Complete Healthcare Compliance Manual

☐ Code of Conduct

☐ Technology P&P’s

☐ Conflict of Interest P&P’s

☐ Social Media P&P’s

☐ Drug/Alcohol Use P&P’s

☐ Workplace Relationships/Boundaries P&P’s

☐ Financial P&P’s

☐

☐ Gifts/Gratuities P&P’s

☐

☐ Interactions with Patients/Clients P&P’s

☐

☐ Harassment/Discrimination P&P’s

☐

☐ Privacy P&P’s

☐

☐ Billing and Coding Issues

☐ Improper Employment or Disciplinary Actions

☐ Conflict of Interest

☐ Misconduct/Inappropriate Behavior

☐ Disclosure of Confidential Information

☐ Patient Care/Safety

☐ Discrimination

☐ Theft/Vandalism

☐ Drug/Medication Control

☐ Unlawful/Improper Payments

☐ Harassment

☐ Workplace Retaliation/Retribution

☐ Y

☐ N

Alleged violation of state or federal law or the code of ethics that would result in serious harm to individuals or the organization, or significant civil or criminal penalties?

☐ Y

☐ N

Allegation against executive leadership member?

☐ Y

☐ N

Allegation involving more than a single team or multiple reports from various teams directed toward a single leader?

☐ Y

☐ N

Allegation involving multiple sites, a region or the organization?

☐ Y

☐ N

Allegation that could undermine the effectiveness of the compliance program?

☐ Y

☐ N

Allegation that could result in media attention, damage (monetary or reputational)?

☐ Y

☐ N

Allegation that could result in government actions against the company?

☐ Y

☐ N

Allegations that could result in the need to make a regulatory report?

☐ Lead Investigation Dept

☐ Lead Investigator

☐ Co-investigator/Note-taker

☐ Stakeholders

☐ Reporter(s)

☐ Implicated Person(s)

☐ Witnesses/Interviewees

☐ In-house Counsel

☐ Personnel file (Implicated Person)

☐ Department Schedules/Shift Logs

☐ Personnel file (Reporter)

☐ Timecards

☐ Prior Investigation Files (Implicated Person)

☐ Financial records

☐ Prior Investigation Files (Reporter)

☐ Email communications

☐ Supervisory files

☐ Surveillance footage

☐ Photographs

☐ Network drives/ Hard drives

☐ Voicemails

☐ Professional Code of Conduct

☐ Incident Reports

☐ Policies & Procedures

☐ Patient Records

☐ Social Media Activity

☐ Electronic health record activity (Keystrokes)

☐ Text Messages

☐ Plan the order of interviews (often with the reporter first, then witnesses, and the implicated person last)

☐ Be aware of interviewee’s employment status & regular work hours

☐ Mark calendar invites “private”

☐ Schedule interviews in a confidential location

☐ Whenever possible, do not include managers/supervisors in direct report interviews

☐ Limit information shared with managers/supervisors (minimum necessary; need to know)

☐ Prepare interview script and questions

☐ Anticipate interviewee answers/reactions/behaviors/questions and plan your response

☐ Begin investigation as soon as practical after receipt of complaint or once there is reason to believe that inappropriate conduct, violation of policy, etc. has occurred.

☐ Open and maintain a case (whether electronically or on paper); document in real-time

☐ Create a timeline and update as investigation evolves

☐ Determine whether an investigation should be attorney-client privileged (consult with in-house counsel)

☐ Assume that all emails, notes and other investigation materials are discoverable in litigation

☐ Determine who needs to be in the know and how much information should be provided

☐ Determine who needs to be part of your investigation interviews and involve them right away in the process

☐ Introduce and provide explanation of interview (i.e. goal to gather information that person may have)

☐ Explain the investigation process and your role

☐ Discuss confidentiality; do not promise absolute confidentiality

☐ Review non-retaliation policy; explain what constitutes retaliation; provide interviewee with notice doc

☐ If the interview is conducted by an attorney, provide Upjohn Warning

☐ Let the interviewee give their story; record all details (day, time, place, witnesses, documents)

☐ Begin with general non-leading questions (what is your role at the organization; how long have you worked with the implicated person; how would you describe your relationship)

☐ Move into more specific questions (when did the incident occur)

☐ Drill down highly specific questions (describe the incident, persons involved, has this happened before)

☐ Determine identity of all persons involved in conduct

☐ Determine identity of all witnesses involved in conduct

☐ Explore whether the interviewee knows if any other individuals have been subjected to conduct

☐ Go through events chronologically again; document details and relevant statements

☐ Do not record or transcribe interviews, document exact statements in quotes, as appropriate

☐ Obtain or request relevant documents or evidence

☐ Invite the interviewee to contact you with questions or additional information

☐ Separate parties

☐ Temporary reassignment

☐ Administrative leave (with or without pay)

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☐ Suspend network/email access

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☐ Review all notes, statements and evidence

☐ Determine if any additional or follow-up interviews are needed

☐ Update timeline

☐ Analyze each interviewee’s story; assess credibility and plausibility

☐ Determine whether a violation of policy, Code of Ethics, the law or inappropriate conduct has occurred

☐ Prepare final report; detail steps taken and reasons for conclusions; do not make legal conclusions

☐ Inform the key stakeholder(s) of the findings; share the final report with person(s) responsible for determining remedial/corrective action

☐ Offer recommendations (i.e. Coaching; verbal or written warning; PIP; termination, return to work plan)

☐ Follow-up with reporter to ascertain whether retaliation has occurred

☐ Follow-up with key stakeholder(s) to learn final actions/disciplinary action

☐ Document the case outcome

☐ Document final actions taken

☐ Close the investigation (i.e. close electronic file or finalize and secure all documentation if on paper)