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Nursing Home Survey Readiness Checklist To Avoid Immediate Jeopardy

The goal of every nursing home and long-term care administrator and facility should be survey readiness—and by extension, the avoidance of immediate jeopardy. You should think about your survey all year and not wait until the state survey team shows up at your door. The absolute best practice is to be prepared for the nursing home survey with a checklist and survey readiness binder covering all your bases and touching on everything a surveyor might ask for during their visit.

The Centers for Medicare & Medicaid Services (CMS) depends on the surveyors’ knowledge, objectivity, professionalism, and commitment to monitor compliance with the regulatory conditions and requirements. It is up to you and your team to meet their expectations in order to continue providing quality care to your residents.

Some items on this checklist are required by surveyors within one hour of their arrival. Meanwhile, other items you can have ready after a few hours or 24 hours after the surveyor’s entrance into your facility. When you have all of these items available and up-to-date, it saves a tremendous amount of time and anxiety in gathering the necessary information. Having a binder ready with things like the updated floor plan, Hospice Agreements, Dialysis Agreements, ANE policy and other items that can be readily available in the binder in the case the survey team shows up can aleve some of the anxiety and pressure of the survey process.

Check out our Guide to Mitigating Immediate Jeopardy Risks!

The CMS Survey Readiness Checklist

This survey checklist is current and designed for nursing homes and long-term care facilities operating in 2022-23. It will be updated as changes occur in CMS survey requirements.

Information needed from the facility immediately upon the surveyor’s entrance.

  1. Census number
  2. Complete matrix for new admissions in the last 30 days who are still residing in the facility and their date of admission to the facility.
  3. An alphabetical list of all residents (note any resident out of the facility).
  4. A list of residents who smoke, designated smoking times, and locations.
  5. A list of current residents who are confirmed or suspected cases of COVID-19.
  6. Name of facility staff responsible for Infection Prevention and Control Program.
  7. Name of facility staff responsible for overseeing the COVID-19 vaccination effort.

Entrance Conferencestrong>

  1. The survey team coordinator will conduct a brief Entrance Conference with the Administrator
  2. Information regarding full time DON coverage (verbal confirmation is acceptable).
  3. Information about the facility's emergency water source (verbal confirmation is acceptable).
  4. Signs announcing the survey that are posted in high-visibility areas such as the entrance to the facility or on a facility notification board.
  5. A copy of an updated facility floor plan, if changes have been made, including designated areas for COVID-19 observation and COVID-19 units.
  6. Name of the Resident Council President.
  7. The Survey Team will provide the facility with a copy of the Certification And Survey Provider Enhanced Reports (CASPER).

Information needed from the facility within one hour of the surveyor’s entrance.

  1. Schedule of meal times, locations of dining rooms, copies of all current menus including therapeutic menus that will be served for the duration of the survey, and the policy for food brought in from visitors.
  2. Schedule of Medication Administration times.
  3. Number and location of medication storage rooms, medication and treatment carts.
  4. Actual working schedules for all staff, separated by departments, for survey time period.
  5. List of key personnel, location, and phone numbers. It is helpful to include a complete facility employee list with tiles and phone numbers as well. Note contract and volunteer staff (e.g., rehab services). Also include the name of the staff members responsible for notifying all residents, representatives, and families of confirmed or suspected COVID-19 cases in the facility.
  6. If the facility employs paid feeding assistants, provide the following information:
    1. Whether the paid feeding assistant training was provided through a state-approved training program by qualified professionals as defined by State law, with a minimum of 8 hours of training.
    2. The names of staff (including agency staff) who have successfully completed training for paid feeding assistants, and who are currently assisting selected residents with eating meals and/or snacks.
    3. A list of residents who are eligible for assistance and who are currently receiving assistance from paid feeding assistants.
  7. The facility’s mechanism(s) used to inform residents, their representatives, and families of confirmed or suspected COVID-19 activity in the facility and mitigating actions taken by the facility to prevent or reduce the risk of transmission, including if normal operations in the nursing home will be altered (e.g., supply the newsletter, email, website, etc.). If the system is dependent on the resident or representative to obtain the information themselves (e.g., website), provide the notification/information given to residents, their representatives, and families informing them of how to obtain updates.
  8. Documentation related to COVID-19 testing, which may include the facility’s testing plan, logs of county-level positivity rates and the level of community transmission, testing schedules, a list of staff who have confirmed or suspected cases of COVID-19 over the last four weeks with the date of onset, and if there were testing issues, documentation of contact with state and local health departments.

Information needed from the facility within four hours of the surveyor’s entrance.

  1. Complete the matrix for all other residents.
  2. Admission packet.
  3. Dialysis Contract(s), Agreement(s), Arrangement(s), and Policy and Procedures, if applicable.
  4. List of qualified staff providing hemodialysis or assistance for peritoneal dialysis treatments, if applicable.
  5. Agreement(s) or Policies and Procedures for transport to and from dialysis treatments, if applicable.
  6. Does the facility have an onsite separately certified ESRD unit?
  7. Hospice Agreement, and Policies and Procedures for each hospice used (name of facility designee(s) who coordinate(s) services with hospice providers).
  8. Infection Prevention and Control Program Standards, Policies and Procedures, to include the Surveillance Plan, Procedures to address residents and staff who refuse testing or are unable to be tested, and Antibiotic Stewardship Program.
  9. Influenza, Pneumococcal, and COVID-19 Immunization Policy & Procedures.
  10. List of residents and staff and their COVID-19 vaccination status.
  11. Numbered list of resident cases of confirmed COVID-19 over the last four weeks. Indicate whether any resident cases resulted in hospitalization or death.
  12. COVID-19 Healthcare Staff Vaccination Policies and Procedures.
  13. COVID-19 Staff Vaccination Matrix (Note: Facilities may complete the COVID-19 Vaccination Matrix for Staff or provide a list containing the same information as required in the staff matrix).
  14. QAA committee information (name of contact, names of members and frequency of meetings).
  15. QAPI Plan.
  16. Abuse Prohibition Policy and Procedures.
  17. Description of any experimental research occurring in the facility.
  18. Facility assessment.
  19. Nurse staffing waivers.
  20. List of rooms meeting any one of the following conditions that require a variance:
    1. Less than the required square footage
    2. More than four residents

Information needed by the end of the first day of the surveyor’s visit to your facility.

  1. Provide each surveyor with access to all resident electronic health records–do not exclude any information that should be a part of the resident’s medical record. Provide specific information on how surveyors can access the EHRs outside of the conference room.

Information needed from the facility within 24 hours of the surveyor’s visit.

  1. Completed Medicare/Medicaid Application (CMS-671).
  2. Completed Census and Condition Information (CMS-672).
  3. Beneficiary Notice — Complete a List of Residents Discharged from a Medicare Covered Part A Stay with Benefit Days Remaining within the Last Six Months. Please indicate if a resident was discharged home or remained in the facility.
  4. Complete an Electronic Health Record (EHR) Information Form that provides specific instructions on how and where surveyors can access the following charted documentation for residents:
    1. Pressure Ulcers
    2. Dialysis
    3. Infections
    4. Nutrition
    5. Falls
    6. ADL Status
    7. Bowel/Bladder
    8. Hospitalizations
    9. Elopements
    10. Change of Condition
    11. Medications
    12. Diagnoses
    13. PASARR
    14. Advanced Directives
    15. Hospice
    16. COVID-19 Test results
  5. Provide the Name and Contact Information for IT and back-up IT for surveyor questions


Being thoroughly prepared for a CMS annual or complaint survey makes it that much easier to meet the demands of the state agency. You can organize the items on this checklist in any way you wish.

One important detail to remember: Complete the above mentioned documentation for a survey readiness Entrance Conference. Do NOT give any additional documentation unless requested by the survey team. If you just hand over any and every piece of information (other than the required documentation noted above), it may lengthen your survey as it might trigger them to look into areas they had not planned on. Also, do not hand them your originals. Make a copy of all originals, and ensure the copy is given to the survey team, because there is a good chance you will not get it back.

Having a checklist like this on hand goes a long way in avoiding immediate jeopardy. But what happens if something goes awry and you end up with an immediate jeopardy judgement? In that case, you need Qsource. Connect with us today!

 Download the Nursing Home Survey Readiness Checklist  


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