Tips to Pass a Surprise Audit

Posted by Ken Reiher

Gerry Blass, President & CEO, ComplyAssistant

Dana Penny, Chief Compliance Officer, The New Jewish Home

In the aftermath of the COVID-19 pandemic, it’s more important than ever for healthcare providers to maintain industry standards for patient care within their respective enterprises. State departments of health (DOHs) are taking a closer look at emergency preparedness plans with a more intentional focus on pandemic response through the implementation of spot or “surprise” audits.

In a recent article published in Compliance Today, ComplyAssistant’s President and CEO Gerry Blass and The New Jewish Home’s Chief Compliance Officer Dana Penny discussed what providers can do to ensure their organizations are prepared for such an audit. Takeaways from the article include:

  • New ways to prepare your organization’s pandemic emergency preparedness plan and efficiently maintain it on an ongoing basis
  • How to use checklists from the Centers for Disease Control, World Health Organization, Department of Health and Human Services, Centers for Medicare & Medicaid Services and more to gather required data
  • Recommended structure for an organization’s emergency preparedness team
  • Recommended processes to successfully pass an audit and demonstrate regulatory compliance
  • Four common compliance challenges to tackle proactively

The article covers the story of The New Jewish Home, a comprehensive, mission-driven nonprofit senior healthcare system in New York City. Last year, the New Jewish Home was suddenly spot audited in the middle of conducting a mock audit. Using ComplyAsssistant software to guide preparations for the audit, which incorporates customized checklists based on CDC and CMS guidelines, Penny and his team passed with high scores. By making sure all documentation was complete, up to date, and available in both paper and online formats, they were able to easily answer surveyors’ questions and provide proper evidence.

Governance, risk, and compliance (GRC) software is a tool designed to guide users like Penny in doing their due diligence and documentation organization to avoid being caught off guard if a spot audit occurs. It keeps the responses in one place and thorough enough for the auditors to see what they need to review. 

Once all documents were organized, Penny and Blass recommended building an emergency preparedness plan (EPP) team. This team is made up of representatives from medical leadership, administrative leadership, HR, nursing, materials management, and more. The purpose of the EPP team is to join forces on any potential hazard that could occur and make sure a proper plan is in place.

In the case of COVID-19, the duties of the EPP team would have been to discuss expectations and responsibilities regarding hygiene, personal protective equipment, and remote work. The team would have used their various levels of expertise to troubleshoot common issues in each area and then train staff to handle them in a timely manner.

The article concluded with four compliance challenges that healthcare leaders can begin to address, such as building a structured system to manage audits, assessments, incident response, and subject matter contracts. Each challenge outlined was met with a solution for organizations to follow so when the time comes, leaders and EPP teams can pass an audit with flying colors. Ready to help your organization take the first step in making sure you’re prepared for a surprise audit? Read the full article here.