1

Pre Audit

to

Exit Interview

Review

2

Audit Purpose

Verify the Recognized entity was compliant with the National

Standard’s at the time of application and has remained

compliant during the current recognition cycle.

Key Points

Recognition Cycle is 4 years

Audit items from application Reporting Period (participant with at least one DSMES encounter in the reporting period)

Audit items for Current Period (participant with at least one DSMES encounter in the 6 months prior to

the audit date)

If needed can request items from other period during

the recognition cycle

3

Auditor Role

To review the documents provided as evidence of

compliance with the NSDSMES and report the facts back

to the ERP committee based on the documents provided

for each indicator

If documents are missing ask the service representative for

elements of indicators that are missing

To provide coaching on tools and resources that may assist

a service in understanding or implementing the indicators

4

Auditor’s Approach

Auditor’s approach should be:

Objective during audit process

Prompt in arrival time

Open-minded

Ask clear questions when unable to find elements of

indicators

Responsible for giving appropriate feedback

Able to recognize minimal standards vs. ideal

standards

5

Dress Code

As an ERP auditor you are representing ADA

Professional Dress

No Jeans, Jeggings or Leggings

No Flip Flops

Panty Hose are not required

6

Audit Outcome

Auditors do NOT

make the audit outcome decision Auditors gather facts to present to National Committee and the

committee to determine audit outcome.

1. Continued Recognition

2. Provisional (Corrective action required)

3. Withdraw Recognition

7

Service Audit

Notification

Service receives first Audit Notification

10 business days prior to audit from ERP.

***ERP staff will contact lead auditor as

each service has responded to audit

notification.

8

Guidance for the

Lead Auditor

Once Notified

by ERP

to Contact the

Quality Coordinator

9

Key Points for Coordinator Call

Ask if QC has any questions – put QC at ease.

Ask QC if the charts will be paper or electronic and if

electronic if they can be printed and de-identified.

If the service chooses not to print and de-identify the

charts inform QC that the service representative that logs

on the EMR will need to be present and navigate the

EMR for the auditors.

10

Key Points for Coordinator Call

Due to HIPAA and HI TECH laws, some services

legal and compliance officers are requiring all dates be

removed from charts.

Rather than asking the QC if the dates will be removed

from charts, ask all QCs that will have charts printed

to separate the reporting period charts from the current

period charts and label each chart with A – J of the

DSMES cycle.

11

Key Points for Coordinator Call

Remind QC to have staffing list complete for each

site.

Explain brief (15-30 minute) pre audit conference – set

time expectation!

Inform that the auditors will arrive on site at either 8am or

9am.

Verify address, parking entrance – ask for points of

interest with directions.

12

QC Call Pearls

Ask to meet QC or representative at front desk.

Get QCs cell number

Chart review in EMR

Let QC know that the two auditors will need to

have place o\to discuss findings with one another

At the end of the call ask the QC what the area is like

where your hotel is located.

13

Pre-Audit Preparation

Print and review the Service Audit Packet

Print and review the Auditor Packet from Auditor’s

Resource Center Only one packet now and each auditor needs to print

If service has more than one multi site print additional chart review forms

based on the multi site table on page one of the auditor packet

Coordination with co-auditor Ensure you have co-auditors travel itinerary and cell phone number

Airport meeting time and location

Car Rental – ensure the car rental is in the name of the auditor who will pick it up

Driving – Navigation shared duties – Both auditors can drive on corporate account

Pearl – be sure to bring your car cell phone charger

14

Audit Logistics Huddle

At dinner the night before or breakfast the day of

audit:

Review the service documents

Decide who will review documents for the

Reporting Period and Current Period

Decide when/where to have lunch

Discuss pre-audit meeting questions and

who will ask them

15

Pre-Audit Meeting Meet coordinator, other staff, administrators

Introduce yourselves with your ID (Driver’s Licenses)

Explain audit purpose

Describe audit process

Invite coordinator/staff to describe their service

Example: Advisory Group, CQI, Population Served

With a participant experience in mind walk me through your

program

Establish PC/QC contact and availability during audit

Be prepared for compliance requirements

Begin your audit fact finding phase

Pearl - Set the expectation 15-30 minute pre-audit meeting

16

Audit – Fact Finding Phase

First - Ask QC for DSMES Team Members list with grey areas

completed.

Criteria applies to all participants of the Recognized service

regardless of payment source.

Use auditor tools to guide you in confirming what is present and

what is not present during documentation review.

Analyze throughout the fact finding process.

Discuss “iffy” points with co-auditor and decide whether more

evidence is needed.

Contact QC if you are not finding items for explanation.

17

Audit – Fact Finding Phase

Investigate inconsistencies further.

You may not need to look at all documentation provided.

Anticipate questions that may be posed by the ERP Committee

for clarification and decision making - seek answers prior to

leaving the audit site/

Both Auditors must agree on all findings based on analysis.

Ensure that your findings can be validated (CMS).

Pearl – Committee may ask if the education hand outs had

current medications, meters, pumps, etc... on them.

18

Exit Meeting Gather coordinator and others.

Express gratitude.

Present findings: service strengths, then weaknesses;

recommendations if any.

Use review criteria as guide.

Provide opportunity for program/service to respond to deficient findings.

Explain post audit process – highlight.

Audit facts will be presented to the ERP National Committee Subgroup.

The Committee will make the audit outcome decision of:

Continued Recognition

Provisional Recognition

Withdrawal of Recognition.

19

Exit Meeting

Pearl –

Notify QC 30 minutes before you are finished with

the fact finding phase so she/he can be ready for the

exit conference

If many standards are not met, you may want to first

meet with the QC alone to discuss findings (this

prevents the QC from being blind sided)

20

QC Post Audit Submissions Only items that are in place at the time of the audit

can be submitted prior to the DSC call.

Team Members List (if not complete at time of audit)

Credentials and CEU Certificates

Organizational Chart

Mission Statement

Advisory Group Activity

If one is upcoming and still within the annual activity time frame)

21

Post Audit Submissions

Guidelines

Auditor should notify ERP immediately via email of detailed

items the service was advised to submit

Service should be instructed that items will only be accepted if

submitted to ERP within 3 business days of the onsite

audit

The Service ID number must be on all documents submitted to

ERP

22

Post Audit Submissions

Not Accepted QC should not be advised to submit

to ERP prior to the DSC

X New Forms

X Service Goals or Goal Review

X Advisory Group Activity that are over due

X Population Served Assessment

X Curriculum or Annual Review

X Any chart item/s that were not present at the time of the

audit including DSMS Plans and Behavior Goal Outcomes

23

for your service as an

ADA ERP Auditor!