Compliance Program Essentials | Workshop Day 2

This training provides an overview of the foundational elements of an effective health center compliance program. Participants will learn how to build, implement, and maintain a compliance program that aligns with federal guidance, mitigates risks, and supports a culture of integrity and accountability.

Developed by a former health center compliance officer, this workshop provides practical suggestions for implementing and improving your health center’s compliance program. Topics include:

• Developing the Office of the Inspector General (OIG)’s seven elements of an effective compliance program in a health center
• Roles and responsibilities of compliance officers, staff compliance committees, staff members and board members
• Developing and updating policies and procedures
• Conducting risk assessments and developing auditing activities
• Responding to compliance issues and implementing corrective actions

This session is ideal for compliance officers, leaders, and staff responsible for maintaining or enhancing their health center’s compliance program. Participants will leave with practical strategies and tools to strengthen their program and ensure ongoing regulatory compliance. Engaging, practical, and available for attendees to review on demand, this training is essential for developing your health center’s compliance program.

Agenda Day 2: 

Compliance program elements covered in this session include:

1. Lines of communication: Building a culture of compliance depends on open communication —staff members should feel comfortable raising concerns, leadership should respond constructively, and the compliance officer should communicate regularly about compliance risks. This session will address key health center questions, including:
   1. Are health centers required to have anonymous reporting methods?
   2. Can an incident reporting system also be used for reporting compliance issues?
2. Risk assessments, auditing and monitoring: Compliance risk assessments identify, evaluate and prioritize potential risks and help health centers focus resources on their areas of greatest risk, including by developing strategic auditing and monitoring plans. This session will address key health center questions, including:
   1. How frequently should health centers conduct a compliance risk assessment?
   2. How is a compliance risk assessment related to the clinical risk assessments required for FTCA deeming?
   3. Who should conduct compliance audits – the compliance officer, leadership or an outside auditor?
3. Enforcing standards: Compliance programs should include both consequences for noncompliance and incentives for compliance. This session will address key health center questions, including:
   1. Are health centers required to have a separate disciplinary policy for the compliance program?
   2. Who determines appropriate disciplinary action – the compliance officer, the manager or human resources?
   3. How can health centers encourage participation in the compliance program?
4. Responding to detected offenses and developing corrective action initiatives: When a compliance issue is reported or identified, the health center should investigate, report issues when required and develop corrective action plans to minimize similar issues in the future. This session will address key health center questions, including:
   1. Who should conduct the investigation – the compliance officer, the manager or human resources?
   2. How should complaints involving the CEO be handled?
   3. What information should the board receive about compliance investigations?

Audience:

• Compliance Officers
• Risk Managers
• COOs

Presenters:

• Dianne Pledgie
• Alexander Lipovtsev