Review the document The Law, Compliance Tools, and Managerial Actions document in the Content area. ***Note: Laws are not compliance tools.
Use Week 12 Managerial Compliance Tools links in the Classroom Law Library to find tools.
Review the compliance tools we have applied in course discussions and assignments throughout the course such as contract clauses, policies, COSO, checklists, etc.
Demonstrate critical thinking by linking each compliance tool to specific law(s) we discussed in each module. For example, the compliance tools for Business Transactions should relate to laws discussed in Business Transactions such as Certificate of Need (CON), antitrust, Corporate Practice of Medicine (CPOM), state incorporation laws, non-profit tax laws, Sarbanes Oxley Law (SOX), False Claims Act (FCA), Anti-kickback Statute (AKS), Physician Self-Referral Law (Stark law).
Include 10 different tools.
Select tools you will use as a manager.
MANAGERIAL TOOLKIT
FOR
LEGAL COMPLIANCE
Name:
Date:
Tool Name
URL or Cloud pathway to access the tool
Brief Description of the Tool
Tool Justification (Explain why you selected this tool over others)
Trigger to Use Tool (What will happen for you to need to use the tool)
Tool Use (Explain how the tool will be used)
Example: (Dont reuse this tool.)
Tool Name:
HHS OIG Health Care Compliance Program Tips
URL or Cloud pathway to access the tool
https://oig.hhs.gov/compliance/provider-compliance-training/files/Compliance101tips508.pdf
Brief Description of the Tool
This tool lists the 7 fundamental elements of an effective compliance program and five tips to create a culture of compliance.
Tool Justification (Explain why you selected this tool over others)
I selected this tool because it can be used for a variety of compliance issues. I would list it in the Business Transactions category, but it can
also be used for government program, HIT, and employment compliance issues.
Trigger to Use Tool (What will happen for you to need to use the tool)
1. I would use this tool proactively within my department to prevent compliance problems.
2. I would use this tool after a bad compliance audit to correct compliance issues with a corrective action plan.
3. Whenever compliance issues arise, I would review this tool to be sure that any actions I take encourage a culture of compliance and
support my organizations compliance program.
Tool Use (Explain how the tool will be used)
1. I would use this tool to remind me of the general components of a compliance program, then work within the organization on specific
components that need to be improved based on what is going on in the organization or my department.
2. I would use this tool to review compliance requirements so that I can have meaningful compliance conversations about strategies for
compliance in a way that meets federal law requirements.
BUSINESS TRANSACTOINS
1.Tool Name
URL or Cloud pathway to access the tool
Brief Description of the Tool
Tool Justification (Explain why you selected this tool over others)
Trigger to Use Tool (What will happen for you to need to use the tool)
Tool Use (Explain how the tool will be used)
2.Tool Name
URL or Cloud pathway to access the tool
Brief Description of the Tool
Tool Justification (Explain why you selected this tool over others)
Trigger to Use Tool (What will happen for you to need to use the tool)
Tool Use (Explain how the tool will be used)
GOVERNMENT PROGRAMS
1.Tool Name
URL or Cloud pathway to access the tool
Brief Description of the Tool
Tool Justification (Explain why you selected this tool over others)
Trigger to Use Tool (What will happen for you to need to use the tool)
Tool Use (Explain how the tool will be used)
2.Tool Name
URL or Cloud pathway to access the tool
Brief Description of the Tool
Tool Justification (Explain why you selected this tool over others)
Trigger to Use Tool (What will happen for you to need to use the tool)
Tool Use (Explain how the tool will be used)
HEALTH INFORMATION TECHNOLOGY
1.Tool Name
URL or Cloud pathway to access the tool
Brief Description of the Tool
Tool Justification (Explain why you selected this tool over others)
Trigger to Use Tool (What will happen for you to need to use the tool)
Tool Use (Explain how the tool will be used)
2.Tool Name
URL or Cloud pathway to access the tool
Brief Description of the Tool
Tool Justification (Explain why you selected this tool over others)
Trigger to Use Tool (What will happen for you to need to use the tool)
Tool Use (Explain how the tool will be used)
PATIENT CARE
1.Tool Name
URL or Cloud pathway to access the tool
Brief Description of the Tool
Tool Justification (Explain why you selected this tool over others)
Trigger to Use Tool (What will happen for you to need to use the tool)
Tool Use (Explain how the tool will be used)
2.Tool Name
URL or Cloud pathway to access the tool
Brief Description of the Tool
Tool Justification (Explain why you selected this tool over others)
Trigger to Use Tool (What will happen for you to need to use the tool)
Tool Use (Explain how the tool will be used)
LABOR AND EMPLOYMENT
1.Tool Name
URL or Cloud pathway to access the tool
Brief Description of the Tool
Tool Justification (Explain why you selected this tool over others)
Trigger to Use Tool (What will happen for you to need to use the tool)
Tool Use (Explain how the tool will be used)
2.Tool Name
URL or Cloud pathway to access the tool
Brief Description of the Tool
Tool Justification (Explain why you selected this tool over others)
Trigger to Use Tool (What will happen for you to need to use the tool)
Tool Use (Explain how the tool will be used)
Week 12: Managerial Tools for Compliance
Compliance and Risk Management Tools
Checklists
AAFP Closing your practice checklist
https://www.aafp.org/dam/AAFP/documents/practice_management/admin_staffin
g/ClosingPracticeChecklist.pdf
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
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 HIPAA Security Checklist for Healthcare
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
HMSA Medical Record Documentation Checklist
https://hmsa.com/portal/provider/PM09-189_Documentation_Checklist_1209.pdf
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
HPSO Staff Credentialing Checklist https://www.hpso.com/riskeducation/individuals/articles/Staff-Credentialing-Checklist
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
Medicare Discharge Planning Checklist
https://www.medicare.gov/Pubs/pdf/11376-discharge-planning-checklist.pdf
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
SHRM Employee Termination Checklist
https://www.shrm.org/resourcesandtools/tools-and-samples/hrforms/pages/termination_checklist.aspx
SHRM Hiring Checklist https://www.shrm.org/resourcesandtools/tools-andsamples/hr-forms/pages/hiringpracticeschecklist.aspx
WHO Surgical Safety Checklist
https://apps.who.int/iris/bitstream/handle/10665/44186/9789241598590_eng.pdf?
sequence=1&isAllowed=y
Codes of Ethics
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
AMA Code of Ethics https://www.ama-assn.org/delivering-care/ethics/codemedical-ethics-overview
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
AHIMA Toolkits
https://bok.ahima.org/searchresults?q=&fs=source_facet|AHIMA+toolkit
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 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/
LEP Toolkit https://www.dol.gov/agencies/oasam/centers-offices/civil-rightscenter/external/limited-english-proficient/toolkit
IRS Exempt Employers 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
Corporate Management and Documents
Drexel Agreement to Mediate Health Care Disputes
https://www.drexel.edu/~/media/Files/studentlife/DSHC/Mediation%20Agreement
.ashx?la=en
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
AHIMA:A Model Contract for Health information Exchange
https://bok.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
IRS 990 – Tax Form for Tax Exempt Organizations https://www.irs.gov/pub/irspdf/f990.pdf
IT Risk Assessment Excel 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
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
x
Medical Records Release Authorization Form/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
Risk Register Template for Excel
SHRM Performance Appraisal form
https://www.shrm.org/resourcesandtools/tools-and-samples/hrforms/pages/cms_002017.aspx
Stoel Rives Sample Litigation Hold Notice
https://www.stoel.com/StoelRives/files/fa/fac01e84-5bad-48e6-9b1ffcb997d9ded2.pdf
Guidelines and Protocols
AHIMA Guidelines: The Cybersecurity Plan https://journal.ahima.org/wpcontent/uploads/2017/12/AHIMA-Guidelines-Cybersecurity-Plan.pdf
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
AHRQ Quality and Patient Safety Programs by Setting: Long-Term Care
https://www.ahrq.gov/patient-safety/settings/long-term-care/index.html
ASAM National Practice Guidelines For the Treatment of Opioid Use Disorder
https://www.asam.org/docs/default-source/quality-science/npg-jamsupplement.pdf?sfvrsn=a00a52c2_2
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
COSO Guidance https://www.coso.org/Pages/guidance.aspx
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 https://oig.hhs.gov/compliance/complianceguidance/
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
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 https://www.mombaby.org/wpcontent/uploads/2020/02/Palliative-Care-Guidelines-2017.pdf
NIST Calibration Procedures https://www.nist.gov/pml/weights-andmeasures/laboratory-metrology/calibration-procedures
NIOSH Workplace Safety and Health Topics Guidelines
https://www.cdc.gov/niosh/topics/default.html
U.S. Preventive Services Task Force Preventive Service Recommendations
https://www.uspreventiveservicestaskforce.org/uspstf/recommendationtopics/uspstf-and-b-recommendations
Policies and Procedures
American Hospital Association (AHA) Bill of Rights
Cleveland Clinic Policy on Do Not Resuscitate (DNR)
http://www.clevelandclinic.org/bioethics/policies/dnr.html
ISO Procedure for Equipment Calibration and Maintenance
https://isoconsultantkuwait.com/2019/01/23/procedure-for-equipment-calibrationand-maintenance/
John Hopkins Policies and Employee Handbooks
https://www.hopkinsmedicine.org/human_resources/about/policies_handbooks.ht
ml
John Hopkins Policy on Physician Impairment
https://www.hopkinsmedicine.org/Medicine/education/hstrainingprogram/applican
ts/policies/phys_impair.html
Molina Healthcare Employee Handbook
https://www.molinahealthcare.com/~/media/Molina/PublicWebsite/PDF/members/
common/en-US/Careers/mmm-emp-handbook.pdf
Providence Health and Services Oregon: Professional Staff Peer Review
Policy
https://oregon.providence.org/~/media/Files/Providence%20OR%20PDF/Medical
%20Staff%20News/providencepeerreview.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 Maryland Medical System Policies
https://www.umms.org/about/policies
WSHA Records Management and Retention Policy http://www.wsha.org/wpcontent/uploads/Chapter_28_Appendix_A_SampleRecords_Management_and_
Retention_Policy.pdf
Risk Management and Assessment Tools
ASQ Root Cause Analysis Tools https://asq.org/quality-resources/root-causeanalysis/tools https://asq.org/quality-resources/root-cause-analysis/tools
National Quality Forum (NQF) quality measures (search measures)
https://www.qualityforum.org/Home.aspx
PlanDo-Check-Act (PDCA) Model for Risk Management
https://simplifyiso.com/connect-the-dots-pdca-risk-based-thinking-and-theprocess-approach/
Risk Assessment and Plan (RAP) https://strategies.rmf.harvard.edu/clinical-riskassessments?sc_camp=B601A279E6F0413B8B50EC296D3EA4DC#riskassess
mentplanrap
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
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
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