JCAHO warns: Look out for surveyor impostors

It’s 3 a.m., and a well-dressed man and woman approach the triage nurse with official-looking clipboards in hand. They claim to be surveyors from the Joint Commission on Accreditation of Healthcare Organizations, and they demand to be shown your medication storage areas.

If this occurred at your ED, would these individuals be given carte blanche access to drugs, documentation, and confidential information? Or would they be asked for identification and told to wait while administration and security were notified?

Unfortunately, the above scenario is not just a hypothetical situation from a disaster drill. The Joint Commission has warned that hospitals in Boston, Detroit, and Los Angeles have reported impostors posing as surveyors and individuals posing as federal law enforcement, inspectors, and physicians recently tried to gain access to hospitals, in some cases coming through the ED.

Both the number of incidents and the behavior of the impostors point to a chilling possibility. "I believe that the events described do not carry the common hallmarks of simple criminal activity," says Joe Cappiello, the Joint Commission’s vice president of accreditation field operations. "Maybe the criminals have become more sophisticated, but you cannot in good conscience rule out the possibility of terrorism. Sept. 11 broadened our thinking, and we would do ourselves a disservice to dismiss this possibility." (To read the Joint Commission’s security alert, go to www.jcaho.org. Click on "Accredited Organizations," "Security Notice Updates.")

At Wyoming Medical Center in Casper, access to the ED is controlled by locked doors, says Trudy Meehan, RN, CHE, director of emergency medical services. "The chances of a surveyor or imposter just walking in are low," she says. However, ED nurses have been instructed that should anyone present themselves as a surveyor, they must ask to see photo identification and a signed letter, as requested by the Joint Commission. They are then to contact hospital administration, or if after hours, to inform their supervisor and ask for the administrator on call to be notified.

"The staff have been instructed to decline to answer any questions until the individual’s credentials have been verified by someone from hospital administration," says Meehan.

ED staff also have been instructed to approach individuals found wandering near work areas and patient rooms, says Meehan. "In a busy ED, this can be a challenge, but every staff member must be vigilant and proactive in approaching individuals who appear out of place," she says.

If such individuals have accompanied a patient, they are directed back to that patient’s room and informed they are not allowed to roam the department due to patient confidentiality issues, says Meehan. "If they have not accompanied a patient and do not have a badge indicating they are a vendor, they are escorted out of the ED," she says.


For more information on surveyor impostors, contact:

  • Trudy Meehan, RN, CHE, Director of Emergency Medical Services, Wyoming Medical Center, 1233 E. Second St., Casper, WY 82601. Telephone: (307) 577-2231. Fax: (307) 577-7857. E-mail: tmeehan@wmcnet.org.