Is your nursing facility survey ready? Are you up to date with all of the upcoming regulatory changes effective in October 2022? Preparation for the annual recertification survey should be ongoing, with a formal mock survey process  several months prior to the facility’s survey window so that a proper corrective action plan can be prioritized, developed, implemented and evaluated for effectiveness by the QAPI team.  This week’s blog examine’s survey readiness including tips for implementing a successful mock survey process.

A recent PMR Blog: Ready for Survey? provided readers with a survey readiness sample checklist. Nursing facilities can take survey prep a step further by conducting a mock survey either independently or through a third party consultant group.

Mock Survey Tips:

Mock surveys are an excellent prep tool to determine survey readiness by identifying potential risk areas and areas of possible non-compliance. Although a mock survey may consist of a smaller sample size, it should still closely mimic an actual survey, utilizing similar processes and tools, such as:

  1. An Entrance Conference Worksheet includes data required within specific timeframes during the first 24 hours of survey. Facilities would benefit by having a readiness binder/file containing this data with staff members assigned to keep data up to date. Including completion of this worksheet and producing all documents during a mock survey is excellent practice for facility staff. The worksheet is broken down in to the following time requirements:
      • Information needed within 1 hour of entrance
      • Information needed within 4 hours of entrance
      • Information needed by the end of the first day
      • Information needed within 24 hours of entrance
  1. The Initial Pool Process consists of interviews, observations and review of high-risk conditions/events. The CMS Tools for the Initial Pool Process are available and should be used on the limited resident sample during a mock survey. The tools include:
      • Resident Interview
      • Resident Observation
      • Resident Representative Interview
      • Limited Record Review
  1. Critical Pathways are CMS tools used during the survey process that consist of observations, interviews and record reviews. Ten (10) of the top 25 deficiencies (CMS Fiscal Year 2022 Standard Surveys–QCOR Casper data 8/28/2022) are investigated through these pathways. Here are the mandatory tasks and the top deficiency associated with them:
      • Dining (F812, F880, F550, F584, F692, F804)
      • Infection Control (F880)
      • SNF Beneficiary
      • Kitchen Observation (F812)
      • Medication Administration (F880, F761, F755, F759, F658)
      • Medication Storage (F761, F755)
      • Resident Council Meeting (F550)
      • Sufficient and Competent Nurse Staffing Review
      • Environment (F584)

At the conclusion of the mock survey, the facility should review and prioritize identified concerns and potential deficient practices. Action planning to address possible deficiencies should be discussed with the QAPI team.

Mock Survey Services

 It can be beneficial to have a consultant group to conduct the mock survey to provide another perspective.  At times, deviations from standards of care and/or facility policies occur gradually and become routine practice in a facility. Have you heard staff say, “we’ve always done it this way” or “this is the way I was taught? ” An outside consultant is able to recognize these degressions from standards of care and identify where there is a lack of knowledge or need for process update.

For best results, let your staff and residents know that the mock survey team has been asked to come in to help identify areas of improvement needed so they can share concerns and ask questions.

      • Staff are often times nervous when being observed by surveyors while providing care. Having a mock surveyor observe the staff member can be a learning opportunity and better prepare them for actual survey observations.
      • Staff should feel comfortable asking the mock survey team members about regulatory requirements and/or their own performance.
      • When residents understand that the mock survey team is there at the request of the facility administration to identify needs/concerns they may be more forth coming with concerns.

A consultant mock team should discuss and collaborate on their findings and relay areas of concern to the facility team during an exit conference. They should then follow up with a thorough report of findings. Additional services may include:

      • Suggested corrective action plan
      • Sample forms/tools to be used as part of the corrective action plan
      • Training and Resources

Proactive offers mock survey services to assist providers in preparing for the annual survey process.  Our experienced team identifies potential deficiencies related to your systems, procedures and processes of care. The mock survey process includes initial pool process interviews, observations, and record reviews for a partial survey sample. Proactive consultants complete:

      • All 9 mandatory tasks
      • A review of all additional areas triggered for review through the initial pool process
      • A detailed report of findings to guide any needed plan of correction

Resources and guidance are available as needed in follow-up to the mock survey visit including consultation on developing a plan of correction, policy and procedure development, follow-up compliance visits, staff training, and on-going regulatory compliance consultation services.

Contact us to learn more and to schedule your next mock survey.

Make Proactive training part of your ongoing survey readiness strategy. Access Survey Readiness for the DON to learn additional tips and strategies for survey readiness for the Nursing Department. You may also make plans to join us for the year-long Survey Success-Avoiding Top Citations series on the first Tuesday of each month for analysis of the top citations in the nation and strategies to avoid them. On-demand access to past sessions is available here.


Angie Hamer, RN, RAC-CT
Clinical Consultant

Learn more about the rest of the Proactive team.