The Centers for Medicare & Medicaid Services (CMS) is the federal agency responsible for administering the Medicare program and working with states to manage Medicaid and the Children’s Health Insurance Program (CHIP). To ensure healthcare facilities receiving federal funds meet minimum quality and safety requirements, CMS conducts regular regulatory inspections called surveys. These surveys serve as the primary tool for oversight, verifying that providers adhere to established standards to protect beneficiaries and maintain eligibility to participate in these government-funded programs. The entire survey process, including foundational rules, onsite methodology, and enforcement, is designed to compel compliance across the healthcare system.
The Regulatory Foundation and Purpose
Healthcare providers that wish to receive reimbursement from Medicare or Medicaid must comply with a detailed set of federal regulations. These requirements are broadly known as Conditions of Participation (CoPs) for providers like hospitals and nursing homes, or Conditions of Coverage (CoCs) for suppliers such as laboratories and durable medical equipment companies. The CoPs and CoCs outline the minimum health, safety, and quality standards a facility must meet to operate and receive federal payment.
The purpose of the CMS survey is to determine whether a provider is in substantial compliance with every applicable CoP or CoC. By verifying compliance, the surveys help protect the health and safety of beneficiaries and ensure the quality of care delivered across the country. Failure to meet these requirements can jeopardize a facility’s ability to receive federal funding, making the survey a powerful regulatory mechanism.
Key Categories of CMS Surveys
CMS utilizes different types of surveys, each triggered by a distinct event or schedule, to monitor compliance effectively. The most common visit is the Standard or Recertification Survey, which is a routine, comprehensive inspection conducted periodically, typically unannounced, to ensure continued adherence to all federal requirements. The frequency of these routine inspections varies by facility type, but for nursing homes, they are required at least once every 15 months.
A separate category is the Complaint Survey, which is initiated by specific allegations of harm, abuse, or other serious non-compliance reported by residents, family members, or staff. These investigations focus on the area of concern and may look at medical records and practices dating back to the previous standard survey to determine if the complaint is substantiated. Complaint investigations often result in more serious citations because they are triggered by specific, high-risk events.
A third type is the Validation Survey, which CMS conducts to check the accuracy and consistency of surveys performed by state agencies or accrediting organizations. For facilities with “deemed” status through a CMS-approved accreditation body, validation surveys ensure the accrediting organization is effectively enforcing federal standards. This process involves CMS surveyors observing the accrediting body’s survey team or conducting a separate review to assess for any condition-level deficiencies that may have been missed.
The Onsite Survey Process and Methodology
CMS surveys are generally unannounced to provide a genuine snapshot of daily operations within the facility. The process begins with the survey team, often composed of state agency staff, presenting their credentials to facility leadership during an Entrance Conference. Immediately following this, surveyors begin the systematic Information Gathering phase.
Information is collected through direct observation of care delivery, comprehensive tours of the facility, and detailed review of documentation, including patient medical records and administrative policies. Surveyors also conduct private interviews with staff, residents, and family members to gather perspectives on the quality of care and the facility’s environment. This evidence-based methodology ensures that findings are grounded in observable performance and practice.
The survey team continuously engages in Team Analysis, correlating the collected evidence against the specific language of the CoPs and CoCs. Any practice or condition that violates the federal standard is documented as a deficiency. The final step is the Exit Conference, an informal meeting where the survey team communicates its preliminary findings to the facility’s administrator and leadership. The facility is cautioned that the official Statement of Deficiencies will follow in writing, as the preliminary findings are subject to change following a formal supervisory review.
Post-Survey Requirements and Enforcement Actions
Once the survey team concludes its onsite visit, the formal regulatory process moves into the administrative phase. Within a set timeframe, the facility receives the official Statement of Deficiencies, documented on Form CMS-2567, which lists all cited violations of the CoPs or CoCs. This document formally outlines the specific regulation violated and the factual evidence collected by the surveyors to support the finding.
For most cited deficiencies, the healthcare provider is required to submit a written Plan of Correction (PoC) to the survey agency within ten calendar days of receiving the CMS-2567. The PoC must detail the following elements:
- The corrective actions taken to fix the immediate problem.
- The systemic changes implemented to prevent recurrence.
- The timeline for completion.
- The person responsible for monitoring the change.
The PoC serves as the facility’s formal allegation of compliance with the federal standards.
If the deficiencies are severe or if the facility fails to return to compliance, CMS may impose various Enforcement Actions. These remedies can include civil money penalties (fines), denial of payment for new admissions, or the appointment of temporary management. The most serious consequence for persistent non-compliance is the termination of the facility’s Medicare and Medicaid provider agreement, which effectively ends its ability to operate with federal funding.