Question
Please help me fill in questions 1-5 (10 tools). There is an example below. I have references at the bottom. Example: (Don't reuse this tool.)
Please help me fill in questions 1-5 (10 tools). There is an example below. I have references at the bottom. |
Example: (Don't reuse this tool.) Tool Name: HHS OIG Health Care Compliance Program Tips URL or Cloud pathway to access the tool https://oig.hhs.gov/compliance/provider-compliance-training/files/Compliance101tips508.pdf Brief Description of the Tool This tool lists the 7 fundamental elements of an effective compliance program and five tips to create culture of compliance. Tool Justification(Explain why you selected this tool over others) I selected this tool because it can be used for a variety of compliance issues. I would list it in the Business Transactions category, but it can also be used for government program, HIT, and employment compliance issues. Trigger to Use Tool(What will happen for you to need to use the tool) 1. I would use this tool proactively within my department to prevent compliance problems. 2. I would use this tool after a bad compliance audit to correct compliance issues with a corrective action plan. 3. Whenever compliance issues arise, I would review this tool to be sure that any actions I take encourage a culture of compliance and support my organization's compliance program. Tool Use(Explain how the tool will be used) 1. I would use this tool to remind me of the general components of a compliance program, then work within the organization on specific components that need to be improved based on what is going on in the organization or my department. 2. I would use this tool to review compliance requirements so that I can have meaningful compliance conversations about strategies for compliance in a way that meets federal law requirements. |
Question 1: BUSINESS TRANSACTIONS |
a. Tool Name Maryland Certificate of Need (CON) Application Forms Tool Guide URL or Cloud pathway to access the tool https://mhcc.maryland.gov/mhcc/Pages/hcfs/hcfs_con/hcfs_con_applications.aspx Brief Description of the Tool Tool Justification(Explain why you selected this tool over others) Trigger to Use Tool(What will happen for you to need to use the tool) Tool Use(Explain how the tool will be used) |
b. Tool Name Model Business Associate Agreement Tool URL or Cloud pathway to access the tool https://www.hhs.gov/sites/default/files/model-business-associate-agreement.pdf Brief Description of the Tool Tool Justification(Explain why you selected this tool over others) Trigger to Use Tool(What will happen for you to need to use the tool) Tool Use(Explain how the tool will be used) |
Question 2: GOVERNMENT PROGRAMS |
a. Tool Name CMS Documentation Matters Toolkit URL or Cloud pathway to access the tool https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Program/Education/Documentation Brief Description of the Tool Tool Justification(Explain why you selected this tool over others) Trigger to Use Tool(What will happen for you to need to use the tool) Tool Use(Explain how the tool will be used) |
b. .Tool Name COSO Guidance Tool URL or Cloud pathway to access the tool Guidance (coso.org) Brief Description of the Tool Tool Justification(Explain why you selected this tool over others) Trigger to Use Tool(What will happen for you to need to use the tool) Tool Use(Explain how the tool will be used) |
Question 3: HEALTH INFORMATION TECHNOLOGY |
a. Tool Name Security Risk Assessment (SRA) Tool URL or Cloud pathway to access the tool https://www.healthit.gov/topic/privacy-security-and-hipaa/security-risk-assessment-tool Brief Description of the Tool Tool Justification(Explain why you selected this tool over others) Trigger to Use Tool(What will happen for you to need to use the tool) Tool Use(Explain how the tool will be used) |
b. Tool Name HHS ONC HIT HIPAA Security Checklist Brief Description of the Tool https://www.healthit.gov/sites/default/files/comments_upload/hipaa-security-checklist.pdf URL or Cloud pathway to access the tool Tool Justification(Explain why you selected this tool over others) Trigger to Use Tool(What will happen for you to need to use the tool) Tool Use(Explain how the tool will be used) |
Question 4: PATIENT CARE |
a. Tool Name HHS OHRP Research Informed Consent Checklist URL or Cloud pathway to access the tool https://www.hhs.gov/ohrp/regulations-and-policy/guidance/checklists/index.html Brief Description of the Tool Tool Justification(Explain why you selected this tool over others) Trigger to Use Tool(What will happen for you to need to use the tool) Tool Use(Explain how the tool will be used) |
b. Tool Name HCCA: EMTALA Compliance Checklist URL or Cloud pathway to access the tool https://assets.hcca-info.org/Portals/0/PDFs/Resources/Conference_Handouts/Compliance_Institute/2016/308handout2.pdf Brief Description of the Tool Tool Justification(Explain why you selected this tool over others) Trigger to Use Tool(What will happen for you to need to use the tool) Tool Use(Explain how the tool will be used) |
Question 5: LABOR AND EMPLOYMENT |
a. Tool Name Hiring Process Checklist URL or Cloud pathway to access the tool https://www.hiresuccess.com/blog/hiring-process-checklist-step-by-step-guide Brief Description of the Tool Tool Justification(Explain why you selected this tool over others) Trigger to Use Tool(What will happen for you to need to use the tool) Tool Use(Explain how the tool will be used) |
b. Tool Name National Staffing Credentialing Checklist URL or Cloud pathway to access the tool Credentialing Checklist - Requirements for Application (nationalstaff.com) Brief Description of the Tool Tool Justification(Explain why you selected this tool over others) Trigger to Use Tool(What will happen for you to need to use the tool) Tool Use(Explain how the tool will be used) |
Please use below as a references:
Managerial Tools for Compliance
Compliance and Risk Management Tools
Checklists
- AAFP Closing your practice checklisthttps://www.aafp.org/dam/AAFP/documents/practice_management/admin_staffing/ClosingPracticeChecklist.pdf
- ACEP/PAI Physician Checklist for Appealing Audit Findings http://www.physiciansadvocacyinstitute.org/Portals/0/assets/docs/checklist-for-appealing-audits.pdf
- AcomHealth 2020 Coding and Billing Checklisthttps://acomhealth.com/wp-content/uploads/2020/02/2020-Coding-Billing-Checklist.pdf
- AHA Checklists to Improve Patient Safetyhttps://www.aha.org/ahahret-guides/2013-07-10-checklists-improve-patient-safety
- CANDOR Disclosure Checklisthttps://www.ahrq.gov/patient-safety/capacity/candor/modules/checklist5.html
- Central Line Insertion Checklisthttp://www.ihi.org/resources/Pages/Tools/CentralLineInsertionChecklist.aspx
- CURI Medical Record Check-List Assessment https://assets.hcca-info.org/Portals/0/PDFs/Resources/Conference_Handouts/Clinical_Practice_Compliance_Conference/2019/Tuesday/602_Handout.docx.pdf
- Employee Termination ChecklistEmployee Termination Checklist (25 tasks) [PDF & Printable]
- GDPR Checklist for data controllershttps://gdpr.eu/checklist/
- Greenway Health: Information sharing/Information Blocking Checklisthttps://www.greenwayhealth.com/sites/default/files/files/2021-05/Greenway%20Health%20Information%20Blocking%20Checklist_2.pdf
- HCCA: EMTALA Compliance Checklisthttps://assets.hcca-info.org/Portals/0/PDFs/Resources/Conference_Handouts/Compliance_Institute/2016/308handout2.pdf
- HHS ONC HIT HIPAA Security Checklisthttps://www.healthit.gov/sites/default/files/comments_upload/hipaa-security-checklist.pdf
- HHS OHRP Research Informed Consent Checklisthttps://www.hhs.gov/ohrp/regulations-and-policy/guidance/checklists/index.html
- Hiring Process Checklisthttps://www.hiresuccess.com/blog/hiring-process-checklist-step-by-step-guide
- Holland and Hart HIPAA Privacy Checklisthttps://www.hollandhart.com/pdf/HIPAA-Privacy-Checklist-HH.pdf
- Holland and Knight: Affordable Care Act Compliance Checklist for Employershttps://www.hklaw.com/files/Uploads/Documents/Practices/EmployeeBenefits/ACAComplianceChecklist.pdf
- HRET Checklist to Improve Patient Safetyhttp://www.hpoe.org/Reports-HPOE/CkLists_PatientSafety.pdf
- JCRINC Point of Care Medical Record Checklisthttps://info.jcrinc.com/rs/494-MTZ-066/images/POINT-OF-CARE30.pdf?ref...
- KYMA Sample Compliance Checklists for Electronic Health Recordshttps://kyma.org/shared/content/uploads/2015/12/ehr-compliance-checklist.pdf
- Maryland Non-Profits: Starting a Nonprofit in Maryland Checklisthttp://marylandnonprofits.org/wp-content/uploads/Start-a-Nonprofit-Checklist-Maryland.pdf
- Medical documentation and checklists Medical Documentation and Checklists (novitas-solutions.com)
- Medicare Discharge Planning Checklist https://www.medicare.gov/Pubs/pdf/11376-discharge-planning-checklist.pdf
- National Staffing Credentialing ChecklistCredentialing Checklist - Requirements for Application (nationalstaff.com)
- NSF 2019 Equipment Calibration Checklisthttps://d2evkimvhatqav.cloudfront.net/documents/bsc_2019_equipment_annual_form.pdf?mtime=20200716154310&focal=none
- Premera Provider Credentialing Document Checklisthttps://www.premera.com/documents/023163.pdf
- RAC Preparedness Checklisthttps://assets.hcca-info.org/Portals/0/PDFs/Resources/Conference_Handouts/Clinical_Practice_Compliance_Conference/2013/301-Handout2.pdf
- SCRIBD Medical Records Audit Checklisthttps://www.scribd.com/doc/183749634/Medical-Records-Audit-Checklist-docx
- Termination Risk Assessment Checklisthttps://www.hollandhart.com/presentations/Healthcare-Bootcamp_LE-Termination_Risk.pdf
- WHO Surgical Safety Checklist https://apps.who.int/iris/bitstream/handle/10665/44186/9789241598590_eng.pdf?sequence=1&isAllowed=y
Codes of Ethics
- ACHE Code of Ethicshttps://www.ache.org/about-ache/our-story/our-commitments/ethics/ache-code-of-ethics
- AHIMA Code of Ethicshttps://bok.ahima.org/doc?oid=105098#.YZMsDWDMKUk
- AHRQ Health IT Evaluation Toolkit and Evaluation Measures Quick Reference GuidesHealth IT Evaluation Toolkit and Evaluation Measures Quick Reference Guides | Digital Healthcare Research (ahrq.gov)
- AMA Code of Ethics https://www.ama-assn.org/delivering-care/ethics/code-medical-ethics-overview
- AMA Informed Consent Opinion 2.1.1https://www.ama-assn.org/delivering-care/ethics/informed-consent
- AMA Medically Ineffective Interventions Code of Medical Ethics Opinion 5.5https://www.ama-assn.org/delivering-care/ethics/medically-ineffective-interventions
- ANA Code of Ethicshttps://nursing.rutgers.edu/wp-content/uploads/2019/06/ANA-Code-of-Ethics-for-Nurses.pdf
- John Hopkins Conflict of Interest Policyhttps://www.hopkinsmedicine.org/supply-chain/policies-and-procedures/jhhs-conflict-of-interest-policy.html
- Mayo Clinic Code of Conducthttps://mcforms.mayo.edu/mc2500-mc2599/mc2570.pdf
- NAHQ Code of Ethicshttps://nahq.org/about/code-of-ethics/
Compliance Toolkits
- AHIMA Toolkitshttps://bok.ahima.org/searchresults?q=&fs=source_facet|AHIMA+toolkit
- AHRQ Communication and Optimal Resolution (CANDOR) Toolkit Communication and Optimal Resolution (CANDOR) Toolkit | Agency for Healthcare Research and Quality (ahrq.gov)
- ASHRM Active Risk Control Toolkit: Better Solutions After Risk Assessmenthttps://www.ashrm.org/resources/arc_toolkit
- ASHRM Health Care Facility Workplace Violence Risk Assessment Toolhttps://www.ashrm.org/resources/workplace_violence
- ASHRM Root Cause Analysis Playbookhttps://ams.aha.org/EWEB/DynamicPage.aspx?WebCode=ProdDetailAdd&ivd_prc_prd_key=111f753d-a277-4c89-8e38-4d1fd6289654
- CMS Connected Care ToolkitConnected Care Toolkit - Chronic Care Management Resources for Health Care Professionals and Communities (cms.gov)
- CMS Documentation Matters Toolkithttps://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Program/Education/Documentation
- CMS Hospice Benefit Toolkithttps://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Program/Education/Hospice
- HHS OIG Compliance Toolkitshttps://oig.hhs.gov/compliance/compliance-toolkits/
- HRSA Quality Improvement Toolkit HRSA Quality Improvement Toolkit | National Rural Health Resource Center (ruralcenter.org)
- Institute for Healthcare Improvement Patient Safety Essentials Toolkit Patient Safety Essentials Toolkit | IHI - Institute for Healthcare Improvement
- LEP Toolkithttps://www.dol.gov/agencies/oasam/centers-offices/civil-rights-center/external/limited-english-proficient/toolkit
- IRS Exempt Employer's Toolkithttps://www.irs.gov/charities-non-profits/exempt-employers-toolkit
- MHS Indiana Medical record Documentation Audit Toolhttps://www.mhsindiana.com/content/dam/centene/mhsindiana/medicaid/pdfs/Medical-Record-Audit-Tool-July-2015.pdf
- NICU Toolkit: Transitioning Newborns from NICU to Homehttps://www.ahrq.gov/patient-safety/settings/hospital/resource/nicu/index.html
- Texas Pediatric Society Palliative Care Toolkithttps://txpeds.org/palliative-care-toolkit
Contract Clauses
- Drexel Agreement to Mediate Health Care Disputeshttps://www.drexel.edu/~/media/Files/studentlife/DSHC/Mediation%20Agreement.ashx?la=en
- Good Faith Negotiation Clause Sampleshttps://afterpattern.com/clauses/good-faith-negotiation
- Sample Arbitration Clausehttps://www.adr.org/Clauses?gclid=EAIaIQobChMIjcaFgPKb9AIVwHxvBB2U2gqVEAAYAiAAEgIelfD_BwE
- Sample Data Protection Clausehttps://www.lawinsider.com/clause/data-protection
- Sample Limitation of liability Clauseshttps://www.lawinsider.com/clause/limitation-of-liability
- Sample Termination of Contract clauseshttps://www.lawinsider.com/clause/termination-of-contract
- Sample Managed Care Contracthttps://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Practice%20Management/Office%20Operations/sample_managed_care_contract.pdf
Forms and Templates
- Against Medical Advice Form Against Medical Advice (AMA) Form PDFfiller - against medical advice form.pdf /
- AHIMA:A Model Contract for Health information Exchangehttps://bok.ahima.org/PdfView?oid=63657
- Baylor Scott and White Health Electronic Medical Record Access agreement for Non-Baylor Scott & White Health Usershttps://www.bswhealth.med/Documents/physician-relations/emr-access-agreement.pdf
- Cornell IRB Consent Form Templateshttps://researchservices.cornell.edu/forms/irb-consent-form-templates
- Hofstra IRB Informed Consent Formhttps://medicine.hofstra.edu/pdf/research/sample-informed-consent-form-for-hofstra-irb-proposal.pdf
- IRS 990 - Tax Form for Tax Exempt Organizationshttps://www.irs.gov/pub/irs-pdf/f990.pdf
- IT Risk Assessment Excel Templatehttps://www.projectmanager.com/templates/it-risk-assessment-template
- Living Will Formshttps://eforms.com/living-will/
- Maryland MOLST Formhttps://marylandmolst.org/docs/MOLST%20MM3%202013%20FINAL%20PROPOSED%2072613%20POSTED%2021714-no-instructions.pdf
- Medication Error Reporting Formhttps://jipmer.edu.in/sites/default/files/Medication-error-reporting-form.pdf
- NLC Contracting Guidelines and Checklist for EHR Vendor Selectionhttps://www.healthit.gov/resource/nlc-contracting-guidelines-and-checklist-ehr-vendor-selection
- Maryland Application for a 1915 Home and Community Based Services Waiverhttps://health.maryland.gov/mmcp/waiverprograms/SiteAssets/Pages/Home/Medical%20Day%20Care%20Services%20renewal%202021%20CLEAN%2001.28.21.pdf
- Maryland Certificate of Need (CON) Application Formshttps://mhcc.maryland.gov/mhcc/Pages/hcfs/hcfs_con/hcfs_con_applications.aspx
- Medical Records Release Authorization Form/HIPAAhttps://eforms.com/release/medical-hipaa/
- Model Business Associate Agreementhttps://www.hhs.gov/sites/default/files/model-business-associate-agreement.pdf
- PHR Model Privacy Notice Templatehttps://www.healthit.gov/sites/default/files/phr-model-privacy-notice-final-2011.pdf
- Responsible-Accountable-Consulted-Informed (RACI)Matrix in excelhttps://www.projectmanager.com/templates/raci-matrix-template
- Risk Register Template for Excelhttps://www.projectmanager.com/templates/risk-tracking-template
- Stoel Rives Sample Litigation Hold Noticehttps://www.stoel.com/StoelRives/files/fa/fac01e84-5bad-48e6-9b1f-fcb997d9ded2.pdf
Guidelines and Protocols
- AHRQ Quality and Patient Safety Programs by Setting: Ambulatory Carehttps://www.ahrq.gov/patient-safety/settings/ambulatory/index.html
- AHRQ Quality and Patient Safety Programs by Setting: Emergency Departmenthttps://www.ahrq.gov/patient-safety/settings/emergency-dept/index.html
- AHRQ Quality and Patient Safety Programs by Setting; Hospitalhttps://www.ahrq.gov/patient-safety/settings/hospital/index.html
- AHRQ Quality and Patient Safety Programs by Setting: Long-Term Carehttps://www.ahrq.gov/patient-safety/settings/long-term-care/index.html
- AMA Guides to the Evaluation of Permanent Impairment: an overviewhttps://www.ama-assn.org/delivering-care/ama-guides/ama-guides-evaluation-permanent-impairment-overview
- ASAM National Practice Guidelines For the Treatment of Opioid Use Disorder https://www.asam.org/docs/default-source/quality-science/npg-jam-supplement.pdf?sfvrsn=a00a52c2_2
- Clinical Practice Guidelines for Quality Palliative Care https://www.nationalcoalitionhpc.org/wp-content/uploads/2020/07/NCHPC-NCPGuidelines_4thED_web_FINAL.pdf
- CMS Guidelines for Teaching Physicians, Interns, and Residentshttps://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/teaching-physicians-fact-sheet-icn006437.pdf
- CMS Teaching Physicians, Interns, and Residents Guidelineshttps://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/teaching-physicians-fact-sheet-icn006437.pdf
- COSO GuidanceGuidance (coso.org)
- Creighton Health Record Documentation Policies and Procedureshttps://www.creighton.edu/fileadmin/user/GeneralCounsel/docs/2.5.4._Health_Record_Documentation__2-1-2020.pdf
- Department of Justice (DOJ) Horizontal Merger Guidelineshttps://www.justice.gov/atr/horizontal-merger-guidelines-0
- Guide to Reporting Abuse in Marylandhttps://cdn.ymaws.com/www.nasw-md.org/resource/resmgr/imported/child%20abuse%20reporting%20checklist.pdf
- HHS OIG Compliance GuidanceCompliance Guidance | Office of Inspector General | Government Oversight | U.S. Department of Health and Human Services (hhs.gov)
- HHS OIG Contractual Joint Ventures Special Advisory Bulletinhttps://oig.hhs.gov/documents/special-advisory-bulletins/885/042303SABJointVentures.pdf
- HHS OIG Health Care Fraud Self-Disclosure Protocolhttps://oig.hhs.gov/documents/self-disclosure-info/1006/Self-Disclosure-Protocol-2021.pdf
- Joint Commission Universal Protocolhttps://www.jointcommission.org/standards/universal-protocol/
- Maryland Guide to Legal Aspects of Doing Business in Marylandhttps://www.marylandattorneygeneral.gov/Securities%20Documents/legalaspects.pdf
- Maryland 2022 Home Health Agency Certificate of need (CON) Guidelines https://mhcc.maryland.gov/mhcc/pages/hcfs/hcfs_homehealth/documents/2022_HHA_Guidelines.pdf
- NCQA Guidelines for Medical Record Documentationhttps://www.ncqa.org/wp-content/uploads/2018/07/20180110_Guidelines_Medical_Record_Documentation.pdf
- Newborn Critical Care Center (NCCC) Clinical Guidelines: Neonatal Palliative Care GuidelinesNewborn Critical Care Center (NCCC) Clinical Guidelines - DocsLib
- NIST Calibration Procedureshttps://www.nist.gov/pml/weights-and-measures/laboratory-metrology/calibration-procedures
- U.S. Preventive Services Task Force Preventive Service Recommendationshttps://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-and-b-recommendations
Policies and Procedures
- American Hospital Association (AHA) Bill of Rightshttps://www.americanpatient.org/aha-patients-bill-of-rights/
- CCHC Employee Handbookhttps://www.cchchealthcare.com/wp-content/uploads/2014/10/CCHC-Employee-Handbook.pdf
- Cleveland Clinic Policy on Do Not Resuscitate (DNR)http://www.clevelandclinic.org/bioethics/policies/dnr.html
- FSMB Policy on Physician Illness and Impairmenthttps://www.fsmb.org/siteassets/advocacy/policies/policy-on-physician-impairment.pdf
- FSMB Policy on Physician Impairment https://www.fsphp.org/assets/docs/physician-impairment.pdf
- ISO Procedure for Equipment Calibration and Maintenancehttps://isoconsultantkuwait.com/2019/01/23/procedure-for-equipment-calibration-and-maintenance/
- John Hopkins Policies and Employee Handbookshttps://www.hopkinsmedicine.org/human_resources/about/policies_handbooks.html
- Kennedy University Hospital Peer Review PolicyPOLICY: (kennedyhealth.org)
- Renaissance Stonybrook Disruptive Provider Policyhttps://renaissance.stonybrookmedicine.edu/sites/default/files/disruptive%20final_0.pdf
- UCLA David Geffen School of Medicine Resident Policieshttps://medschool.ucla.edu/gme-resident-policies
- University of Buffalo Impaired Physician PolicyImpaired Physician Policy - Jacobs School of Medicine and Biomedical Sciences - University at Buffalo
- University of Maryland Medical System Policies https://www.umms.org/about/policies
Risk Management and Assessment Tools
- ASQ Root Cause Analysis Tools https://asq.org/quality-resources/root-cause-analysis/toolshttps://asq.org/quality-resources/root-cause-analysis/tools
- National Quality Forum (NQF) quality measures (search measures)https://www.qualityforum.org/measures_reports_tools.aspx
- Plan-Do-Check-Act (PDCA) Model for Risk Managementhttps://simplifyiso.com/connect-the-dots-pdca-risk-based-thinking-and-the-process-approach/
- Risk Assessment and Plan (RAP)https://strategies.rmf.harvard.edu/clinical-risk-assessments?sc_camp=B601A279E6F0413B8B50EC296D3EA4DC#riskassessmentplanrap
- Security Risk Assessment (SRA) Toolhttps://www.healthit.gov/topic/privacy-security-and-hipaa/security-risk-assessment-tool
- UNNUS Strength-Weakness-Opportunities-Threats (SWOT) Analysishttps://unnus.com/medical/healthcare-swot-analysis/
- Wolters Kluwer The Bowtie Method Risk Management Toolhttps://www.cgerisk.com/knowledgebase/The_bowtie_method
Training Materials
- CDC NIOSH Training and Workforce Developmenthttps://www.cdc.gov/niosh/training/default.html
- CMS Evaluation and Management Services Guidehttps://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf
- eCQM and eCQI Educational resourceshttps://ecqi.healthit.gov/ecqm-and-ecqi-education-resources
- HHS ONC Security Risk Assessment Videoshttps://www.healthit.gov/topic/privacy-security-and-hipaa/security-risk-assessment-videos
- HHS OIG A Roadmap for New Physicians: Physician Education Training Materialshttps://oig.hhs.gov/compliance/physician-education/
- HHS Training Materials on HIPAAhttps://www.hhs.gov/hipaa/for-professionals/training/index.html
- OSHA Training Toolshttps://www.osha.gov/training/library/materials
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