Healthcare Compliance Forms and Tools

☐ Code of conduct

☐ Technology P&Ps

☐ Conflict of interest policies and procedures (P&Ps)

☐ Social media P&Ps

☐ Drug/alcohol use P&Ps

☐ Workplace relationships/boundaries P&Ps

☐ Financial P&Ps

☐

☐ Gifts/gratuities P&Ps

☐

☐ Interactions with patients/clients P&Ps

☐

☐ Harassment/discrimination P&Ps

☐

☐ Privacy P&Ps

☐

☐ Billing and coding issues

☐ Improper employment or disciplinary actions

☐ Conflicts 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 department

☐ Lead investigator

☐ Co-investigator/Notetaker

☐ 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 and 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 and 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 nonretaliation policy, explain what constitutes retaliation, and provide interviewee with notice document.

☐ 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 nonleading 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 and 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)

☐

☐ Suspend network/email access

☐

☐ 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, and 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 (e.g., coaching, verbal or written warning, performance improvement plan, 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).