Last updated: November 2026
CIHQ hospital accreditation readiness helps acute care hospitals preparing for CIHQ’s Medicare-participating program assess records, discharge planning and medical staff evidence against applicable requirements. Integral Healthcare Solutions (IHS) reviews a sample of charts against 42 CFR Part 482 and the CIHQ materials the hospital supplies, drafts missing policies and templates for hospital leaders to approve, and reports gaps found in that review.
IHS works in three practice lines: accreditation consulting, compliance services and program development. This page is the accreditation line. The Center for Improvement in Healthcare Quality (CIHQ) decides your accreditation, and your hospital deals with CIHQ directly.
What is CIHQ hospital accreditation?
CIHQ offers separate hospital programs for Medicare-participating and non-Medicare hospitals. This page addresses acute care hospitals using its Medicare-participating program. The CIHQ hospital program page (page opened 2026-11-05) lists CIHQ Hospital Accreditation Standards - Participating in Medicare, effective 1.26; CIHQ Accreditation Policies for Hospitals, Critical Access & Psychiatric Hospitals Participating in Medicare, effective 6.26; and CIHQ Hospital Accreditation Survey Activity Guide - Participating in Medicare, effective 1.26. Your hospital supplies the applicable materials for IHS’s review.
CMS allows hospitals to demonstrate compliance with applicable Medicare conditions through a CMS-approved accreditation program. Accreditation outside an approved deeming program does not establish deemed compliance. The hospital Conditions of Participation are in 42 CFR Part 482, Conditions of Participation for Hospitals (eCFR text read 2026-11-05 from the govinfo build of 2026-11-04; Title 42 last amended 2026-10-08).
CMS approved CIHQ’s hospital accreditation program for the period January 1, 2023 through January 1, 2028. See the CMS final approval notice, CMS-3429-FN (page opened 2026-11-05 through the official Federal Register XML).
Who needs it and what triggers it
A hospital may consider IHS’s readiness support in situations such as these:
- The hospital is on the CIHQ route, or comparing it, and wants a mock survey before the next one.
- Leadership turned over, or a merger moved two record systems into one.
- Telemedicine or a new service line added patient types the discharge planning process does not yet cover.
CMS says a patient can still complain to the State Survey Agency about a Medicare-participating hospital that is accredited and has deemed status. IHS draws one inference: the chart has to hold up outside the accreditation survey too.
How IHS helps
IHS starts from the patient chart because it is where the record and discharge planning requirements can be checked against one patient's file. The method:
- Gap assessment of record content, retention, discharge planning and medical staff files against Part 482, and against the CIHQ materials your hospital supplies.
- Evidence index that ties each requirement to the form, policy, minute or chart element that shows it.
- Drafts of the record-completion policy and discharge planning evaluation template, for your clinicians and medical records leaders to approve.
- Mock survey built on patient tracers: a chart is followed from admission to discharge, then checked against policy and against what staff say they do.
- Readiness support for the weeks before the survey.
Your hospital supplies a sample of records prepared under its own privacy rules, its policy set, bylaws, committee minutes, QAPI plan, survey date if one is set, and the CIHQ materials it holds.
The limit: IHS does not attend the survey, predict findings or take part in CIHQ's decision. IHS does not communicate with CIHQ; your hospital's named contact does. IHS markets its process and makes no claim about past work with this accreditor.
What to have ready
These six starting points are drawn from 42 CFR Part 482, Conditions of Participation for Hospitals (eCFR text read 2026-11-05; govinfo build 2026-11-04). They are not a complete hospital accreditation checklist.
| Chart-side evidence | Part 482 section | What the text asks for |
|---|---|---|
| Record retention schedule and indexing system | 482.24(b)(1) and (b)(2) | Records kept in original or legally reproduced form for at least 5 years, and a system of coding and indexing that allows timely retrieval by diagnosis and procedure to support medical care evaluation studies. |
| Entry standards and authentication policy | 482.24(c)(1) | Entries legible, complete, dated, timed and authenticated, in written or electronic form, by the person responsible for providing or evaluating the service, consistent with hospital policies and procedures. |
| Discharge planning process and evaluations | 482.43(a) | Identify, at an early stage of hospitalization, patients likely to suffer adverse health consequences upon discharge without adequate discharge planning, and provide them an evaluation; also provide one to other patients on request of the patient, the patient's representative or the patient's physician. |
| Medical staff selection criteria | 482.12(a)(6) | The governing body must ensure the criteria for selection are individual character, competence, training, experience and judgment. |
| Medical staff bylaws | 482.22 | An organized medical staff that operates under bylaws approved by the governing body and is responsible for the quality of medical care provided to patients. |
| QAPI plan fed by chart audits | 482.21 | The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven QAPI program. Its governing body must ensure that the program reflects the complexity of the hospital’s organization and services, involves every department and service, including services supplied under contract or arrangement, and focuses on indicators of improved health outcomes and prevention and reduction of medical errors. The hospital must maintain and demonstrate QAPI evidence for CMS review. |
IHS uses individual charts to test how entry standards and discharge planning work in practice, then reviews policies, staff interviews and broader evidence to assess the underlying processes. Have the applicable CIHQ materials and any scheduled survey date ready as well. The introductory call is the place to discuss a review of your hospital’s evidence.
How it compares
CMS describes accreditation through a CMS-approved hospital program as a voluntary alternative to the state survey route for demonstrating compliance with Medicare health and safety requirements. IHS does not tell you which to choose, or which approved organization.
IHS has pages on Joint Commission hospital readiness and DNV hospital readiness, and the site has a page on ACHC acute care hospital accreditation. All start from Part 482. This page is for a hospital on the CIHQ route and is organized around the patient chart.
What it costs
CIHQ does not publish a fee schedule on the hospital program page we reviewed (page opened 2026-11-05); that page directs hospitals to request pricing. Verify current fees with CIHQ. IHS scopes each engagement after a free introductory call.
What this is not
IHS is not an accrediting body and does not grant accreditation or deemed status.
This page is not legal advice. IHS is a consulting firm, not a law firm.
IHS does not guarantee a survey result, does not write clinical content without your clinicians' approval, and does not file anything with CMS, a state agency or CIHQ. Your hospital submits.
Frequently asked questions
What does CIHQ hospital readiness cover?
It covers patient records, discharge planning, medical staff files and the QAPI program, tested against 42 CFR Part 482. IHS also reads the CIHQ materials your hospital holds. You receive an evidence index, drafted documents and a ranked findings list.
Is CIHQ approved by CMS?
Yes. CMS approved CIHQ’s hospital accreditation program for January 1, 2023 through January 1, 2028, as stated in its final approval notice, CMS-3429-FN (page opened 2026-11-05).
Does accreditation replace the state survey?
For Medicare certification, accreditation through a CMS-approved hospital program can demonstrate compliance with the applicable Medicare conditions instead of a State Survey Agency certification survey. That accreditation route is voluntary. Patients may still complain to the State Survey Agency about an accredited Medicare-participating hospital with deemed status.
What is a mock survey and what do we receive?
A mock survey is a practice review of selected records, policies and staff explanations against the requirements in scope. IHS follows patient charts from admission to discharge, reviews documents and interviews leaders. You receive a ranked findings list and an evidence index.
Which federal hospital rules does IHS map to?
IHS maps to 42 CFR Part 482, including governing body at 482.12, QAPI at 482.21, medical staff at 482.22, medical records at 482.24 and discharge planning at 482.43. The text used is the eCFR as of the govinfo build of 2026-11-04.
Who approves the clinical content?
Your clinicians and medical records leaders. IHS drafts policies and templates, and nothing clinical takes effect until your clinicians approve it.
Can IHS speak with CIHQ for us?
No. IHS does not communicate with CIHQ or submit anything to it. Your hospital's named contact does, and IHS prepares the documents behind it.
What does Part 482 require for medical records and discharge planning?
Sections 482.24(b)(1) and (b)(2) require retention of original or legally reproduced medical records for at least 5 years, plus coding and indexing that permits timely retrieval by diagnosis and procedure to support medical care evaluation studies. Under 482.24(c)(1), all patient medical record entries must be legible, complete, dated, timed and authenticated in written or electronic form by the person responsible for providing or evaluating the service, consistent with hospital policies and procedures. Under 482.43(a), the hospital must identify early in hospitalization patients likely to suffer adverse health consequences without adequate discharge planning and provide them a discharge planning evaluation; it must also provide an evaluation for other patients when requested by the patient, the patient’s representative or the patient’s physician.
Where does the QAPI program come in?
The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven QAPI program. Its governing body must ensure that the program reflects the complexity of the hospital’s organization and services, involves every department and service, including services supplied under contract or arrangement, and focuses on indicators of improved health outcomes and prevention and reduction of medical errors. The hospital must maintain and demonstrate QAPI evidence for CMS review. IHS checks whether findings from chart reviews inform the hospital’s QAPI work.
What does it cost?
CIHQ does not publish a fee schedule on the hospital program page we reviewed; that page directs hospitals to request pricing. Verify current fees with CIHQ. IHS scopes each engagement after a free introductory call.
Related pages
- Joint Commission hospital accreditation readiness
- DNV hospital accreditation readiness
- Joint Commission critical access hospital readiness
- Accreditation Consulting