How to stay survey-ready every day
Short answer
CMS surveys of ASCs and nursing homes are unannounced, so readiness is a weekly habit, not a project. Keep five records current: the incident log, transfers and deaths, QAPI minutes with data, a corrective-action log with verification, and training records.
What does it mean to be survey-ready?
You can answer a surveyor's first requests within an hour or two, any day. CMS says ASC and nursing home surveys are unannounced. A nursing home standard survey may come within 15 months of the last.
| Item | ASC | Nursing home |
|---|---|---|
| Survey notice | Unannounced | Unannounced |
| QAPI rule | 42 CFR 416.43 | 42 CFR 483.75 |
| Where surveyors look | Appendix L, tags Q-0080 to Q-0084 | Appendix PP, tags F865, F867, F868 |
Accreditors set their own rules.
What do surveyors ask for first?
Lists of cases, quality data and proof that fixes worked.
| Request | Setting | Source |
|---|---|---|
| Surgeries from the past 6 months | ASC | CMS Appendix L |
| Transfers to a hospital or deaths in the past year | ASC | CMS Appendix L |
| Infection control and quality self-assessment papers | ASC | CMS Appendix L |
| Quality and adverse event data, with causes | ASC | CMS Appendix L, 42 CFR 416.43 procedures |
| QAA minutes, data reviewed and action plans | Nursing home | 42 CFR 483.75(g); F867, F868 |
| Proof that actions worked and held | Nursing home | 42 CFR 483.75(d)(1) |
CMS tells ASC surveyors an ASC should generally supply the first lists within 1 to 2 hours.
ASC quality indicators should include hospital transfers, surgery and infection control measures, and a system for tracking adverse patient events.
Five records to keep current
Keep five linked records current and you can answer most first requests.
- Incident log with dispositionEvery event: date, type, severity, who was told, outcome.
- Transfers and deaths listA filtered view of the log, not a second sheet.
- QAPI minutes with dataData, decisions and owners.
- Corrective-action logOwner, due date, evidence and a dated check.
- Training tied to actionsShow who was retrained, when and on what. ASC rules expect all staff to know the preventive strategies (42 CFR 416.43(c)(3)).
Keep them as one chain: incident, investigation, action, verification, QAPI minutes. A surveyor should follow one case unaided.
What to have ready on survey day
Surveyors ask for a private workspace and a phone, and expect copies of records promptly. This works for state, validation and complaint surveys.
- A point person and a backup.
- A runner who pulls records.
- A private room with a phone.
- A request log: what was asked, when, what was handed over.
- Dated lists made fresh from live records.
A 30-minute weekly routine
Thirty minutes a week keeps the five records honest.
| Task | Minutes | Result |
|---|---|---|
| Review new incidents for gaps | 5 | Every case complete |
| Check overdue actions, call owners | 10 | No silent overdue items |
| Run and check the dated lists | 5 | Lists ready |
| Spot-check one closed action | 5 | Proof it held |
| Note items for the next QAPI meeting | 5 | An agenda starter |
Record who ran the routine each week. A dated sign-off shows the program is ongoing, as ASC and nursing home QAPI rules ask.
What surveyors cite, and mistakes to avoid
CMS examples of F867 citations are record failures. At Level 1, a facility planned monthly monitoring for three months but had no evidence of it in month two. At the most serious level, it collected hot-water temperatures and never analyzed them.
A nursing home QAA committee must meet at least quarterly (42 CFR 483.75(g)(2)(i)) and act on its data. Collecting is not enough.
- Making readiness one person's job. Name an owner and backup per record.
- Building survey binders. They go stale the day they are finished.
- Keeping transfers in a spreadsheet nobody updates.
- Closing actions at completion, with no check they worked.
- Skipping the routine in busy weeks.
- Tracking only outcomes. Near misses show problems earlier.
How IncidentKit changes the job
Reports are filed as events happen, so the log stays current. Compliance packets build QAPI summaries and survey packets from the same records. A person reviews each one.
Corrective actions keep owner, due date, evidence and effectiveness check. The audit trail shows who changed what and when. The survey readiness check tests your records for free.
The parts of IncidentKit behind this
- Incident reporting: The full record holds who, what, where, harm, evidence and what happens next.
- Compliance packets: Records laid out the way surveyors and inspectors want them.
- Corrective actions (CAPA): Every fix has an owner, a date and proof. Unverified fixes keep it open.
- Audit trail: Every edit is logged, so you can show who changed what, and when.
- Analytics: See which rooms, shifts and equipment keep showing up in your incidents.
- Routing and escalation: Severity decides who gets paged, and it escalates if nobody acts.
Frequently asked questions
Are all surveys unannounced?
Yes. CMS says all ASC and nursing home surveys, including standard, complaint and revisit surveys, are unannounced. Accreditors set their own policy, so check yours.
How far back should the incident log go?
Keep six months of surgeries and a year of transfers and deaths for ASC surveyors. OSHA requires the 300 log, annual summary and 301 reports for five years after the year they cover. Your state or accreditor may require longer.
Who should own survey readiness?
One named leader per site, with a backup, usually the administrator or quality lead. Give each record an owner too. A nursing home QAA committee reviews results at least quarterly.
What is the difference between readiness and a mock survey?
A mock survey tests your answers on one day. Readiness is the weekly routine behind them. Do both, and run the survey readiness check yearly.
Sources
- CMS: State Operations Manual Appendix L, guidance for surveyors of ASCs
- CMS: State Operations Manual Chapter 7, survey and enforcement for nursing homes (sections 7205, 7207)
- CMS: State Operations Manual Appendix PP, F867 and F868
- eCFR: 42 CFR 483.75, nursing home QAPI
- eCFR: 42 CFR 416.43, ASC QAPI
- OSHA: 29 CFR 1904.33, retention
Reviewed against the sources above on Oct 5, 2026. Rules change: confirm current requirements with the issuing body or your counsel before relying on any summary.
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