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

Amber Ratcliffe
Group of medical staff giving high-fives because they are CMS survey-ready

For healthcare facilities, ensuring compliance with regulations and maintaining high standards of patient care is of the utmost importance. One crucial aspect of this is knowing how to prepare for a CMS inspection by the Centers for Medicare & Medicaid Services. Let’s start with a checklist followed by tips for compliance reports to help you be CMS survey-ready.


Get everything you need to know about the 9 compliance reports you can't live without.

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

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 a number of steps you and your team can take well in advance to prepare for a CMS inspection and reduce audit anxiety.

Understand CMS Requirements. The first step in preparing to be CMS survey-ready is to thoroughly understand the scope of a CMS inspection. 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 an 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 to ensure a well-organized and thorough preparation process.

Conduct Regular Internal Audits. Regular internal audits or mock inspections can help identify potential areas of non-compliance before the CMS inspection. Review policies, procedures, and practices to ensure they align with CMS requirements. Address any issues discovered during the audit promptly and create an action plan for improvement.

Review Policies and Procedures. Thoroughly review and update your facility’s policies and procedures to ensure they reflect current CMS guidelines. Make sure all staff members are aware of the changes and are trained to follow the updated protocols.

Staff Training and Education. Properly trained and educated staff play a critical role in ensuring compliance and providing quality patient care. Conduct regular training sessions to ensure that all employees are aware of CMS requirements, policies, and procedures. Keep records of training sessions as they may be requested during the inspection.

Implement Infection Control Measures. Infection control is a significant focus of CMS inspections, especially in healthcare settings. Review and enhance your facility’s infection control plan, including hand hygiene, cleaning procedures, and isolation protocols, to minimize the risk of infections. Use this guide for developing an effective infection control plan.

Leverage Modern Technology. Consider taking advantage of a software solution that houses and accelerates your organization’s compliance in a user-friendly platform. Modern technology can drastically simplify your processes, save your organization time, identify areas for improvements, and reduce costs incurred by upkeeping time-consuming manual processes. 

Prepare Reports. Efficient compliance tracking and reporting is crucial during a CMS inspection. Ensure that patient records, policies, training records, incident reports, and other relevant documents are complete, up to date, and easily accessible.

Are You CMS Survey-Ready? Nine Reports You Need To Prepare

A healthcare inspector for CMS will ask for proof of compliance. Here are nine reports you to prepare ahead of time to help you meet those requirements:

  1. Credentialing. Prove that your staff meet clinical standards for providing care to patients with a report displaying providers’ basic information, privileges, verifications (such as DEA), and any other mandatory documents.
  2. Payer Enrollments. Ensure you and the surveyor are on the same page with a comprehensive list of which providers are legitimately qualified and enrolled with Medicare/Medicaid. 
  3. Exclusions. Avoid significant monetary penalties and demonstrate your organization’s diligence in protecting patient well-being with an exclusions monitoring report (ex: OIG-LEIE and SAM checks).
  4. Licenses. Show that your staff members’ licenses are current, from medical qualifications and board-certification to first-aid and restraint.  
  5. Courses. Illustrate your company’s staff training and educational achievements with a report that shows the status of each employee’s training progress.  
  6. Course Performance. Demonstrate organizational accountability and intent to improve training initiatives with a summary of pass/fail rates of assigned courses. 
  7. Incidents. Prepare for surveys and protect your organization, employees, and patients with a thorough incident reporting process, along with an up-to-date summary of all reports made in order to identify areas for improvement.  
  8. Safety Plans. Record your facility’s safety plans and staff acknowledgements to prove collective awareness and preparedness. 
  9. Policies. Keep a log of past and present company policies and procedures to demonstrate advancement of compliance standards as they evolve.

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 understanding the requirements, conducting regular internal audits, implementing robust preparation strategies, and building the right reports, you can work towards a successful inspection that demonstrates your commitment to patient safety and high-quality care. 

An easy-to-use, cloud-based platform like MedTrainer can support your compliance strategy and help you to maintain survey readiness. A robust course library, automated training reminders, customizable reporting features, credentialing services with primary source verification and exclusions monitoring, safety plan templates, incident report forms, and more, are all options within the nation’s leading all-in-one healthcare compliance software solution. Learn more about MedTrainer’s tools for preparing for an inspection.