Complete Healthcare Compliance Manual

Time: [TIME] [A.M./P.M.]–[TIME] [A.M./P.M.] [TIME ZONE]

Date: [MM/DD/YYYY]

Location: [ROOM NAME], [BUILDING NAME]]

Remote Access: via [TEAMS, ZOOM, or Webex]

Members

Guests

• _____[NAME], [JOB TITLE]_____________

• _____[NAME], [JOB TITLE]_____________

• _____[NAME], [JOB TITLE]_____________

• _____[NAME], [JOB TITLE]_____________

• _____[NAME], [JOB TITLE]_____________

• _____[NAME], [JOB TITLE]_____________

• _____[NAME], [JOB TITLE]_____________

• _____[NAME], [JOB TITLE]_____________

• _____[NAME], [JOB TITLE]_____________

Record of Attendance/Start Time: Compliance officer (CO) [NAME]

[Response examples follow]

All but one member attended in person. [NAME] was excused and out of town. Quorum.

Approval of Minutes: CO [NAME]

Upon review, members approved minutes of the [XX/XX/XXXX] meeting

Compliance Program Update: CO [NAME]

New hire, hybrid work

• Human Resource (HR) director reported an update on candidates for new compliance manager position.

• Several department heads reported challenges their staffs had with timely completion of the specialized compliance training in the LMS due to technical issues and network access for remote workers.

• A lengthy discussion ensued on hybrid work environments and efficiencies in compliance training. CIO wanted to follow up with senior system admin on access issues.

Policies, Procedures, and Code of Conduct Update: Presenter(s) [NAMES]

Code of Conduct: revisions status

• Code of Conduct draft version 2/2022 was presented by CO and discussed members’ requested edits to intro letter and Attestation Statement.

• CO brought back Exclusion Screening Policy, draft version 2a, after incorporating requested edits in prior meeting. Members approved the revised version.

• To ensure procedure matches process, CO emphasized importance of getting the COI policy revised and finalized prior to the upcoming annual COI survey.

CO to revisit policy comments, edit suggestions with policy committee and compliance team, then bring back to next meeting.

Exclusion Screening Policy: update

Conflict of Interest (COI) Policy: draft

Arrangements with Providers Policy: update

Billing Monitoring Policy: draft

Corporate Compliance Committee Charter: update

False Claims Act Policy: revision

Risk Areas, Auditing, and Monitoring: CO, Presenter(s) [NAMES]

HHS OIG Work Plan: risk areas follow-up

Annual Risk Assessment: status

Annual Compliance Work Plan: progress report

Compliance score review/metrics: update

Regulatory update:

• Sunshine Act reporting requirements

• 21st Century Cures Act final rule (information blocking)

• COVID-19 blanket waivers

• Telemedicine

External government audits update:

• RAC

• ZPIC

• TPE

• OIG

Annual Compliance Program Assessment: schedule and planning status

External audit: outsourced coding-audit status

Regulatory update:

• Sunshine Act reporting requirements

• 21st Century Cures Act Final Rule (information blocking)

• COVID-19 blanket waivers

Compliance Training and Education Update: Presenter(s) [NAMES]

Board compliance training presentation: schedule and content

New employee orientation/HR meeting

General compliance training [YEAR]: vendor proposal for LMS/content

General compliance training: statistics

Coding compliance training: schedule and content

Exclusion Screening/Enforcement: Presenter(s) [NAMES]

LEIE screening: update on monthly [YEAR] results

Screening vendor: contract status

Effective Communication (Hotline/Disclosures): Presenter(s) [NAMES]

Hotline summary report: Q3/[YEAR]

Quarterly Compliance Newsletter: Q4/[YEAR] draft

HIPAA: Presenter(s) (e.g., Privacy Officer [PO]), Security Officer [SO]) [NAMES]

OCR disclosure/incident

Upcoming HIPAA security assessment

Open Forum: All

Adjournment/End Time [TIME] [A.M./P.M.] [TIME ZONE]

Meeting concluded at [TIME] [AM/PM] [TIME ZONE]

Next meeting scheduled [MM/DD/YYYY]