Inside a Mock Survey: What Documentation Surveyors Actually Want to See

Preparing for a home health survey can feel overwhelming—surveyors seem to ask for everything at once, and agencies often struggle to prioritize what’s most important. That’s why mock surveys are one of the most powerful tools for readiness. They give you a clear picture of your agency’s compliance and allow you to fine-tune your documentation before CMS or accrediting bodies arrive.

At SummitRidge, we help agencies navigate mock surveys to take the guesswork out of preparation. Let’s walk through the documentation surveyors actually want to see—and how you can present it in a way that builds confidence.

Why Documentation Matters

Surveyors evaluate compliance with the Medicare Conditions of Participation (CoPs) (42 CFR Part 484). They do this by observing care, interviewing staff and patients, and—most importantly—reviewing documentation.

Documentation tells your agency’s story:

• How you admit, assess, and care for patients.

• How you track, investigate, and correct adverse events.

• How you ensure quality through your QAPI program.

• How your staff are trained, competent, and following policy.

If the documentation doesn’t exist—or is incomplete—it’s as if the compliance never happened.

The Core Documentation Surveyors Expect

A mock survey should mirror what surveyors look for during an actual visit. Here are the top categories of documentation they will request:

1. Patient Care Documentation

• Comprehensive Assessments (§484.55): Complete OASIS and individualized assessments.

• Plans of Care (§484.60): Current, physician-signed, and reflective of patient needs.

• Visit Notes: Evidence of services provided, consistent with orders.

• Discharge Summaries (§484.58): Timely and complete, including coordination with physicians.

Surveyors will often pull a patient list and request active and discharged records—be sure these are accurate and easy to access.

2. Quality Assessment and Performance Improvement (QAPI) Program (§484.65)

Surveyors want to see a living, breathing QAPI program. Documentation should include:

• Governing body meeting minutes that reference QAPI.

• Data reports (hospitalization rates, infection control, patient satisfaction).

• Active Performance Improvement Projects (PIPs) with goals, timelines, and outcomes.

• Annual program evaluation with measurable results.

Tip: Keep your QAPI binder (or digital equivalent) survey-ready at all times.

3. Infection Prevention and Control (§484.70)

This is a high-focus area for surveyors. Key documents include:

• Written infection control policies and procedures.

• Logs of infection surveillance and investigations.

• Staff training records in infection prevention.

• Evidence of corrective actions after outbreaks or infection-related incidents.

4. Personnel and Staff Competency (§484.75 & §484.80)

Surveyors will ask: “Can you prove your staff are qualified and competent?” Documentation should show:

• Personnel files with licenses, credentials, and background checks.

• Orientation and ongoing education records.

• Skills checklists and competency assessments (especially for home health aides).

• Supervision notes, including aide supervisory visits.

5. Governing Body & Administrative Oversight (§484.105)

Surveyors need to see that leadership is actively engaged in compliance. Documentation should include:

• Governing body meeting minutes.

• Organizational chart.

• Policies and procedures (current and reviewed annually).

• Evidence of budget approval and overall program oversight.

6. Emergency Preparedness (§484.102)

Surveyors expect proof that your agency can respond to emergencies. Documentation should include:

• All-hazards emergency preparedness plan.

• Risk assessments.

• Communication plans.

• Training and drills with after-action reports.

7. Other High-Interest Documentation

• Complaint logs and follow-up actions.

• Contract agreements with DME suppliers, pharmacies, labs, and facilities.

• Volunteer program records (if applicable).

• Clinical records policies for confidentiality and retention (§484.110).

• Incident reports and corrective actions.

How to Present Documentation During a Mock Survey

Surveyors aren’t just looking for paperwork—they’re looking for organization, consistency, and accessibility. Here’s how to prepare:

1. Centralize Access: Whether paper binders or electronic files, create a system that staff can access quickly.

2. Label Clearly: Use tabs, dividers, or digital folders that mirror the survey categories above.

3. Cross-Reference to CoPs: Highlight where each document ties back to regulations.

4. Keep It Current: Outdated policies or unsigned care plans are common citation triggers.

5. Train Staff: Staff should know where documents are kept and be able to explain their role in compliance.

What Surveyors Don’t Want

Surveyors don’t want to sift through stacks of unrelated paperwork. Overloading them with excessive or irrelevant documents can raise red flags. Instead, focus on:

• Accuracy – Does the documentation match practice?

• Completeness – Are all required signatures, dates, and data present?

• Timeliness – Were assessments, transmissions, and follow-ups done within regulatory timeframes?

Why Mock Surveys Pay Off

Mock surveys give agencies the chance to find and fix gaps before the official survey. At SummitRidge, we simulate real survey conditions by:

• Reviewing patient records against CoP requirements.

• Interviewing staff to assess readiness.

• Testing documentation retrieval and organization.

• Providing a prioritized action plan for corrections.

Agencies that conduct regular mock surveys approach real surveys with confidence instead of fear.

Documentation tells the story of your agency’s compliance, quality, and commitment to patient care. By focusing on the categories surveyors actually care about—and ensuring your team is ready to present them—you can transform the survey experience into an opportunity to showcase your strengths.

At SummitRidge, we specialize in helping agencies prepare with mock surveys, QAPI consulting, and ongoing compliance support. With the right preparation, your documentation won’t just pass review—it will impress.