What are the Top Survey Readiness Strategies for Hospice Care Agencies?

For hospice organizations, survey readiness is not an annual event. It’s an ongoing state of operational improvement and monitoring. The Centers for Medicare & Medicaid Services (CMS) and accrediting bodies such as ACHC, CHAP, and The Joint Commission focus on patient-centered care, documentation integrity, and the link between quality and compliance. In today’s environment, hospices that treat survey readiness as a daily discipline are better positioned to maintain compliance and protect reimbursement. In this article we will cover several survey readiness strategies.

Build a Culture of Ongoing Readiness

The foundation of survey readiness is cultural, not procedural. The most compliant organizations incorporate survey preparedness into their daily routines rather than segregating it as a standalone project. Leaders can set the tone by emphasizing that compliance is inextricably linked to quality and by creating an environment of transparency.

A continuous readiness culture includes:

• Routine self-audits of clinical records, billing accuracy, and plan of care updates.
• Embedding regulatory awareness into team huddles, staff meetings, and onboarding.
• Encouraging staff to speak up about documentation or care gaps without fear of blame and celebrating when someone proactively finds gaps.

When employees view surveys as validation of the good work they already do, both performance and morale improve.

Maintain Survey-Ready Documentation

Inadequate documentation is the most common and preventable source of survey deficiencies. Records need to show the rationale for eligibility, the narrative of decline, and the physician’s involvement in recertification. They should demonstrate symptom management, care coordination, and responsiveness to family concerns. A well-written record connects the plan of care to the actual interventions provided, and it evolves dynamically as the patient’s condition changes. Important side note, technology tools deigned for hospice care agencies like a solid hospice EMR can go a long way in assurance of strong documentation and records integrity.

At the end of the day, a good rule of thumb is that if an outside reviewer can’t understand why the patient is hospice-appropriate or how care is being managed from the documentation alone, the record isn’t survey-ready. 

Conduct Mock Surveys Regularly

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A well-run mock survey can be one of the most effective strategies to uncover and fix deficiencies before regulators do. Ideally, a hospice would conduct both internal and external mock surveys.

• Internal mock surveys help staff practice for surveyor interviews and to identify gaps in process or knowledge. Hospices can rotate internal “reviewers” to promote objectivity and cross-training.
• External mock surveys utilize experienced hospice consultants or former surveyors to simulate the tone, depth, and unpredictability of real surveys.

When conducting a mock survey, document all findings, corrective actions, and follow-up validation.

Strengthen IDG Processes and Documentation

Interdisciplinary Group (IDG) documentation remains an area of survey scrutiny. The IDG must demonstrate coordinated care planning, effective communication, and timely plan-of-care updates. Hospices should:

• Verify all required disciplines (nurse, social worker, chaplain, physician) participate meaningfully and that attendance is documented.
• Confirm that the IDG reviews all patients within the regulatory timeframe and updates plans of care accordingly.
• Avoid “copy-forward” plans. Surveyors look for individualized notes reflecting real-time changes in condition or goals.
• Ensure that the medical director’s participation is well-documented, especially regarding certification, recertification, and medication or treatment decisions.

Strong IDG processes are linked to better survey outcomes and quality of care.

Audit Conditions of Participation and Payment

Many hospices are on top of the Conditions of Participation (CoPs) but underestimate the importance of the Conditions of Payment. Failing to meet one can jeopardize certification while failing to meet the other can cost the organization its reimbursement. Regular internal audits should verify that certifications and recertifications are timely, that election statements meet CMS requirements, and that face-to-face encounters are properly documented and linked to the correct benefit period.

Operational leaders should also review their Notice of Election (NOE) and Change of Election processes to ensure timeliness. Missed submission deadlines remain some of the most frequent and costly errors. Ultimately, payment integrity is inseparable from clinical compliance.

Engage Staff Through Education and Real-Time Coaching

At survey-ready hospices, nurses, social workers, chaplains, and CNAs not only deliver quality care, but also understand how their actions and documentation align with regulations. Best practices include:

• Ongoing education. Incorporate short, focused sessions on common survey focus areas, such as medication reconciliation, care coordination, and patient rights.
• Providing real-time feedback. Instead of waiting for audit cycles, provide coaching immediately when documentation or process gaps occur.
• Role-playing survey interviews. Simulate surveyor questions, such as “How do you know this patient is eligible?”  or “Where is this documented?” to build staff confidence and consistency.

The team’s comfort level with discussing compliance topics leads to a better survey experience.

Monitor Quality Indicators and Performance Trends

CMS surveyors review Quality Assessment and Performance Improvement (QAPI) data as evidence of an organization’s self-governance. A strong QAPI program demonstrates how data leads to action.

For example, if medication reconciliation audits show inconsistencies, QAPI should lead to education, follow-up audits, and measurable improvement. Surveyors respond favorably to closed feedback loops: data identified the issue, leadership intervened, and the outcome improved.

Ensure Physical Environment and Safety Compliance

Physical environment and emergency preparedness standards matter during a survey. Hospice organizations should routinely review and update their:

• Emergency Preparedness Plans. Ensure all required elements (hazard vulnerability analysis, communication plans, training, and drills) are current and site-specific.
• Infection Control Program. Verify that logs, surveillance, and employee health records reflect ongoing monitoring.
• Medication Management: Check storage, labeling, and disposal practices in both facilities and patient homes.

To ensure readiness, hospice leaders can perform unannounced walk-throughs to evaluate cleanliness, signage, and staff knowledge of emergency procedures.

Manage Survey Logistics and Communication

When surveyors are on site, execution and communication are key. Assign clear roles in advance, such as:

• A survey lead to coordinate activities and serve as the primary point of contact.
• A document runner to retrieve records quickly.
• A scribe to capture questions, requests, and feedback in real time.
• Leaders on standby to clarify policies or provide interviews as needed.

Never argue about findings during the visit—clarify factual errors politely, but reserve formal rebuttals for the post-survey process if warranted.

Close the Loop After the Survey

The post-survey period is also important. The post-survey process—which entails reviewing findings, identifying root causes, and validating corrections—shows whether an organization is truly committed to continuous improvement. A timely, thorough Plan of Correction that includes responsible parties, timelines, and measurable verification steps demonstrates accountability. Hospice leaders should share lessons learned with various departments.

The Takeaway

Survey readiness is not just passing an inspection—it’s about cultivating operational excellence that honors the hospice mission of compassionate, compliant care. When leadership sets expectations for continuous readiness, engages staff in the “why” behind the standards, and maintains consistent self-auditing, surveys become a validation of quality.

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Author’s Note: Views, information, and guidance in this resource are intended for information only. We are not rendering legal, financial, accounting, medical, or other professional advice. Alora disclaims any liability to any third party and cannot make any guarantee related to the content.

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