Apiary Labs · AuditCare

23

open compliance gaps found, on average, when a hospital completes this assessment for the first time. Most were present at the last submission.

CMS IQR Conditions of Participation Value-Based Purchasing Joint Commission NPSG NHSN Reporting

This is what a gap looks like in your assessment

HIGH RISK CMS IQR · 4Ms · Domain 2

Are all four 4Ms (What Matters, Medication, Mentation, Mobility) documented in the care plan for every patient aged 65 or older?

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Failure Impact

Incomplete 4Ms documentation may suppress this measure from public CMS reporting and directly affects your HVBP Total Performance Score.

Required Action

Implement structured 4Ms documentation in EHR for all patients 65+. Validate completeness rate before your submission window closes.

Responsible Role

CNO / Chief Nursing Officer

Evidence Required

EHR audit report showing 4Ms documentation rate; signed policy on file dated within current cycle.

Your hospital likely has several like this. Some you know about. Some you don’t.

6 frameworks · 181 questions: what do you actually know?

CMS IQR

Age-Friendly Care (4Ms)

Are all four Ms documented in every care plan for patients 65 or older?

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CDC NHSN

Patient Safety & HAI

Is NHSN reporting current for all required HAI measure types this reporting period?

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CMS IQR

Care Transitions

Do patients receive a documented follow-up contact within 72 hours of discharge?

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TJC NPSG

National Patient Safety Goals

Is a universal protocol in place and documented for all invasive procedures at this facility?

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CMS State Survey

Conditions of Participation

Are nursing staff licenses and credentials verified and on file within 30 days of hire?

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CMS QualityNet

Value-Based Purchasing

Is HVBP baseline period data verified and submitted to QualityNet for the current performance year?

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No account · 20-30 min · Free · Shows your exposure

Apiary Labs AuditCare · CMS Compliance System

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

One guided pass across IQR structural measures (Age-Friendly, PSSM, Maternal Morbidity), DACA, NHSN, CoP, NPSG, and HVBP. The scan is free. Professional files the evidence pack and exports the packet.

Professional · $5,000 / facility / year

Decide without a sales call

Built for hospitals with CMS IQR / NHSN / structural attestations. The full scan is free. Professional is the dated evidence file, defense-ready posture, and export — $5,000 per facility / year.

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).

Bed range

Open CFO decision packet ↗

Apiary Labs: other regulatory tooling

Regulatory intelligence

Regulatory feed

Subscribe to alerts

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).

Hospital name *

Your name

Your role

Hospital type

Work email

State

Hospital beds

CCN (CMS Cert #)

Primary EHR

Health system

Quality FTEs

Weekly digest

Monday compliance updates by email (uses your work email when saved).

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)

JanuaryJoint Commission NPSGs — new goal year effective; refresh policies, education, and tracer prep to the current NPSG publication.
FebruaryNHSN housekeeping — verify OrgID, user roles, and any annual NHSN surveys applicable to your facility type.
MarchHQR dry-run — validate CCN routing, structural measure selections, and attestor accounts before the spring window.
Aug 17, 2026IQR Q1 quarterly submission — chart-abstracted, HCAHPS, population/sampling, and NHSN HAI data for Jan–Mar 2026 discharges. Source: QualityNet Important Dates and Deadlines.
Nov 15, 2026IQR Q2 quarterly submission — same measure families for Apr–Jun 2026 discharges. CMS moves weekend deadlines to the next business day; confirm on QualityNet.
April – MayCMS IQR structural attestation — annual HQR window for Age-Friendly, Maternal Morbidity, and DACA; PSSM is submitted in NHSN on the same typical April 1–May 15 window. HQRP publishes firm open/close dates on QualityNet.
April – JuneQualityNet · HVBP / VBP — reconcile performance reports, domain scores, and estimated payment adjustments for the performance year.
RollingCDC NHSN patient safety reporting — HAI measures and PSSM live on CDC deadlines (separate from HQR logins).
Mid-yearEvidence refresh — mid-cycle audit of policies, EHR extracts, and committee minutes referenced in affirmations.
Summer / fallCMS Care Compare publication waves — public display timing follows the attested performance year (watch CMS announcements).
SeptemberSeasonal infection prevention — respiratory bundle readiness; confirm any NHSN seasonal reporting notices.
NovemberBudget & board — fund structural remediation for gaps that span more than one department.
DecemberYear-end binder — assemble documentation for surveys, leadership briefings, and next cycle attestations.

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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.

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

Decide without a sales call

Strong fit

Usually pass

IQR penalty sketch

Set up your compliance profile

Major deadlines & rhythm

Year-round highlights (planning view)

The scan is free. The file is Professional.

Mark as submitted

Assign domains to colleagues

Draft stakeholder email

Mark gap as closed

Save your progress

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