Accreditation and CMS compliance overlap, but they are not the same thing, and deemed status does not make the Conditions of Participation somebody else’s problem. A validation survey, a complaint survey or a state licensure inspection can arrive independently of your accreditation cycle.
Where we work
- Hospital Conditions of Participation — governing body, patient rights, QAPI, nursing services, medical records, infection control and antibiotic stewardship, discharge planning.
- Long-term care requirements of participation and the F-tag survey process, including the areas that most often drive scope-and-severity above the substandard-quality-of-care threshold.
- Home health and hospice Conditions of Participation, including the patient-rights and comprehensive-assessment requirements that generate the most condition-level findings.
- Ambulatory surgery center Conditions for Coverage.
- State licensure regulations, which frequently exceed the federal floor and are the requirement organizations most often overlook entirely.
QAPI that is actually a program
Quality assessment and performance improvement is a condition in its own right, and it is where surveyors go when they suspect the rest is theatre. A QAPI program that meets the requirement has data that leadership actually reviews, projects chosen from that data rather than from convenience, and documented evidence that findings changed something. We build that, or we tell you honestly that what you have is a meeting with minutes.