a. CMS Certification Readiness and Assessment (1) Conduct a comprehensive CMS Certification Readiness Assessment and Mock Survey to evaluate the hospital’s current level of compliance with CMS Conditions of Participation and TJC. (2) Conduct document reviews, staff interviews, and environment of care inspections. (3) Assess compliance across governance, clinical care, patient safety, Quality Assurance and Performance Improvement (QAPI), infection control, and life safety domains. b. Deficiency Identification and Corrective Action Planning (1) Identify deficiencies and potential Condition-Level findings. (2) Develop a detailed Corrective Action Plan that outlines corrective measures, responsible parties, and completion timelines. (3) Provide consultation and technical assistance to hospital leadership to support the implementation of corrective actions and sustainable compliance strategies. c. Reports and Follow-up (1) Prepare Executive Summary Reports summarizing key findings, strengths, and overall readiness for the deliverables listed below (3.3). (2) Conduct a follow-up validation review to confirm completion and effectiveness of corrective actions.
