Q4 2025 Healthcare Compliance Newsletter: Year-End Wrap-Up & 2026 Readiness

A Message from Stacy Mensah, Owner

Welcome to the Q4 2025 edition of The Mensah Group Newsletter.

This quarter marked significant regulatory activity. CMS finalized 2026 payment rules. AAAHC released updated survey standards. AHCA enforcement patterns shifted.

Your compliance infrastructure requires attention before January 1.

This newsletter covers what you need to know: and what you need to do: before the calendar turns.

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CMS 2026 Final Rules: Key Highlights

OPPS Final Rule (Outpatient Prospective Payment System)

CMS released the CY 2026 OPPS Final Rule in November 2025. Critical updates for ASC compliance include:

Payment Rate Adjustments

• Overall ASC payment increase: 2.8%

• Updated wage index calculations affecting facility-specific reimbursement

• New device pass-through categories added

ASCQR Program Updates

• Two new quality measures added for CY 2026 reporting

• ASC-11 (Cataracts: Improvement in Patient's Visual Function) reporting threshold adjusted

• Non-compliance penalty remains at 2.0% payment reduction

Prior Authorization Expansion

• Seven-calendar-day processing timeline now standard for authorization requests

• API integration requirements for improved transparency

• Documentation standards updated for surgical procedures

IPPS Final Rule (Inpatient Prospective Payment System)

Hospital partners and dual-accredited facilities should note:

• Base payment rate increase: 2.9%

• Disproportionate Share Hospital (DSH) payment methodology unchanged

• Value-Based Purchasing Program modifications effective October 2025

• Hospital-Acquired Condition Reduction Program thresholds adjusted

Gag Clause Attestation Deadline

December 31, 2025: Plans and issuers must submit gag clause prohibition compliance attestations to CMS under the Consolidated Appropriations Act of 2021. Verify submission status immediately.

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Q4 Compliance Checklist

Year-end compliance activities require completion before December 31. Use this checklist for your facility.

QAPI Annual Requirements

Task	Deadline	Status
Annual QAPI program evaluation	December 31	☐
Quality indicator trend analysis	December 31	☐
Performance improvement project documentation	December 31	☐
Governing body QAPI review meeting	December 31	☐
2026 QAPI goals established	January 15	☐

Risk Assessment Activities

Infection Control Risk Assessment

• Annual ICRA completion required

• Construction/renovation projects evaluated

• High-risk procedures identified and documented

Security Risk Assessment

• HIPAA-required annual assessment

• HHS encouraging recognized security certifications for 2026

• AI governance policies now recommended

Hazard Vulnerability Analysis

• Emergency Management Plan review required

• Community hazard changes documented

• Mitigation strategies updated

Policy and Procedure Review

Annual review requirements:

• Infection prevention policies

• Emergency management procedures

• Patient rights documentation

• Informed consent processes

• Medication management protocols

• Sterilization and high-level disinfection

Need policy updates? The Mensah Group offers comprehensive Policies & Procedures Packages for ASCs and office-based procedure facilities.

Staff Training Verification

December training completion deadlines:

• OSHA Bloodborne Pathogens annual training

• Fire safety and evacuation drills

• HIPAA privacy and security refresher

• Infection control competencies

• Emergency response procedures

Schedule your OSHA Bloodborne Pathogens Training or Annual Biohazard Training before year-end.

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2026 Survey Readiness: AAAHC and AHCA

AAAHC Survey Preparation

The Accreditation Association for Ambulatory Health Care updated standards for 2026 surveys. Key focus areas:

Enhanced Documentation Requirements

• Patient identification protocols strengthened

• Timeout procedure documentation more prescriptive

• Discharge criteria documentation must be specific and measurable

Infection Prevention Emphasis

• Sterilization monitoring documentation scrutiny increased

• Environmental cleaning logs required for all patient care areas

• Hand hygiene compliance monitoring expected

Emergency Preparedness

• Full-scale drill documentation required annually

• Community coordination evidence expected

• 96-hour sustainability planning for applicable facilities

Top 10 AAAHC Deficiency Categories (2025 Data)

1. Infection prevention documentation gaps

2. Quality improvement program deficiencies

3. Patient rights notification failures

4. Medication storage violations

5. Equipment maintenance documentation

6. Credentialing file incompleteness

7. Emergency drill documentation

8. Informed consent deficiencies

9. Medical record documentation gaps

10. Environment of care issues

AHCA Survey Trends (Florida Facilities)

Florida Agency for Health Care Administration enforcement patterns for Q4 2025:

Increased Scrutiny Areas

• Life Safety Code compliance

• Emergency generator testing documentation

• Infection control practitioner qualifications

• Background screening compliance

Common Citation Categories

• Physical environment deficiencies

• Staffing documentation gaps

• Incident reporting delays

• Patient grievance response timelines

Survey Readiness Actions

1. Conduct internal mock survey (minimum 90 days before scheduled survey)

2. Verify all staff licenses current and documented

3. Complete life safety equipment testing

4. Update emergency management plan for 2026

5. Review and resolve any open plans of correction

Need survey preparation assistance? Book a consultation with The Mensah Group.

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Data Security and AI Governance: 2026 Priorities

HHS released guidance encouraging healthcare organizations to adopt recognized security certifications demonstrating commitment to HIPAA and FISMA compliance.

Recommended Actions for 2026

AI Policy Development

• Establish AI use policies for clinical and administrative applications

• Document AI tool vetting procedures

• Create staff training requirements for AI-assisted workflows

Cybersecurity Enhancements

• Multi-factor authentication implementation

• Incident response plan updates

• Vendor security assessment procedures

• Annual penetration testing consideration

Documentation Accuracy Initiatives

• HCC coding accuracy programs

• Risk adjustment data validation preparation

• HEDIS reporting enhancement planning

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The Mensah Group: Q4 Updates

Client Success Highlights

ASC Accreditation Achievement Three ASC clients achieved successful AAAHC reaccreditation surveys in Q4 2025 with zero deficiencies in infection prevention categories.

AHCA Survey Outcomes Two Florida ASC clients completed AHCA surveys with minimal findings following Mensah Group mock survey preparation.

QAPI Program Development Four facilities implemented comprehensive QAPI programs resulting in measurable quality indicator improvements within 90 days.

New Service Offerings for 2026

Emergency Management Plan Development Complete emergency management plan services now available: including hazard vulnerability analysis, policy development, and drill facilitation.

Office-Based Procedure Support Expanded support for office-based procedure facilities with dedicated policy and procedure packages.

Incident Reporting System Templates New incident reporting tools available for immediate implementation.

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January 2026 Action Items

Week	Priority Action
Week 1	Finalize 2026 QAPI goals and submit to governing body
Week 2	Complete annual policy review sign-offs
Week 3	Verify Q1 training schedule established
Week 4	Submit ASCQR data for applicable measures

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Connect with The Mensah Group

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The Mensah Group LLC provides healthcare compliance consulting, survey readiness preparation, and accreditation support for ambulatory surgery centers and medical clinics. Based in Riverview, Florida, serving clients nationwide.

Stay compliant. Stay ready. Stay ahead.