Survey Preparation Suggestions

1. Create a Survey Team within your hospital
   The team should be responsible for gathering necessary and preferred documentation (and keeping it current), working with department managers and other staff to ensure everyone understands their role in the survey process, and checking for compliance on a regular basis.
2. Survey documents
   Have a folder ready with the following documents. Be sure to keep these documents updated.
   • Map/floor plan
   • Organizational chart
   • List of staff and hours of operation
   • List of services including those that are contracted
   • Quality Assurance/Quality Improvement Plans
   • Infection Control Plan
   • Network agreement
   • Copy of CLIA or other certifications and the most recent survey documentation
3. Policy documentation and processes
   The Conditions of Participation (see Checklist, below) frequently refer to processes and patient care policies (and revise, as necessary). Each department should be responsible for the review of their policies, it is important to have a written explanation of how the group described in TAG C272 is involved in this process. Both a description of the process and evidence of this group’s involvement must be readily available for a surveyor’s review. Consider having all policies available in an electronic format or providing access for surveyors to a shared drive with all current policies and procedures.
4. Environmental walk-through
   Part of the survey process includes a walk-through of the facility. The survey team makes observations and interviews staff during the walk-through. These observations often lead to further policy review. One of the functions of your survey team should be to periodically conduct a walk-through, observing as a surveyor.