The following checklist is provided to assist the compliance officer in setting up and implementing a corporate compliance program. The checklist is divided into initial activities (those undertaken to initially set up the program) and ongoing activities (those that should be undertaken on an ongoing basis after the inception of the program).
Initial Activities:
Develop a written corporate compliance program. This should consist of the substantive policies and procedures that will guide the provider’s daily operations, such as policies on inducements for referrals, vendor contracts, etc.; and the mechanical operation of the provider’s compliance program, including methods for reporting suspected violations, employee compliance training, etc.
Develop a set of Employee Standards and Code of Conduct. This should not simply be a reproduction of the entire compliance program. Rather, it should be a short, clearly written document, which includes the general legal principles to which employees must adhere, stated in simple language, and a description of how the process works mechanically, including how employees report, a reminder that participation in the compliance program is mandatory and related issues.
Establish a compliance committee.
Train the compliance committee and provide committee members with clear guidance regarding their roles.
Distribute the Employee Standards and Code of Conduct.
Conduct, or arrange for, Board of Directors/Owners training on the compliance program, including information on quality of care performance (see section entitled A Special Note on the Board of Directors and/or Owners for details on what you should include in this training).
Conduct initial compliance program training of all employees. Remind employees and supervisors that all employees must sign an affirmation statement.
Consider conducting special training for supervisors, stressing their roles in the compliance program.
Establish systems for monitoring (including the audit functions), and for ongoing training of employees.
Ensure that the entire written compliance program is housed at the employment site where all employees can access it, and advise employees where and how to access the written compliance program.
Ensure that compliance-related files are established and maintained as described in the manual.
On-going Activities:
Periodically review and revise the written compliance program and the Employee Standards and Code of Conduct as appropriate. This would occur typically when applicable laws change; employees do not understand the program; recurring operational problems keep occurring or other times as needed.
Ensure that on-going training of employees is conducted and documented. Make sure that training is frequent enough so that new employees receive training promptly.
Manage and monitor the employee reporting process. Ensure that employee reports are seriously and promptly investigated and addressed, including implementing systems or policy changes as needed, and working with human resources personnel to instigate disciplinary action when needed.
Provide ongoing training, as needed, for the Board of Directors/Owners on all aspects of the compliance program, including quality of care performance (see section entitled A Special Note on the Board of Directors and/or Owners for details on what you should include in this training).
Ensure that systems for routine auditing of billing practices, quality of care, contracts and related areas are in place and are working. Modify these as needed.
Make routine, periodic compliance reports to the Board of Directors, Owners, or other management (including an annual report) regarding compliance activities, even if no violations are detected.