Content by Ken Burgess
Sample Policy on Compliance Filing Systems
The compliance officer should establish and maintain a filling system for all compliance-related documents. The following seven files should be established:
- Compliance Manual, Codes, And Policies
This file shall contain this compliance manual and any amendments, the Employee Standards and Code of Conduct, all conflict of interest statements, and any compliance program policy statements issued after the program’s initiation.
This file shall document the appointment of the compliance officer, all non-privileged communications to the compliance officer, all [Board of Directors, Owner(s)] minutes in which compliance issues are discussed, and any other oversight records.
- Information and Education Campaign
This file shall contain signed affirmation statements, all employee training records, educational materials provided to employees, notices and fraud alerts that have been posted or placed in payroll envelopes (and the dates and locations of such notices), and all other written records of training activities.
- Monitoring and Auditing
This file shall contain all physician contracts, equipment and office leases, loan instruments, joint venture documents, partnership agreements, and other documents relating to financial relationships with physicians. Finally, opinion letters from legal counsel approving physician contracts shall be included.
This file shall contain all documents pertaining to the enforcement of the compliance program, such as disciplinary action taken, policies regarding graduate punishment, and informal and formal reprimands issued
Note: Files containing information relating to employee sanctions or disciplines present special legal issues. As much, access to these files should be controlled. With regard to notices related to an employee’s failure to follow the compliance program, access should be limited to the compliance officer and others whose access is approved by the Human Resources Department. Additional language can be inserted in the Enforcement file policy, reading “The Enforcement File shall be maintained by the compliance officer and the Human Resources Department and access shall be limited to the compliance officer and individuals approved by the human resources director.”
This file shall contain all documents reflecting actions taken after an issue has been detected, as well as efforts to deter and prevent future violations.
This file shall include a record of requests for legal assistance or legal opinions in connection with reports received via [the hotline, anonymous drop box, post office box, etc.] or reported to the compliance officer, and the response from legal counsel. This file shall be privileged and confidential; its content shall be kept in a secure location and only the compliance officer and legal counsel shall have access. All material in this file shall be treated as subject to the attorney-client and/or work product privilege and shall not be disclosed to people outside the privileged relationship.