ASC Survey Preparation: A 90-Day Checklist for Audit Readiness

The mindset

A facility that runs its compliance program well needs almost no special preparation. The countdown below is for the realities of operations: hand-offs, vacations, schedule pressure, and the natural drift between policy and practice.

90 days out

1. Confirm the standards version your survey will use.
2. Pull your accreditor's most recent surveyor checklist.
3. Walk every chapter; identify policy and surveyable evidence.
4. Audit credentialing — nothing expired. See credentialing .
5. Pull 12 months of QAPI minutes — gaps, missing actions.
6. Audit 90 days of every required log .
7. Pick three improvement projects to refresh.

60 days out

1. Run an individual tracer on a real recent patient.
2. Run a system tracer on medication management or infection control.
3. Walk life safety with floor plans — penetrations, exits, fire-rated doors.
4. Validate every fire drill, generator test, and emergency drill is logged.
5. Retrain on any policy where the tracer revealed practice drift.
6. Validate the IC program: hand hygiene, sterilization & HLD, environmental, SSI.

30 days out

1. Final credential and log audit; remediate immediately.
2. Walk medication management workflow start-to-finish.
3. Walk patient experience: signage, posted rights, complaint process.
4. Confirm staff and provider files: licenses, vaccinations, fit testing, BLS/ACLS.
5. Dry-run the document request list every accreditor publishes.
6. Brief leadership on opening conference talking points.

7 days out

1. Stage a digital survey binder with policy library, credential dashboard, log archive, QAPI minutes.
2. Confirm escort assignments by area and shift.
3. Confirm leadership coverage for likely survey window.
4. Brief front-line staff: how to respond, who to call, how to find a policy.
5. Confirm contact-tree for sentinel events that may occur during survey.

Survey day playbook

• Welcome the surveyor; confirm scope, agenda, document desk.
• Assign escorts who can speak to their area and produce evidence quickly.
• Document desk runs in parallel: a single owner pulling every requested document.
• Daily evening debrief: today's findings, tomorrow's risk, anything to remediate overnight.
• Photograph and time-stamp anything fixed during survey.

After the survey

Findings are addressed through a Plan of Correction or Evidence of Standards Compliance. Both share the structure of a strong corrective action plan . Submit on time. Build follow-up measures into QAPI for at least 12 months — surveyors revisit weak actions on the next cycle.

FAQ