Holiday Audits

Posted by Steve DeGenaro on Mon, Dec 07, 2020 @ 12:09 PM


Nothing says “Merry Christmas” and “Happy Holiday Season” like a good audit.  The end of the year is an arbitrary date to be sure; but it’s a good marker for reminding us that we need to check our businesses to ensure we’re still compliant with the multitude of law and regulation these businesses face.  As the holiday season approaches, let’s look at a quick checklist of audit activities we can perform to keep up with our complex and ever-changing industry. 

  • Walk the business and look around. Look for issues in how equipment is stored and processed.  Is clean, patient ready equipment separated effectively from dirty equipment waiting for processing and obsolete equipment?  Monitor safety systems including fire extinguishers, eyewash stations, first aid kits, and exit signage.  Make sure retail showroom areas are clean and that items for sale are organized, priced, and within expiration dates. 
  • Are my delivery vehicles compliant with policy & procedure? This is an area that requires constant vigilance.  When the survey is over, and when no one is looking, we still need to maintain our delivery vehicles.  Spot check for separation of clean and dirty equipment.  Make sure personal protective equipment and supplies are present.  With Covid, masks are in short supply.  Is each delivery vehicle equipped with an adequate supply of masks?  Also, make sure to check for documentation of vehicle maintenance, daily vehicle check forms, and delivery logs. 
  • Human resource files review. The end of the year is as good as any time to audit personnel files.  Look for all the basic documentation: job descriptions, applications for employment, orientation checklists, performance evaluations, and competency assessments. Are the files current with evaluations, assessments, and continuing education?  Is there a current driver’s license in the file?  If the employee is a clinician, do you have a copy of their current clinical license?
  • Patient record review. Ditto the patient records.  Whether they are electronic or paper files, on occasion it is a good idea for staff to review a cross section of files.  Use an audit tool customized for your particular organization’s needs.  Simply list out the forms and documents you expect to see for a compliant, complete patient record.  Then review a sampling of records to ensure they are complete.  Note any missing documents, correct any issues of non-compliance, and be sure to educate staff regarding where any shortcomings or issues were found.  Make sure to select a randomized cross section representative of your organization’s services, equipment, and payer sources.
  • Review the Quality Improvement Program. Make sure quarterly meetings and annual reviews for all quality improvement activities are well documented.  Make sure the indicators (the issues you study within the program) are relevant.  Hopefully, you can use the program to show that you’ve improved some processes within your organization. 
  • Are my policies & procedures up to date? Be sure that your policy & procedure manual is current and up to date.  If you’ve added product or service lines, do the P&P’s reflect it?  Is the scope of service up to date?  If forms or documentation requirements have changed, have you updated the P&P to reflect the revisions?  Documenting an annual review of all P&P is a good idea. 
  • Are we tracking equipment and supplies as required? Select some serial numbers for a cross section of equipment.  Be sure to cull the serial numbers from delivery logs, charts, grabbing numbers off equipment in the warehouse, etc.  Whether your tracking process is electronic or paper, run the numbers and make sure the equipment is documented in the correct place.  You should be able to “find” every piece of medical equipment that has a serial number.  Also, review logs and records for documentation of lot numbers for supplies such as catheters, diabetic testing supplies, and oxygen cylinder contents. 

The list above is just a start—think of it as a view from 10,000 feet.  Your organization may want to drill down a little deeper in some areas, or concentrate on additional audit activities.  Customize the process to suit your individual needs and the type of equipment and services you offer. 

These audit activities are good to do on an ongoing basis, and the end of the year/first of the year is a good place in the schedule, because it’s an easily remembered timeframe.  Audit activities are a very good use of your resources and time.  So, take some time over the holidays to look around and see what your organization is doing to maintain compliance.  If you find mistakes or shortcomings, fix them right away.  If you don’t, at least you’ll be re-assured and can pat staff members on the back.  Keep up the good work you are doing, stay vigilant, and push yourself to improve and do even better going forward.