Kusserow on Compliance: Questions board-level compliance committees should be asking

HHS OIG compliance guidance calls for a Board-level committee to oversee the Compliance Program (CP). The HHS Inspector General noted that the best boards are those that are active, questioning, and exercise (constructive) skepticism in their oversight, asking probing questions about the compliance program. Boards need to know what type of questions they should be asking, and compliance officers should assist them with this problem. However, compliance officers in turn should be prepared to provide full and complete answers to them. The OIG and American Health Lawyers Association developed specific suggested questions that Board’s should be asking in their jointly produced “Corporate Responsibility and Corporate Compliance: A Resource for Health Care Boards of Directors” and “Corporate Responsibility and Health Care Quality (2007): A Resource for Health Care Boards of Directors”. The following are drawn from these advisory documents:

  1. Does the compliance officer have sufficient authority to implement the CP?
  2. What is the level of resources necessary to properly implement and operate the CP?
  3. Has the compliance officer been given the sufficient resources to carry out the mission?
  4. Have compliance-related responsibilities been delegated across all levels of management?
  5. What evidence is there that all employees are held equally accountable for compliance?
  6. How has the code been incorporated into corporate policies across the organization?
  7. What evidence is there that the code is understood and accepted across organization?
  8. Has management taken affirmative steps to publicize importance of code to employees?
  9. Have compliance-related policies been developed that address compliance risk areas?
  10. Are there policies/procedures for CP operation and how they should be reviewed/updated?
  11. What kind of document management ensures compliance-related documents are up to date?
  12. What is the scope of compliance-related education and training?
  13. What evidence is there of the effectiveness of CP training?
  14. What measures enforce training mandates and provide remedial training?
  15. What evidence is available that employees understand compliance expectations?
  16. How are compliance risks identified?
  17. What is the evidence that identified compliance risks are being addressed?
  18. Is the board being kept up to date on regulatory and industry compliance risks?
  19. How is the compliance program structured to address such risks?
  20. How are “at risk” operations assessed from a compliance perspective?
  21. Is conformance with the CP periodically evaluated?
  22. Does the CP undergo periodical independent evaluation of its effectiveness?
  23. What is the process for the evaluation and responding to suspected compliance violations?
  24. What kind of training is provided to those who conduct investigation of reported violations?
  25. How do the CO, HRM, and legal counsel coordinate in resolving compliance issues?
  26. What are the policies to ensure preservation of relevant CP documents and information?
  27. What policies address protection of “whistleblowers” and those accused of misconduct?
  28. What are the results of ongoing compliance monitoring by all program managers?
  29. How is ongoing compliance auditing being performed and by whom?
  30. How often is sanction-screening conducted and with what results?
  31. Are results from sanction-screening included in a signed report by the responsible parties?
  32. Has the CP been evaluated for effectiveness by a qualified independent reviewer?
  33. What evidence regarding effectiveness of hotline operation and follow-up investigations?
  34. What are the metrics being used to evidence CP effectiveness?
  35. What are the results of an independent review and assessment of the CP?

 

More information regarding available tools and resources available to assist in answering these questions, contact Daniel Peake at (dpeake@complianceresource.com) (703-236-9854).

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Compliance officers cite HIPAA as their highest priority

The 2019 Compliance Benchmark Survey respondents reported that compliance officers are finding dealing with data breaches as their highest-ranked priority, with two-thirds of respondents citing HIPAA Security/Cyber-security and over half for HIPAA Privacy as their number one concern. This represented the biggest change since last year’s survey. Coupled with this finding was that nearly 75 percent of respondents reported the compliance office has assumed responsibility for HIPAA Privacy and nearly one-third assumed responsibility for HIPAA Security. So far this year, OCR has reportedly received upwards of a quarter million HIPAA privacy complaints.

The Survey did not focus on privacy laws and regulations emerging on the state level, nor did it provide much understanding on how organizations and compliance offices were responding to the challenges. As such, a separate 2019 survey has been designed to gather that information along with a variety of other issues.  It is designed to provide a general understanding of levels and nature of current commitment to this area.  Those who wish to participate in the 2019 HIPAA Compliance Survey can do so by clicking on the following hyperlink.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Even the FBI has been a victim of cyber-attacks

The FBI confirmed that least three of its websites were hacked

Records of thousands of officers and federal agents stolen

Hackers have put the data up for free download.

As health care entities struggle to guard their data against cyber-attacks, the seriousness of the need was underscored by the fact that even the FBI has trouble protecting its systems. A group of hackers has exploited the flaws of at least three FBI-affiliated websites and leaked thousands of federal and law enforcement agents’ personal details, according to TechCrunch. The hackers infiltrated multiple websites run by the FBI National Academy Association that promote law enforcement training. The sites also support graduates of the FBI Academy through local chapters.  Three of the sites were breached and the “personal information has been obtained to be sold on the web.”

The hackers announced they were able to break into the pages and download the contents, which they then uploaded on their own website. In all, they were able to steal around 4,000 unique details. Those include member names, job titles, email addresses (some personal, some government-owned), physical addresses, as well as phone numbers. The hackers also said they have over a million pieces of information on federal agents and are planning to publish more data from hacked government websites in the future. Seeing as this is far from the first security breach to affect federal workers, the government and organizations linked to its agencies may want to think of more ways to beef up their security measures.

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Top initiatives for compliance programs in 2019

In the 2019 survey of health care compliance professionals, compliance professionals were asked about their initiatives for improving their program this year. The responses can be categorized in three tiers. The major focus for respondents was risk identification and mitigation—three of the four highest ranked selections deal with this area. The second tier—earning the third and fifth rankings—involved issues related to HIPAA compliance. The four items at the bottom of the list related to independent assessment compliance program effectiveness: effectiveness evaluation and gap analysis, arrangements with physicians, and compliance knowledge surveys. The third tier included four items, including use of independent parties for gap analysis, effectiveness evaluations, arrangements review, and surveying. The following are the results in descending order:

  1. Working with program managers to improve ongoing monitoring of their risk area (57 percent)
  2. Building a more robust ongoing auditing program (51 percent)
  3. Enterprise-Wide Regulatory Risk Assessment (34 percent)
  4. HIPAA Privacy and Security Assessment (43 percent)
  5. HIPAA Security/Cyber-Security Compliance Evaluation (31 percent)
  6. Independent Compliance Program Effectiveness Evaluation (22 percent)
  7. Independent Compliance Program Gap Analysis (14 percent)
  8. Independent Compliance Review of Arrangements with Physicians (9 percent)
  9. Independently developed/administered Compliance Knowledge Survey (6 percent)

Also noteworthy is the fact that approximately one quarter of those participating in the survey passed on answering this question, either because they have not yet developed a plan, had it approved, or don’t have annual work plans.

For more information regarding results of the Survey, contact Richard Kusserow, CEO, Strategic Management (rkusserow@strategicm.com).

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2019 Strategic Management Services, LLC. Published with permission.