Survey success starts with daily habits, not last-minute fixes. Use this guide to embed readiness into your everyday routines.
Preparing for the annual CMS survey should be a part of daily routines-not just a last-minute scramble. The key is simple: Do the right thing all the time, and you don't have to worry about correcting shortcuts. When everyone embraces daily accountability, quality of care improves, and survey readiness becomes second nature.
1. Conduct a mock survey to objectively identify risks
Opportunity for staff training, documentation reviews, and preparedness testing
- Schedule a third-party mock survey
- Simulate staff/resident interviews
- Review documentation systems
- Identify and correct compliance gaps
2. Conduct frequent rounds and review high-risk resident charts
Increases visibility and accountability while ensuring accurate, consistent care and documentation for at-risk residents.
- Perform leadership rounds daily/weekly
- Review care plans for high-risk residents
- Check for documentation of enteral tubes, falls, pressure injuries, behaviors
- Document and follow up on findings
3. Utilize Critical Element Pathways and routinely update required CMS forms
Helps identify areas of vulnerability before the survey while keeping census and condition data accurate and up-to-date for the survey team.
- Complete Critical Element Pathways for common issues
- Review for areas of vulnerability
- Update Form 672 weekly (daily during survey week)
- Update 802 Matrix Form regularly
4. Meet with the team to discuss expectations and assignments during the survey
Clarifies responsibilities and communication structure to ensure survey readiness across all units and disciplines.
- Assign staff to specific units/roles
- Ensure all staff wear visible name badges
- Conduct pre-survey huddles and review plans
5. Interview a sample of residents using Critical Element questions
Prepares residents for likely survey interviews and identifies areas of concern or misunderstanding in advance.
- Identify interview-prone residents (e.g., council leaders, those with SRIs)
- Conduct practice interviews
- Use actual surveyor questions from CMS Pathways
6. Review QAPI (Quality Assurance and Performance Improvement)
Ensures performance trends are addressed proactively while demonstrating a culture of accountability and continuous improvement.
- Analyze current QAPI data and trends
- Document actions taken for identified issues
- Ensure all QAPI initiatives are active and monitored
7. Update 802 and 672 Forms and Prepare Your Entrance Conference Worksheet
Reflects accurate, up-to-date resident and facility data while ensuring surveyors receive complete and timely documentation.
- Ensure current Form 672 reflects accurate census and conditions
- Keep 802 Matrix updated with resident categories
- Complete Entrance Conference Worksheet with required documents:
- Census info
- Alphabetical list
- COVID-19 status
- Smoking policy
8. Ensure Medical Director is aware of survey process and expectations
Reviews new expectations for surveyor meetings, reinforces the Medical Director’s engagement and leadership, and prepares them to support the facility during key survey interactions.
- Meet with Medical Director to review their role
- Confirm their availability during survey
- Discuss key risk areas and recent incidents
Use this guide to prepare proactively and confidently for your annual CMS survey. Consistency, documentation, and communication are your best defenses!
National data shows over 85% of mock surveys identify issues that can be resolved promptly. To schedule your mock survey, reach out to the team at Polaris Group.
