CMS Conditions of Participation Self-Assessment Survey

Self-assessment survey organized by CMS Conditions of Participation chapter and standard to support survey preparation and readiness review.

Survey Readiness Overview

• Overall, how ready is your department for a CMS survey today?
  Use a 5-point Likert scale: Strongly disagree, Disagree, Neither agree nor disagree, Agree, Strongly agree.
• Which CMS Conditions of Participation chapter is the strongest area of readiness?
  Select the chapter that is most prepared for survey review.
• Which CMS Conditions of Participation chapter is the highest-risk gap area?
  Select the chapter that needs the most immediate attention.

Patient Rights and Safety

• Policies and practices consistently protect patient rights and informed consent requirements.
  Use a 5-point Likert scale: Strongly disagree, Disagree, Neither agree nor disagree, Agree, Strongly agree.
• Patients and families receive timely communication about rights, grievances, and complaint pathways.
  Use a 5-point Likert scale: Strongly disagree, Disagree, Neither agree nor disagree, Agree, Strongly agree.
• If this area is rated 3 or below, what is the primary gap affecting compliance?
  Describe the specific issue, evidence gap, or process breakdown.
• Patient safety events are reviewed, trended, and escalated through the appropriate process.
  Use a 5-point Likert scale: Strongly disagree, Disagree, Neither agree nor disagree, Agree, Strongly agree.

Care Delivery and Medical Staff

• Care plans, orders, and documentation are complete, timely, and consistent with CMS requirements.
  Use a 5-point Likert scale: Strongly disagree, Disagree, Neither agree nor disagree, Agree, Strongly agree.
• Medical staff credentialing, privileging, and reappointment files are current and complete.
  Use a 5-point Likert scale: Strongly disagree, Disagree, Neither agree nor disagree, Agree, Strongly agree.
• If this area is rated 3 or below, what evidence is missing or incomplete?
  List missing records, overdue reviews, or documentation inconsistencies.
• Interdisciplinary communication supports safe, coordinated care across shifts and departments.
  Use a 5-point Likert scale: Strongly disagree, Disagree, Neither agree nor disagree, Agree, Strongly agree.

Infection Control and Environment of Care

• Infection prevention practices are consistently followed and monitored across the organization.
  Use a 5-point Likert scale: Strongly disagree, Disagree, Neither agree nor disagree, Agree, Strongly agree.
• Environmental rounds identify and correct hazards, cleanliness issues, and equipment concerns promptly.
  Use a 5-point Likert scale: Strongly disagree, Disagree, Neither agree nor disagree, Agree, Strongly agree.
• If this area is rated 3 or below, what is the primary operational barrier?
  Describe staffing, training, supply, workflow, or accountability issues.
• Required logs, audits, and corrective actions are maintained and available for survey review.
  Use a 5-point Likert scale: Strongly disagree, Disagree, Neither agree nor disagree, Agree, Strongly agree.

Governance, Quality, and Compliance

• Leadership reviews quality, safety, and compliance data with clear follow-up on identified risks.
  Use a 5-point Likert scale: Strongly disagree, Disagree, Neither agree nor disagree, Agree, Strongly agree.
• Corrective action plans are tracked to completion and verified for effectiveness.
  Use a 5-point Likert scale: Strongly disagree, Disagree, Neither agree nor disagree, Agree, Strongly agree.
• If this area is rated 3 or below, what is the main reason corrective action is not closing the gap?
  Describe ownership, timeline, resource, or escalation issues.
• Staff know how to escalate compliance concerns without fear of retaliation.
  Use a 5-point Likert scale: Strongly disagree, Disagree, Neither agree nor disagree, Agree, Strongly agree.

Open Feedback and Optional Demographics

• What is the single most important action needed to improve CMS survey readiness in the next 30 days?
  Focus on the highest-impact action.
• Anything else?
  Share any additional comments, concerns, or context.
• Optional: Which department or function are you responding from?
  Optional demographic question shown last to reduce collection bias.