Q.

Should an auditor’s final report reflect deficiencies that were found in the interim report and actions taken to correct them during the corrective action period?

A.

Starting on August 20, 2016, which is the first day of the first year of the second three year audit cycle, auditors are required to submit a report to the audited agency within 45 days of completion of an on-site audit.  It is expected that if an auditor determines that a facility does not meet one or more of the standards, this report will be considered an “interim report,” triggering a 180-day corrective action period, and the auditor will include in the report recommendations for any required corrective action and shall jointly develop with the agency a corrective action plan to achieve compliance. The auditor is required to “take necessary and appropriate steps to verify implementation of the corrective action, such as reviewing updated policies and procedures or re-inspecting portions of a facility.”  At the completion of the corrective action period, the auditor has 30 days to issue a “final report” with final determinations.  Section 115.404 (d) states that, “After the 180-day corrective action period ends, the auditor shall issue a final determination as to whether the facility has achieved compliance with those standards requiring corrective action.”  The final report, which is a public document that the agency is required to post on its web site or otherwise make publicly available, should include a summary of the actions taken during the corrective action period to achieve compliance.

Revised August 15, 2016. Original posting date April 23, 2014

Standard
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Audit Process,
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