1. Randy Benson RHQN Executive Director May, 2012

2. Compliance Issues During Survey Compliance Officers monitor healthcare facilities (hospitals and clinics) to ensure compliance with regulations laid out by government agencies. These regulations cover everything from: Billing Procedures Medical coding Staff ethics Patient rights. Government Agencies include: The Occupational Safety and Health Administration (OSHA) The Centers for Medicare and Medicaid Services (CMS) The Department of Health (DOH) Te Department of Social and Health Services (DSHS)

3. Compliance Issues During Survey Hospital Compliance Officer Duties and Responsibilities: 1. Develop, initiate, maintain, and revise policies and procedures of the Compliance Program 2. Develop and periodically review/revise the facility Standards of Conduct for all employees 3. Collaborate with other departments (Risk, Admin., H.R., etc.) to direct compliance issues related to compliance investigations 4. Respond to alleged violations of standards of conduct and maintains a system for uniform handling of violations

4. Compliance Issues During Survey Compliance Officer Duties and Responsibilities (cont.) 5. Identifies potential areas of compliance vulnerability and risk; develops corrective plans for resolution of the risk 6. Report, on a regular basis, to keep Administration and the Board informed of operation and progress of compliance efforts and compliance with those efforts 7. Establishes and manages the compliance hotline 8. Institutes an effective communication and training program for all employees concerning the Standards of Conduct.

5. Compliance Issues During Survey Surveyor Checklist: Privacy and Confidentiality Discussion of patient information within earshot of the public Patient information visible to the public (e.g. information on computer screens, written on staff communication boards) Security Electronic records not designed with protective firewalls Unauthorized staff having access to health information records Archived records (e.g. x-rays) not stored in a secure area

6. Compliance Issues During Survey Surveyor Checklist (cont.) Patient Access No policies or out-of-date policies and procedures for patient to gain access to their own health information Patient Rights Patients not notified of their right for confidentiality and privacy of their health information and their right to see their health records.

7. Compliance Issues During Survey Surveyor Walk Through of Nursing Unit White Board (staff communication board) Computer screens at nurses station visible to the public Documentation laptops on wheels accessible to the public Questioning staff about communication issues Review of nursing unit compliance policies EOC Surveyor Walkarounds Location of archived medical records and x-rays Questioning staff about vendor relationships

8. Compliance Issues During Survey What To Do: Check all compliance policies to ensure that they have all be reviewed or revised in the last 12-24 months. Do a chart review to ensure documentation that all patients were provided a copy of their patient rights and that they know how to get access to their health information. Be sure that all patients moving from nursing home bed to hospital bed to swing bed and back receive a copy of their patient rights each time they move.

9. Compliance Issues During Survey What To Do: Assure that all communication boards are out of sight of the public or are so encrypted that the public would not understand what is written on the board. Be sure that all unattended desktop computers and documentation laptops that can access confidential patient information (nursing units, lab, pharmacy, therapies, admitting, etc.) time out quickly and a password must be used to re-access the computer. Ascertain that all archived patient records (e.g. patient charts, x-rays, etc.) are properly secured

10. Compliance Issues During Survey What To Do: Confirm that all receptacles for collection and storage of discarded confidential and personal health information are safe from theft or diversion and that the information in them is protected. Where found Who disposes of information Locked containers Proper staff education Proper control of shredding process

11. Compliance Issues During Survey Questions? Randy Benson RHQN Executive Director 206 577-1821 randyb@wsha.org