Random Site Visit
Random site visits are performed on an undisclosed date. However, the IAC is will provide facilities with a three-month timeframe during which to anticipate the site visit. The facility will be notified via e-mail that they have been selected to undergo a site visit. The facility is required to respond to the e-mail providing hours of operation, availability of key staff and other information as outlined in the notification. If the facility fails to notify the IAC or provides inaccurate details and upon their arrival the site visitor cannot complete the site visit the facility will be responsible for the cost incurred for the incomplete site visit and will be required to undergo a site visit on another undisclosed date.
Accredited facilities selected to complete an audit will be notified via e-mail and provided a 30-day timeframe by which the audit information must be submitted. Failure to submit the information will result in suspension of the facility’s accreditation and potential revocation of the accreditation which would necessitate the facility resubmitting an entire application for accreditation. Any of the following items may be requested as part of the facility audit:
- Facility demographics
- Changes in facility operations
- Confirmation of Medical Director and Technical Director
- Copies of licenses or credential cards
- Changes in personnel
- Changes in equipment and any applicable protocol updates due to change in equipment
- QA meeting minutes
- Final reports
- Case studies
- Attestation of maintaining compliance regarding correction of delay deficiencies (if applicable)
Facilities will be notified of the findings that result from their random audit or site visit. If deficiencies are noted, the facility will be required to submit appropriate preventative action plans or other documentation as deemed necessary, based upon the significance of the infraction. If substantial lack of adherence to the Standards exists or findings pose immediate jeopardy to the public or facility personnel, the IAC will follow its Grounds for Adverse Action Against Accreditation policy (IAC Accreditation Policies and Procedures, Section 12). Included in this policy are the following sanctions:
- Denial of accreditation
- Revocation of accreditation
- Non-renewal of accreditation
- Suspension of accreditation
- Other corrective action
The IAC will continue to evaluate and monitor the random audit and site visit processes to ensure they are fair and effective methods of evaluating continued compliance with the Standards.
Facilities with questions about the random audit and site visit process may contact Amanda Cooper, IAC Audit Coordinator at email@example.com or Cindy Shavatt, IAC Compliance Manager, at firstname.lastname@example.org.