Compliance Command Center

Review each chart for

Inspect

• Licenses, certificates, and required postings.
• Emergency exits and evacuation maps.
• Medication, supply, and specimen storage.
• Expiration dates and open-date labels.
• Sharps, biohazard, and waste handling.
• Temperature, quality-control, and equipment logs.
• Required binders and downtime forms.
• Patient privacy and secure record handling.

Required elements

• Specific deficiency or finding.
• Immediate risk-reduction action.
• Root cause of the issue.
• Long-term correction.
• Assigned owner.
• Completion deadline.
• Monitoring method.
• Verification that the correction was effective.

Staff expectations

• Access only the information required for assigned duties.
• Verify identity before releasing information.
• Use private areas for sensitive conversations.
• Do not leave records, labels, or screens visible.
• Use secure systems for patient information.
• Dispose of protected information using approved methods.
• Report suspected privacy concerns immediately.

Required practices

• Use unique passwords and multifactor authentication.
• Never share usernames or passwords.
• Lock computers whenever stepping away.
• Do not click unexpected links or attachments.
• Use only approved devices and applications.
• Report lost devices or suspicious activity immediately.
• Remove system access promptly when employment ends.

Immediate steps

1. Stop or contain the disclosure when possible.
2. Notify leadership or the privacy contact immediately.
3. Do not delete, alter, or conceal evidence.
4. Document what information was involved.
5. Identify who received or accessed the information.
6. Follow instructions for recovery, mitigation, and review.

Before testing

• Confirm the clinic has the correct CLIA certificate.
• Use only tests approved for the site’s certificate type.
• Confirm staff training and competency.
• Verify kit storage, expiration date, and lot information.
• Complete required quality control.

Document

• Patient identifiers.
• Date and time of testing.
• Test name and result.
• Lot number and expiration date when required.
• Staff member performing the test.
• Quality-control results and corrective action.

Include

• Date and time.
• Equipment or test name.
• Control lot number and expiration.
• Expected and actual results.
• Staff initials or signature.
• Corrective action for failed controls.
• Supervisor review when required.

Standards

• Store medications according to manufacturer requirements.
• Limit access to authorized staff.
• Check expiration dates routinely.
• Use received-date or open-date labels when required.
• Separate expired or damaged items immediately.
• Maintain sample inventory and distribution logs.
• Follow additional controls for controlled substances.

Document

• Date and time checked.
• Current, minimum, and maximum temperature when available.
• Staff initials.
• Any temperature excursion.
• Items affected.
• Manufacturer or pharmacy guidance received.
• Final disposition of affected items.

Core expectations

• Perform hand hygiene before and after patient contact.
• Use PPE based on anticipated exposure.
• Disinfect reusable surfaces and equipment.
• Dispose of sharps immediately after use.
• Do not overfill sharps or biohazard containers.
• Follow exposure-control procedures after a needlestick or splash.
• Maintain accessible cleaning and spill supplies.

Inspect monthly

Document

• Date and type of drill.
• Staff participating.
• Scenario used.
• Evacuation or response time.
• Communication process.
• Problems identified.
• Corrective actions and follow-up.

Confirm

• Kit is sealed, labeled, and accessible.
• Required supplies are present.
• Medications and supplies are not expired.
• Oxygen and delivery equipment are ready when applicable.
• Emergency numbers and instructions are current.
• Inspection is documented.

Track

• Equipment name and serial number.
• Location and responsible department.
• Required inspection or calibration schedule.
• Service dates and vendor.
• Repair history.
• Out-of-service dates.
• Replacement or retirement date.

Immediate priorities

1. Protect the patient, employee, or public from further harm.
2. Obtain emergency assistance when needed.
3. Notify the appropriate supervisor.
4. Preserve relevant evidence and records.
5. Complete the incident report promptly.
6. Cooperate with investigation and follow-up.

Document objective facts

• Who was involved.
• What occurred.
• When and where it happened.
• Observed injuries or effects.
• Immediate actions taken.
• People notified.

Immediate action

1. Wash needlestick or skin exposure with soap and water.
2. Flush eyes, nose, or mouth with water.
3. Notify the supervisor immediately.
4. Obtain urgent medical evaluation.
5. Complete exposure and incident documentation.
6. Follow testing, treatment, and follow-up instructions.

Staff response

• Listen without interrupting or becoming defensive.
• Document the patient’s concern accurately.
• Explain the next step and expected follow-up.
• Escalate clinical, privacy, discrimination, or safety issues.
• Do not promise a specific outcome before review.
• Document resolution and communication.

Common required topics

• HIPAA privacy and security.
• OSHA and bloodborne pathogens.
• Infection prevention and PPE.
• Emergency response and fire safety.
• Workplace violence and harassment prevention.
• Fraud, waste, abuse, and code of conduct.
• Role-specific clinical competencies.

Maintain as applicable

• Emergency and evacuation binder.
• Suicide-safety and crisis resources.
• Vaccine Information Statements.
• CLIA and point-of-care testing binder.
• Quality-control logs.
• Equipment maintenance records.
• Safety Data Sheets.
• Downtime forms and procedures.
• Exposure-control plan.