AAAHC’s New v45 Standards Provide Guidance for Artificial Intelligence Use

AAAHC recently released v45 Standards for all Accreditation and Certification programs, with an effective date of December 15. These Standards were developed with input from ambulatory care experts and incorporated feedback from the Public Comment period which enhanced clarity and comprehensibility. Across all programs, Standards revisions focused on realigning requirements for better relevance and flow. In that same vein, Standard identifiers in v45 may differ from v44’s due to additions and revisions.

With v45, AAAHC integrates Standards on cybersecurity and artificial intelligence (AI) in all AAAHC Accreditation programs. These Standards do not require organizations to utilize AI, but instead aim to ensure that organizations have core governance in place before AI becomes more deeply embedded in health care. They emphasize foundational principles of safe and responsible AI use, such as:

Governance and oversight
Risk management
Staff training
Patient consent
Data security and privacy
Vendor management

Most AI Standards have been designated as Level 0 in v45, while some AI requirements were added as Elements of Compliance (EOCs) to current Standards. For the definition of each Standard level by program, please refer to this chart:

New Standards assigned Level 0 do not require submission of a Plan of Correction to AAAHC if cited as deficient and the rating of that Standard is not considered in the accreditation decision. New requirements included as an EOC of a current Standard follow the POC rules currently in place for each program, and the Standard rating will be considered in the accreditation decision.

Additionally, enhancements to the Behavioral Health (BEH) Standards are included in the v45 Ambulatory Accreditation (AMB) program.

The Medicare Deemed Status (MDS) Physical Environment Checklist has no substantive changes, as the applicable versions of the National Fire Protection Association (NFPA) Life Safety Codes® have not changed. With this new edition, our Standards team sought to improve clarity and surveyability, combine or remove redundant requirements, expand the Guidance & References, and update NFPA references where necessary.

What other changes can I expect?

In addition to the Standards revisions, AAAHC has updated policies and procedures for v45. Many updates clarify process expectations, terminology, timing, and responsibilities. Key changes include:

New timeframes for POC submission. All programs now require client submission of POCs within
10 calendar days of receiving the notification. Organizations still have 30 calendar days from a POC request to make corrections
Inclusion of a Permitted Use Notice for reproducing survey materials
A new section on records retention and data protection
An expanded Good Faith Participation policy
Addition of Managing Business Unit (MBU) to the Business Unit (BU) structure, with information on access to accreditation information

Click here to learn more about v45.

Download AAAHC’s New Expert Perspectives

Integrating Behavioral Health into Primary Care Settings

Behavioral health concerns are increasingly appearing in primary care, making early identification and coordinated intervention more critical than ever. To support organizations in strengthening whole-person care, AAAHC published Integrating Behavioral Health into Primary Care Settings, a new evidence-informed white paper authored by Keith Anderson, PhD, FACHA, AAAHC Board Member, and Joy Himmel, Psy.D, LCPC, NCC, RN, FACHA, EMDR-C, AAAHC Immediate Past Board Chair.

This resource provides practical guidance for integrating behavioral health into everyday clinical practice through standardized screening, trauma-informed care, motivational interviewing techniques, collaborative care models, and evidence-based assessment tools. It also includes implementation strategies, referral guidance, and quality improvement resources to help organizations strengthen their behavioral health practices.

Released in conjunction with the new AAAHC v45 Handbooks, this white paper serves as a practical companion to the Standards by helping organizations operationalize behavioral health expectations and strengthen patient-centered care.

Read a brief synopsis and download the complimentary white paper. Whether your organization is launching new behavioral health services or strengthening existing programs, this white paper shares practical strategies to support better outcomes for patients and the communities you serve.

Addressing High-Deficiency Rates in Allergy Documentation

AAAHC provides resources for Clinical Records Standard (CRD.210)

The 2026 Quality Roadmap highlights allergy documentation (Standard CRD.210) as an important area of continued focus across ambulatory care. Current data show 17.9 percent of surgical/procedural organizations and more than 30 percent of primary care settings have opportunities to improve the consistency and completeness of documentation. Due to its importance, accurate allergy verification should be performed and documented 100% of the time.

Insight from our most recent Allergy Documentation Benchmarking Study reinforces this target. In that study, only 59 percent of participating organizations indicated their staff consistently documented both the symptoms (e.g., rash, anaphylaxis) and the severity (e.g., localized vs. systemic reactions) associated with each reported allergy.

To support improvement, organizations can utilize several high impact strategies:

Participate in the AAAHC Allergy Documentation Benchmarking Studies
Benchmarking offers valuable insight into your organization’s baseline performance, identifies variation, and highlights best practices used by your peers. This collective learning strengthens improvement efforts.
Conduct a Targeted Quality Improvement (QI) Study
By analyzing workflow steps, identifying barriers, and tracking data both before and after intervention, organizations can identify root causes of incomplete documentation and implement sustainable improvements.
Utilize the AAAHC Allergy Documentation Toolkit
This toolkit provides evidence based guidelines, and practical staff resources to standardize and streamline documentation processes.
Optimize Workflow and Reinforce Education
Embedding allergy verification as a clear, required step in the intake and/or rooming workflow ensures consistency. Use EHR prompts and refresher education to maximize impact.

By combining internal QI strategies with external benchmarking and structured tools, ambulatory care organizations can improve reliability, strengthen patient safety, and close the deficiency gap on Standard CRD.210 performance.

1095 Engage Plan of Correction (POC) Enhancements

AAAHC is pleased to announce new enhancements to Plans of Correction (POC) in 1095 Engage. These changes are based upon feedback received from clients.

The enhancements include:

Ability to “Save in Process” while working on a POC
Removal of the requirement to complete two Evidence of Compliance fields; the first Evidence of Compliance field is required
Second Evidence of Compliance field is now optional to provide additional evidence, as applicable

For more detailed information regarding the updates to the POC, review the updated Plan of Correction Guidance resource in the 1095 Engage Help Curtain or call AAAHC at 847.853.6060.

Specialty Corner

Vaccination Safety: Protecting Patients Through Standards-Driven, Daily Practices

Vaccination is among the most effective preventive health tools available, protecting individuals and communities while reducing the spread of infectious disease. Ambulatory health care organizations play a critical role in this effort, not only by administering vaccines, but by ensuring they are stored, handled, and delivered safely.

Through our Medication Management (MED) Standards, we have established clear expectations for maximizing vaccination safety. Standard MED.240 requires organizations to maintain written policies and procedures governing vaccine storage and handling, including continuous temperature monitoring and documented contingency plans for equipment failure or power loss. Staff responsible for vaccine management must be trained and demonstrate competency in these processes, ensuring consistency and reliability across all settings. Proper storage is not optional—failure to maintain required conditions can reduce vaccine potency, result in waste, and place patients at risk.

Equally important is the patient’s role in the vaccination process. AAAHC’s Patient Rights, Responsibilities, and Protections (PRR) Standards reinforce the need for transparency and informed decision-making. Standard PRR.250 requires documentation of informed consent for vaccinations, ensuring patients understand the benefits, risks, and alternatives. In ambulatory health care settings, clear communication builds trust, supports shared decision-making, and reinforces patient-centered care.

Late summer—just ahead of flu season—is an ideal time for organizations to reassess vaccine and vaccination protocols, validate staff training, and confirm cold-chain readiness. However, vaccination safety is a year-round responsibility, particularly as organizations continue to manage COVID-19 boosters and routine immunizations for patients of all ages.

AAAHC Standards are further supported by guidance from the Centers for Disease Control and Prevention (CDC), which provides detailed recommendations on vaccine storage temperatures, equipment, handling procedures, and response to cold-chain breaches. The CDC’s Vaccine Storage and Handling Toolkit offers practical, field-tested resources to help ambulatory care organizations maintain compliance and safeguard vaccination integrity.

By aligning AAAHC Standards with CDC best practices, ambulatory health care facilities can strengthen vaccination safety, protect patient trust, and support public health—demonstrating readiness and reliability every day.