State Survey Entrance Conference Document Packet

Inspection template for preparing and verifying the document packet handed to surveyors at the entrance conference, including required matrices, policies, licenses, safety records, and readiness materials.

Packet Assembly and Control

• Entrance conference packet assembled in the current approved format
• Packet includes a table of contents or document index
• All documents are dated, version-controlled, and legible
• Packet is organized in the same order as the surveyor walk-through or facility SOP
• Backup copy of the packet is available on-site and electronically
• Packet custodian and escalation contact are identified
  Enter the name/title of the primary packet owner and the backup contact.

Required Survey Matrix and Facility Profile

• Current census or resident/patient profile matrix included
• Matrix includes required categories such as unit, acuity, payer mix, and special care needs
• Facility profile reflects current licensed beds, services, and operating units
• Current organizational chart and leadership roster included
• Current contact list for administrator, DON, medical director, and department leads included
• Surveyor request log or document request tracker prepared

Licenses, Certifications, and Posted Notices

• Current facility license included
• Current Medicare/Medicaid certification or provider agreement documents included, if applicable
• Required state and federal postings are current and accessible for review
• Any waivers, variances, or exceptions affecting operations are included
• Most recent survey results, plans of correction, or enforcement correspondence included when required
• Document set includes the latest CMS survey document updates used by the facility

Safety and Emergency Preparedness Documents

• Emergency preparedness plan and annexes included
• Fire drill and emergency drill logs included for the required review period
• Life safety inspection or fire alarm/suppression inspection records included
• OSHA-related safety program summaries or exposure control documents included when applicable
• Infection prevention and outbreak response documents included
• Emergency contact list and after-hours escalation plan included

Surveyor Handoff Readiness and Sign-Off

• Packet is physically staged at the designated entrance conference location
• Electronic version is accessible to designated staff without delay
• Known deficiencies or missing documents are documented with corrective actions
• Survey lead or administrator reviewed the packet before surveyor arrival
• Inspector notes and follow-up requests can be logged during the entrance conference
• Final readiness sign-off completed