CMS Mock Survey Checklist - FREE PDF
Conduct CMS mock survey for survey readiness.
- Industry: Healthcare
- Frequency: Quarterly / Annual
- Estimated Time: 8-40 hours
- Role: Quality / Administration
- Total Items: 32
- Compliance: CMS CoP, State Operations Manual
Compliance Review
Review CMS CoP requirements.
- Policy and procedure followed?
- Documentation complete and accurate?
- Regulatory requirements met?
Process Verification
Verify process implementation.
- Staff competent in process?
- Required equipment/supplies available?
- Process effective for patient safety?
Patient/Resident Impact
Assess impact on patient care.
- Patient safety maintained?
- Patient dignity and rights respected?
- Patient satisfaction addressed?
Findings & Corrective Actions
Document audit findings.
- Audit Result
- Deficiencies Found
- Corrective Actions Required
- Follow-up Required?
- Auditor Signature
Pre-Assessment Information
Initial assessment documentation and patient/facility identification
- Assessor Name / Credentials
- Assessment Date
- Department / Unit
- Assessment Type (Routine/Annual/Complaint)
- Previous assessment findings reviewed?
Infection Prevention & Control
Verify infection control practices per CDC and Joint Commission standards
- Hand hygiene compliance observed?
- Appropriate PPE available and properly used?
- Isolation precautions properly implemented?
- Sharps containers available and not overfilled?
- High-touch surfaces properly disinfected?
Patient Safety & Identification
Verify patient safety protocols and identification procedures
- Two patient identifiers used before procedures?
- Fall risk assessment completed?
- Call light within patient reach?
- Bed in lowest position with brakes locked?
Medication Safety & Management
Verify medication handling and administration practices
- Medications stored securely and at proper temperature?
- Controlled substances properly secured and counted?
- No expired medications in stock?
- High-alert medications properly labeled?
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Why Use This CMS Mock Survey Checklist?
This cms mock survey checklist helps healthcare teams maintain compliance and operational excellence. Designed for quality / administration professionals, this checklist covers 32 critical inspection points across 8 sections. Recommended frequency: quarterly / annual.
Ensures compliance with CMS CoP, State Operations Manual. Regulatory-aligned for audit readiness and inspection documentation.
Frequently Asked Questions
What does the CMS Mock Survey Checklist cover?
This checklist covers 32 inspection items across 8 sections: Compliance Review, Process Verification, Patient/Resident Impact, Findings & Corrective Actions, Pre-Assessment Information, Infection Prevention & Control, Patient Safety & Identification, Medication Safety & Management. It is designed for healthcare operations and compliance.
How often should this checklist be completed?
This checklist should be completed quarterly / annual. Each completion takes approximately 8-40 hours.
Who should use this CMS Mock Survey Checklist?
This checklist is designed for Quality / Administration professionals in the healthcare industry. It can be used for self-assessments, team audits, and regulatory compliance documentation.
Can I download this checklist as a PDF?
Yes, this checklist is available as a free PDF download. You can also use it digitally in the POPProbe mobile app for real-time data capture, photo documentation, and automatic reporting.