards and maintaining effective quality improvement, compliance, and patient safety processes.
Accreditation and public quality reporting are separate processes.
CMS collects and publicly reports quality information for Medicare-certified providers through Care Compare. Consumers can use CMS resources to compare information about participating home health and hospice providers.
For hospice services, information that was historically available through Hospice Compare is now incorporated into CMS Care Compare resources.
This distinction is important: an accrediting organization and CMS serve different functions in quality oversight and reporting. Accreditation evaluates compliance with an accreditor’s standards, while CMS publicly reports selected quality and provider information through its Medicare comparison resources.
| Regulation | Accreditation |
|---|---|
| Government-established requirements | Standards established and evaluated by an independent accrediting organization |
| Legally enforceable | Generally voluntary, although accreditation may have important implications for certain healthcare programs |
| Establishes required compliance standards | Evaluates quality and organizational performance against established standards |
| Enforced by government agencies | Assessed through accreditation surveys and review processes |
| Required requirements must be maintained | Requires ongoing adherence to applicable accreditation standards |
| May be necessary for Medicare participation | May provide CMS deemed status when the accrediting organization has applicable CMS approval |
The most important distinction is that regulation establishes mandatory legal and program requirements, while accreditation provides an external assessment of an organization’s compliance and quality performance.
Healthcare organizations should not view regulation and accreditation as competing systems. Instead, they often work together to support safe and effective care.
A home health agency or hospice provider must meet applicable government requirements. Accreditation can then provide an additional framework for evaluating organizational performance, identifying weaknesses, strengthening processes, and promoting continuous improvement.
For organizations pursuing Medicare participation through an accrediting organization with CMS deeming authority, the relationship is particularly important because accreditation may serve as a recognized pathway for demonstrating compliance with applicable Conditions of Participation.
Home health and hospice providers deliver care in patients’ homes and other community settings, making strong systems for clinical oversight, communication, documentation, patient rights, and quality improvement essential.
Accreditation can help organizations:
Strengthen patient safety processes
Improve clinical and administrative workflows
Identify compliance gaps
Standardize policies and procedures
Support staff education and accountability
Promote quality assessment and performance improvement
Demonstrate commitment to recognized quality standards
However, accreditation should not be viewed as a substitute for compliance with applicable laws and CMS requirements. Providers remain responsible for understanding and meeting all regulatory obligations that apply to their services.
Regulation consists of mandatory requirements established by government authorities, while accreditation is an independent evaluation that determines whether a healthcare organization meets established quality and performance standards.
CMS Conditions of Participation are federal health and safety requirements that healthcare organizations must meet to participate in Medicare and, where applicable, Medicaid programs. Home health agencies and hospice providers must comply with the CoPs applicable to their services.
CHAP accreditation is an independent assessment of eligible home health, hospice, and community-based healthcare organizations against applicable CHAP standards. The process evaluates areas such as patient care, quality improvement, organizational processes, and compliance.
CMS deemed status means CMS recognizes an approved accrediting organization’s determination that a provider meets applicable Medicare requirements. An organization may therefore use accreditation, when the applicable conditions are met, as an alternative way to demonstrate compliance with certain Medicare Conditions of Participation.
Not necessarily. Providers must meet applicable federal and state requirements, but accreditation requirements and options can vary based on the provider’s circumstances, services, state requirements, and Medicare certification pathway.
CHAP and CMS have different roles in quality information. CMS publicly reports selected quality and provider information through Care Compare. Consumers can also use CHAP’s resources to identify organizations that have received CHAP accreditation.
Accreditation can strengthen quality management, patient safety, documentation, organizational processes, and continuous improvement. It can also provide an independent assessment of whether an organization meets recognized standards.
No. Accreditation indicates that an organization has undergone an assessment against applicable standards, but it does not guarantee a particular clinical outcome for every patient. Consumers should consider multiple sources of information, including CMS Care Compare data, when evaluating providers.
Regulation and accreditation have different but complementary roles in home health and hospice care. Regulation establishes the mandatory legal and program requirements that providers must meet, while accreditation provides an independent assessment of quality and organizational performance.
For Medicare-certified home health and hospice providers, CMS Conditions of Participation establish important federal health and safety requirements. CHAP is an established accrediting organization serving home health, hospice, and community-based healthcare providers, and CMS-approved deeming authority can allow qualifying accreditation to serve as evidence of compliance with applicable Medicare requirements.
Ultimately, effective healthcare oversight depends on more than simply passing a survey. Ongoing compliance, quality improvement, patient safety, strong clinical practices, and transparent performance reporting all contribute to safer and higher-quality home health and hospice services.
Ayer, T. S. (2002). CHAP accreditation: The “other” home care accrediting body. Home Health Care Management & Practice, 14(4), 284–288. https://doi.org/10.1177/1084822302014004006
Centers for Medicare & Medicaid Services. (n.d.). Care Compare. U.S. Department of Health & Human Services. https://www.medicare.gov/care-compare/
Centers for Medicare & Medicaid Services. (n.d.). Home health services. U.S. Department of Health & Human Services. https://www.cms.gov/medicare/health-safety-standards/guidance-for-laws-regulations/home-health-services
Centers for Medicare & Medicaid Services. (n.d.). Hospice. U.S. Department of Health & Human Services. https://www.cms.gov/medicare/health-safety-standards/guidance-for-laws-regulations/hospice
Community Health Accreditation Partner. (n.d.). About CHAP. https://chapinc.org/about/
DeGenaro, S. (2016). Law & regulation: An accreditation issue? Healthcare Quality Accreditation Association. https://info.hqaa.org/hqaa-blog/law-regulation-an-accreditation-issue
Fineout, C. M. (2004). Preparing for CHAP accreditation. Home Healthcare Nurse, 22(3), 156–159.
Rahman, A. N., & Enguidanos, S. (2020). In search of hospice and home care information: Consumer information available on Hospice Compare and Care Compare. Palliative Medicine Reports, 1(1), 18–24. https://doi.org/10.1089/pmr.2020.0022
