Policy AD-613 Functions of the Compliance and Risk Management Committee 2021-07-12

Purpose

To ensure the compliance of Westside Family Healthcare (Westside) with all applicable federal and state laws and regulations, as well as all requirements related to regulatory agencies and organizations, accrediting entities, and grant funding.

Policy

It is the policy of Westside Family Healthcare to support the Corporate Compliance Officer and Chief Operating Officer (COO) / Risk Manager in meeting their responsibilities through its established, standing Compliance and Risk Management Committee (the Committee).

Scope

Entire organization.

Definitions

None.

Procedures

Authority  

• 1. The Compliance and Risk Management Committee is a standing Westside committee and is comprised of health center leadership who are representative of the organization’s major departments, including operations (executive, clinical, and site), finance, human resources, information technology (general and clinical), and quality improvement.  
  2. The Co-Chairs of the Compliance and Risk Management Committee are the Westside Corporate Compliance Officer and Chief Operating Officer (COO)/ Risk Manager.
  3. The Committee serves to support and inform the Corporate Compliance Officer and COO/Risk Manager as they oversee the organization’s compliance and risk management programs, as outlined in the duties listed below.
  4. The Committee serves to support and inform the Corporate Compliance Officer and COO/Risk Manager as they make recommendations to Westside’s Chief Executive Officer, other Chief Officers, and Board of Directors on matters relating to Westside’s compliance and areas of current and potential risk.

Duties  

• 1. As part of its duties, the Compliance and Risk Management Committee advises the Corporate Compliance Officer and COO/Risk Manager and assist in the implementation of the Compliance Program and Risk Management Program.  
  2. The Committee’s functions include, as appropriate:
     1. Identifying Areas of Risk  
        1. The Committee assesses the effectiveness of the Compliance Program and Risk Management Program to determine areas of risk and, if necessary, identifies measures to address such areas of risk.  
        2. In addition, the Committee analyzes issues affecting health centers (and the health care industry generally) and the legal requirements with which the health center must comply.
     2. Monitoring Key Areas of Compliance and Risk
        1. The Committee monitors ongoing completion of an established list of key compliance and risk management-related activities, following up with responsible parties as needed.
           1. The Committee adds newly identified items to the list, as needed.
        2. Members bring key updates and areas of concern related to compliance and risk to the Committee meetings.
     3. Monitoring Audits and Investigations.  
        1. As needed or requested, the Committee monitors the results of internal and external audits and investigations for the purpose of identifying potential risk areas and recommends and implements appropriate corrective and preventive action.
     4. Policies and Procedures  
        1. The Committee works with the Corporate Compliance Officer, COO/Risk Manager, and appropriate Westside personnel, as needed, to develop standards of conduct and policies and procedures that address areas of risk and that promote compliance.  Areas include, but are not limited to:
           1. Westside’s Compliance Program;
           2. Westside’s Risk Management Program;
           3. All applicable laws, including:

laws authorizing and implementing Medicaid and Medicare,

other federal and state health care programs, and

the requirements under Section 330 of the Public Health Service Act; and

• • • • 1. Requirements of insurers.
      1. The Committee supports, as needed, the Corporate Compliance Officer in their responsibility for overseeing policy management – the review and updating of identified policies, as needed.
    1. Implementation
       1. The Committee assists the Corporate Compliance Officer in recommending and monitoring internal systems and controls that seek to ensure compliance with the Health center’s standards of conduct and its written standards and policies and procedures.
    2. Developing Strategy  
       1. The Committee also analyzes and, as needed, develops new methods for promoting compliance and identifying potential violations and for soliciting, evaluating and responding to complaints and reports of alleged non-compliance.
    3. Resources  
       1. The Committee periodically reviews the resources assigned to the health center’s compliance efforts to assess their adequacy for maintaining the Compliance Program’s ongoing effectiveness.

1. The Compliance and Risk Management Committee maintains a Charter that is reviewed annually by the Corporate Compliance Officer, COO/Risk Manager, and the Committee.  The most current version at the time of policy review is provided in Attachment A.

References

1. Compliance Program for Individual and Small Group Physician Practices.  Department of Health and Human Services (DHSS) Office of Inspector General (OIG). Federal Register / Vol. 65, No. 194 / Thursday, October 5, 2000 / Notices.   https://oig.hhs.gov/authorities/docs/physician.pdf

Centers for Medicare and Medicaid Services (CMS) Regulations and Guidance https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance

Health Services Resource Administration (HRSA) Bureau of Primary Care (BPHC) manuals

• 1. Health Services Resource Administration (HRSA). Health Center Program Compliance Manual, August 2018.  https://bphc.hrsa.gov/programrequirements/compliancemanual/
  2. Health Services Resource Administration (HRSA). Health Center Program Site Visit Protocol (SVP), May 27, 2021. https://bphc.hrsa.gov/programrequirements/site-visit-protocol  

HRSA Health Center Risk Management

• 1. HRSA Federal Tort Claims Act (main page) https://bphc.hrsa.gov/ftca/index.html
  2. Chapter 21: Federal Tort Claims Act (FTCA) Deeming Requirements, Demonstrating Compliance (a). Health Services Resource Administration (HRSA). Health Center Program Compliance Manual, August 2018. https://bphc.hrsa.gov/programrequirements/compliancemanual/chapter-21.html#titletop
  3. FTCA Deeming Requirements. Health Services Resource Administration (HRSA). Health Center Program Site Visit Protocol (SVP), February 27, 2020. https://bphc.hrsa.gov/sites/default/files/bphc/programrequirements/pdf/ftca-deeming-requirements.pdf

The Joint Commission (TJC) manual

• 1. The Joint Commission (TJC) Comprehensive Accreditation Manual for Ambulatory Health Care (CAMAC), January 1, 2021.  

ECRI Clinical Risk Management

• 1. Risk Management Toolkit, 3/8/2021 https://www.ecri.org/components/HRSA/Pages/RMToolkit.aspx
  2. Risk Management Manual for Health Centers https://www.ecri.org/components/HRSA/Documents/RiskManagementManual.pdf