CHPC Study Group

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  • 1.  Compliance Investigation Form

    Posted 13 days ago
    Does anyone have a compliance investigation form that they fill out when a matter has been brought to your attention?  I'm not talking about a suspected breach, but a matter that is compliance related and warrants an investigation.  If you would be willing to share, that would be helpful.

    Thank you,

    Patrick Forand, MPH, CHPC
    Senior Director of Compliance
    CAN Community Health
    Sarasota, Florida
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  • 2.  RE: Compliance Investigation Form

    Posted 12 days ago
    This is a great question!  I am eager to see what others have in place so I can improve our process.  I have something very basic that I put in place.  The following specifics are placed into a MEMO to file:
    • Date/Time of the event and if this involved any individuals (name and title)
    • Who reported the compliance event and the date and time
    • Date/Time the event was discovered
    • Description of the event
    • Interventions
    • Closure - which should include any education, system/process reviews/changes and employee corrective action
    • Whether or not legal counsel was involved and their synopsis
    • Notification to insurance carrier if necessary
    •  Notification to law enforcement if necessary
    • When the Compliance Committee will be informed
    • When the Board will be informed.

    Debra Larkin
    Corporate Director of
    Compliance/Privacy Officer

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  • 3.  RE: Compliance Investigation Form

    Posted 12 days ago
    I don't have a template or an intake form per se but I will share a framework that I was trained to follow when conducting investigations. Following these steps have proven to be useful and cover many (if not all) the bases, in my opinion. You might add other concepts as you see necessary. Good luck. These can take a significant amount of time to conduct.

    Maybe it depends on the seriousness of the allegations, but I usually keep legal counsel advised as the investigation progresses.

    1. Create an investigation plan:
    • what what regs, policies, best practices, etc were violated
    • list out individuals to interview and their role
    • Paper before people - you need to know what questions to ask. Request data (audits) and review key details (I label and log all documents for the investigation file)
    2. Mitigate harm (This might be the first step considering the issue)
    • "stop the bleed" to protect patients, organization, employee, etc
    3. Conduct Interview
    • Document, document, document everything (date/time all notes)
    • use open ended questions
    • verify details
    4. Develop Root cause analysis- Why did this happen?

    5. Implement and Monitor CAP
      • What underlying issues needs to be improved, then monitor CAP
    6. Follow up 
    • Disciplinary action needed?
    • Close loop with reporter
    • Report to stakeholders

    Patricia Radatz
    Regulatory Manager
    Cleveland Clinic Quality Alliance

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  • 4.  RE: Compliance Investigation Form

    Posted 11 days ago
      |   view attached
    See attached. I have since made this electronic through our new reporting software but the same general information is on there.

    Savannah Knuettel
    Compliance Officer
    Galen Medical Group

    The views expressed herein are my own and do not represent those of my employer or clients. They are not meant to constitute legal advice or create an attorney-client relationship.


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