My First Compliance Audit: Complete Isn't the Same as Correct | Blog No. 143

Walking In

I wasn't the auditor. I was the new guy, there to shadow, watch, and learn how a compliance audit actually works.

The first thing we opened was the stack of policy documents. From where I stood, they looked complete. Every section had a heading. Every heading had content. Binders were labeled, files were named, nothing jumped out as missing.

I remember thinking: this facility has its act together. This should be quick. 

Then We Started Digging

I learned firsthand the reason for what I’ve heard called “pencil whipping,” where a consultant settles for the 30,000-foot view of compliance but fails to dig in, because the further we dug in, the more we found little things. After all, that’s what we’re there to find…the things an auditor might find. 

None of these things looked like a big deal on its own. In fact, many of these things uncovered were only discovered after 2 follow up questions, and seeing them from a different angle revealed the gap. A number here that didn't line up. A section there that didn't quite fit. 

That was my first real lesson: a document can look complete and still be wrong.

Numbers Need Proper Context

Another major learning for me: just because the number is right doesn’t mean you’re done. You need to outline these calculations in detail, and if there’s context behind a number or a unique process, it needs to be detailed. Why? If the team who has all that context is no longer available, the knowledge and the context surrounding that number can easily be called into question. 

In retrospect, the unique process to finding this calculation was well defended, and props to the team for knowing their stuff and retaining the knowledge of this situation…but the second pitfall is using this out-of-context figure for something it was never meant to weigh in on, again another reason to add context to calculations. 

Two Facilities, One Document, & Empty Folders

To start the audit, I heard “we’re here as a regulator, to find anything they’d find.”  Perhaps the most vivid example of that was seeing a whole chunk of a policy section accidentally missing on one document (but present for a different facility). A policy document had been mirrored between two different facilities. Same structure, same language, same format.

The attention to detail flagged, and the whole purpose of the audit started to make more sense to me. Every three years, these things will compile, and it’s critical to have someone review each element of compliance. 

The last takeaway was minimizing empty folders. 

You click into a folder, and it's empty. You know a record exists somewhere, and the hunt begins. Each of those moments seems small. Together, they stretch the audit out, minute by minute, while everyone waits.

A document nobody can find in the moment might as well be missing.

Compliance Isn't a One-Sitting Job

If I had to sum up my first audit in one sentence, it would be this: it makes way more sense why PSM and compliance aren't done in one sitting.

Those documents looked finished the day we opened them. But systems change, inventories change, facilities get copied from one another, and files drift. Keeping a program accurate takes hands-on attention, again and again, by people who know the system and keep the records where they can be found.

The binder that looks complete is where the work starts, not where it ends.

Previous Blog: https://www.machapsm.com/post/how-to-get-the-most-out-of-the-national-reta-conference-blog-no-142

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