Accreditation: Accreditation yesterday doesn't ensure reaccreditation today

Q. What are the top deficiencies among reaccrediting providers?

A. If you’ve been an accredited DMEPOS provider for years, you’ve probably grown accustomed to a certain reaccreditation process. But Jan. 1, 2026, changed the rules – for everyone.

Under the CMS final rule, 100% compliance is required on all standards. What may have not been a deficiency last accreditation period, may be cause for denial or revocation this time around.

We’ve identified the top deficiencies surprising providers during reaccreditation. As you read each one, ask yourself: Would I be 100% compliant if my onsite survey were today?

Patient file requirements

CMS requires your accreditation organization (AO) to review five files from Medicare patients with Medicare-covered items at your onsite survey. If you need to use other payer sources like Medicaid or Medicare Advantage, your AO must contact CMS for approval – a step that adds time.

Equipment storage

Written policies and procedures, documented equipment management processes and strict adherence to manufacturer guidelines must all be in place. This includes proper storage of oxygen tanks which have their own specific mandatory compliance standards that need to be met.

Training & documentation

There are many areas such as corporate compliance, HIPAA and OSHA requiring annual training and documentation of that training. Create a binder or digital file documenting training titles, attendees and completion dates. Set calendar reminders well in advance. To your surveyor, undocumented training is the same as no training.

Staffing during posted hours

A simple requirement to meet, and a top reason to be denied, is to not be open and/or staffed during posted business hours. This is considered non-operational by CMS and is an automatic denial/revocation. Your posted business hours are filed with CMS and your AO. Consequently, your onsite surveyor, who arrives unannounced, will refer to those days and times.

State licensure

Not sure when your facility license expires? Don’t find out the day of your survey. An expired license, including any product-specific licenses, can result in denial or revocation and be reported to CMS. Mark renewal dates on your calendar three to six months out.

The DMEPOS industry is evolving, and yesterday’s rules don’t always apply today. Providers and AOs alike must up our game to meet today’s stricter requirements—all of which are designed to support our shared goal of improving patient care.

Sandra Canally, RN, is founder and CEO of The Compliance Team.