NSG 468 Week 2 Health Care Accreditation

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University of Phoenix

NSG/468 Influencing Quality within Healthcare

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Date

Regulation vs. Accreditation in Home Health and Hospice Care

Regulation and accreditation are not the same. Regulations are legally required rules that healthcare organizations must follow, while accreditation is a voluntary evaluation conducted by an independent accrediting body to verify that an organization meets or exceeds established quality standards. In home health and hospice care, organizations accredited by the Community Health Accreditation Partner (CHAP) may receive deemed status from the Centers for Medicare & Medicaid Services (CMS), meaning they are recognized as meeting the federal Conditions of Participation (CoPs) required for Medicare certification.

Regulation vs. Accreditation in Healthcare

Healthcare organizations must comply with both regulatory requirements and quality standards to provide safe, effective patient care. Although the terms regulation and accreditation are often used interchangeably, they have distinct meanings and purposes.

• Regulation refers to laws, rules, and government requirements that healthcare providers are legally obligated to follow.

• Accreditation is a formal recognition awarded by an independent accrediting organization after verifying that a provider meets established standards of quality and performance.

According to DeGenaro (2016), accreditation serves as evidence that an organization complies with recognized standards, many of which are based on existing laws and regulations. While regulations establish the minimum legal requirements, accreditation encourages organizations to exceed those minimum standards through continuous quality improvement.

Understanding CMS Conditions of Participation (CoPs)

The Centers for Medicare & Medicaid Services (CMS) establishes the Conditions of Participation (CoPs) for home health agencies and hospice providers. These federal requirements define the minimum standards organizations must meet to participate in Medicare and Medicaid programs.

Key Objectives of the CMS Conditions of Participation

• Protect patient health and safety

• Standardize quality of care

• Promote evidence-based clinical practices

• Support ongoing performance improvement

• Ensure compliance with federal healthcare regulations

Organizations that fail to meet these requirements risk losing Medicare certification and reimbursement eligibility.

What Is CHAP?

The Community Health Accreditation Partner (CHAP) is one of the leading independent accrediting organizations for home health, hospice, and community-based healthcare providers in the United States.

CHAP evaluates organizations against nationally recognized quality standards that align with—or exceed—CMS requirements. Healthcare providers accredited by CHAP are generally considered to have demonstrated a strong commitment to quality improvement and patient-centered care.

History of CHAP

CHAP was founded in 1965 through a partnership between the American Public Health Association (APHA) and the National League for Nursing (NLN). It became the first accrediting body dedicated specifically to home and community-based healthcare services.

Important Milestones

Receiving deeming authority means CMS recognizes that CHAP accreditation standards meet or exceed the federal Conditions of Participation required for Medicare certification.

Purpose of CHAP Accreditation

CHAP’s mission extends beyond regulatory compliance. Its primary objective is to help healthcare organizations continuously improve quality, safety, and operational performance.

CHAP Accreditation Goals

Improve Patient Care

CHAP promotes evidence-based practices that improve patient outcomes and safety.

Support Continuous Quality Improvement

Organizations are encouraged to monitor performance, identify improvement opportunities, and implement ongoing quality initiatives.

Strengthen Organizational Processes

Accreditation helps providers improve clinical workflows, leadership practices, documentation, and compliance systems.

Maintain Medicare Eligibility

Because CHAP has CMS deeming authority, accredited organizations can demonstrate compliance with federal participation requirements more efficiently.

How CHAP Accreditation Works

The CHAP accreditation process follows a structured review designed to evaluate compliance with national quality standards.

Step 1: Organizational Self-Assessment

The healthcare organization performs an internal evaluation of its policies, procedures, and operational practices against CHAP standards.

Step 2: On-Site Survey

Experienced surveyors conduct an on-site assessment by reviewing documentation, observing operations, interviewing staff, and evaluating patient care processes.

Step 3: Board of Review

Survey findings are submitted to CHAP’s Board of Review (BOR). The Board evaluates:

• Compliance with CHAP standards

• Accuracy of survey findings

• Areas requiring corrective action

• Final accreditation decision

The Board consists of healthcare leaders and subject matter experts with experience in home and community-based care.

Step 4: Continuous Monitoring

Accreditation is not a one-time event. Organizations must maintain compliance through continuous quality improvement and periodic reassessments.

Public Reporting and Quality Transparency

CMS requires Medicare-certified home health and hospice providers to collect, submit, and publicly report quality measures.

Consumers can compare provider performance using CMS public reporting platforms, including:

• Care Compare

• Hospice Compare (now integrated into Care Compare)

Although CHAP does not publish detailed quality scores for accredited providers, it maintains a public directory that allows patients and families to search for CHAP-accredited organizations. This directory helps consumers identify providers that have met nationally recognized Standards of Excellence.

Benefits of CHAP Accreditation

Healthcare organizations that achieve CHAP accreditation may experience several advantages.

Enhanced Quality of Care

Accreditation promotes standardized clinical practices that improve patient safety and treatment outcomes.

Greater Public Confidence

Patients, families, referral sources, and healthcare partners often view accredited organizations as more trustworthy and committed to quality.

Regulatory Alignment

CHAP standards closely align with CMS regulations, making compliance management more efficient.

Operational Improvement

The accreditation process encourages better governance, documentation, staff education, and organizational performance.

Competitive Advantage

Accreditation can differentiate providers in an increasingly competitive healthcare marketplace.

Regulation vs. Accreditation: Key Differences

Summary

• Regulation refers to legally enforceable healthcare requirements established by government agencies.

• Accreditation is an independent evaluation confirming that a healthcare organization meets recognized quality standards.

• CMS Conditions of Participation establish the federal requirements for Medicare-certified home health and hospice providers.

• CHAP is one of the oldest and most recognized accrediting organizations for home and community-based healthcare.

• CMS granted CHAP deeming authority for home health agencies in 1992 and hospice organizations in 1999.

• CHAP accreditation supports continuous quality improvement, patient safety, and regulatory compliance.

• CMS publicly reports quality measures through Care Compare, while CHAP maintains a directory of accredited providers.

Frequently Asked Questions (FAQs)

What is the difference between regulation and accreditation?

Regulation consists of legally enforceable rules established by government agencies. Accreditation is a voluntary review process conducted by an independent organization to verify that a healthcare provider meets recognized quality standards.

What are the CMS Conditions of Participation?

The CMS Conditions of Participation (CoPs) are federal health and safety requirements that home health and hospice providers must meet to participate in Medicare and Medicaid programs.

What is CHAP accreditation?

CHAP accreditation is an independent assessment that verifies whether home health, hospice, and community-based healthcare organizations meet nationally recognized quality standards aligned with CMS requirements.

What is CMS deemed status?

Deemed status means CMS accepts accreditation from an approved accrediting organization, such as CHAP, as evidence that a provider meets the Medicare Conditions of Participation.

Does CHAP publish provider quality scores?

No. CHAP does not publicly report quality performance scores. However, it maintains a searchable directory of accredited providers, while CMS publishes quality measures through Care Compare.

Why is accreditation important in home healthcare?

Accreditation strengthens patient safety, improves organizational performance, supports regulatory compliance, and demonstrates a provider’s commitment to continuous quality improvement.

Key Takeaways

Healthcare regulations establish the legal foundation for safe patient care, while accreditation recognizes organizations that demonstrate excellence beyond those minimum requirements. In home health and hospice care, CHAP accreditation plays an important role by supporting continuous quality improvement and helping organizations achieve CMS deemed status for Medicare participation. Together, regulatory compliance and accreditation contribute to higher-quality, safer, and more transparent healthcare services.

References

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

CHAP. (n.d.). About CHAP. https://chapinc.org/about

DeGenaro, S. (2016). Law & Regulation: An Accreditation Issue? HQAA. 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.

National Hospice and Palliative Care Organization. (n.d.). Regulatory and Quality Resources. http://www.nhpco.org/regulatory-and-quality

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