Policy required document Healthcare
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, technology, 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.
Obligation ledger
Who requires it, and what each one says.
| Source | Applies when | What it requires | Status |
|---|---|---|---|
| CARF standards manuals Section 1 ASPIRE to Excellence, 1.A through 1.N, plus program-specific sections (2026 manuals effective July 1, 2026) | You apply for CARF accreditation | Written policies and procedures wherever a standard says written; documented personnel orientation and training; annual review of specified plans (accessibility, risk management, technology, health and safety); performance measurement and analysis. Accreditor requirement, contractual once you apply; some states and payers make CARF mandatory. | Implied |
| ACHC accreditation standards, home health, hospice, home care ACHC HH, HSP and HC standards manuals, updated annually | You apply for ACHC accreditation | Written policies and procedures per standard, personnel records with orientation, competency and training, and annual review of policies by the governing body or designee. Accreditor requirement; deemed status ties it to the Medicare CoPs. | Implied |
| 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. Verify per state. | 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 1.J)
- Rights of persons served: rights statement, complaint and grievance process, informed consent, confidentiality (CARF 1.K; patient rights under 484.50 and 418.52)
- Accessibility plan reviewed annually (CARF 1.L)
- Performance measurement, management and improvement, including the QAPI program for Medicare providers (CARF 1.M, 1.N; 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
What changed
Change log.
Frameworks
Where this document is required.
Who looks at it
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 |
Who helps write it
Consultants.
Firms that name these standards in their own material.
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Where it lives
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From the publisher
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Route it for approval, keep every version, and record a named acknowledgment from everyone who has to read it.
Questions
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.
Who owns this site?
AllyMatter, a policy management tool that may appear in listings on this page. It is labeled every time, excluded from picks, and receives nothing from the matching form unless you name it.