Decision packet
Six frameworks · one workflowIQR · NHSN · CoP · NPSG · HVBP · HCHE
1
Assessment
›
2
Gap Review
›
3
Assignment
›
4
Documentation
›
5
Submission Readiness
Apiary Labs AuditCare · CMS Compliance System

Know what will fail a CMS audit.
Fix it before you submit.

One guided pass across IQR, NHSN, CoP, NPSG, HCHE, and HVBP: gaps, owners, evidence, and portal-ready outputs.

Professional · $5,000 / facility / year

Decide without a sales call

Built for hospitals with CMS IQR / NHSN / structural attestations. If that is not you, pass. Otherwise use the checklist, then run the free scan.

Strong fit

  • You attest IQR / NHSN measures and need evidence behind answers
  • Quality owns cross-functional follow-ups before submissions
  • $5k is cheaper than one week of leadership time spent chasing spreadsheets

Usually pass

  • No Medicare attestations (or CMS portals handled entirely elsewhere)
  • You only need policy templates, not gap + evidence workflow
  • You already run enterprise GRC with dedicated compliance FTEs satisfied with it

IQR penalty sketch

Bed band as a proxy for Medicare revenue × 0.0075 (illustrative only; not legal or financial advice).

Printable CFO brief (PDF)

Apiary Labs: other regulatory tooling

CMS reporting runs on fixed annual windows

Unsupported attestations create reimbursement and visibility risk. Close gaps with lead time; remediation rarely fits one sprint.

Six assessment modules live
Regulatory intelligence
Regulatory feed
Subscribe to alerts
⚠️
4Ms Domain 3: malnutrition screening required
CMS added validated malnutrition screening (MNA-SF, MUST, or equivalent) to the Age-Friendly Hospital Measure Domain 3 requirements in August 2025. Hospitals that did not update their admission protocols are at risk of a domain gap on the CY 2025 attestation.
August 2025 · 4Ms Domain 3
📋
HCHE on Care Compare (Jan 2026)
Hospital Commitment to Health Equity scores from the CY 2024 attestation cycle are now publicly visible on CMS Care Compare as of January 2026. Patients, payers, and accreditors can see your current score. Your next successful attestation cycle updates how that score moves.
January 2026 · HCHE · Action required
📌
PSSM: submit in NHSN, not CMS HQR
PSSM moved to CDC NHSN in 2024. It will not appear in HQR. NHSN logins differ from CMS HQRP; confirm an active NHSN OrgID before the window.
Ongoing · PSSM · Submission note
AuditCare tracks Federal Register, QualityNet, NHSN, and CMS rules that affect attestations. Subscribe for alerts

Set up your compliance profile

Personalizes matrices, briefings, evidence lists, and the regulatory feed (~60 sec). Benchmarking when CMS publishes peer results (fall 2026).

Weekly digest
Dashboard›Reporting deadlines

Major deadlines & rhythm

Illustrative U.S. hospital cadence for CMS IQR/HQR, NHSN, QualityNet, and Joint Commission work — not legal advice. Confirm every date on QualityNet, NHSN, and your accreditor.

Year-round highlights (planning view)

  1. JanuaryJoint Commission NPSGs — new goal year effective; refresh policies, education, and tracer prep to the current NPSG publication.
  2. FebruaryNHSN housekeeping — verify OrgID, user roles, and any annual NHSN surveys applicable to your facility type.
  3. MarchHQR dry-run — validate CCN routing, structural measure selections, and attestor accounts before the spring window.
  4. April – MayCMS IQR structural attestation (typical) — HQRP publishes firm open/close for each payment year on QualityNet (4Ms, PSSM, HCHE, etc.).
  5. April – JuneQualityNet · HVBP / VBP — reconcile performance reports, domain scores, and estimated payment adjustments for the performance year.
  6. RollingCDC NHSN patient safety reporting — HAI measures and PSSM live on CDC deadlines (separate from HQR logins).
  7. Mid-yearEvidence refresh — mid-cycle audit of policies, EHR extracts, and committee minutes referenced in affirmations.
  8. Summer / fallCMS Care Compare publication waves — public display timing follows the attested performance year (watch CMS announcements).
  9. SeptemberSeasonal infection prevention — respiratory bundle readiness; confirm any NHSN seasonal reporting notices.
  10. NovemberBudget & board — fund structural remediation for gaps that span more than one department.
  11. DecemberYear-end binder — assemble documentation for surveys, leadership briefings, and next cycle attestations.
⚠
Important: All results and AI-generated content are based on self-reported answers. Not legal or compliance advice. Verify against primary CMS and Joint Commission sources before attestation decisions.
✦

Your gap analysis is complete

You know what to fix before submission. Professional adds owners, evidence requirements, and submission-ready documentation.

Multi-facility? Email us

You’ll complete payment on Stripe’s secure page, then return here automatically.

✓
Stakeholder accountability matrix Each gap: owner, action, deadline. Built for CMS audit defensibility (a signed record, not a loose sheet).
✓
Evidence requirements per question The exact documentation CMS or Joint Commission would expect for each confirmed answer. Know what to retain before the submission window closes.
✓
Compliance Briefing for leadership Briefing memo from your gap profile: risk, decisions needed, dates. CNO/Board ready with minimal edits.
✓
12-month Compliance Calendar Built from your specific open gaps, not a generic template. Shows what must happen this month versus next quarter, with owners assigned.
✓
Submission Guide (HQR · NHSN · QualityNet) Step-by-step portal instructions mapped to your specific answers. Includes attestation language to paste directly into each submission portal.
✓
Policy document verification Upload a policy PDF and it maps to compliance questions, upgrading self-reported answers to document-verified status with source citation.
✓
Audit Defense Packet A complete, printable compliance record: answers, evidence map, closed gaps with notes, and submission confirmations. Share with surveyors or auditors as a single document.
Questions? maisie@apiary-labs.com

Mark as submitted

Record your CMS submission to create an audit trail.

Assign domains to colleagues

Each colleague receives a private link to answer only their assigned domains. Their answers merge into your assessment.

⚠ Review before sending. AI draft from your assessment. You know stakeholders and context better than the model.

Mark gap as closed

Closing a gap requires an accountable owner on record. This creates an audit-defensible closure entry.

Progress saved