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This guide covers getting survey-ready before a surveyor arrives, and responding when deficiencies are cited. Most survey findings are avoidable and involve records you already hold — they just have a blank field where evidence should be.

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Before you start

You need the Compliance Officer, Location Admin, or Organization Admin role.

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What surveyors examine

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The fields that cause findings

Almost every avoidable finding comes down to one of these being blank:
Run a pre-survey sweep filtering each of these fields for blanks. It takes an afternoon and catches most of what a surveyor would find.

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Preparing

1

Check licences and renewals

Work from Renewal Due, not Expires. See Licences and surveys.
2

Clear open compliance findings

Start with the aging count. See Compliance.
3

Sweep personnel files

Credentials with expiry dates, background checks current, orientation acknowledged, competency reassessment dates set.
4

Sweep member files

PAS consent, chart inventory done, member rights acknowledged, HHS forms signed.
5

Check care plans and supervisory visits

Nothing past Next Review or Next Due.
6

Confirm QAPI has closed initiatives with follow-up

Three closed initiatives with measured outcomes beat a dozen open ones.
7

Confirm governing body oversight

Meetings held, quorum met, QAPI and compliance reviewed.
8

Confirm emergency plans have been drilled

Check Last Drill against your required frequency.

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During the survey

1

Record the survey

Type, agency, and date in Licences and surveys.
2

Produce records from the system

Working from OfficeRidge rather than paper copies shows the records are live and maintained.
3

Note what is requested

Requests indicate where the surveyor is focusing.

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Responding to deficiencies

1

Record the outcome

NO_DEFICIENCIES, DEFICIENCIES_CITED, or IMMEDIATE_JEOPARDY.
2

Record each deficiency separately

One record per cited tag, with its own severity and deadline.
3

Note the POC Due date

Your plan of correction deadline, set by the surveying agency.
4

Correct each deficiency

Move Correction Status through to COMPLETED with a Completed date.
5

Track through to VERIFIED

The agency confirms the correction. COMPLETED is your view; VERIFIED is theirs.
6

Open QAPI initiatives for systemic causes

A deficiency reflecting a process problem needs an initiative, not just a fix.
An IMMEDIATE_JEOPARDY finding carries the shortest deadlines and the most serious consequences, including potential licence action. Escalate to your administrator the day it is cited.

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Pre-survey checklist

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Next

Compliance

Findings, audits, and the calendar.

QAPI

Turning findings into improvement.