UMGC HCAD650 Corrective Action Plan (CAP) Memo

Your health care organization has just learned that it is out of compliance in the problem areas listed below.
You have been asked to research
ONE problem and prepare an interoffice research memo that is double-spaced and not more than four pages.
The Memo should be addressed to the VP of Finance and include the following sections with a heading in bold for each section. Use APA 7 for in-text citations and references.

Memo Heading

• Memo To:
• Memo From:

Date:

Re: (Regarding – Name the topic)

• Brief description of the problem
• State the Law and agency guidelines or regulations that govern the issue, including the penalty for non-compliance. Include the code or regulatory citation. How does the law apply to the problem? Tip: Look for both state and federal laws.
• Describe and evaluate how the COSO framework, components, and principles can improve compliance and correct system-wide problems. How does COSO apply to the problem? See COSO Internal Control – Integrated Framework: An Implementation Guide for the Healthcare Provider Industry PDF.

Recommend a strategic corrective action plan (CAP) that implements components and principles from COSO to correct the specific problem. Name and describe at least three managerial actions you recommend to correct the specific problem and bring the organization into compliance using the COSO compliance tool.

Give reasons to support the selection of these actions. Indicate which COSO components and principles you relied on and why.

Problems (select one)

Your hospital has had multiple repeat hospital admissions of patients with pneumonia within 30 days of discharge, in violation of the Hospital Readmissions Reduction Program (HRRP). CMS.gov Website: Hospital Readmissions Reduction Program (HRRP) Landing Page

• Your hospital has scored in the 75th percentile for Surgical Site Infection (SSI) during the last six months raising concerns under the Hospital-Acquired Condition Reduction Program (HACRP). CMS.gov Website: Hospital-Acquired Condition (HAC) Reduction Program Landing Page and AHRQ Website: Patient Safety Network – Never Events Landing Page
• Your long-term care facility has multiple never events, with multiple patients developing Stage III and IV pressure ulcers during the last year. CMS State Medicaid Payments HAC Letter PDF

Your long-term care facility has had multiple adverse events from medication errors that led to the deaths of five patients at your facility within the last month. You have been so busy investigating that you haven’t considered voluntary reporting under the FDA Adverse Event Reporting System (FAERS). FDA Website: Questions and Answers about the FDA’s Adverse Event Reporting System (FAERS) Link

TIPS TO COMPLETE THE MEMO

Use a memo format with citations and references in APA 7 format. The memo should be double-spaced and include headings. The memo format should include the following:

• Memo Heading,
• Problem Description
• State of the Law
• Describe the COSO framework and evaluate how it would apply

Recommend a strategic action plan suing COSO. State 3 actions to take to resolve the problem.

Use the assignment links as well as the classroom law library, compliance library, textbooks, and course web links to complete the assignment.

Choose a problem that would be in a useful setting or useful situation that you might encounter as a health care manager.

Also review laws and guidelines in the textbook, Classroom law library and textbooks as well as course web links.

Name the law and give a U.S.C. citation to the code section related to the law you are discussing. This should be in the format of 26 U.S.C. 442 (2021).

There are links to the U.S.C. in the Classroom Law Library. Here is another link to the U.S.C. at https://www.law.cornell.edu/uscode/text

State code sections should indicate the state you are referring to and he
code citation.

There are also code sections in the textbook.

What is COSO?

COSO stands for the Committee of Sponsoring Organizations of the Treadway Commission. It has guidelines for an enterprise risk management (ERM) system to control organizational risk.

You can find COSO information at https://www.coso.org/SitePages/Home.aspx

Include a short description of the COSO enterprise risk management ERM) system in your memo.

What does it mean to create a corrective action plan (CAP)?

A corrective action plan (CAP) is a multiple step plan to correct the problem. A good corrective action plan should be specific to correct the stated problem, should state specific actions to take to correct things.

Consider actions that incorporate the compliance and risk management strategies we have discussed.

What is the difference between a corrective action plan (CAP) and a compliance plan?

A corrective action plan (CAP) corrects a specific problem. This may include investigation of the issue, government reporting, employment action with an employee who made an error, etc.

A compliance plan is a plan to comply with a specific law. The plan focuses on preventing problems by putting strategies in place to avoid problems.

What does it mean to state three actions to correct the problem?

The corrective action plan should state three things you can do to correct the problem. Each thing you do should be an action.

Make sure the actions are specific to correct the problem you have focused on. Look for innovative ways to resolve the issue.

How do I integrate COSO into the corrective action plan?

COSO sets forth ways to make system wide changes for enterprise risk management (ERM). Take the COSO principles and adapt them to the specific problem you have selected to create a corrective action plan based on COSO and specific to the problem. Explain how your plan relates to COSO and its principles.

This means that you will explain COSO and its principles and then consider how to use them to correct the specific problem.

For example, if the problem was fraudulent billing of the government. Consider which COSO principles will correct the billing problem and keep the problem from occurring again. Make sure your corrective action is specific and corrects the specific problem.

Be sure to talk about and apply COSO
principles in your memo.

Week 4 and 5: Government Programs
Additional Resources
Medicare
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Medicare and Medicaid Conditions of Participation: https://www.cms.gov/Regulationsand-Guidance/Legislation/CFCsAndCoPs/index.html?redirect=/CFCsAndCoPs/
Conditions of Participation for Hospitals https://www.govinfo.gov/content/pkg/CFR2017-title42-vol5/xml/CFR-2017-title42-vol5-part482.xml
Conditions of Participation for Home Health Services https://www.ecfr.gov/cgi-bin/textidx?node=pt42.5.484&rgn=div5
Requirements for Long Term Care eCFR :: 42 CFR Part 483 Subpart B — Requirements
for Long Term Care Facilities
Accountable Care Organizations (ACOs): General
Information https://innovation.cms.gov/initiatives/ACO
Your Guide to Medicare Preventive Services Your Guide to Medicare Preventive
Services | Guidance Portal (hhs.gov)
Medicaid
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State Medicaid Plans and Waivers: https://www.cms.gov/Outreach-andEducation/American-Indian-Alaska-Native/AIAN/LTSS-TA-Center/info/state-medicaidpolicies.html
National Council on Disability: Chapter 1. An Overview of Medicaid Managed Care |
NCD.gov
The Urban Institute (2012). Medicaid and CHIP Risk-Based Managed Care in 20
States: https://www.urban.org/sites/default/files/publication/25646/412617-Medicaidand-CHIP-Risk-Based-Managed-Care-in-States.PDF
Medicaid A Primer (CRS): https://www.kff.org/medicaid/issue-brief/medicaid-aprimer/
Medicaid Financing: The Basics https://www.kff.org/medicaid/issue-brief/medicaidfinancing-the-basics/
Federal Medical Assistance Percentage (FMAP) for Medicaid and Multiplier
https://www.kff.org/medicaid/state-indicator/federal-matching-rate-andmultiplier/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22so
rt%22:%22asc%22%7D
State Health Departments https://www.usa.gov/state-health
Maryland Department of Health https://health.maryland.gov/pages/home.aspx
Medicaid and the Affordable Care Act: https://www.medicaid.gov/affordable-careact/index.html
Medicaid Expansion: https://www.kff.org/health-reform/issue-brief/a-guide-to-thesupreme-courts-decision/
Food and Drug Administration (FDA)
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FDA https://www.fda.gov/
Drug Regulation https://www.fda.gov/drugs
Medical Device Regulation https://www.fda.gov/medical-devices
Radiation-Emitting Products https://www.fda.gov/radiation-emitting-products
Vaccines, Blood & Biologics https://www.fda.gov/vaccines-blood-biologics
Tobacco Products https://www.fda.gov/tobacco-products
State Department of Health
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State Health Departments https://www.usa.gov/state-health
Maryland Department of Health https://health.maryland.gov/pages/home.aspx
CDC https://www.cdc.gov/
Medicaid and the Affordable Care Act: https://www.medicaid.gov/affordable-careact/index.html
Affordable Care Act
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Affordable Care Act Tax Provisions for Large Employers
https://www.irs.gov/affordable-care-act/employers/affordable-care-act-tax-provisionsfor-large-employers
Summary of the Affordable Care Act https://www.kff.org/health-reform/factsheet/summary-of-the-affordable-care-act/
ACA Information Center for Applicable Large Employers
(ALE) https://www.irs.gov/affordable-care-act/employers/aca-information-centerfor-applicable-large-employers-ales
Preventive health care services https://www.kff.org/health-reform/fact-sheet/summaryof-the-affordable-care-act/
Burwell v. Hobby Lobby Stores (2014) https://www.oyez.org/cases/2013/13-354
Appealing Health Plan Decisions https://www.hhs.gov/healthcare/about-theaca/cancellations-and-appeals/appealing-health-plandecisions/index.html#:~:text=You%20have%20the%20right%20to,to%20terminate%2
0your%20health%20coverage.&text=You%20can%20appeal%20your%20insurance,fai
r%20review%20of%20its%20decision
CMS RAC Audits
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CMS Recovery Audit Contractors (RAC) https://www.cms.gov/Research-StatisticsData-and-Systems/Monitoring-Programs/Medicare-FFS-CompliancePrograms/Recovery-Audit-Program
The Recovery Audit Program and Medicare https://www.cms.gov/Research-StatisticsData-and-Systems/Monitoring-Programs/Medicare-FFS-CompliancePrograms/Recovery-Audit-Program/Downloads/The-Recovery-Audit-Program-andMedicare-Slides-051313.pdf
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Approved RAC Topics https://www.cms.gov/Research-Statistics-Data-andSystems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-AuditProgram/Approved-RAC-Topics
Medicare Pard D RAC Appeals Process https://www.cms.gov/Research-StatisticsData-and-Systems/Monitoring-Programs/recovery-audit-program-parts-c-andd/Appeals-Process
Interoperability and Information Blocking
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CMS Policies and Technology for Interoperability and Burden Reduction
https://www.cms.gov/Regulations-and-Guidance/Guidance/Interoperability/index
CMS Interoperability Final Rule https://www.cmspatientaccessrule.com/
HIMSS Final CMS Interoperability Regulation: What you Need to Know
https://www.himss.org/news/final-onc-interoperability-regulation-what-you-needknow#:~:text=The%20CMS%20Interoperability%20and%20Patient%20Access%20Fina
l%20Regulation,more%20informed%20decision%20makers%20leading%20to%20bett
er-informed%20treatment.
Information Blocking https://www.healthit.gov/topic/information-blocking
Information Blocking FAQ https://www.healthit.gov/curesrule/resources/informationblocking-faqs
How do I comply with info blocking and where do I start? https://www.amaassn.org/system/files/2020-11/info-blocking-compliance.pdf
Understanding the Eight Exceptions to Information Blocking
https://journal.ahima.org/understanding-the-eight-exceptions-to-information-blocking/
Children’s Health Insurance Program (CHIP)
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The Children’s Health Insurance Program (CHIP)
https://www.healthcare.gov/medicaid-chip/childrens-health-insurance-program/
Children’s Health Insurance Program Overview
https://www.ncsl.org/research/health/childrens-health-insurance-programoverview.aspx
Center for Disease Control
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CDC https://www.cdc.gov/
COSO
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COSO https://www.coso.org/
COSO Guidance https://www.coso.org/guidance-on-ic
COSO Guidance for Health care Providers https://www.coso.org/healthcare-providers
COSO: Governance https://www.coso.org/governance
Laws, Compliance Tools and Managerial Actions
Success Tip: Talk about the law, compliance tools and managerial actions in all
coursework.
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Evaluate what the law requires the organization to do.
Evaluate how compliance tools can be used to ensure legal compliance or
correct legal problems.
Evaluate how specific management actions can be taken to use compliance tools
and ensure legal compliance.
What is a law?
A law arises from a Constitution, statute, regulation or court decision at the federal or
state level. It sets the standard of conduct of what is required. Laws often include
penalties that state what will happen if the requirements of the law are not met. This
can include financial penalties or jail time. For example, HIPAA ;aw has both civil and
criminal penalties.
Tip: Always start by knowing what the law requires and what the penalties are for noncompliance.
Examples:
Federal/State Type of Law
Citation Example and Web Link
Federal
U.S.
Constitution
U.S. Const. Art I
https://constitution.findlaw.com/
Federal
Statute
United States
Code
(U.S.C.)
Regulation
Code of
Federal
Regulations
(C.F.R.)
Federal
Cases
U.S.
Supreme
Court
42 U.S.C. 325 (2021)
https://www.law.cornell.edu/uscode/text
Federal
Federal
U.S. Court of
Appeals
29 C.F.R. 151 (2021)
https://www.ecfr.gov/
Advocate Health Care Network v. Stapleton, No. 1675 (2017)
https://www.supremecourt.gov/opinions/slipopinion/21
Jones v. Smith, No. 3:2021cv12349 (2nd Cir. 2021)
https://law.justia.com/cases/federal/appellate-courts/
U.S. District
Court
Markson v. Knox, No. 1:2021cv01334 (Md. Ct. 2021)
https://law.justia.com/cases/federal/district-courts/
State
State
Constitution
Maryland Const. Art. IV
https://law.justia.com/constitution/maryland/
State
State Statute
Maryland Mental Health Facilities §10-404 (2018)
https://codes.findlaw.com/
State
State Rule
COMAR 09.11.02.01C(2)(a)(i) (2020)
http://www.dsd.state.md.us/COMAR/ComarHome.html
State
State Cases
North Hospital v. Zenick, No. 34ag/21 (MD. Ct. App.
2021)
https://law.justia.com/cases/maryland/
What is a Compliance or Risk Management Tool?
A compliance or risk management tool is something that is used to help an organization
comply with the law. Any tool that is used to solve a problem should be evaluated to
determine how it will apply to correct the specific problem. For example, a general tool
such as a corporate checklist would need to be adapted to include items on the
checklist to ensure that the company met a specific compliance goal such as avoiding
discrimination in hiring.
Tip: Any managerial tool should be adjusted to meet the specific problem. Evaluate
how to use the general principles of the tool to correct specific problems. Give reasons
to support how your tools resolve the legal problem.
Tip 2: Use the week 12 managerial tools for compliance links throughout the course
to assist with compliance tools for assignments.
Examples:
Tool Examples
How it could be used to limit risk or comply with the law
Litigation Hold Letter
A litigation hold letter is issued to ensure that electronic and
other evidence is preserved for litigation by putting a hold
on destruction of relevant evidence while litigation is
pending.
A contract should comply with the law and include contract
clauses to limit the risk of the organization should a dispute
arise. A contract should be adapted to meet the needs of
the specific situation and risks.
Contracts and Contract
Clauses
Cloud Based Contract
Management System
Corporate documents
including policies and
procedures
Enterprise Document
Management (EDM)
System
HHS OIG Compliance
Protocol
COSO Internal Control
Framework
Health Information
Technology
Code of Ethics from a
Professional
Organization or from
the Hospital, Clinic or
Care Facility
Security Risk
Assessment (SRA)
Health Information
Technology or other
Internal Audits
Checklists
A cloud based contract management system helps ensure
that the organization complies with the requirements of the
contract and tracks the life cycle of the contract to limit risk
from non-renewal or renegotiation.
Corporate documents set the standards, vision, rules for
the organization to meet. They ensure consistency of
managerial actions and should be complied with. Any
management actions should comply with both law as well
as organizational documents and policies.
An Enterprise Document Management System (EDM)
creates is a way to keep all organizational documents in
digital forma for prompt review and retrieval. This gives the
organization a system wide process to manage, use, and
archive documents.
The HHS OIG Compliance protocol provides elements an
organization can use to comply with the law and limit the
risk of fraud and abuse.
The COSO Internal Control Framework provides a number
of controls that can be used in order to reduce risk within an
organization. General principles of control can be adapted
to manage specific organizational risks..
Health Information Technology can be used as a
compliance and risk management tool when the tool is set
up to comply with specific legal requirements and to limit
risk of non-compliance.
A Code of Ethics sets an ethical standard for those who
belong to the organization. Many organizations require a
person to sign the Code of Ethics as indication that they
agree and will comply with the ethical standards. This
ensures high ethical behavior which improves the likelihood
of legal compliance as well and limits the risk of
wrongdoing.
This is an assessment of the security risk to health
information within an organization. It is required by law and
helps ensure compliance with the law.
Internal audits give an organization a chance to catch
problems before an outside auditor, government regulator,
or accreditation agency comes in and finds a problem. This
allows the organization to correct the problem in order to
comply with legal requirements.
Checklists can be for a variety of activities and include a
surgical checklist, hiring, termination, or evaluation checklist
to ensure that all steps for safety are taken before a
procedure or activity. Checks can ensure consistency in
legal compliance no matter who is conducting the activity.
AHRQ, NCQA, Joint
Commission
Guidelines. and HHS
OIG Compliance
Guidelines
Sample Forms and
Documents
Training Tools
Guidelines provide a tool to meet high standard of practice.
They are not enforced like the law, but set high standards
that improve compliance and prevent problems.
Sample forms can help an organization set up a form for
patient intact, informed consent, consent refusal, prevent
violence, or encourage patient safety, ensure advanced
directives comply with state law, or take other actions in a
way that minimizes risk and complies with the law.
Formal training tools can be used to provide employee
training on HIPAA, OSHA Safety, or other issues to
encourage patient safety, legal compliance, etc.
What are Managerial Actions?
Managerial actions are things that you can DO as a manager to comply with the law.
These actions may include ways to use compliance and risk management tools to
comply with the law. Something that the government does is not a managerial action.
For example, issuing a litigation hold letter would be a managerial action to preserve
evidence when a lawsuit is anticipated.
Tip: Any recommended managerial actions should be specific to the problem and
correct the problem, reduce the risk, and prevent future problems. Always explain how
the recommended action will do this. Include reasons to support your recommended
managerial actions.
Examples:
Managerial Action
Related Tool
Legal Problem it could correct
Issue a Litigation
Hold Letter as soon
as you know a
lawsuit will be filed.
Add an arbitration
clause to a contract
to keep a contract
dispute out of court
and the public
limelight.
Create a new policy
on bullying to
prevent bullying in
the workplace.
Litigation Hold Letter
This would ensure evidence is
preserved for the lawsuit that is
anticipated before issuing the
litigation hold letter.
This could keep an contract issue
form going to court and limit
public exposure to the issue.
Contract clauses
Corporate Documents
When an issue arises a policy
can be created to prevent the
issue in the future and ensure
that if it arises it is consistently
Train employees on
Training Tools
how to use the
health information
technology system to
keep PHI private and
secure with a quiz at
the end of training as
a knowledge check..
Establish a
Corporate Documents
corrective action
plan for an employee
who is chronically
late to work with a 30
day follow up
meeting.
Create a checklist for Checklists
patient discharge to
ensure everything
that needs to be
completed prior to
discharge is
completed.
Conduct an internal
Audits
medical record audit
to see if initial visit
coding is supported
by the medical
record
documentation.
Create a hospital
Forms and Guidelines
protocol for opioid
use disorder (OUD)
screening based on
national guidelines to
ensure consistent
screening of all
patients.
handled in conjunction with the
policy.
Any training should be specific to
the legal problem and provide
specific information to employees
so that the problem is less likely
to recur.
This allows the manager to
correct a problem a specific
employee is having. It should be
followed up with review to see if
the corrective actions were
properly implemented by the
employee after a preset period
such as 30, 60 and/or 90 days.
This ensures that patient meets
medical criteria for discharge, has
received any training or
medication for discharge, and
that the discharge is in
compliance with the law.
An internal audit allows the
organization to review its own
records related to legal standards
and make needed changes to
comply with the law before an
outside auditor, regulator or
accreditor comes in to audit and
finds a problem.
Protocols ensure consistent
actions for all who do the same
activity.
Forms ensure that the
information that needs to be
captured to comply with the law is
on the form.
Week 12: Managerial Tools for Compliance
Compliance and Risk Management Tools
Checklists
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AAFP Closing your practice checklist
https://www.aafp.org/pubs/fpm/blogs/inpractice/entry/departing_physician.html
ACEP/PAI Physician Checklist for Appealing Audit Findings
http://www.physiciansadvocacyinstitute.org/Portals/0/assets/docs/checklist-forappealing-audits.pdf
AcomHealth 2020 Coding and Billing Checklist https://acomhealth.com/wpcontent/uploads/2020/02/2020-Coding-Billing-Checklist.pdf
AHA Checklists to Improve Patient Safety https://www.aha.org/ahahretguides/2013-07-10-checklists-improve-patient-safety
CANDOR Disclosure Checklist https://www.ahrq.gov/patientsafety/capacity/candor/modules/checklist5.html
Central Line Insertion Checklist
http://www.ihi.org/resources/Pages/Tools/CentralLineInsertionChecklist.aspx
CURI Medical Record Check-List Assessment https://assets.hccainfo.org/Portals/0/PDFs/Resources/Conference_Handouts/Clinical_Practice_Co
mpliance_Conference/2019/Tuesday/602_Handout.docx.pdf
Employee Termination Checklist Employee Termination Checklist (25 tasks)
[PDF & Printable]
GDPR Checklist for data controllers https://gdpr.eu/checklist/
Greenway Health: Information sharing/Information Blocking Checklist
https://www.greenwayhealth.com/sites/default/files/files/202105/Greenway%20Health%20Information%20Blocking%20Checklist_2.pdf
HCCA: EMTALA Compliance Checklist https://assets.hccainfo.org/Portals/0/PDFs/Resources/Conference_Handouts/Compliance_Institute/
2016/308handout2.pdf
HHS ONC HIT HIPAA Security Checklist
https://www.healthit.gov/sites/default/files/comments_upload/hipaa-securitychecklist.pdf
HHS OHRP Research Informed Consent Checklist
https://www.hhs.gov/ohrp/regulations-and-policy/guidance/checklists/index.html
Hiring Process Checklist https://www.hiresuccess.com/blog/hiring-processchecklist-step-by-step-guide
Holland and Hart HIPAA Privacy Checklist
https://www.hollandhart.com/pdf/HIPAA-Privacy-Checklist-HH.pdf
Holland and Knight: Affordable Care Act Compliance Checklist for Employers
https://www.hklaw.com/files/Uploads/Documents/Practices/EmployeeBenefits/AC
AComplianceChecklist.pdf
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HRET Checklist to Improve Patient Safety http://www.hpoe.org/ReportsHPOE/CkLists_PatientSafety.pdf
JCRINC Point of Care Medical Record Checklist https://info.jcrinc.com/rs/494MTZ-066/images/POINT-OF-CARE30.pdf?ref…
KYMA Sample Compliance Checklists for Electronic Health Records
https://kyma.org/shared/content/uploads/2015/12/ehr-compliance-checklist.pdf
Maryland Non-Profits: Starting a Nonprofit in Maryland Checklist
http://marylandnonprofits.org/wp-content/uploads/Start-a-Nonprofit-ChecklistMaryland.pdf
Medical documentation and checklists Medical Documentation and Checklists
(novitas-solutions.com)
Medicare Discharge Planning Checklist
https://www.medicare.gov/Pubs/pdf/11376-discharge-planning-checklist.pdf
National Staffing Credentialing Checklist Credentialing Checklist – Requirements
for Application (nationalstaff.com)
NSF 2019 Equipment Calibration Checklist
https://d2evkimvhatqav.cloudfront.net/documents/bsc_2019_equipment_annual_f
orm.pdf?mtime=20200716154310&focal=none
Premera Provider Credentialing Document Checklist
https://www.premera.com/documents/023163.pdf
RAC Preparedness Checklist https://assets.hccainfo.org/Portals/0/PDFs/Resources/Conference_Handouts/Clinical_Practice_Co
mpliance_Conference/2013/301-Handout2.pdf
SCRIBD Medical Records Audit Checklist

Termination Risk Assessment Checklist
https://www.hollandhart.com/presentations/Healthcare-Bootcamp_LETermination_Risk.pdf
WHO Surgical Safety Checklist
https://apps.who.int/iris/bitstream/handle/10665/44186/9789241598590_eng.pdf?
sequence=1&isAllowed=y
Codes of Ethics
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ACHE Code of Ethics https://www.ache.org/about-ache/our-story/ourcommitments/ethics/ache-code-of-ethics
AHIMA Code of Ethics https://bok.ahima.org/doc?oid=105098#.YZMsDWDMKUk
AHRQ Health IT Evaluation Toolkit and Evaluation Measures Quick Reference
Guides Health IT Evaluation Toolkit and Evaluation Measures Quick Reference
Guides | Digital Healthcare Research (ahrq.gov)
AMA Code of Ethics https://www.ama-assn.org/delivering-care/ethics/codemedical-ethics-overview
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AMA Informed Consent Opinion 2.1.1 https://www.ama-assn.org/deliveringcare/ethics/informed-consent
AMA Medically Ineffective Interventions Code of Medical Ethics Opinion 5.5
https://www.ama-assn.org/delivering-care/ethics/medically-ineffectiveinterventions
ANA Code of Ethics https://nursing.rutgers.edu/wpcontent/uploads/2019/06/ANA-Code-of-Ethics-for-Nurses.pdf
John Hopkins Conflict of Interest Policy https://www.hopkinsmedicine.org/supplychain/policies-and-procedures/jhhs-conflict-of-interest-policy.html
Mayo Clinic Code of Conduct https://mcforms.mayo.edu/mc2500mc2599/mc2570.pdf
NAHQ Code of Ethics https://nahq.org/about/code-of-ethics/
Compliance Toolkits
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AHIMA Information Governance Toolkit 2.0
https://bok.ahima.org/doc?oid=301510
AHRQ Communication and Optimal Resolution (CANDOR) Toolkit
Communication and Optimal Resolution (CANDOR) Toolkit | Agency for
Healthcare Research and Quality (ahrq.gov)
ASHRM Active Risk Control Toolkit: Better Solutions After Risk Assessment
https://www.ashrm.org/resources/arc_toolkit
ASHRM Health Care Facility Workplace Violence Risk Assessment Tool
https://www.ashrm.org/resources/workplace_violence
ASHRM Root Cause Analysis Playbook
https://ams.aha.org/EWEB/DynamicPage.aspx?WebCode=ProdDetailAdd&ivd_p
rc_prd_key=111f753d-a277-4c89-8e38-4d1fd6289654
CMS Connected Care Toolkit Connected Care Toolkit – Chronic Care
Management Resources for Health Care Professionals and Communities
(cms.gov)
CMS Documentation Matters Toolkit https://www.cms.gov/Medicare-MedicaidCoordination/Fraud-Prevention/Medicaid-IntegrityProgram/Education/Documentation
CMS Hospice Benefit Toolkit https://www.cms.gov/Medicare-MedicaidCoordination/Fraud-Prevention/Medicaid-Integrity-Program/Education/Hospice
HHS OIG Compliance Toolkits https://oig.hhs.gov/compliance/compliancetoolkits/
Institute for Healthcare Improvement Patient Safety Essentials Toolkit Patient
Safety Essentials Toolkit | IHI – Institute for Healthcare Improvement
LEP Toolkit https://www.dol.gov/agencies/oasam/centers-offices/civil-rightscenter/external/limited-english-proficient/toolkit
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IRS Exempt Employer’s Toolkit https://www.irs.gov/charities-non-profits/exemptemployers-toolkit
MHS Indiana Medical record Documentation Audit Tool
https://www.mhsindiana.com/content/dam/centene/mhsindiana/medicaid/pdfs/Me
dical-Record-Audit-Tool-July-2015.pdf
NICU Toolkit: Transitioning Newborns from NICU to Home
https://www.ahrq.gov/patient-safety/settings/hospital/resource/nicu/index.html
Texas Pediatric Society Palliative Care Toolkit https://txpeds.org/palliative-caretoolkit
Contract Clauses
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Law Insider – Mediation Sample Clauses https://www.lawinsider.com/clause/disputeresolution-mediation
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Good Faith Negotiation Clause Samples https://afterpattern.com/clauses/goodfaith-negotiation
Sample Arbitration Clause
https://www.adr.org/Clauses?gclid=EAIaIQobChMIjcaFgPKb9AIVwHxvBB2U2gq
VEAAYAiAAEgIelfD_BwE
Sample Data Protection Clause https://www.lawinsider.com/clause/dataprotection
Sample Limitation of liability Clauses
https://www.lawinsider.com/clause/limitation-of-liability
Sample Termination of Contract clauses
https://www.lawinsider.com/clause/termination-of-contract
Sample Managed Care Contract
https://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Practice%
20Management/Office%20Operations/sample_managed_care_contract.pdf
Forms and Templates
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Against Medical Advice Form Against Medical Advice (AMA) Form
https://www.thesullivangroup.com/risk_resources/ToolBox/AMA_form.pdf
AHIMA:A Model Contract for Health information Exchange
https://library.ahima.org/PdfView?oid=63657
Baylor Scott and White Health Electronic Medical Record Access agreement for
Non-Baylor Scott & White Health Users
https://www.bswhealth.med/Documents/physician-relations/emr-accessagreement.pdf
Cornell IRB Consent Form Templates
https://researchservices.cornell.edu/forms/irb-consent-form-templates
Hofstra IRB Informed Consent Form
https://medicine.hofstra.edu/pdf/research/sample-informed-consent-form-forhofstra-irb-proposal.pdf
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IRS 990 – Tax Form for Tax Exempt Organizations https://www.irs.gov/pub/irspdf/f990.pdf
IT Risk Assessment Excel Template

IT Risk Assessment Template

Living Will Forms https://eforms.com/living-will/
Maryland MOLST Form
https://marylandmolst.org/docs/MOLST%20MM3%202013%20FINAL%20PROP
OSED%2072613%20POSTED%2021714-no-instructions.pdf
Medication Error Reporting Form
https://jipmer.edu.in/sites/default/files/Medication-error-reporting-form.pdf
NLC Contracting Guidelines and Checklist for EHR Vendor Selection
https://www.healthit.gov/resource/nlc-contracting-guidelines-and-checklist-ehrvendor-selection
Maryland Application for a 1915 Home and Community Based Services Waiver
https://health.maryland.gov/mmcp/waiverprograms/SiteAssets/Pages/Home/Medi
cal%20Day%20Care%20Services%20renewal%202021%20CLEAN%2001.28.2
1.pdf
Maryland Certificate of Need (CON) Application Forms
https://mhcc.maryland.gov/mhcc/Pages/hcfs/hcfs_con/hcfs_con_applications.asp
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Medical Records Release Authorization Form/HIPAA
https://eforms.com/release/medical-hipaa/
Model Business Associate Agreement
https://www.hhs.gov/sites/default/files/model-business-associate-agreement.pdf
PHR Model Privacy Notice Template
https://www.healthit.gov/sites/default/files/phr-model-privacy-notice-final-2011.pdf
Responsible-Accountable-Consulted-Informed (RACI)Matrix in excel

RACI Matrix Template

Risk Register Template for Excel

Risk Register Template

Stoel Rives Sample Litigation Hold Notice
https://www.stoel.com/StoelRives/files/fa/fac01e84-5bad-48e6-9b1ffcb997d9ded2.pdf
Guidelines and Protocols
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AHRQ Quality and Patient Safety Programs by Setting: Ambulatory Care
https://www.ahrq.gov/patient-safety/settings/ambulatory/index.html
AHRQ Quality and Patient Safety Programs by Setting: Emergency Department
https://www.ahrq.gov/patient-safety/settings/emergency-dept/index.html
AHRQ Quality and Patient Safety Programs by Setting; Hospital
https://www.ahrq.gov/patient-safety/settings/hospital/index.html
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AHRQ Quality and Patient Safety Programs by Setting: Long-Term Care
https://www.ahrq.gov/patient-safety/settings/long-term-care/index.html
AMA Guides to the Evaluation of Permanent Impairment: an overview
https://www.ama-assn.org/delivering-care/ama-guides/ama-guides-evaluationpermanent-impairment-overview
ASAM National Practice Guidelines For the Treatment of Opioid Use Disorder
https://www.asam.org/quality-care/clinical-guidelines/national-practice-guideline
Clinical Practice Guidelines for Quality Palliative Care
https://www.nationalcoalitionhpc.org/wp-content/uploads/2020/07/NCHPCNCPGuidelines_4thED_web_FINAL.pdf
CMS Guidelines for Teaching Physicians, Interns, and Residents
https://www.cms.gov/outreach-and-education/medicare-learning-networkmln/mlnproducts/downloads/teaching-physicians-fact-sheet-icn006437.pdf
CMS Teaching Physicians, Interns, and Residents Guidelines
https://www.cms.gov/outreach-and-education/medicare-learning-networkmln/mlnproducts/downloads/teaching-physicians-fact-sheet-icn006437.pdf
COSO Guidance https://www.coso.org/guidance-on-ic
Creighton Health Record Documentation Policies and Procedures
https://www.creighton.edu/fileadmin/user/GeneralCounsel/docs/2.5.4._Health_Re
cord_Documentation__2-1-2020.pdf
Department of Justice (DOJ) Horizontal Merger Guidelines
https://www.justice.gov/atr/horizontal-merger-guidelines-0
Guide to Reporting Abuse in Maryland https://cdn.ymaws.com/www.naswmd.org/resource/resmgr/imported/child%20abuse%20reporting%20checklist.pdf
HHS OIG Compliance Guidance Compliance Guidance | Office of Inspector
General | Government Oversight | U.S. Department of Health and Human
Services (hhs.gov)
HHS OIG Contractual Joint Ventures Special Advisory Bulletin
https://oig.hhs.gov/documents/special-advisorybulletins/885/042303SABJointVentures.pdf
HHS OIG Health Care Fraud Self-Disclosure Protocol
https://oig.hhs.gov/documents/self-disclosure-info/1006/Self-Disclosure-Protocol2021.pdf
Joint Commission Universal Protocol
https://www.jointcommission.org/standards/universal-protocol/
Maryland Guide to Legal Aspects of Doing Business in Maryland
https://www.marylandattorneygeneral.gov/Securities%20Documents/legalaspects
.pdf
Maryland 2022 Home Health Agency Certificate of need (CON) Guidelines
https://mhcc.maryland.gov/mhcc/pages/hcfs/hcfs_homehealth/documents/2022_
HHA_Guidelines.pdf
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NCQA Guidelines for Medical Record Documentation https://www.ncqa.org/wpcontent/uploads/2018/07/20180110_Guidelines_Medical_Record_Documentatio
n.pdf
Newborn Critical Care Center (NCCC) Clinical Guidelines: Neonatal Palliative
Care Guidelines Newborn Critical Care Center (NCCC) Clinical Guidelines DocsLib
NIST Calibration Procedures https://www.nist.gov/pml/weights-andmeasures/laboratory-metrology/calibration-procedures
U.S. Preventive Services Task Force Preventive Service Recommendations
https://www.uspreventiveservicestaskforce.org/uspstf/recommendationtopics/uspstf-and-b-recommendations
Policies and Procedures
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American Hospital Association (AHA) Bill of Rights

AHA Patient’s Bill of Rights

CCHC Employee Handbook https://www.cchchealthcare.com/wpcontent/uploads/2014/10/CCHC-Employee-Handbook.pdf
Cleveland Clinic Policy on Do Not Resuscitate (DNR)
http://www.clevelandclinic.org/bioethics/policies/dnr.html
FSMB Policy on Physician Illness and Impairment
https://www.fsmb.org/siteassets/advocacy/policies/policy-on-physicianimpairment.pdf
FSMB Policy on Physician Impairment
https://www.fsphp.org/assets/docs/physician-impairment.pdf
ISO Procedure for Equipment Calibration and Maintenance https://projectlead.eu/2020/12/31/iso-9001-as-9100-calibration-requirements-and-procedure/
John Hopkins Policies and Employee Handbooks
https://www.hopkinsmedicine.org/human_resources/about/policies_handbooks.ht
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Memorial Hospital Peer Review Policy https://www.beaconhealthsystem.org/wpcontent/uploads/2018/08/Medical-Staff-Peer-Review.pdf
Renaissance Stonybrook Disruptive Provider Policy
https://renaissance.stonybrookmedicine.edu/sites/default/files/disruptive%20final
_0.pdf
UCLA David Geffen School of Medicine Resident Policies
https://medschool.ucla.edu/gme-resident-policies
University of Buffalo Impaired Physician Policy Impaired Physician Policy Jacobs School of Medicine and Biomedical Sciences – University at Buffalo
University of Maryland Medical System Policies
https://www.umms.org/about/policies
Risk Management and Assessment Tools
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ASQ Root Cause Analysis Tools https://asq.org/quality-resources/root-causeanalysis/tools https://asq.org/quality-resources/root-cause-analysis/tools
Plan–Do-Check-Act (PDCA) Model for Risk Management
https://simplifyiso.com/connect-the-dots-pdca-risk-based-thinking-and-theprocess-approach/
NIST Risk Assessment Tools https://www.nist.gov/itl/appliedcybersecurity/privacy-engineering/collaboration-space/focus-areas/riskassessment/tools
Security Risk Assessment (SRA) Tool https://www.healthit.gov/topic/privacysecurity-and-hipaa/security-risk-assessment-tool
UNNUS Strength-Weakness-Opportunities-Threats (SWOT) Analysis
https://unnus.com/medical/healthcare-swot-analysis/
Wolters Kluwer The Bowtie Method Risk Management Tool
https://www.cgerisk.com/knowledgebase/The_bowtie_method
Training Materials
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CDC NIOSH Training and Workforce Development
https://www.cdc.gov/niosh/training/default.html
CMS Evaluation and Management Services Guide
https://www.cms.gov/outreach-and-education/medicare-learning-networkmln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf
eCQM and eCQI Educational resources https://ecqi.healthit.gov/ecqm-and-ecqieducation-resources
HHS ONC Security Risk Assessment Videos
https://www.healthit.gov/topic/privacy-security-and-hipaa/security-riskassessment-videos
HHS OIG A Roadmap for New Physicians: Physician Education Training
Materials https://oig.hhs.gov/compliance/physician-education/
HHS Training Materials on HIPAA https://www.hhs.gov/hipaa/forprofessionals/training/index.html
OSHA Training Tools https://www.osha.gov/training/library/materials