What Is Accreditation?

Half of the AL communities have been randomly selected to participate in the accreditation process. ACHC works with each community to achieve accreditation. Due to funds provided by the State of North Carolina, these communities have the opportunity to receive accreditation at no charge (a $13,450 value), and if accredited, to retain accreditation status for 3 years.

ACHC is a non-profit, nationally recognized accreditation organization with more than 35 years of experience in the health care accrediting field. Each community is assigned a contact person from ACHC as a partner throughout the accreditation process.

Accreditation demonstrates a commitment to delivering quality care, and provides an opportunity to identify strengths and areas for improvement. ACHC uses a survey approach focused on enhancing provider education through materials, webinars, and workshops, and compliance with standards that are created by experts and approved/endorsed by industry organizations.

There are three phases in the ACHC accreditation process:
1. Pre-Survey Activities

Preparation for accreditation:
Create an ACHC account, after which an advisor is assigned to support your community throughout the process
Download and review the standards and perform an internal gap analysis
Submit the Preliminary Evidence Report (PER) Checklist indicating community readiness for survey
2. On-Site Survey Activities

Education-based onsite review of information related to standards covering:
Organization and administration
Program/service operations
Fiscal management
Human resources
Care provision and recording
Quality outcomes/performance improvement
Risk management/infection and safety control
3. Post-Survey and Intracycle Activities

ACHC provides a Summary of Findings document, after which:
If indicated, the community develops a Plan of Correction
ACHC approves the Plan of Correction and provides an accreditation decision
After an award of accreditation, the community completes self-audited compliance checklists at 12 months and 24 months to maintain accreditation

The advisor and ACHC Assisted Living Program staff are available at any time, and the process, participants, and timing are flexible to meet the needs of each community.

The survey itself is a 2-3 day process, involving one or two staff to provide documents, answer questions, and provide a tour. The surveyors will share their observations throughout, meaning that during the exit conference, the Summary of Finding will have no surprises.

The extent of resources required by the community depends on its size and complexity; in general, assigning an “accreditation coordinator” and additional individuals for specific topics works well for most communities.