A Department of Health survey is an unannounced regulatory inspection of a licensed healthcare facility, carried out by a state survey agency to check whether the provider meets state licensing rules and the federal Conditions of Participation required for Medicare and Medicaid billing. These inspections reach hospitals, nursing homes, assisted living facilities, home health agencies, and other licensed providers. The result can be routine, or it can end a facility’s ability to operate.
The authority comes from state law and, for federally certified providers, from 42 CFR Part 488, which sets the survey, certification, and enforcement framework.1eCFR. 42 CFR Part 488 – Survey, Certification, and Enforcement Procedures Because Medicare and Medicaid make up the bulk of revenue for most nursing homes, losing certification through enforcement effectively forces closure. That is why a survey carries more weight than a standard regulatory audit.
The Three Kinds of Surveys You Might Get
A standard survey is a comprehensive compliance review covering the full range of federal and state requirements. It must be unannounced.2eCFR. 42 CFR 488.307 – Unannounced Surveys For nursing homes, no more than 15 months can pass between standard surveys at a given facility, and each state must keep its statewide average interval at 12 months or less.3eCFR. 42 CFR 488.308 – Survey Frequency So one cycle might run 10 months and the next 14, as long as the state’s overall average holds.
A complaint survey is triggered by a specific allegation, usually from a resident, family member, or staff member. It is also unannounced and focuses narrowly on the reported concern.4Centers for Medicare & Medicaid Services. Policy Regarding Unannounced Surveys If surveyors substantiate the complaint, a citation follows, and related practices may be reviewed as well.
A revisit, or follow-up survey, happens after a facility has been cited. Its scope is limited to the deficiencies from the earlier survey, and surveyors look for real, sustainable correction rather than paperwork fixes.
What Happens During the On-Site Inspection
The survey opens with an entrance conference. The lead surveyor identifies the team, presents credentials to the administrator, requests contact information for the governing body, and asks about resident and family council groups. A facility representative usually walks with the team throughout the visit.
Evidence gathering runs on three tracks. Surveyors observe care and the physical plant directly, checking things like food storage temperatures, medication administration, and life-safety features. They audit clinical records for a sample of residents, looking at care plans, physician orders, and incident reports. And they interview residents, family members, and staff privately to corroborate what the records and observations suggest. Personnel files and facility policies must be produced on request.
How Findings Are Rated
Every deficiency gets plotted on a two-dimensional grid. Scope measures how many residents are affected (isolated, pattern, or widespread). Severity measures actual or potential harm. Together they produce a letter rating from A through L.
- Levels A, B, C: no actual harm and only minimal potential for harm. Usually no enforcement action.
- Levels D, E, F: no actual harm but more than minimal potential for harm. Most enforcement remedies start here.
- Levels G, H, I: actual harm short of immediate jeopardy. Heavier penalties and faster correction deadlines.
- Levels J, K, L: immediate jeopardy to resident health or safety. Mandatory enforcement.
A “J” citation is isolated immediate jeopardy; an “L” is widespread immediate jeopardy and represents the worst possible outcome. The letter drives which remedies apply and how quickly the facility must act.
The Statement of Deficiencies
Once the on-site work ends, the team holds an exit conference to communicate preliminary findings and let the facility offer clarifying information. The formal document that follows is the Statement of Deficiencies, issued on Form CMS-2567.5Centers for Medicare & Medicaid Services. CMS 2567 – Statement of Deficiencies and Plan of Correction Each citation carries a tag number keyed to the specific regulation violated, a narrative describing the deficient practice, and its scope and severity rating.
The CMS-2567 becomes publicly available within 14 days after the facility receives it.6Centers for Medicare & Medicaid Services. Release of CMS-2567 – Statement of Deficiencies and Plan of Correction For nursing homes, findings flow into CMS’s Care Compare website, where prospective residents and families can look up inspection history and star ratings.
Writing a Plan of Correction
After receiving the Statement of Deficiencies, the facility must submit a Plan of Correction, typically within ten calendar days. Submitting one is not an admission of fault. Each cited deficiency needs its own response covering four things: what was done to address harm for any affected residents, what systemic changes prevent recurrence, how compliance will be monitored, and who is responsible for that monitoring.
Vague responses get rejected. “Staff will be retrained” with no content, deliverer, timeline, or effectiveness measure will come back for revision, and enforcement clocks keep running while the facility rewrites.
Challenging a Citation
A facility that believes a citation was issued in error can request Informal Dispute Resolution. States must offer IDR for non-federal surveys, and CMS provides it for federal surveys.7GovInfo. 42 CFR 488.331 – Informal Dispute Resolution The facility can present additional evidence challenging the citation itself or the scope and severity rating assigned.
One thing to be clear about: IDR does not pause enforcement. Any penalties accrue while the dispute is pending. If the challenge succeeds, the citation is removed from the Statement of Deficiencies and enforcement actions tied solely to that citation are rescinded.7GovInfo. 42 CFR 488.331 – Informal Dispute Resolution Nursing homes facing civil money penalties held in a CMS escrow account can request an independent IDR instead, in writing, within ten days of CMS’s offer.
What Enforcement Looks Like
When a facility is out of compliance, CMS and the state have a menu of remedies beyond termination:8eCFR. 42 CFR Part 488 Subpart F – Enforcement of Compliance for Long-Term Care Facilities With Deficiencies
- Civil money penalties, on a daily or per-instance basis.
- Denial of payment for new admissions, meaning the facility keeps current residents but cannot bill Medicare or Medicaid for new ones.
- Temporary management, where an outside manager takes operational control.
- State monitoring by an appointed observer.
- Directed plan of correction, where CMS or the state prescribes the fix.
- Directed in-service training on the specific deficiency area.
- Transfer of residents or facility closure in the worst cases.
How Much the Fines Run
Civil money penalties are the most common financial sanction. Statutory ranges are adjusted annually for inflation. The current lower daily range runs from $136 to $8,211, and the upper daily range for immediate jeopardy deficiencies runs from $8,351 to $27,378. Per-instance penalties run from $2,739 to $27,378.9Federal Register. Annual Civil Monetary Penalties Inflation Adjustment Daily fines accumulate until compliance is achieved or the provider agreement is terminated, so a moderate daily amount reaches six figures within a few months.
When Denial of New Admissions Becomes Mandatory
Denial of payment for new admissions starts as an optional remedy but becomes mandatory in two situations: when a facility remains out of substantial compliance three months after the survey that identified the problem, or when it has been cited with substandard quality of care on three consecutive standard surveys.10eCFR. 42 CFR 488.417 – Denial of Payment for New Admissions Without the ability to admit new Medicare and Medicaid residents, census falls until the finances no longer work.
Immediate Jeopardy
Immediate jeopardy is the highest-severity classification, defined as noncompliance that has caused, or is likely to cause, serious injury, harm, impairment, or death.11eCFR. 42 CFR 488.301 – Definitions The “likely to cause” wording matters. A surveyor does not need to find that anyone was actually hurt; conditions that make serious harm probable are enough. CMS guidance requires three components together: noncompliance with a federal requirement, a serious adverse outcome that has occurred or is likely, and a need for immediate corrective action.12Centers for Medicare & Medicaid Services. State Operations Manual Appendix Q – Core Guidelines for Determining Immediate Jeopardy
When immediate jeopardy is cited, the timeline compresses. The state must either terminate the facility’s provider agreement within 23 calendar days of the last day of the survey or appoint a temporary manager to remove the jeopardy.13eCFR. 42 CFR 488.410 – Action When There Is Immediate Jeopardy If the facility refuses to hand control to a temporary manager, termination proceeds within that same window. There is no extension.
Facilities can avoid termination by removing the jeopardy before the deadline, which means eliminating the conditions creating the risk and putting safeguards in place. Even then, the facility usually remains out of compliance at a lower severity level and still has to complete the full correction cycle with an approved Plan of Correction.
Termination of the Provider Agreement
Termination ends a facility’s ability to participate in Medicare and Medicaid. CMS can terminate when a facility fails to meet the Conditions of Participation, refuses to permit records examination, fails to furnish required information, or commits any of the other violations listed in the regulations.14eCFR. 42 CFR 489.53 – Termination by CMS Facilities can appeal, but when immediate jeopardy is involved, the process moves fast.
For facilities not in immediate jeopardy, there is still a hard stop. Any facility that remains out of compliance six months after the survey identifying the noncompliance faces mandatory termination, regardless of whether it is making progress. Six months is treated as enough time to fix any correctable problem.