Templates › Surveys › SEO page

Run: CMS Conditions of Participation Self-Assessment Survey

CMS Conditions of Participation self-assessment survey for survey readiness, organized by chapter and standard. Use it to identify high-risk gaps, capture ev...

Fill this out, get a PDF emailed to you. No account required. Want to run it with your team and track results? Sign up free →

Survey Readiness Overview

Overall, how ready is your department for a CMS survey today? (required)

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. (required)

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. (required)

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. (required)

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. (required)

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. (required)

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. (required)

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. (required)

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. (required)

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. (required)

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. (required)

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. (required)

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. (required)

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.

Get your results

Enter your email — we'll send you a PDF of your filled-out template, plus the occasional MangoScoop newsletter (templates, workflow tips, product updates). Unsubscribe anytime — link is in every email.

Email (required)

Your name (optional)

Generated with MangoApps Templates — browse 250+ free