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.
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
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.
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.
