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.

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:

  • Corporate Compliance Plan

  • Training and Education Agendas

  • Standards of Conduct

  • Whistleblower Protection Policy

View the Table of Contents on the Agenda tab.

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 confidentiality or browse our training curriculum for an upcoming program.

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    Table of Contents

    I. Element One: Compliance Program Structure
    • Board Resolution Establishing a Compliance Program: Sample
    • Board Resolution Developing and Implementing a Compliance Program: Sample
    • Board Corporate Compliance Committee Charter: Sample
    • Board Resolution Appointing a Compliance Officer: Sample
    • Compliance Officer Job Description: Sample
    • Responsibility and Authority of the Compliance Officer Policy and Procedure: Sample
    • Compliance Officer Evaluation Form: Sample
    • Staff Compliance Committee Charter: Sample

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

    III. Element Three: Training and Education
    • Training and Education Policy and Procedure: Sample
    • General Compliance Training Agenda for Individuals Newly Affiliated with the Health Center: Sample
    • Training Agenda for Board Members: Sample
    • Specialized Training Agenda for Billing and Coding Personnel: Sample
    • Training Log: Sample
    • Training Sign-In and Certification Form: Sample
    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 Policy and Procedure: Sample
    V. Element Five: Internal Monitoring and Auditing
    • Internal Monitoring and Auditing Policy and Procedure: Sample
    • Internal Monitoring and Auditing Report: Sample
    VI. Element Six: Responding to Detected Offenses
    • Responding to Detected Offenses Policy and Procedure: Sample
    • Responding to Detected Offenses Memo to File: Sample
    • Responding to Allegations of Non-Compliance Concerning the CEO Policy and Procedure: Sample
    • Responding to External Compliance Audits or Investigations Policy and Procedure: Sample
    VII. Element Seven: Enforcing Disciplinary Standards
    • Enforcing Disciplinary Standards Policy and Procedure: Sample
    • Compliance Provisions for Position Descriptions and Contracts: Sample

    About the Authors

    This Toolkit and its resources were created in response to requests from health centers across the country for compliance resources to prevent and detect conduct inconsistent with laws, regulations, and other legal requirements. Attorneys from Feldesman Tucker Leifer Fidell LLP provide a full range of health care corporate compliance counseling services for the development, evaluation, implementation, operation, and support of effective compliance programs, informed by decades of experience advising federally qualified health centers, behavioral health providers, primary care associations, and health-center controlled networks.


    A Partner in the firm’s health law practice group, Molly advises health centers on the management of clinical, employment and workforce related risks, with a particular focus on professional liability, Federal Tort Claims Act, and HIPAA matters. From her experience as both a private attorney and in-house counsel, Molly knows the importance of managing liability and risk issues in mission-driven organizations. [Full Bio]


    A Partner in FTLF’s health law practice group, Adam counsels a diverse spectrum of community-based organizations that render primary and behavioral healthcare services on a wide range of health law issues, with a particular focus on fraud and abuse, reimbursement and payment, and antitrust and competition matters. [Full Bio]


    As Partner and Compliance Counsel with the firm’s health law practice group, Dianne advises health centers on implementing effective compliance programs and on addressing top compliance risk areas. Dianne counsels health centers and other organizations on developing compliance programs that include the OIG’s seven elements, respond to identified compliance risk areas and reflect the organization’s culture.  Dianne also advises health centers and other organizations on patient privacy and confidentiality, including the HIPAA Privacy Rule and 42 CFR Part 2.  She has experience responding to privacy and security incidents, including determining whether there has been a breach, notifying patients and the government, and creating corrective action plans. [Full Bio]


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


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    Access Period

    Purchasing this Toolkit provides access for one calendar year. This access includes any updates or additions FTLF makes to Toolkit resources throughout the year at no extra charge.

    Approval Process

    We only allow community health centers to purchase Toolkits. As a result, we must review and approve all purchases to verify eligibility. We review and approve Toolkit purchases as quickly as possible, but there are occasional delays. Please allow 3-5 business days for approval.

    PCAs, HCCNs, and other membership organizations interested in purchasing Toolkit subscriptions for their health center members should Contact Us for pricing options.


    By purchasing this Toolkit, you acknowledge and agree to our Terms of Use and Privacy Policy. This Toolkit has been prepared by attorneys at Feldesman Tucker Leifer Fidell LLP (FTLF) and includes original materials developed by FTLF. This Toolkit is designed as a resource to assist your health center in developing and implementing an effective Compliance Program consistent with the expectations of the United States Department of Health and Human services (HHS), Office of the Inspector General (OIG). The materials are not intended to be adopted word for word; FTLF recommends that each organization tailor the materials to fit your health center's legal, financial, administrative, and programmatic needs. Failing to modify the original materials to the specific needs of your program may have adverse consequences. 

    By purchasing this Toolkit, you acknowledge and agree that the materials contained herein do not constitute legal advice and your purchase does not create an attorney-client relationship between you and FTLF, nor is it intended to do so. If legal advice or other expert assistance is required, your organization should enter into an engagement agreement with FTLF or seek the services of another competent professional. Each legal problem is different, and past performance does not guarantee future results.

    By purchasing this Toolkit, you acknowledge and agree that, unless otherwise indicated, FTLF owns the copyright to the resources in this Toolkit. All such materials are for personal/non-commercial use only and, any other use or disclosure is a violation of federal copyright law and is punishable by the imposition of substantial fines. Unless otherwise noted, all materials in this Toolkit remain the intellectual property of FTLF and are protected under the copyright of Feldesman Tucker Leifer Fidell LLP. Copyright is claimed in all original material, including but not limited to the sample forms, policies and procedures, and similar resources. Any and all such copyrighted materials may not be republished for or distributed to any third party at any time or in any form without written permission from FTLF.