Clinical Site External Audit Services

The vendor is required to provide professional and qualified suppliers to perform and external audit.
- External audit is to independently evaluate the compliance, effectiveness, and risk management practices related to environmental health and safety (EHS), hipaa compliance, controlled substance management, financial operations, and credentialing/privileging at three clinical sites.
- The audit will identify strengths, areas for improvement, regulatory compliance status, and potential risks across operational, clinical, and financial domains.
- Regulatory compliance:
• Assessment of adherence to local, state, and federal environmental, health, safety, privacy, and controlled substance regulations, including agencies, and applicable healthcare-specific standards.
- Facility safety:
• Inspection of building infrastructure related to fire safety, emergency exits, electrical safety, chemical storage, waste disposal (including biomedical and hazardous waste), and facility maintenance.
- Occupational health and safety:
• Review of policies and procedures for employee safety, including personal protective equipment (PPE) usage, exposure control plans, training records, incident reporting systems, and workers' compensation procedures.
- Emergency preparedness:
• Review of emergency response plans, including fire drills, active shooter protocols, natural disaster preparedness, and evacuation plans.
- Infection control:
• Assessment of infection prevention measures, such as sanitation practices, sterilization procedures, air quality management, and compliance with CDC guidelines.
- Training and awareness:
• Verification of staff EHS training, HIPAA training, controlled substance handling training, including initial onboarding and annual refresher trainings.
- Financial audit and compliance:
• Evaluation of financial controls, billing practices, documentation accuracy, and compliance with institutional and federal financial policies (e.g., CMS regulations, medicare/medicaid billing standards).
• This includes a review of revenue cycle management, audit trails, and internal control mechanisms to ensure financial integrity and minimize risk of fraud or mismanagement.
- Credentialing and privileging:
• Review of the processes and timelines for ensuring that all clinical providers have current, verified credentials and appropriate privileges prior to patient care.
• This includes identifying gaps in onboarding procedures, re-credentialing timelines, and documentation practices.
- The full audit process (site visits, analysis, reporting) is expected to take approximately 6–8 weeks from the start of engagement.
- Questions/Inquires Deadline: May 21, 2025