Survey & Accreditation Readiness
Ready on any day a surveyor walks in.
State surveys and accreditation visits are unannounced, and findings can threaten your certification. We review your operations against the Conditions of Participation and accreditation standards, run realistic mock surveys, and help you fix what we find before it becomes a deficiency.
Who this is for
Built for organizations like yours
New Agencies
Agencies preparing for an initial certification or accreditation survey.
Established Providers
Agencies due for recertification or concerned about recent complaints.
Agencies With Deficiencies
Providers who need a credible plan of correction and evidence that it is working.
The problem
Risks we address
Condition-level deficiencies
Serious findings that can lead to termination of Medicare certification if not corrected.
Evidence you can't find
Compliant practices that fail survey because nobody can produce the records quickly.
Programs that exist only on paper
QAPI, infection control and emergency preparedness plans that staff don't know or follow.
What's included
How we help
Readiness Reviews
- Conditions of Participation gap review
- Unannounced-style mock surveys
- Clinical record and personnel file sampling
- Patient rights and complaint process review
- Survey day roles and evidence binders
Programs & Correction
- QAPI program design and performance projects
- Emergency preparedness plan and exercises
- Infection prevention and control program
- Plans of correction and monitoring evidence
- Governing body and policy reviews
Aligned with
- 42 CFR Part 484
- 42 CFR Part 418
- ACHC
- CHAP
- The Joint Commission
- State licensing rules
Our approach
How an engagement runs
Review
Compare your policies, records and practices with the applicable standards.
Mock Survey
Run an on-site or remote survey the way state and accreditation surveyors do.
Correct
Prioritize findings and fix them with clear owners and deadlines.
Sustain
Build monitoring into QAPI so readiness doesn't depend on a pre-survey scramble.
Why Thornshield
Why work with us
Built for Care in the Field
Recommendations that work for clinicians in patients' homes, not just for staff in an office.
Security and Compliance Together
HIPAA safeguards, Conditions of Participation and IT security handled as one program.
Business Associate Ready
When our work involves PHI, we sign a BAA and handle data under the safeguards it requires.
Automation That Saves Hours
Where compliance work is repetitive, we automate it so your team can focus on patients.
FAQ
Common questions
Do you act as our accrediting organization?
No. Accreditation is granted by ACHC, CHAP, The Joint Commission or the state survey agency. We prepare you for those surveys and help you respond to their findings.
We already received deficiencies. Can you still help?
Yes. We help write a plan of correction that addresses root causes, then build the monitoring evidence that shows surveyors the corrections are working.
Works well with
Related services
Talk to us about survey & accreditation readiness
Tell us about your organization and what worries you most. We'll come back with an honest view of your risks and the most practical way to address them.