Joint Commission & CMS Readiness

🎯 Survey Readiness Overview

Real-time readiness score based on chapter compliance, open POCs and tracer results

Readiness Breakdown

Your organisation scores 78% overall survey readiness. Priority attention required on Life Safety (LS) chapter before the survey window opens.

Standards Compliance89%

POC Completion62%

Documentation Currency91%

Staff Training Completion76%

Mar 2023

Last Survey Date

Mar 2026

Next Survey Window

~120 days

Days Until Window

3

Outstanding POCs

📋 Chapter Compliance Status

All 17 Joint Commission accreditation chapters — click a row to view standards detail

Chapter	% Compliant	Standards	Last Review	Owner	Status

🎯 Tracer Audit Programme

Tracers simulate Joint Commission survey methodology — follow a patient or system through your organisation

System Tracer Focus Area

Department / Unit

📄

Upload completed tracer results for AI analysis

Drag & drop PDF, Word or Excel — or click to browse

🤖 AI Tracer Analysis — Joint Commission Surveyor Perspective

📝 Plan of Correction Tracker

Track all open findings and corrective actions through to closure

#	Finding	Standard	Root Cause	Responsible Party	Due Date	Status	Actions

🤖 Generated POC Template

⚕️ CMS Conditions of Participation

42 CFR Part 482 — Hospital Conditions of Participation compliance status

⭐ CMS Star Ratings & Quality Benchmarking

Hospital Compare star ratings, HCAHPS scores and Leapfrog safety grade tracking

CMS Hospital Compare

CMS Certification Number (CCN)

Hospital Name (optional)

🏥 EMTALA Compliance

Emergency Medical Treatment and Labor Act — ED compliance requirements

EMTALA Requirements Checklist

Medical screening examination provided to all ED patients

Stabilising treatment provided before transfer

Transfer requirements documented (if transfer needed)

On-call physician list maintained and current

EMTALA signage posted in ED

Patient logs maintained (ED visits)

Transfer records maintained

On-call physician response time policy documented

Annual EMTALA training for ED staff

0%

Common EMTALA Violation Areas

Failure to Provide MSE Critical

Failure to conduct a medical screening examination for every individual who presents to the ED is the most frequently cited EMTALA violation.

Mitigation: Implement triage protocols requiring documented MSE for 100% of ED presentations regardless of ability to pay.

Premature Discharge Before Stabilisation High

Discharging or transferring patients before an emergency medical condition has been stabilised exposes the facility to significant EMTALA liability.

Mitigation: Require attending physician sign-off on stabilisation documentation before any discharge or transfer order.

Inappropriate Transfer High

Transfers that do not meet the EMTALA transfer criteria — including physician certification, patient consent, and accepting facility confirmation — are a compliance risk.

Mitigation: Standardise transfer documentation forms to capture all mandatory EMTALA transfer elements.

On-Call Physician Failure to Respond Medium

If a specialist on the on-call list fails to respond when called, both the physician and the hospital may be cited for EMTALA violations.

Mitigation: Maintain response time logs and enforce on-call response policies with clear escalation paths.

Log & Recordkeeping Failures Medium

Incomplete ED logs, missing transfer records, or absence of the central log required by EMTALA are commonly found during CMS investigations.

Mitigation: Audit ED logs monthly; ensure all transfers have a complete paper trail retained for 5 years.