Making Time for Your Annual Facility Review

To quote this year’s Compliance Calendar, “Success doesn’t come from what you do occasionally but what you do consistently.” For some, it’s just human nature to wait until the last minute. But, when it comes to your facility’s annual compliance, it’s best to start early to ensure these tasks don’t pile up and give you stress at resurvey time! Not only are the following standards required for accreditation, but they can also drastically improve your onsite survey results and reduce your chances of needing to submit a corrective action plan (CAP).

You may already be addressing and reviewing many of these standards as part of your regular staff meetings and that’s great! Just make sure you document any changes you’ve made to your policies and procedures, inform your staff of those changes and ensure that the required documentation is in a central location available to staff. Complete documentation is the step facilities miss most. But remember, if it’s not documented, we can’t confirm that it actually happened.

The following standards are required every year – that means that when you are up for renewal, you will need three years’ worth of documentation for your surveyor.

Annual Standards:

  • AD.1.2.1 – Business Licenses, Certificates and Permits
  • AD.1.2.2 – Professional Licenses and Certificates
  • AD.5.1 – OIG List
  • HR.7 – Employee Performance Reviews
  • HR.7.1 – Continued Competence of Staff Related to Equipment and Services
  • PC.8.1 – Emergency Preparedness Plan and Implementation
  • PR.6 & PR.6.1.1 – Patient Chart Documentation
  • PM.1.1 – Input from Employees, Patients and Referral Sources
  • PM.2.1 – Patient Satisfaction Surveys
  • PM.10 – Performance Management Program Review
  • FS.1 – Written Safety Management Review
  • FS.3.2.1 & FS.3.2.2 – Emergency Evacuation Drill and Review
  • CB.4.1 – Chart Audits

Still having trouble remembering to review these standards? Try these tips to help keep you on track.


  • Set up electronic reminders throughout the year on your office calendar or phone to make sure you never miss a review.
  • Incorporate your annual standards review into regular staff meetings – addressing one standard or group of related standards at each meeting.
  • Share any trends with your staff, so you can continue to improve your operations and services and keep everyone informed and on the same page. 


Subscribe to ABC CredCast

Listen on Apple PodcastsListen on Apple Podcasts (opens in a new tab) Listen on Google PodcastsListen on Google Podcasts (opens in a new tab) Listen on Spotify