What to Expect During a CMS Survey

The Centers for Medicare and Medicaid Services (CMS) survey can bring a lot of stress for continuing healthcare providers (e.g., nursing homes or assisted living communities), home health agencies, and hospices. Many facility administrators feel anxious because surveyors often arrive without warning.

It's important to know what to expect during a CMS survey to ensure compliance and prevent your staff from scrambling. Non-compliance and survey deficiencies can affect your funding, public ratings, and daily operations.

This guide discusses the typical CMS survey process and the common areas to focus on. You'll learn what to expect and face surveyors with more confidence.

TL;DR

• A CMS survey reviews how your facility delivers quality care, follows rules, and protects residents.
• Surveyors often focus on patient care, clinical services, medication handling, food safety, emergency plans, quality assurance, and data accuracy.
• This survey is often unannounced, so it's important to run mock surveys, train your staff, and organize proof of compliance in one place.
• MyFieldAudits helps you prepare for CMS surveys by conducting mobile inspections and giving you real-time visibility into daily operations.

The CMS Survey Process

The CMS survey checks if a facility meets CMS regulations for quality care and safety.

It typically starts with an entrance conference. State survey agencies visit your site unannounced and meet with facility administrators. They discuss the survey's purpose, scope, type, objectives, timeline, and expectations from both parties.

From there, CMS surveyors begin their review right away. They observe different areas of your healthcare facility, from food safety management to infection control.

They also review documentation, including resident care plans, daily activity programs, patient charts, dietary restrictions, and facility records.

Additionally, surveyors interview residents and their families to identify the concerns that matter most to them.

After a thorough evaluation of your healthcare facility, CMS surveyors discuss findings and determine if deficiencies (violations) exist.

Finally, the survey process ends with an exit conference, where you receive initial findings and any issues observed. Final results come later in a written report.

MyFieldAudits is a mobile inspection platform that puts real-time visibility and performance tracking directly in the hands of facility administrators. With mobile audits and shareable reports, you can identify gaps early and face a CMS survey with confidence. Book a demo today to get instant clarity into your operations and compliance!

7 Key Areas Covered by the Centers for Medicare and Medicaid Services

CMS surveys focus on specific areas that show how your facility operates daily.

1. Patient Care and Rights

CMS surveyors spend significant time reviewing how your facility treats residents. They look at daily care routines, personal needs, and how staff interact with residents.

Surveyors also check if your internal team understands and follows care plans. They want to see consistent care across all shifts, not just during peak hours.

Interviews with residents play a large role in this part of the review. Surveyors listen closely to their concerns and identify patterns.

It's crucial to recognize the rights of individuals, including choice, dignity, and freedom from harm. Poor communication, rushed care, or ignored requests can lead to survey deficiencies.

2. Clinical Care and Services

This involves reviewing how your facility handles medical needs, including treatments, therapies, and follow-ups.

Inspectors evaluate clinical judgment, care coordination, and staff readiness. They also compare physician orders against actual care provided to patients.

Plus, the CMS verifies that staff have proper licenses, certifications, and training for their roles. This includes checking credentials, competency records, and ongoing education.

3. Medication Management

During a CMS survey, state agencies pay close attention to dose accuracy, timing, and staff authorization. They look at medication logs to ensure accurate data.

They also conduct inspections of storage areas. They check whether medications are maintained in clean, sanitary conditions with proper temperatures.

4. Food Safety Standards

The CMS reviews food standard operating procedures (SOPs) within your healthcare facility. They evaluate how your kitchen staff prepare, store, cook, and serve food.

Daily procedures should meet food safety requirements to protect residents against hazards and foodborne illnesses.

It's also important to follow dietary needs, allergies, and special diets. This ensures both safety and user satisfaction.

5. Emergency Preparedness

Emergency preparedness shows how ready your facility is to protect residents during unexpected events.

CMS surveyors review emergency plans, drill records, and staff knowledge. They want to see that your team knows what to do during fires, weather events, or power failures.

Surveyors also check backup systems, fire equipment, and clear access to emergency exits.

They can even question staff about communication plans and evacuation steps. If your team cannot explain procedures, surveyors may question readiness.

6. Quality Assessment and Performance Improvement (QAPI)

During a CMS survey, state agencies want to see how your facility tracks, reviews, and corrects issues over time. They check whether improvement efforts lead to real changes.

Surveyors expect leadership involvement and clear accountability.

Poor QAPI initiatives often lack follow-up actions or rely on surface fixes. Facilities that take QAPI seriously show ongoing effort to improve care, reduce errors, and support staff performance.

7. Clinical Documentation Accuracy

CMS surveyors review patient charts, care plans, and daily notes to confirm that records match what actually happened. Missing entries, late updates, or differences in notes raise concern.

Documentation must be complete and clearly show assessments, care provided, and resident responses.

Surveyors often compare records across departments and states (if you manage a multi-site facility) to identify gaps. Consistency and transparency matter.

How to Prepare for CMS Surveys

Here are some expert tips to help you face CMS surveys with confidence.

• Review and update current policies: Assess current policies and confirm that they still meet federal regulations and CMS standards. If not, update them to comply with the Conditions of Participation (CoPs) or Conditions for Coverage (CfCs) for Medicare and Medicaid.
• Conduct mock surveys: Schedule regular mock surveys and internal audits where you walk through your facility the same way a CMS official will do. Have leaders and frontline staff participate so everyone knows what to expect.
• Train staff: Make sure your team knows how to respond to surveyors' questions. You should also educate staff on the latest laws and best practices in facility management.
• Store and organize documents: Keep records easy to access and well-organized. Having a survey data repository, clear labels, and current logs can save time and reduce confusion when surveyors request specific resources.
• Invest in quality assurance software: Use quality assurance and inspection software to track real-time issues. You can also use this platform to assign corrective actions, generate reports, and store documents in one place.

MyFieldAudits Helps You Face CMS Surveys with Confidence

MyFieldAudits helps your assisted living facility or nursing home prepare for unexpected CMS surveys. Its mobile-friendly platform makes it easy for site teams to conduct inspections anytime, anywhere.

This gives you real-time visibility into what's happening on the ground. You can quickly fix on-site issues and maintain high standards across various locations, helping you pass CMS surveys without deficiencies.

MyFieldAudits acts as a retention engine for your facility. It manages the entire inspection lifecycle, from mobile field execution to real-time reporting. This lets you focus on what you do best: capturing the critical data that drives operational excellence.

Schedule a demo today to get started! You can also watch this product overview to learn how MyFieldAudits handles the heavy lifting for your facility.

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FAQs About CMS Survey

What is a CMS survey?

A CMS survey is a review of how healthcare facilities (nursing homes, home health agencies, hospitals, etc.) follow federal care and safety rules. Surveyors observe care, review records, and interview both staff and residents. The goal is to confirm quality standards and protect resident well-being.

Is a CMS survey legitimate for Medicare?

Yes, a CMS survey is required for Medicare participation. Facilities must pass surveys to confirm ongoing eligibility for Medicare and Medicaid programs. Poor results can lead to penalties or payment limits.

What is CMS in surveying?

In surveying, CMS sets the rules and oversees how states review healthcare facilities. CMS defines the standards, while trained surveyors carry out the on-site review. This approach keeps inspections consistent across facilities nationwide.

What does CMS stand for?

CMS stands for the Centers for Medicare and Medicaid Services. This federal agency oversees healthcare programs and facility standards.