General Policy Statement
[PROVIDER] is committed to completing an effective investigation of all credible allegations submitted internally or externally to the compliance department. Corrective action will be imposed for all substantiated allegations.
Suggested Elements
Providers may want to include the following suggested elements as part of their corporate compliance policy:
INFORMATION GATHERING:
The individual receiving the initial information will obtain as much detailed information as possible to initiate the investigation including:
- Name of Entity;
- Detailed information regarding all allegations including:
- Individual[s] involved;
- Resident[s]/Patient[s] involved; and
- Dates of Service.
- Name/Title of individual reporting the information (unless they request to remain anonymous); and
- Phone number of the caller (unless they request to remain anonymous).
The information logged into the Compliance database will be filed together, and include:
- A control number for the complaint;
- A control number for the caller for follow up discussions; and
- A primary investigator “name” assigned by the Compliance Officer – usually a member of the compliance staff.
All calls relating to employment and employee grievances are referred to Compliance Officer.
INVESTIGATION:
The primary investigator will begin the preliminary investigation no later than 48 hours of receiving the complaint. The primary investigator will:
- Review the initial complaint;
- Notify the appropriate upper management of the complaint unless they are implicated in the complaint;
- Obtain additional information as necessary and develop a plan for the investigation;
- Discuss the issues with legal counsel. The legal staff will determine if the investigation should be conducted under Attorney Client Privilege or if outside counsel is needed;
- Review the medical records;
- Conduct interviews with staff, residents and/or management. If interviewing is required as part of the investigation, two people will be present during the interview process;
- Request assistance of staff that may be more knowledgeable in areas of the investigation as necessary. In some instances a multi-disciplinary team may be required to complete the investigation;
- Complete all investigations within 45 days. The time element involved in completing the investigation may vary depending on the complexity of the complaint and the additional information required. An extension will be given only with the approval of the Compliance Officer;
- Determine if the allegations are substantiated or unsubstantiated. This may require discussion with the Compliance Officer and other team members involved in the investigation; and
- Submit a report to the appropriate persons with recommendations. A copy of the report is kept on file in the compliance department. The report will include the: facts of the case, synopsis of the investigation, findings of the investigation and recommended corrective action.
In some instances, the complaint may be referred to other departments for investigation. For example, a quality of care issue will be investigated by the clinical staff. The complaint will be logged into the compliance database and given a control number. A synopsis of the investigation will be kept in the compliance database in order to verify that all investigations have been completed.
CORRECTIVE ACTION:
All substantiated complaints require corrective action. Also, a complaint may be unsubstantiated but there may be issues and concerns that arose during the investigation that require action. The actions that will be taken in either of these instances include:
- The primary investigator is responsible to ensure that the appropriate person[s] receive the corrective action recommendations;
- The Compliance Officer, Human Resources and Senior Management will make the final determination regarding employee recommendations that involve suspension/termination;
- A recommendation may be made for a subsequent audit or follow-up to the complaint. The specific time frame of the follow-up will be determined at the completion of the original investigation;
- Any overpayments to federal health care programs or other payors will be refunded within 60 days of determining the overpayment; and
- [PROVIDER] will submit a copy of the Remittance Advice to the Compliance Department to verify that the adjustment was completed.
COMPLETING THE INVESTIGATION:
A final summary of the investigation will be included in the compliance database and will include:
- The primary investigator will ensure that corrective action recommendations have been addressed;
- The primary investigator will ensure that any overpayments have been refunded to federal health care programs. Copies of the Remittance Advices will be placed in the complaint folder; and
- The Compliance database will be completed with the Close Date, Action Taken, Disciplinary Action Taken and Synopsis of Investigation.
FOLLOW UP INVESTIGATION:
In some instances, subsequent audits/follow up may be required. This will be completed within the time frame determined at the close of the investigation as follows:
- A designee of senior management will be responsible for any follow-up;
- Other relevant management will be notified of any outstanding issues/concerns; and
- Corrective action if needed will be determined at the completion of the subsequent audit/follow-up.