Atlantic Health StrategiesWest Palm Beach, Florida, USA
- What they do
- Compliance consulting
- Who they help
- Its website offers consulting for CARF, HIPAA, 42 CFR Part 2, Joint Commission.
- Standards
- Pricing
- Not published
Accreditation Policy and Procedure Manual (CARF, ACHC, CHAP)
Health and human services accreditors write their standards as statements that the organization has written policies and procedures on a named subject, then send surveyors to read the policies, check personnel and client records for evidence the policies operate, and interview staff to confirm they know them.
CARF does this across its Section 1 ASPIRE to Excellence standards (leadership, legal requirements, financial planning, risk management, health and safety, human resources, rights of persons served, accessibility, performance measurement) and again in each program section.
ACHC and CHAP do it for home health, hospice and home care, with Medicare's Conditions of Participation in 42 CFR Part 484 underneath, because both hold CMS deeming authority.
The result is one large policy and procedure manual, typically 80 to 200 policies, that is the central artifact of the survey. Surveyors do not grade the writing. They check that each standard has a policy, that the policy matches what staff do, that the personnel file shows orientation to it, and that it was reviewed on the schedule the organization itself set.
Also called: Agency policy manual, Administrative and clinical policies, Accreditation policies and procedures, P&P manual
Share
Ad from the publisher
Policy Acknowledgment Proof
AcknowledgedP&P manual v6by name, on record
Field Staff On Recordwith AllyMatter
Survey-Ready the Modern WayYour policy manual, acknowledged by staff who are rarely in the office
01
Approve it, lock the version
Non-author approval, obsolete copies blocked
02
Every aide, counselor and nurse on record
Acknowledged from the phone, before the visit
03
Open the binder before the surveyor asks
From $29/mo, 20 editors, unlimited staff (published)
Who requires it, and what each one says.
| Source | Applies when | What it requires | Status |
|---|---|---|---|
| CARF accreditation standards (ASPIRE to Excellence, all programs) CARF Section 1, including Standards 1.E.2, 1.E.3, 1.H.2, 1.H.5, 1.H.10, 1.H.12, 1.I.5 and 1.J.1 | You seek or hold CARF accreditation (any program) | Written policies and procedures on the subjects the standards name, including responses to legal action, records and confidentiality, health and safety, emergencies, critical incidents, infection control, workforce verification and rights of persons served, plus the program-section policies. CARF does not require them to be bound in one manual. Accreditation requirement. | Mandatory |
| ACHC and CHAP accreditation standards ACHC HH1-1A.01 and ACHC Desk Review Reference Guide [779]; CHAP Home Health, Hospice and Home Care Policy Lists (07.2025) | You seek or hold ACHC or CHAP accreditation | A policies and procedures manual containing each policy the accreditor lists, from governance and patient rights through personnel, clinical records, QAPI, infection control, emergency preparedness and safety. Surveyors review it on site. Accreditation requirement; for deemed status the listed policies include those the Medicare Conditions of Participation require. | Mandatory |
| CHAP Standards of Excellence CHAP Home Health Standards of Excellence v5.x; Hospice and Home Care standards | You apply for CHAP accreditation | Policies and procedures across governance, management, clinical practice, quality and infection control, surveyed from patient care back to the policy. Accreditor requirement; deemed status ties it to the CoPs. | Implied |
| Medicare home health conditions of participation 42 CFR Part 484, including 484.65 QAPI, 484.70 infection control, 484.102 emergency preparedness, 484.105 organization and administration, 484.110 clinical records, 484.115 personnel qualifications | Medicare-certified home health agency | Written policies on patient acceptance, QAPI program, infection prevention and control program, emergency preparedness, clinical record retention, and personnel; the accreditor standards restate these. Legally required as a condition of participation. | Mandatory |
| Medicare hospice conditions of participation 42 CFR Part 418 | Medicare-certified hospice | Written policies for patient rights, QAPI, infection control, staff training, volunteer program, and drug management among others. Legally required. | Mandatory |
| State licensure rules for home care, behavioral health and rehabilitation Varies by state | Licensed in the state | Written policies on listed subjects, often overlapping the accreditor list. Legally required; content varies. | Mandatory |
Required sections
- Governance and leadership: mission, board or ownership responsibilities, organizational chart, succession, ethics code and conflict of interest (CARF 1.A; ACHC and CHAP governance)
- Strategic planning and input from persons served and other stakeholders (CARF 1.B, 1.C)
- Legal requirements: compliance with laws, contracts, records retention, confidentiality, corporate compliance (CARF 1.E)
- Financial planning and management, including fees and billing practices (CARF 1.F)
- Risk management plan reviewed annually; insurance; media relations (CARF 1.G)
- Health and safety: emergency procedures, drills on each shift at each location, incident reporting and analysis, infection control, medication handling, transportation (CARF 1.H; ACHC and CHAP infection control; 484.70)
- Human resources: job descriptions, verification of credentials and background checks, orientation to policies, competency, training, performance evaluation, personnel records content, personnel policies and grievances (CARF 1.I; ACHC personnel standards; 484.115)
- Technology and information management: security, backup, business continuity, telehealth where used (CARF removed its separate technology standards from Section 1 in 2026; keep them where another standard or payer requires them)
- Rights of persons served: rights statement, complaint and grievance process, informed consent, confidentiality (CARF 1.J; patient rights under 484.50 and 418.52)
- Accessibility plan reviewed annually (CARF 1.K)
- Performance measurement, management and improvement, including the QAPI program for Medicare providers (CARF 1.L, 1.M; 484.65; 418.58)
- Program-specific clinical policies: admission and acceptance to service, assessment, individualized plan, transitions and discharge, medication management, clinical record content and retention (CARF program sections; ACHC HH2 and HH5; 484.55, 484.60, 484.110)
- Emergency preparedness plan meeting the CMS all-hazards rule (484.102; 418.113)
- Policy governance: format, approval authority, review schedule, version control, distribution and staff acknowledgment (accreditors expect the organization to define and follow this)
What the examiner asks for
Written planThe full manual with approval signatures or records, effective and review dates on each policy, and evidence of the annual review the organization committed to. Accreditation consultants (CARF, ACHC, CHAP specialists) and template libraries; policy tools hold versions and review schedules
AttestationPersonnel files showing orientation to policies with dates, annual training completion, acknowledgment of the rights statement, code of conduct and confidentiality; surveyor interviews confirm staff knowledge. Policy tools, HRIS, LMS, accreditation consultants who audit files before survey
Operational recordsDrill logs, incident reports and analyses, risk management and accessibility plan reviews, performance data and improvement records, complaint and grievance logs, clinical record audits, QAPI minutes, board minutes. The organization; accreditation consultants; QAPI consultants
Technical controlsEHR configuration for clinical record content, backup and security evidence for the technology plan. EHR vendors, MSPs
Change log.
2026-07-01CARF 2026 standards manuals took effect for surveys July 1, 2026 through June 30, 2027.
2025-02-21CMS published notice of ACHC's application for continued approval of its home health accreditation program.
2024-08-16ACHC revised home health standard HH2-1A acceptance to service to align with 484.105 and require annual review.
2018-01-13Revised Medicare home health CoPs in 42 CFR Part 484 took effect, including the QAPI condition and patient rights rewrite.
Where this document is required.
Where this document gets checked.
No one certifies a document like this on its own. It is read during the audits and inspections below, and by the agency behind each rule.
| Where it is looked at | Who looks at it |
|---|---|
| ACHC/CHAP | ACHC and CHAP surveyors employed or contracted by each accreditor, typically clinicians with home care or hospice experience. Surveys for Medicare deemed programs are unannounced |
| CARF | CARF surveyors, who are peer professionals employed in accredited or comparable organizations, trained and assigned by CARF. Surveys are scheduled and on site for two to three days |
Consultants.
Firms that name these standards in their own material.
Listed in random order, reshuffled each time the page loads. Firms that pay for a listing are shown at the top, labeled Sponsored.
Circa Behavioral Healthcare SolutionsMission Viejo, California, USA
- What they do
- Compliance consulting
- Who they help
- Its website offers consulting for CARF, HIPAA, Joint Commission.
- Standards
- Pricing
- Not published
MVP Consulting GroupLong Beach, California, USA
- What they do
- Compliance consulting
- Who they help
- Its website offers consulting for CARF, HIPAA, AAAASF, AAAHC, CMS and more.
- Standards
- Pricing
- Not published
Software.
Tools that hold documents like this one and record who has read them.
Need a hand implementing it?
Find a Consultant for Accreditation Policy and Procedure Manual (CARF, ACHC, CHAP)
Tell us what you need done and we will point you to firms that do this work. Your details go to a firm only when you choose it.
From the publisher
Manage This Document in AllyMatter
Route it for approval, keep every version, and record a named acknowledgment from everyone who has to read it.
See how AllyMatter works ↗From $29/mo, 20 editors, unlimited staff
What people ask.
Can we buy a template manual?
Many organizations start from one. Surveyors check that the policy describes what your staff actually do and that your staff know it. A template that names a committee you do not have or a process you do not run produces findings.
How many policies does a survey need?
Enough to cover every standard that says written. For a single-program CARF organization that is often 80 to 120 policies; a multi-program organization or a Medicare home health agency runs higher. The number is not the measure; coverage and evidence of use are.
What do surveyors check in personnel files?
Credential verification, background checks, job description, orientation to policies with dates, competency assessment, annual training, performance evaluation, and for clinical staff the licensure and health requirements. Missing orientation records are among the most common findings.
We are Medicare-certified. Is accreditation required?
No. A home health agency or hospice can be surveyed by the state agency instead. Accreditation with deemed status substitutes the accreditor survey for the state survey and adds the accreditor's standards on top of the CoPs.