Effective January 1, 2026, CMS enacted significant changes to accreditation survey requirements, including annual accreditation surveys, which will impact the Corrective Action Plan (CAP) process.

Per CMS, facilities must now demonstrate full compliance with all applicable standards before accreditation can be granted. Even a single non-compliant or partial compliant finding will trigger a required Corrective Action Plan (CAP), and organizations will have only two weeks after receiving survey results to submit a complete response.

Perhaps most notably, CMS rules also prohibit extending accreditation expiration dates even while CAPs are under review.

This means that facilities whose accreditation expires before survey completion and CAP approval could experience a lapse in accreditation status—a situation that may also affect Medicare billing privileges.

A More Rigid Compliance Timeline

Previously, facilities often had greater flexibility while corrective actions were under review. Under the new CMS framework, however, facilities remain accredited only through their current accreditation cycle expiration date.

If deficiencies are identified during a survey, accreditation cannot be granted until the CAP is fully approved.

Key Changes Facilities Need to Know

• Facilities must achieve full compliance to receive accreditation.
• Any non-compliant or partially compliant finding will require a Corrective Action Plan (CAP).
• Organizations have only two weeks after receiving survey results via email to submit a complete CAP.
• Accreditation will not be awarded until the CAP is approved.
• Temporary accreditation during CAP review is no longer available.
• Accreditation expiration dates cannot be extended.
• A lapse in accreditation may affect Medicare billing privileges.

How to Prepare

• Communicate the updated requirements to the leadership teams responsible for accreditation-readiness compliance.
• Identify recurring compliance gaps and strengthen internal processes and responsiveness.
• Take advantage of existing accreditation preparation resources to ensure staff can respond quickly should deficiencies be identified.
• Apply for reaccreditation by your facility’s application due date.
• Ensure ABC has a valid email address for your facility as all accreditation notices and reminders are sent to the primary email on file.
• Regularly check email for other important ABC accreditation updates.

Remember

When submitting a CAP, you must submit complete corrective action materials. Blank worksheets, templates, or unsupported attestations will not satisfy CAP requirements. Please note, as required by CMS, copies of your CAP and CAP decisions are sent to CMS.

ABC will work to review CAP submissions as promptly as possible, but providers are ultimately responsible for ensuring survey completion, maintaining compliance with the Standards, and CAP approval occur before their accreditation expiration date.

Key Takeaway: Accreditation readiness can no longer be treated as a periodic exercise — it must become an ongoing operational priority.