Accredited facilities selected to complete an audit are 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
  • QI meeting minutes
  • Required QI assessments
  • Final reports
  • Case studies
  • Attestation of maintaining compliance regarding correction of delay deficiencies (if applicable)

Facilities are notified of the findings that result from their random audit. If deficiencies are noted, the facility is required to submit appropriate process improvement 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
  • Reprimand
  • Other corrective action

The IAC continuously evaluates and monitors 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 the IAC office by telephone 800-838-2110 or e-mail