> ## Documentation Index
> Fetch the complete documentation index at: https://docs.officeridge.com/llms.txt
> Use this file to discover all available pages before exploring further.

# Survey preparation

> Get your agency survey-ready, and respond when deficiencies are cited.

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.

## Before you start

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

## What surveyors examine

| Area                                | Where the evidence lives                                |
| ----------------------------------- | ------------------------------------------------------- |
| Licences current                    | [Licences and surveys](/licensing/licenses-and-surveys) |
| Personnel files complete            | [Employees](/employees)                                 |
| Member files complete               | [Member records](/members/records)                      |
| Care plans current and reviewed     | [Care Plans](/care-plans)                               |
| Supervisory visits on schedule      | [Care Plans](/care-plans)                               |
| Member rights acknowledged          | [Member safeguards](/compliance/member-safeguards)      |
| Incidents reported and investigated | [Member safeguards](/compliance/member-safeguards)      |
| Complaints resolved                 | [Member safeguards](/compliance/member-safeguards)      |
| QAPI active with follow-up          | [QAPI](/compliance/qapi)                                |
| Governing body meeting with quorum  | [Governing body](/corporate/governing-body)             |
| Policies reviewed on schedule       | [Resources](/resources)                                 |
| Emergency plans drilled             | [Emergency Preparedness](/emergency)                    |
| Fraud prevention programme active   | [Fraud prevention](/operations/fraud-prevention)        |

## The fields that cause findings

Almost every avoidable finding comes down to one of these being blank:

| Field            | Where                                    | Why it matters                                |
| ---------------- | ---------------------------------------- | --------------------------------------------- |
| **Acknowledged** | Member rights, wage notices, orientation | Providing is not acknowledging                |
| **Signed**       | Texas HHS forms, compliance docs         | Generated is not signed                       |
| **Next Review**  | Care plans, policies, compliance docs    | Blank means never reviewed                    |
| **Next Due**     | Supervisory visits, risk assessments     | Blank means no cycle                          |
| **Reassess**     | Competency assessments                   | One-off assessment proves nothing ongoing     |
| **Expires**      | Credentials, background checks           | Blank means no expiry warning                 |
| **Follow-up**    | QAPI, drill critiques                    | Closed without follow-up shows no improvement |
| **Quorum Met**   | Board meetings                           | Decisions without quorum are invalid          |

<Tip>
  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.
</Tip>

## Preparing

<Steps>
  <Step title="Check licences and renewals">
    Work from **Renewal Due**, not **Expires**. See
    [Licences and surveys](/licensing/licenses-and-surveys).
  </Step>

  <Step title="Clear open compliance findings">
    Start with the aging count. See [Compliance](/compliance).
  </Step>

  <Step title="Sweep personnel files">
    Credentials with expiry dates, background checks current, orientation acknowledged, competency
    reassessment dates set.
  </Step>

  <Step title="Sweep member files">
    PAS consent, chart inventory done, member rights acknowledged, HHS forms signed.
  </Step>

  <Step title="Check care plans and supervisory visits">
    Nothing past **Next Review** or **Next Due**.
  </Step>

  <Step title="Confirm QAPI has closed initiatives with follow-up">
    Three closed initiatives with measured outcomes beat a dozen open ones.
  </Step>

  <Step title="Confirm governing body oversight">
    Meetings held, quorum met, QAPI and compliance reviewed.
  </Step>

  <Step title="Confirm emergency plans have been drilled">
    Check **Last Drill** against your required frequency.
  </Step>
</Steps>

## During the survey

<Steps>
  <Step title="Record the survey">
    Type, agency, and date in [Licences and surveys](/licensing/licenses-and-surveys).
  </Step>

  <Step title="Produce records from the system">
    Working from OfficeRidge rather than paper copies shows the records are live and maintained.
  </Step>

  <Step title="Note what is requested">
    Requests indicate where the surveyor is focusing.
  </Step>
</Steps>

## Responding to deficiencies

<Steps>
  <Step title="Record the outcome">
    `NO_DEFICIENCIES`, `DEFICIENCIES_CITED`, or `IMMEDIATE_JEOPARDY`.
  </Step>

  <Step title="Record each deficiency separately">
    One record per cited tag, with its own severity and deadline.
  </Step>

  <Step title="Note the POC Due date">
    Your plan of correction deadline, set by the surveying agency.
  </Step>

  <Step title="Correct each deficiency">
    Move **Correction Status** through to `COMPLETED` with a **Completed** date.
  </Step>

  <Step title="Track through to VERIFIED">
    The agency confirms the correction. `COMPLETED` is your view; `VERIFIED` is theirs.
  </Step>

  <Step title="Open QAPI initiatives for systemic causes">
    A deficiency reflecting a process problem needs an initiative, not just a fix.
  </Step>
</Steps>

<Warning>
  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.
</Warning>

## Pre-survey checklist

| Done | Item                                                                |
| :--: | ------------------------------------------------------------------- |
|   ☐  | All licences active, renewals in progress where due                 |
|   ☐  | Open compliance findings cleared, aging count low                   |
|   ☐  | No credentials or background checks expired or missing expiry dates |
|   ☐  | Orientation records acknowledged, not just sent                     |
|   ☐  | Competency reassessment dates set and current                       |
|   ☐  | TB clearances current with next screen dates                        |
|   ☐  | Fraud prevention training complete for all staff                    |
|   ☐  | Member rights acknowledged for every member                         |
|   ☐  | PAS consent and chart inventory recorded                            |
|   ☐  | Texas HHS forms signed, not just generated                          |
|   ☐  | Care plans active with next review dates                            |
|   ☐  | Supervisory visits current                                          |
|   ☐  | Incidents investigated and reported where required                  |
|   ☐  | Complaints resolved with resolution dates                           |
|   ☐  | QAPI initiatives closed with follow-up recorded                     |
|   ☐  | Governing body met with quorum and reviewed QAPI                    |
|   ☐  | Policies reviewed on schedule                                       |
|   ☐  | Emergency plans drilled with participation recorded                 |
|   ☐  | Business associate agreements current                               |
|   ☐  | Contingency agreements unexpired                                    |

## Next

<CardGroup cols={2}>
  <Card title="Compliance" icon="shield-check" href="/compliance">
    Findings, audits, and the calendar.
  </Card>

  <Card title="QAPI" icon="trending-up" href="/compliance/qapi">
    Turning findings into improvement.
  </Card>
</CardGroup>