The Situation

A multi-specialty ambulatory surgery center in the Southwest had operated for nearly a decade on a compliance model that worked — until it didn’t. Policies lived in binders that hadn’t been updated since their last accreditation cycle. Staff pulled their compliance officer into hallway conversations to answer routine questions. When infection control procedures changed, no one could confirm whether the update had actually reached every department.

The administrator knew a CMS survey was coming. What she didn’t know was exactly where they were exposed — and that uncertainty was the real compliance risk.

The Gap Assessment

KATKOSH began with a structured 30-minute discovery call followed by a full regulatory mapping exercise. Every governing agency with jurisdiction over the facility was identified — CMS Conditions of Participation, OSHA bloodborne pathogen and safety standards, AAAHC accreditation requirements, state health department licensing, and HIPAA privacy and security rules. The mapping revealed three critical gaps the facility had not previously identified:

The Build

Over five weeks, KATKOSH deployed a custom AI compliance infrastructure built exclusively for this facility. Every policy in the knowledge base was sourced from the facility’s actual procedures and cross-referenced against current regulatory requirements. Role-based access was structured so that front desk staff, clinical personnel, HR, and billing each operated within their own authorized access layer. A live compliance health score gave leadership real-time visibility across every department — including the two infection control standards that had been out of alignment.

The Outcome