Infection Control Survey Preparation and Mock Surveys
Infection control survey preparation tests a facility's program the way surveyors will, while there is still time to remediate what they would find. ICCS prepares healthcare facilities for the infection control portion of Centers for Medicare & Medicaid Services (CMS), state, and accreditation surveys through engagements that combine a mock survey, process review, and staff education. An ICCS consultant pinpoints likely citations and recommends specific corrections before the survey team arrives.
How Surveyors Evaluate Infection Control
Most CMS, state, and accreditation surveys are unannounced, so an infection prevention program has to hold up on whatever day the surveying team walks in. Surveyors review the infection prevention plan, risk assessment, and policies, then apply them to daily practice. They observe several practices and processes, ask frontline employees to explain procedures, and follow patients and equipment through the facility to see whether written policy matches what happens.
Infection control findings can carry serious consequences. A significant lapse, such as improper reprocessing or unsafe injection practices, can result in an Immediate Jeopardy citation, which requires prompt corrective action and puts a facility's certification or accreditation at risk.
What Survey Preparation Includes
ICCS builds each engagement around the standards and survey tools that apply to your facility, including the CMS infection control surveyor worksheet for facilities surveyed with it. ICCS offers offsite/virtual services too for facilities that do not want an onsite visit.
Advance review of your infection prevention plan, risk assessment, policies, and surveillance data
Walkthroughs of clinical workflows, from patient intake through instrument reprocessing and room turnover
Tracer reviews that follow a patient, instrument, or medication to compare policy with actual practice
Staff interviews in the question-and-answer format surveyors use
In-service education for staff, focused on the issues observed
A closing debrief with leadership on priority findings
A written report of findings and recommendations, ranked by risk
Follow-up guidance as your team makes corrections
Accreditation, CMS, and State Survey Preparation
ICCS provides guidance and assistance for the following surveys:
CMS certification and state licensure
Accreditation by organizations including Joint Commission, the Accreditation Association for Ambulatory Health Care (AAAHC), ACHC (formerly HFAP), Quad A, and DNV
Initial surveys for new (de novo) facilities preparing to open
Follow-up surveys after cited deficiencies, supported by plan of correction development
Facilities that want year-round survey readiness can pair survey preparation with ongoing infection control program oversight.
Request a Consultation
“I wanted to thank you again for all of your advice and support. I thought you would like to know that we were visited by CMS and then three days later we were visited by Joint Commission. In the Joint Commission follow up, they stated that they had no findings. I have no doubt that you played a big part in that.”
Frequently Asked Questions About Survey Preparation
When should a facility schedule a mock survey?
Six to twelve months before an expected survey is a practical starting point. That timeline leaves room to correct findings, update policies, retrain staff, and confirm new practices are consistent before surveyors arrive.
What should a facility have ready for survey preparation?
ICCS typically requests the infection prevention plan, most recent risk assessment, infection control policies, surveillance data, staff education and competency records, and reports from recent surveys. Reviewing these virtually before any onsite work keeps the engagement focused and reduces travel time and cost.
How is an infection control mock survey different from an internal audit?
Internal audits are performed by staff who know the facility's routines and may no longer notice long-standing problems. A mock survey brings in an outside infection prevention expert who applies surveyor methods, questions staff the way a surveyor would, and evaluates practice without assumptions about how things are usually done.
What happens if a mock survey uncovers a serious problem?
Findings that could lead to an Immediate Jeopardy citation are reported to leadership immediately, before the written report is complete. The facility can begin addressing the issue during the engagement, and ICCS follows up to confirm the correction is in place before the survey.
Does survey preparation include staff education?
Yes. ICCS consultants deliver in-service education targeted to the issues observed, onsite or virtually, so staff learn the correct practice while the finding is still fresh. Facilities that need broader training can add ICCS education programs.
Does ICCS prepare new facilities for their first survey?
Yes. ICCS works with facilities before they open to build the infection prevention program, policies, and staff training that an initial licensure, certification, or accreditation survey will evaluate. An initial onsite visit is often requested to review the environment for opening, or prior to a final state inspection for licensure.