It’s a best practice for organizations to have regular self-assessments/reviews to maintain a level of survey or audit readiness. There is nothing worse than getting caught off guard during an Accreditation Survey or audit inspection and having the auditor finding a glaring red mark. I’ve been there, done that on both sides of the road.
JACHO & IDPH is always an attention getter, as is the College of American Pathology Survey (CAP). It’s not just about HIPAA. It’s important for leadership to do rounding to ensure their teams are compliant. I’ve found some eye opening issues as a manager, CAP Surveyor and auditor that includes: visible PHI in public areas, printed reports sitting on a counter, secured doors that aren’t secure, user ids/passwords posted in work areas (I’ll never forget the Unit Supervisor that had a comprehensive list of staff id’s/passwords posted on the wall next to their PC in a staff station), backup media carelessly stored, network closets that were too hot and or too dirty, poor wiring habits that cause trip hazards, cigarette butt’s on the floor in a fire suppression room. The list is long.
As part of JACHO preparation a director had his management team survey 12 or 15 random users in their department, the labs and patient care areas on their knowledge of policy and procedures. I always enjoyed when staff would reply with a smile as to where they can find them or recite the process. Then there were a few that were clueless.
MD Technology Services, LLC provides Comprehensive Privacy & Risk Assessments with in depth Site Surveys & Policy and Procedure wellness reviews to help place you in a better position in the event you do get audited. We are also available to perform just a site survey or policy/procedure review to provide some unbiased opinions & offer opportunities for improvement if you opt to not have us do a risk assessment for your organization. We additionally have a library of essential policies and procedures that can be customized to meet the needs of your practice or organization.
You may visit our website at: www.mdtsllc.com for the full range of services we can provide! For additional information please email: email@example.com or call 773 482 2005 or contact me directly at firstname.lastname@example.org.