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Resource guide

Pediatric ICF/IID Regulatory Survey Readiness

Understand what surveyors evaluate, identify compliance risks before the survey, and prepare your documentation, staff, medications, clinical systems, and facility environment for regulatory review.

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Watermarked PDF · For organizational use · two versions available

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Important regulatory notice

  • Survey procedures vary by state, by survey type — certification, recertification, licensure, complaint investigation — by facility, and by the circumstances found on site. Nothing here describes how any particular survey will be conducted.
  • This guide supports internal readiness work. It does not replace current federal regulations, state licensing or Medicaid requirements, official CMS survey guidance, or legal advice.
  • Each facility is responsible for verifying the requirements that apply to its own jurisdiction, provider type, and certification status.
  • Following this guide does not guarantee a deficiency-free survey, and Pediatric Compliance Partners is not affiliated with, approved by, or endorsed by CMS, any state survey agency, or any accrediting body.

Downloads

Two guides, two jobs

Version 1 is the general readiness overview. Version 2 is the expanded operational framework for running a structured mock survey. Both are current — pick the one that matches what you are doing.

Version 1 · General Readiness Guide

Pediatric ICF/IID Survey Readiness Guide

A practical overview of survey expectations, documentation readiness, medication safety, staff preparation, and continuous compliance.

  • 29 pages
  • PDF
  • Printable checkboxes
  • Watermarked
Download Version 1

Watermarked PDF · For organizational use

Version 2 · Comprehensive Mock Survey FrameworkNew expanded version

Pediatric ICF/IID Comprehensive Mock Survey Guide

An expanded operational guide with measurable survey tasks, medication and clinical tracers, high-risk corrective-action requirements, and a complete two-day mock survey schedule.

  • 52 pages
  • PDF
  • Printable checkboxes
  • Watermarked
Download Version 2

Watermarked PDF · For organizational use

What Version 2 adds

  • Every survey task now carries a defined measurable — what is reviewed, the sample, the expected standard, and the follow-up when the target is not met.
  • A high-risk intervention framework: identifying an error is not the finding. The finding must show how the resident/patient is protected now and how recurrence is prevented.
  • A prescription-to-administration medication tracer covering twenty linked points, with a calculated alignment percentage.
  • A document location and retrieval test — staff demonstrate where a current record is, rather than stating that it exists.
  • Enteral feeding definition, port identification and labeling verification, with a direct-observation measurable.
  • A standardized medication and treatment cart audit producing an overall compliance percentage.
  • A standing-orders and protocol test using resident/patient scenarios.
  • A required structure for every mock survey finding, with risk level, mitigation factors, owner, monitoring, and status.
  • A complete two-day mock survey time-and-task plan, post-survey report development, and 30-day sustained-compliance verification.
  • Eighteen printable worksheets covering the full engagement.
  • Terminology changed to resident/patient throughout.

Version 2 uses resident/patient throughout, in line with current practice. Version 1 follows the regulation's own term and is unchanged.

No sign-up required. Neither download collects personal or health information.

Scope of review

What state and CMS surveyors are looking for

Across survey types, the underlying questions are consistent. Surveyors are determining whether the facility delivers continuous active treatment and protects the people in its care — and whether what is written down is what actually happens.

Surveyors are determining whether

  • Each child receives continuous active treatment appropriate to assessed needs.
  • The Individual Program Plan is individualized, measurable, current, and actually implemented.
  • Physician orders, the IPP, staff practice, and documentation agree with one another.
  • Clients are protected from abuse, neglect, mistreatment, and avoidable harm.
  • Staff understand each child's needs and can demonstrate the competencies their role requires.
  • Clinical care is delivered safely and consistently, not just described in policy.
  • Incidents are recognized, reported, investigated, corrected, and monitored for recurrence.
  • Leadership identifies and corrects risk before it becomes repeated or systemic.
  • The physical environment is clean, safe, appropriately maintained, and prepared for emergencies.

Methods surveyors may use

  • Direct observation of care and interaction
  • Client-level tracers
  • Direct care staff interviews
  • Leadership interviews
  • Client record review
  • Drug pass observation and pharmacy review
  • Policy and procedure review
  • Incident and investigation review
  • Environmental and infection-prevention inspection
  • Review of previous deficiencies and Plans of Correction
  • Review of quality data and evidence that correction was sustained

Observation is the primary method — not paperwork

CMS survey guidance is explicit that observation leads. Appendix J instructs surveyors to "use observation as the primary method of information gathering" and to conduct interviews and record reviews afterward to confirm specific issues. It also directs that in-depth review of progress notes or historical data is not performed unless outcomes fail to occur for clients.

The practical implication for leadership: preparing the paperwork is not preparing for the survey. If bedside practice does not match the record, tidy documentation makes the discrepancy easier to find, not harder.

CMS State Operations Manual, Appendix J, Part I — Survey Protocol (Rev. 178, eff. 04-13-18)

What to expect

How an ICF/IID survey is generally conducted

CMS guidance defines three survey levels and a sequence of survey tasks. The names below are those used in the survey protocol.

Focused fundamental survey

May be used for recertification surveys. Covers the entrance and exit plus Tasks One through Three, concentrating survey time on the basic elements of the active treatment process, with increased client observation time.

Extended survey

A recertification survey may be expanded to an extended survey at any point based on surveyor findings — for example where standard-level deficiencies suggest a Condition of Participation may be out of compliance.

Full survey

Required for initial certification surveys, and may be used for recertification where the State Survey Agency identifies concerns about the provider's capacity to furnish adequate services.

  1. Entrance conference

    Surveyors identify themselves, explain the scope of the survey, and request initial information. Leadership should be notified immediately and the facility's survey liaison assigned.

  2. Task One — Sample selection

    Selection of the clients whose care and records will be examined. Expect medically complex and higher-risk children to be selected: tracheostomy and ventilator support, seizure disorders, enteral feeding, diabetes, behavioral supports, recent hospitalization, falls, weight loss, or pressure injury.

  3. Task Two — Review of facility systems to prevent abuse, neglect and mistreatment, and to resolve complaints

    Conducted in two phases, combining observation, interviews, and record review to test whether the facility's protective systems function in practice.

  4. Task Three — Focused observation

    Sustained observation of active treatment, interactions, and daily routines for the sampled clients.

  5. Task Four — Required interviews with clients, family or advocates, and direct care staff

    Interviews explore whether staff know the individual children they support, what those children's objectives are, and how staff carry them out.

  6. Task Five — Drug pass observation

    Direct observation of medication administration. This is a distinct, named survey task — medication practice is watched, not only reviewed on paper.

  7. Task Six — Visit to each area of the facility serving certified clients

    Environmental review of every living and program area in use, including cleanliness, safety, equipment, and infection prevention.

  8. Task Seven — Record review of clients in the sample

    Record review focused on the Individual Program Plan, the comprehensive functional assessment, program monitoring and change, and health and safety supports.

  9. Exit conference

    Surveyors present findings. The facility should record what is described, ask clarifying questions, and avoid speculating about matters it has not verified.

  10. Plan of Correction and follow-up, where applicable

    Where deficiencies are cited, the facility prepares a Plan of Correction and is subject to follow-up verification.

Order and scope can change. The order and scope can change during the survey. Observations, complaints, previous deficiencies, immediate risks, or inconsistencies found on site can all expand or redirect a review, and a recertification survey can be converted to an extended or full survey based on findings.

Readiness domains

Ten areas to verify before surveyors arrive

Each domain follows the same structure: what surveyors may examine, what to verify, common warning signs, evidence to have ready, and what to do immediately when a gap is found.

1. Active Treatment and Individual Program Plans

42 CFR 483.440

Active treatment is the centre of the ICF/IID model, and the declared principal focus of the survey process. The facility must demonstrate more than custodial care: a continuous programme of interventions and services, at sufficient intensity and frequency, directed at the objectives in each child's IPP.

What surveyors may examine

  • Whether each client receives a continuous active treatment programme, observed in daily routines rather than described in a binder
  • Whether the comprehensive functional assessment is accurate, current, and identifies strengths, needed skills, and presenting disabilities
  • Whether the IPP identifies discrete, measurable, criteria-based objectives
  • Whether the specific strategies, supports, and techniques named in the IPP are the ones staff actually use
  • Whether the interdisciplinary team reviews the assessment at least annually and revises the IPP as appropriate
  • Whether progress data is systematic and behaviourally stated, and whether it drives change to the programme

What the facility should verify

  • Every client in the facility has a current comprehensive functional assessment and a current IPP
  • Each IPP objective is measurable and has an identified criterion for achievement
  • Interventions named in the IPP appear in the daily schedule and in staff assignments
  • Progress data is being recorded at the stated frequency, by the staff responsible
  • Plans have been revised where a child is not progressing, or where the child's condition has changed
  • Staff on each shift can state a given child's current objectives and their own role in them

Common warning signs

  • Objectives written in general terms with no measurable criterion
  • Data sheets with gaps, or completed in a single hand at the end of a period
  • Plans unchanged for a year despite flat or declining progress
  • Staff describing a child's programme differently from the written IPP
  • Scheduled interventions displaced routinely by staffing pressure
  • Active treatment observable in the classroom or therapy room but not in daily living routines

Evidence that should be ready

  • Current comprehensive functional assessment for each sampled client
  • Current IPP with measurable objectives and named strategies
  • Progress data supporting each active objective
  • Interdisciplinary team review records and evidence of revision
  • Daily schedules and staff assignment records showing when interventions occur

If a gap is found

  • Record the gap as found — do not reconstruct data that was not collected
  • Escalate to the QIDP and administrator the same day
  • Convene the interdisciplinary team to review whether the plan or its implementation is the failure point
  • Put the corrective action in writing with an owner, a deadline, and a monitoring method
  • Document the date the gap was identified, separately from the date it was corrected

2. Nursing and Clinical Care

42 CFR 483.460 — Health care services

Surveyors trace medically complex children through the whole chain: physician order, nursing assessment, plan, staff practice at the bedside, documentation, and the response when something changes. The central question is whether the documented plan and the physician orders match what staff are actually doing.

What surveyors may examine

  • Physician services and physician participation in the IPP
  • Nursing services and nursing staff sufficiency for the population served
  • High-risk care: seizure management, enteral feeding and gastrostomy or jejunostomy care, tracheostomy and respiratory care, oxygen administration, suctioning, catheterization, insulin and diabetes management
  • Skin integrity, wound prevention, and repositioning practice
  • Recognition of and response to change in condition
  • Timeliness of physician and representative notification
  • Hospital and emergency department transfers, and what happened on return

What the facility should verify

  • Every high-risk intervention in use has a current physician order and a corresponding nursing plan
  • Parameters — when to hold, when to call, when to escalate — are written where the administering staff member will actually see them
  • Change-in-condition documentation shows assessment, action, notification, and outcome
  • Post-hospitalization records are reconciled: orders, medications, and plans updated on return
  • Nursing assessments are completed at the required intervals for each client
  • Staff performing high-risk procedures are currently competency-validated for that specific procedure

Common warning signs

  • Bedside practice differing from the written procedure
  • Change-in-condition notes with no documented notification or follow-up
  • Orders and plans not reconciled after a hospital return
  • Seizure or respiratory events recorded in one place but absent from the clinical record
  • Parameters stored centrally but unavailable at the point of care
  • Care delivered by staff whose competency validation has lapsed

Evidence that should be ready

  • Physician orders and evidence of physician participation in the IPP
  • Nursing assessments and notes for the review period
  • Procedure-specific competency validations for staff on duty
  • Change-in-condition, transfer, and return-to-facility documentation
  • Skin, weight, hydration, and monitoring records

If a gap is found

  • Address any immediate clinical risk to the child first
  • Notify the physician and the representative where the gap affects care
  • Record the finding transparently, with the date it was discovered
  • Re-validate competency before the staff member next performs the procedure
  • Add the item to the corrective action log with an owner and a monitoring interval

3. Medication Management

42 CFR 483.460(i)–(m); 483.450(e)

Medication is the most traceable system in the building. A surveyor can follow an objective trail from the physician order to the pharmacy label, the MAR or TAR, the administration itself, the monitoring, and the clinical response — and drug pass observation is a named survey task in its own right.

What surveyors may examine

  • Pharmacy services, drug regimen review, drug administration, drug storage and recordkeeping, and drug labeling
  • Drug usage in relation to client behaviour, including whether medication is used as a substitute for active treatment
  • Agreement between order, pharmacy label, MAR/TAR, and observed administration
  • Missed and late doses, and what the facility did about them
  • PRN indications, administration, effectiveness, and follow-up
  • Expiry and beyond-use dating, storage temperature, and security
  • Controlled substance reconciliation
  • Medication errors: reporting, investigation, correction, and monitoring

What the facility should verify

  • Every medication in use has a current, valid physician order
  • Required laboratory and clinical monitoring is current for every medication that requires it
  • Medication parameters are available to the administering staff member and are followed
  • Discontinued medications have been removed from active storage
  • Staff administering medications hold current authorization, training, and competency validation
  • Observed administration practice matches policy, order, and documentation

Common warning signs

  • MAR entries pre-signed ahead of administration
  • PRN doses recorded with no indication or no documented effect
  • Open-dated products with no date, or past their beyond-use date
  • Refrigerator logs with gaps, or readings outside range with no action recorded
  • Controlled substance counts that reconcile only after adjustment
  • Pharmacy recommendations received but never actioned

Evidence that should be ready

  • Current physician orders reconciled against the MAR and TAR
  • Pharmacy drug regimen review reports and evidence of response
  • Medication error reports with investigation and corrective action
  • Controlled substance records and reconciliation logs
  • Refrigerator and medication room temperature logs
  • Medication administration competency validations

If a gap is found

  • Where a dose was missed or given in error, assess the child and notify the physician per policy
  • Complete a medication error report contemporaneously — never adjust the original entry to remove the discrepancy
  • Remove expired, undated, or discontinued stock immediately and record its disposal
  • Report controlled substance discrepancies through the facility's required channel without delay
  • Track the correction to closure with a defined monitoring period

4. Documentation Consistency

42 CFR 483.410(c) — Client records

Documentation should not merely be complete; it should be internally consistent. When one part of a record contradicts another, the discrepancy is usually what causes a surveyor to widen the review.

What surveyors may examine

  • Agreement between the physician order, the MAR and TAR, nursing documentation, clinical flowsheets, and the IPP
  • Whether incident reports match the clinical record for the same event
  • Whether hospital and emergency department records are reflected in the plan and the orders
  • Whether client records are complete, accessible, and safeguarded
  • Whether entries are dated, timed, and attributable to an identified author

What the facility should verify

  • Order, MAR/TAR, plan, and nursing note describe the same care for the same child on the same date
  • Every incident in the incident log has a corresponding clinical entry, and the reverse
  • Weights, intake and output, and monitoring data are recorded at the ordered frequency
  • Records for sampled clients can be produced promptly and in full
  • Late entries are identified as late entries, with the date of entry and the date of care both shown

Common warning signs

  • The same event described with different times or details in two records
  • Blank spaces on flowsheets with no explanation
  • Documentation completed in blocks rather than at the time of care
  • Records that cannot be located within a reasonable time
  • Corrections made in a way that obscures the original entry

Evidence that should be ready

  • Complete client records for the sampled children, organized and retrievable
  • Incident log cross-referenced to clinical entries
  • Monitoring records at the ordered frequency
  • Records retention and access procedure

If a gap is found

  • Never backdate, recreate, or overwrite a record. Correct in line with policy so the original entry stays visible
  • Where care occurred but was not documented, record it as a late entry showing both dates and the reason
  • Where it cannot be established that care occurred, escalate it as a care issue rather than a documentation issue
  • Log the discrepancy for quality review and identify the systemic cause

5. Incidents, Injuries, Abuse and Neglect Prevention

42 CFR 483.420(d) — Staff treatment of clients

Surveyors work backwards from an incident. The test is whether the facility recognized it, reported it, investigated it thoroughly, analysed why it happened, corrected the cause, and monitored to confirm it did not recur.

What surveyors may examine

  • Whether the facility has and uses written policies prohibiting mistreatment, neglect, and abuse
  • Whether alleged violations are reported immediately to the administrator and to the required agencies
  • Whether investigations are thorough and documented, and whether the client was protected during them
  • Falls, unexplained injuries, medication errors, hospitalizations, seizures, aspiration events, feeding-related incidents, and behavioural incidents
  • Whether staff can state how to recognize and report suspected abuse or neglect
  • Whether corrective action followed the investigation, and whether recurrence was monitored

What the facility should verify

  • Every incident type is captured in the log, including near misses where policy requires it
  • Reporting timeframes were met and are evidenced
  • Investigations reach a conclusion and identify a cause, not just a description
  • Protective measures during investigation are documented
  • Trends are reviewed at leadership level, not only case by case
  • Staff on every shift can describe the reporting route without prompting

Common warning signs

  • Injuries of unknown origin recorded without investigation
  • Investigations that close with no cause identified
  • The same incident type recurring for the same child with no change to the plan
  • Delays between the event, the report, and the investigation
  • Staff naming different reporting routes

Evidence that should be ready

  • Incident log for the review period
  • Abuse and neglect investigation files with conclusions and corrective actions
  • Evidence of required external reporting
  • Grievance records and their resolution
  • Trend analysis presented to leadership

If a gap is found

  • Protect the child first, then report through the required channel immediately
  • Do not delay an external report while the internal investigation is completed
  • Document what was known at each point in time rather than reconstructing a tidy narrative
  • Where an incident was never reported, report it now and record why the original report did not occur
  • Treat repeated incidents of the same type as a systems finding for quality review

6. Staff Competency and Training

42 CFR 483.430 — Facility staffing

Training records alone may not establish competency. Surveyors may interview staff or ask them to demonstrate a procedure, and the question is whether the staff member can explain and perform the care this particular child requires.

What surveyors may examine

  • QIDP qualifications and the sufficiency of professional programme services
  • Direct care staff numbers and the staff training programme
  • Staff knowledge of individual-specific plans for the children they support
  • Competency with high-risk clinical procedures, demonstrated rather than attested
  • Emergency response knowledge and understanding of medication parameters
  • Evidence of competency validation beyond attendance at a training session

What the facility should verify

  • Every staff member performing a high-risk procedure has a current, procedure-specific competency validation
  • Validation records name the observer, the date, and the procedure observed
  • Agency and float staff are validated for the procedures they will perform
  • Staff can locate a child's current plan without assistance
  • Training content matches the population actually served
  • Competency is revalidated after an incident involving that procedure

Common warning signs

  • Attendance sheets used as evidence of competency
  • Validations signed in batches on a single date
  • Staff performing procedures for which no validation exists
  • Staff unable to state a child's objectives or their own role in them
  • Emergency response described differently by different staff

Evidence that should be ready

  • Staff training records and competency validations, indexed by procedure
  • Licences and required credentials, current
  • QIDP documentation
  • Organizational chart and staff schedules for the review period
  • Orientation records for agency and newly assigned staff

If a gap is found

  • Remove the procedure from that staff member's assignment until validation is complete
  • Re-validate by direct observation, not by re-issuing a certificate
  • Record the date the gap was found and the interim staffing arrangement
  • Review whether other staff hold the same gap before treating it as isolated

7. Client Rights

42 CFR 483.420 — Client protections

Client rights should be evident in policy, in documentation, in staff behaviour, in the environment, and in day-to-day care. Surveyors will look for all five, and observation carries the most weight.

What surveyors may examine

  • Protection of clients' rights, client finances, and communication with clients, parents and guardians
  • Dignity and respectful treatment, observed in ordinary interactions
  • Privacy during personal care
  • Informed consent, and that consents on file are current and specific
  • Access to family and representatives, and personal possessions
  • Grievance processes and their outcomes
  • Whether restrictions are the least restrictive appropriate option, with the required review

What the facility should verify

  • Required consents are present, current, and signed by the appropriate party
  • Restrictive measures have documented justification and time-limited review
  • Family and representative notifications occurred and are recorded
  • Grievances are logged, resolved, and communicated back
  • Personal possessions and client funds are handled as policy requires
  • Staff speak to and about children in a manner consistent with dignity

Common warning signs

  • Consents that are generic, undated, or signed by an unauthorized party
  • Restrictions continued past their review date
  • Personal care provided without privacy measures
  • Grievances recorded with no resolution
  • Discussion of children in communal areas

Evidence that should be ready

  • Consent records for the sampled clients
  • Restriction documentation with review dates
  • Family and representative notification records
  • Grievance log and outcomes
  • Client funds records where applicable

If a gap is found

  • Obtain a valid consent before continuing an intervention that requires one
  • End a restriction that lacks current justification and document the decision
  • Notify the representative where notification was missed, and record the delay honestly
  • Refer any dignity concern observed in practice to the abuse and neglect process if it meets that threshold

8. Nutrition and Enteral Feeding

42 CFR 483.480 — Dietetic services

For medically complex pediatric clients, a surveyor can trace a feeding order directly to bedside practice and documentation in a few minutes. Formula, rate, route, and port identification are checked against the order as given.

What surveyors may examine

  • Food and nutrition services, meal services, menus, and dining areas and service
  • Correct formula, rate, volume, route, and schedule against the current order
  • Accurate gastrostomy and jejunostomy port identification
  • Tube placement verification where required, and aspiration precautions
  • Weight, hydration, and nutritional monitoring at ordered intervals
  • Dietitian recommendations and whether they were actioned
  • Documentation of feeding tolerance

What the facility should verify

  • The formula and rate hanging at the bedside match the current physician order
  • Ports are labelled and staff can identify which is which for each child
  • Positioning and aspiration precautions are observed in practice, not only written
  • Weights are taken at the ordered frequency and acted upon when they trend
  • Dietitian recommendations have a documented response
  • Feeding equipment is cleaned and stored as policy requires

Common warning signs

  • Bedside formula or rate differing from the order
  • Weight trends visible in the record with no intervention
  • Missing tolerance documentation for children with a history of intolerance
  • Feeding supplies stored uncovered or undated
  • Positioning not maintained during or after feeds

Evidence that should be ready

  • Current enteral feeding orders
  • Weight and hydration monitoring records
  • Dietitian assessments and recommendations with responses
  • Feeding tolerance documentation
  • Menus and therapeutic diet records

If a gap is found

  • Stop and correct any bedside mismatch immediately, then notify the nurse and physician
  • Document the discrepancy as an incident where policy requires it
  • Re-verify every other feeding order in the building before assuming the error was isolated
  • Add feeding-order reconciliation to the monitoring plan

9. Infection Prevention and Environment

42 CFR 483.470 — Physical environment; 483.470(l); 483.475 — Emergency preparedness

Surveyors combine record review with direct observation to determine whether infection control policies are reflected in actual practice, and they visit every area of the facility serving certified clients.

What surveyors may examine

  • Client living environment, bedrooms, bathrooms, storage, space and equipment
  • Heating, ventilation, floors, paint, and general maintenance
  • Infection control practice: hand hygiene, PPE use, medication preparation, equipment cleaning and storage
  • Enteral and respiratory supply handling, isolation precautions, and infection surveillance
  • Emergency plan and procedures, evacuation drills, and fire protection
  • Emergency preparedness requirements

What the facility should verify

  • Hand hygiene and PPE practice observed on every shift, including at night
  • Equipment is cleaned, dated, and stored so clean and soiled do not mix
  • Respiratory and enteral supplies are dated on opening and changed on schedule
  • Surveillance data is collected, analysed, and reported to leadership
  • Evacuation drills are conducted at the required frequency and documented, including night shift
  • Emergency supplies and equipment are present, sealed where required, and unexpired

Common warning signs

  • Hand hygiene performed inconsistently when observed over a full pass
  • Supplies opened but undated
  • Clean and soiled items sharing storage
  • Drills documented only for day shift
  • Maintenance issues logged but unresolved over successive months

Evidence that should be ready

  • Infection prevention records and surveillance data
  • Cleaning and equipment maintenance schedules and logs
  • Environmental inspection records
  • Emergency preparedness plan, drill records, and fire protection documentation
  • Water temperature and safety check logs

If a gap is found

  • Correct an immediate safety hazard at once and record what was done
  • Where a drill or check was missed, schedule it and record the miss rather than dating it retrospectively
  • Treat repeated environmental findings as a maintenance systems issue for quality review
  • Re-educate at the point of practice, then re-observe to confirm the change held

10. Quality Management and Corrective Action

42 CFR 483.410 — Governing body and management

Strong organizations demonstrate that leadership identifies problems proactively rather than waiting for a surveyor to identify them. Surveyors examine previous deficiencies and Plans of Correction, and look for evidence that the correction was implemented and sustained.

What surveyors may examine

  • Whether the governing body exercises general policy direction and is responsible for the facility's operation
  • Identification of problems and trends, and the data used to find them
  • Root cause analysis rather than description
  • Corrective action planning with owners and deadlines
  • Staff education and intervention following a finding
  • Monitoring of corrective actions and evidence that improvement was sustained
  • Previous survey reports and Plans of Correction

What the facility should verify

  • Each previous citation has evidence of implementation and of sustained compliance, not just a submitted Plan of Correction
  • Quality data is current, relevant, and actually reviewed at leadership meetings
  • Corrective actions have a named owner, a deadline, and a monitoring interval
  • Monitoring continued long enough to show the change held
  • Issues found internally are logged with the same rigour as issues found externally
  • Committee and leadership meeting records show decisions, not just attendance

Common warning signs

  • A Plan of Correction with no evidence of what happened after submission
  • The same deficiency cited at successive surveys
  • Quality data collected but not analysed
  • Corrective actions with no owner or no end date
  • Monitoring that stopped as soon as the immediate pressure passed

Evidence that should be ready

  • Previous survey reports and Plans of Correction
  • Evidence that each correction was implemented and sustained
  • Quality and performance data with analysis
  • Committee and leadership meeting records
  • Corrective action log with owners, deadlines, and monitoring results

If a gap is found

  • Where a previous correction did not hold, say so and re-analyse the cause rather than restating the original action
  • Distinguish a failure of the plan from a failure to implement it — the corrective action differs
  • Assign a named owner and a monitoring interval before closing the item
  • Report unresolved high-risk items to the governing body

Checklist

Documentation readiness

Organize requested records without altering original documentation. Where something cannot be located, record that fact rather than reconstructing it.

Individual client records

For each client selected for review. Organize without altering original documentation.

  • Current comprehensive functional assessment
  • Current Individual Program Plan (IPP)
  • Measurable objectives with criteria for achievement
  • Evidence that active-treatment interventions are implemented
  • Progress data supporting each active objective
  • Evidence of IPP review and revision
  • Physician orders, current and reconciled
  • Nursing assessments
  • Nursing notes
  • Medication Administration Record (MAR)
  • Treatment Administration Record (TAR)
  • Therapy documentation (PT, OT, speech, and others as applicable)
  • Behavioral documentation and support plans
  • Nutritional documentation and dietitian recommendations
  • Weight and hydration monitoring
  • Hospital and emergency department records
  • Discharge and transition documentation
  • Family or representative notifications
  • Required consents, current and specific
  • Incident reports
  • Investigation records
  • Follow-up and corrective actions

Facility-level documents

Held centrally and retrievable on request.

  • Current policies and procedures
  • Organizational chart
  • Staff schedules for the review period
  • Licenses and required credentials
  • QIDP documentation
  • Staff training records
  • Competency validations, indexed by procedure
  • Infection-prevention records and surveillance data
  • Emergency-preparedness records, including drill documentation
  • Medication-error reports with investigation and outcome
  • Controlled-substance records and reconciliation logs
  • Quality and performance data with analysis
  • Previous survey reports
  • Plans of Correction
  • Evidence that previous corrections were implemented and sustained
  • Incident logs
  • Abuse and neglect investigations
  • Grievance records and resolutions
  • Committee and leadership meeting records
  • Equipment maintenance records
  • Environmental inspection records

If you find a gap, correct it transparently

Do not alter, backdate, recreate, or conceal documentation at any point in survey preparation. Where a missing or inconsistent record is discovered, escalate it to the administrator or Director of Nursing, record the correction transparently in line with facility policy so the original entry remains visible, and implement an appropriate corrective action with an owner and a monitoring interval. A discovered and correctly handled gap is a manageable finding. Never alter a record to remove a discrepancy — doing so is a far more serious matter than the gap itself.

Medication and pharmacy

Medication and pharmacy readiness check

Medication is the most traceable system in the facility — order, pharmacy label, MAR or TAR, administration, monitoring, clinical response. Drug pass observation is a named survey task in its own right.

Orders, accuracy, and agreement

  • Every medication has a current, valid physician order
  • Medication name, strength, dose, route, time, frequency, and parameters match across the order, the pharmacy label, the MAR, and actual administration
  • Discontinued medications have been removed from active storage
  • Allergies are documented consistently everywhere they appear
  • Medication parameters are available at the point of administration and are followed
  • The facility has documented action for unavailable or missed medications

Dating, expiry, and beyond-use

  • No medication in the building is expired
  • No opened multidose vial, liquid, insulin, eye drop, inhaler, topical medication, feeding product, or other time-limited product has exceeded its beyond-use date
  • Opened medications are dated and initialed where required
  • Emergency medications and supplies are present, sealed where required, and unexpired

PRN and monitoring

  • PRN indications are clear and specific to the client
  • PRN effectiveness and follow-up are documented after administration
  • Required laboratory and clinical monitoring is current for every medication requiring it
  • Pharmacy recommendations and drug regimen review findings have been reviewed and acted upon

Storage, security, and controlled substances

  • Medications are stored under correct temperature and security conditions
  • Refrigerator temperature logs are complete and within the required range, with action recorded for any excursion
  • Controlled substances are secured, counted, reconciled, and free from unexplained discrepancies
  • Medication carts and medication rooms are clean, organized, locked, and free of expired or discontinued items

Practice, competency, and administration technique

  • Staff administering medications hold current authorization, training, and competency validation
  • Crushing, enteral administration, timing with feeds, and tube-flushing procedures match the order and pharmacy guidance
  • Medication administration practice observed at the bedside matches policy and documentation
  • Medication errors have been reported, investigated, corrected, and monitored

Final medication sweep — day before

Walk the building. Check each area physically rather than from a list on a desk.

  • Medication room
  • Medication carts
  • Refrigerators
  • Emergency kits
  • Controlled substances
  • Individual medication bins
  • Treatment supplies
  • Expiration dates
  • Open dates
  • MAR/TAR accuracy
  • Physician-order reconciliation
  • Pharmacy follow-up items

Tracer method

The five-question readiness test

A facility can have excellent policies and still receive deficiencies when these five elements do not align. Apply all five to every high-risk client tracer — following the record from order to plan, to competency, to bedside observation, to documentation, to incident and quality review, and finally to leadership oversight.

  1. 1

    Is it ordered?

    A current, valid physician order exists for the care being given.

  2. 2

    Is it in the plan?

    The IPP or clinical plan reflects the same care, with measurable objectives where applicable.

  3. 3

    Was it actually done?

    Observation at the point of care confirms the intervention happens as written.

  4. 4

    Was it documented?

    The record shows it was done, when, by whom, and with what result.

  5. 5

    Did leadership verify that it continues to happen?

    Monitoring evidence shows the practice held after the initial correction or education.

Apply all five to

  • Medications
  • Treatments
  • Enteral feeding
  • Respiratory care
  • Seizure management
  • Behavioral supports
  • Therapy
  • Nutrition
  • Infection prevention
  • Incident follow-up
  • Staff competencies
  • Every high-risk client tracer

Timeline

Preparing — and staying prepared

What to do in the month, week, and day before a survey — and on the day itself. Continuous readiness makes most of this routine rather than exceptional.

30 days before

Or as part of continuous readiness

The work below is the same work that keeps a facility ready year-round. Treating it as a pre-survey exercise is what creates the scramble.

  • Review previous deficiencies and Plans of Correction
  • Conduct a leadership risk assessment
  • Select high-risk client tracers
  • Audit documentation consistency across order, MAR/TAR, plan, and notes
  • Review active-treatment implementation by observation
  • Review incidents and investigations for the period
  • Validate staff competencies for high-risk procedures
  • Review medication-management systems end to end
  • Inspect the environment, including areas not in daily use
  • Assign corrective-action owners and deadlines
7 days before

Close the loop on known risk

  • Recheck unresolved high-risk findings
  • Verify medication and supply expirations
  • Reconcile physician orders, IPPs, MARs, and TARs
  • Confirm required records are accessible
  • Confirm leadership and staff responsibilities during a survey
  • Conduct staff interview practice — in staff members' own words, not scripts
  • Verify emergency and infection-prevention readiness
  • Confirm that corrective actions are supported by evidence
Day before

Final sweep

  • Complete the final medication sweep
  • Review high-risk child tracers
  • Check cleanliness, storage, equipment, and safety
  • Organize requested records without altering original documentation
  • Confirm leadership contact procedures
  • Ensure staff know how to locate policies and individual plans
  • Verify survey workspace and document-access arrangements
Survey day

Command and conduct

  • Notify leadership immediately
  • Verify surveyor credentials according to facility policy
  • Conduct the entrance conference
  • Assign an authorized survey liaison
  • Maintain a request log
  • Record which documents were provided
  • Respond accurately and concisely
  • Do not speculate or conceal information
  • Correct immediate safety concerns when appropriate
  • Preserve copies of materials provided when permitted
  • Document survey questions and observations
  • Prepare for the exit conference
After the survey

Correction that holds

  • Conduct an internal debrief
  • Preserve all survey-related notes and requests
  • Validate each cited finding against the record
  • Identify immediate-risk items and act on them first
  • Create corrective actions with owners and deadlines
  • Determine root causes rather than restating the finding
  • Establish monitoring and sustained-compliance evidence
  • Prepare the Plan of Correction when required
  • Schedule follow-up verification

Staff interviews

What staff may be asked

Surveyors may interview direct care staff or ask them to demonstrate a procedure. Training records alone may not establish competency.

  • What are this child's current goals?
  • What is your role in implementing the IPP?
  • What would you do if the child's condition changed?
  • What are the medication or treatment parameters?
  • How do you report suspected abuse or neglect?
  • Where do you find the child's current plan?
  • How do you respond to a seizure, aspiration event, or respiratory emergency?
  • How was your competency for this procedure validated?
  • What corrective actions were introduced after the last incident?

Prepare staff to answer honestly, not to recite

Staff should answer in their own words, from their own practice. Rehearsed answers are transparent to an experienced surveyor and undermine credibility for the rest of the survey. If a staff member does not know something, the correct answer is where they would find it or who they would ask — which is itself evidence of a working system. Do not coach staff to conceal problems or to give answers they cannot support.

Where interview practice reveals that staff genuinely do not know a child's plan or their own role in it, that is a competency finding to correct now — not a scripting problem to paper over.

Sources

Regulatory basis

Verify the current official text before relying on any citation. Regulations and survey guidance are revised, and state requirements may exceed the federal Conditions of Participation.

Pediatric Compliance Partners provides healthcare consulting and educational services. Services do not constitute legal advice, regulatory approval, or a guarantee of survey or accreditation outcomes. Pediatric Compliance Partners is not affiliated with, approved by, or endorsed by CMS, any state survey agency, or any accrediting body, and this guide does not guarantee a deficiency-free survey.

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