Final project

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A. Reviewed/Revised: December 1, 2019

B. Purpose:

_(15) ________________________________________________________ _____________________________________________________________ _____________________________________________________________

C. Policy: It is the policy of Hospital XYZ to maintain an auditing and monitoring program, which will evaluate adherence to corporate compliance policies, meets one of the seven elements as stated in the Office of the Inspector General (OIG) Guidance on Compliance Programs for Hospitals, and the State Office of the Medicaid Inspector General Compliance program requirements, Federal and State regulations and other regulations as may be required.

D. Scope: __(16)_________________ is responsible for documenting clinical information

in the medical record. __(17) ________________ is responsible for auditing the medical record to

ensure documentation is complete.

E. Definitions: (18) ______ __________ __________ __________

Hospital XYZ Health Information Management Department _(14)_____________ Policy and Procedure

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F. Procedures: Techniques for the auditing and monitoring process may include:

• On-site reviews • Unannounced mock surveys, audits and investigations • Interviews with staff. • Check of personnel records to determine whether any individuals who

have been reprimanded for compliance issues in the past are among those currently engaged in improper conduct.

• Interviews with personnel involved in management, operations, and other related activities.

• Questionnaires developed to solicit impressions of a broad cross section of the organization's Representatives.

• Reviews of written materials and documentation prepared by various Representatives .

• Trend analyses or longitudinal studies that seek deviations, positive or negative in specific areas over a given period of time.

• Review of electronic records to determine appropriate or inappropriate accesses.

• Review of departmental policies and procedures. Audit File: All documentation regarding the audit will be maintained in the appropriate audit file. Any corrective action required will be tracked and confirmed. Audit File Retention: A copy of the documentation supporting the findings will be maintained in the designated audit file. This file will be maintained indefinitely. Training Requirements: Individuals designated by the Health Information Management Director to conduct audits shall participate in any training provided by the Corporate Compliance Office. Auditors shall:

• Possess the qualifications and experience necessary to adequately identify potential issues with the subject matter to be reviewed.

• Be objective and independent of line management. • Have access to existing audit and health care resources, relevant

personnel, and all relevant areas of operation. • Report any and all review results and deviations from "norms" to the

Director. • Have the authority to request and review any related information.

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Self-Assessment and Annual Compliance Work Plan An annual risk assessment will be performed to evaluate the effectiveness of and opportunities for improvement in the Compliance Program. Risk areas can include any of the following:

• Regulatory/legal issues • Funds Flow Process • Environmental/health/safety issues • HR issues • IT/systems issues • Reimbursement

The Compliance Staff will assist the Health Information Management Director in determining the elements of the annual work plan, taking into consideration the State Office of the Medicaid Inspector General (OMIG) compliance guidance, yearly audit and monitoring results, risks identified through the annual risk assessment and recommendations from the Compliance Committee. The HIM Director will submit the written compliance work plan for approval by the Executive Committee. Reporting Reviews should be reported to the Director. The Director will maintain audit documentation and report findings on a regular basis to the Compliance Committee and the Executive Committee.

_____________________________

Health Info Mgmt Director

_____________________________ Compliance Director

_____________________________

Chief Executive Officer, XYZ Hospital