Be CMS Survey-Ready With These Tips, Checklists, and Reports

In 2024 alone, Centers for Medicare and Medicaid (CMS) accrediting agencies completed nearly 3,000 surveys at U.S. hospitals. Being CMS survey-ready needs to be a priority at any facility subject to these inspections. The most common citations are related to patients’ rights, with care in a safe setting topping the list for the last few years.

Use this article as a checklist to prepare for a Centers for Medicare & Medicaid Services survey. I’ve also included tips on how to set up your compliance reports to match the requirements so you’re always CMS survey-ready.

CMS Checklist: What Can My Team Do To Prepare for a CMS Survey?

Responsible healthcare organizations don’t procrastinate on proactively preparing for a survey. Waiting until the day of an inspection to get things together is just too risky. There are several steps you and your team can take well in advance to prepare for a CMS survey and reduce audit anxiety.

Tap Into CMS Survey Resources

The first step of the CMS audit checklist is to understand the scope of a CMS inspection thoroughly. These regulations cover a wide range of areas, including patient care, infection control, medical records, staff training, and more. Familiarize yourself with the regulations that pertain to your type of healthcare facility to ensure compliance.

Designate a CMS Survey Inspection Team

Appoint a dedicated team responsible for coordinating the inspection preparations. This team should include individuals from various departments, such as administration, nursing, quality assurance, and compliance. Assign clear roles and responsibilities to each team member for a well-organized and thorough CMS survey preparation process.

Conduct Regular Internal CMS Audits

The next step of the CMS audit checklist includes regular internal audits or mock inspections that can help identify potential areas of non-compliance before the CMS inspection. Address any issues discovered during the CMS audit promptly and create an action plan for improvement.

Review CMS Policies and Procedures

Thoroughly review and update your facility’s policies and procedures on a recurring basis to ensure they reflect current CMS guidelines. Using a healthcare policy management solution, it’s easy to get board approval on updates, distribute to staff, and track reviews. Be sure to train staff on the new policies and ensure they’re prepared to follow the updated protocols.

Ensure Training Completion and Documentation

Properly trained and educated staff play a critical role in ensuring compliance and providing quality patient care. But, as the old saying goes, “if it’s not documented, it didn’t happen.” So be sure your CMS checklist includes a clear picture of your compliance training program — what courses are completed, in progress, and assigned — and associated dates (the survey wants to make sure you didn’t cram them all into the past week!). Be sure the course content aligns with CMS requirements just in case you’re asked!

Focus on Common Citation Areas

Patient rights and infection control are significant focuses of CMS surveys because they are among the most cited. Review your facility’s infection control plan and patient grievance policy, then ask a few employees about these documents, just like a CMS surveyor would. If the responses you get don’t match policy, consider adding additional training on these topics. Use this guide for developing an effective infection control plan.

Leverage Modern Technology

Simplify CMS compliance with a software solution that houses and accelerates your organization’s healthcare compliance management in a user-friendly platform. With all workforce compliance tasks in one platform, it’s easy for employees to stay up-to-date, and automation simplifies program management.

Get Documentation Ready

Review patient records, policies, training records, incident reports, and other relevant documents to be sure they’re complete, up to date, and easily accessible. Digital compliance tracking and reporting makes it much easier to review your documentation prior to a survey to ensure everything is complete for a CMS inspection.

Reports That Keep You Ready For a CMS Survey

A healthcare inspector for CMS will be looking for both written proof and employee actions that demonstrate compliance. The written proof is usually a much easier ask – especially when you set up your reports to reflect the requirements and information that the surveyor will want to see. Hint: This is much easier when you’re using compliance tracking and reporting software.

Here’s how to set up reports to meet the CMS survey requirements.

1. Training. Typically, CMS surveyors will want to see employee name, course name, length, and proof of completion. Any additional information that illustrates your company’s staff training and educational achievements may also be included.  
2. Incidents. It’s usually a pretty comprehensive report to track your incidents – be sure you’ve got the status, resolution, incident and resolution dates, and type of incident easily accessible. You may want to create separate reports for patient grievances and infection control incidents so that you can share more detailed information.
3. Policies. Surveyors will want to see the date of the last policy revision as well as approval from leadership and/or the board of directors. If your report links directly to each policy, it is much simpler for the surveyor to see everything needed. 
4. Credentialing. The surveyor will likely pick an employee and document at random, so having everything in a healthcare credentialing platform is ideal. A report will offer quick confirmation that you have the document in question and that it is still valid. 
5. Exclusions. An exclusions report should include the date the exclusion was checked, the website used for verification, the date of the report, and the employee’s identifying information.
6. Licenses. A report of license expiration dates is probably the most handy before a CMS survey, to check that every clinician is current. 

The best compliance and credentialing reports to surface critical insights and keep you survey ready.

Download Now

Rely on Technology to Simplify Your CMS Inspection Preparations

Being CMS survey-ready requires thorough planning, diligent adherence to regulations, and a collaborative effort from your entire healthcare facility. By following this CMS audit checklist and implementing healthcare compliance software, you can work towards a successful inspection that demonstrates your commitment to patient safety and high-quality care. 

MedTrainer’s robust CMS-aligned course library, automated training and assignment reminders, customizable reporting features, and healthcare policy management make MedTrainer a natural choice for meeting federal regulations and staying CMS survey-ready.

See how MedTrainer simplifies the process of preparing for an inspection.