Seven Elements of a Compliance Program Toolkit

Health centers are faced with an array of compliance risks. As federal grant recipients, health care providers, and community partners, health centers must develop a system to ensure compliance with the applicable laws, rules, and requirements.

The Office of the Inspector General (OIG) for the Department of Health and Human Services (HHS) recommends that all health care entities develop a compliance program that incorporates seven specific elements. The seven elements include designating a compliance officer, developing written compliance standards, providing training and communication, developing open lines of communication, conducting regular monitoring and auditing, responding to detected offenses, and enforcing disciplinary standards.

While some health centers have implemented several of the compliance program elements or some components of them, many have not organized these efforts under the formalized structure of a compliance program. Increasingly, health centers are hiring compliance officers or designating an employee to develop and implement a corporate compliance program that assesses and responds to the health center's risks. Under the Affordable Care Act and its implementing regulations, compliance programs will be mandatory for health centers.

FTLF's Seven Elements of a Compliance Program Toolkit is designed to help health centers develop a corporate compliance program that incorporates the OIG's seven elements. The Toolkit includes customizable sample policies, procedures, and forms, including:

  • Sample Corporate Compliance Plan

  • Sample Training and Education Agendas

  • Standards of Conduct/Conflict of Interest Policy

  • Whistleblower Protection Policy

View the Table of Contents here.

The Seven Elements of a Compliance Program Toolkit is an essential resource for health centers looking to implement, maintain, or improve their compliance program. For support in responding to key health center compliance issues, please see our other Toolkit subscriptions which address federal grants management, Section 330, and confidentility or browse our training curriculum for an upcoming program.

    Course summary
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    2019 Table of Contents

    I. Element One: Compliance Program Structure
    • Board Resolution Establishing a Compliance Program: Sample
    • Board Compliance Committee Charter: Sample
    • Compliance Officer Job Description: Sample
    • Staff Compliance Committee Charter: Sample

    II. Element Two: Written Compliance Standards
    • Corporate Compliance Plan: Sample
    • Standards of Conduct/Conflict of Interest: Sample Policy and Procedure
    • Preventing Fraud, Waste and Abuse: Sample Policy and Procedure
    • Record Retention: Sample Policy and Procedure
    • Exclusion and Debarment Screening: Sample Policy and Procedure
    • Board Member Screening: Sample Policy and Procedure
    • Medicare Enrollment Disclosure for Board Members: Sample Letter and Form

    III. Element Three: Training and Education
    • Training and Education: Sample Policy and Procedure
    • Training for Individuals Newly Affiliated with the Health Center: Sample Agenda
    • Training for Board Members: Sample Agenda
    • Training for Billing and Coding Personnel: Sample Agenda
    • Training Sign-In and Certification: Sample Form
    • Training Log: Sample Form
    IV. Element Four: Open Lines of Communication
    • Reporting Instances of Non-Compliance: Sample Policy and Procedure
    • Compliance Hotline Script: Sample
    • Compliance Issue Reporting and Response: Sample Tool
    • Non-Retaliation and Whistleblower Protection: Sample Policy and Procedure
    V. Element Five: Internal Monitoring and Auditing
    • Internal Monitoring and Auditing: Sample Policy and Procedure
    • Internal Monitoring and Auditing: Sample Report
    VI. Element Six: Responding Appropriately to Detected Offenses
    • Responding to Detected Offenses: Sample Policy and Procedure
    • Responding to Detected Offenses: Sample File Memo
    • Responding to Allegations of Non-Compliance Concerning the CEO: Sample Policy and Procedure
    • Responding to External Compliance Audits or Investigations: Sample Policy and Procedure
    VII. Element Seven: Enforcing Disciplinary Standards
    • Enforcing Disciplinary Standards: Sample Policy and Procedure
    • Compliance Provisions for Position Descriptions and Contracts: Sample Language

    There are no continuing education credits or other attendance records associated with this product.

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    Purchasing this Toolkit provides access through the end of the current calendar year. This access includes any updates FTLF makes to the Toolkit documents throughout that year at no extra charge.

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    PCAs/HCCNs interested in purchasing Toolkit subscriptions for their health center members should Contact Us for pricing options.