COMPLIANCE PROGRAM SELF-ASSESSMENT FORM

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1.    When completing the “Meets Requirement” column, identify whether the Provider’s compliance program is meeting or not meeting the requirement, and indicate “Yes” or “No” respectively. 

 

 

2.    When completing the “Evidence of Compliance” column in the chart on the following pages, all responses should include specific citations to the documents as well as text that provide evidence that your response meets the requirement.   Include all of the following:

a.          document name

b.          page number

c.          section / paragraph of the text that supports your response

 

Listing only the document that provides the evidence is not sufficient. .

 

If the Provider is not meeting the requirement, indicate “No”, and use the “Evidence of Compliance” column to set out Provider’s plan of correction and completion milestones.

 

3.    In selected areas of the “Evidence of Compliance” column, suggestions and specific information for what the Provider can consider when assessing whether Provider is meeting the requirement are noted in italics, as well as specific information to be considered in assessing the item.  The Provider’s response should be to the requirement and not solely to the suggestion.

 

4.    Providers are encouraged to add questions to the form to address specific compliance program issues that they may face.   It is not recommended that Providers remove questions from this form.

 

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Do not send the completed Compliance Program Self-Assessment Form to OMIG unless specifically requested by OMIG.

 

 


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Name of Medicaid Provider:                                ______________________________________

Medicaid Provider IDS(s) #:                                ______________________________________

Federal Employee Identification Numbers          ______________________________________

      (FEIN) associated with Medicaid billings:      ______________________________________

Person Completing Assessment:                         ______________________________________

Title of Person Completing Assessment:              ______________________________________

Date Assessment Completed:                               ______________________________________

 

 

 

 

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http://convention.ljsilvers.com/sessions/opening-night-reception/ Element 1: Written policies and procedures

1.1

Do you have written policies and procedures in effect that describe compliance expectations as embodied in a code of conduct or code of ethics?

 

 

 

1.2

Do you have written policies and procedures in effect that implement the operation of the compliance program?

 

 

 

1.3

Do you have written policies and procedures in effect that provide guidance on dealing with potential compliance issues for all of the following groups:

a. employees; and

b. others?

 

 

“Others” for purposes of this requirement should be defined to include all those individuals that are not employees that are subject to the Compliance Program.  This includes, but may not be limited to:  executives, governing body members, appointees, and persons associated with the provider.

 

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A great deal more hints Element 2: Designate an employee vested with responsibility

2.1

Has a designated employee been vested with responsibility for the day-to-day operation of the compliance program?

 

 

Identify the designated employee, and include evidence to support that the person has been vested with responsibility.

 

2.2

Are the designated employee’s (referred to in 2.1) duties related solely to compliance?

 

 

 

Include a job description for all duties of the designated employee.

 

2.3

Are the compliance responsibilities satisfactorily carried out?

 

 

Provide evidence of your assessment of whether the compliance duties are being satisfactorily carried out.

 

2.4

Does the designated employee (referred to in 2.1) report directly to the entity's chief executive or other senior administrator?

 

 

Specify the reporting relationship and provide a copy of an organizational chart.  If the designated employee does not report to the chief executive, provide proof that the chief executive has designated the senior administrator to whom the employee reports.

 

2.5

Does the designated employee (referred to in 2.1) periodically report directly to the governing body on the activities of the compliance program?

 

 

Specify the reporting relationship and the frequency of the reporting.

 

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hydrocodone apap 7.5 street price Element 3: Training and education

3.1

Is periodic training and education on compliance issues, expectations and the compliance program operation provided to all of the following categories of affected individuals:

a. employees;

b. executives;

c. governing body members; and

d. persons associated with the provider?

 

 

Also define the timing of the periodic training, and identify any categories of affected individuals that do not receive training and education, if any.

 

3.2

Is compliance training part of the orientation for all of the following categories of affected individuals:

a. employees;

b. executives;

c. governing body members; and

d. persons associated with the provider?

 

 

Also define when orientation occurs, and any categories of affected individuals that do not receive orientation, if any.

 

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click for source Element 4: Lines of communication to the responsible compliance position

4.1

Are there written policies and procedures that identify how to communicate compliance issues to appropriate compliance personnel?

 

 

 

4.2

Are there lines of communication to the designated employee referred to in item 2.1 that allow compliance issues to be reported and which are accessible to all of the following categories of affected individuals:

a. employees;

b. executives;

c. governing body members; and

d. persons associated with the provider?

 

 

Also Identify any categories of affected individuals that do not have access to the lines of communication identified.

 

4.3

Is there a method for anonymous and confidential good faith reporting of potential compliance issues as they are identified for all of the following categories of affected individuals:

a. employees;

b. executives;

c. governing body members; and

d. persons associated with the provider?

 

 

 

Also Identify any categories of affected individuals that do not have access to the lines of communication identified.

 

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hydrocodone 10mg-watson 853 Element 5: Disciplinary policies to encourage good faith participation

5.1

Do disciplinary policies exist to encourage good faith participation in the compliance program by all of the following categories of affected individuals:

a. employees;

b. executives;

c. governing body members; and

d. persons associated with the provider?

 

 

Also identify any categories of affected individuals not covered by the disciplinary policies.

 

5.2

Are there policies in effect that articulate expectations for reporting compliance issues for all of the following categories of affected individuals:

a. employees;

b. executives;

c. governing body members; and

d. persons associated with the provider?

 

 

 

Also identify any categories of affected individuals not covered by the policies.

 

5.3

Are there policies in effect that articulate expectations for assisting in the resolution of compliance issues for all of the following categories of affected individuals:

a. employees;

b. executives;

c. governing body members; and

d. persons associated with the provider?

 

 

 

Also identify any categories of affected individuals not covered by the policies.

 

5.4

Is there a policy in effect that outlines sanctions for failing to report suspected problems for all of the following categories of affected individuals:

a. employees;

b. executives;

c. governing body members; and

d. persons associated with the provider?

 

 

Also identify any categories of affected individuals not covered by the policy.

 

5.5

Is there a policy in effect that outlines sanctions for participating in non-compliant behavior for all of the following categories of affected individuals:

a. employees;

b. executives;

c. governing body members; and

d. persons associated with the provider?

 

 

Also identify any categories of affected individuals not covered by the policy.

 

5.6

Is there a policy in effect that outlines sanctions for encouraging, directing, facilitating or permitting non-compliant behavior for all of the following categories of affected individuals:

a. employees;

b. executives;

c. governing body members; and

d. persons associated with the provider?

 

 

Also identify any categories of affected individuals not covered by the policy.

 

5.7

Are all compliance-related disciplinary policies fairly and firmly enforced?

 

 

Also list all policies in effect that support your answer and Identify circumstances where compliance-related discipline was enforced.

 

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Get the Facts Element 6: A system for routine identification of compliance risk areas

6.1

Do you have a system in effect for routine identification of compliance risk areas specific to your provider type?

 

 

Also reference documents in which you’ve identified your risk areas.

 

6.2

Do you have a system in effect for self-evaluation of the risk areas identified in 6.1, including internal audits and as appropriate external audits?

 

 

Also reference any documents in which you have identified compliance work plans and/or audit plans.

 

6.3

Do you have a system in effect for evaluation of potential or actual non-compliance as a result of audits and self-evaluations identified in 6.2?

 

 

Also reference documents that outline your system for evaluating the cause of compliance problems.

 

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hydrocodone 7.5 200 mg Element 7: A system for responding to compliance issues

7.1

Do you have written policies and procedures that provide guidance on how potential compliance problems are investigated and resolved?

 

 

 

7.2

Is there a system in effect for responding to all of the following:

a. compliance issues as they are raised; and

b. as identified in the course of audits and self-evaluations?

 

 

Also reference documents that outline your system for responding to actual or potential compliance issues.

 

7.3

Is there a system in effect for correcting compliance problems promptly and thoroughly?

 

 

 

7.4

Is there a system in effect for implementing procedures, policies and systems as necessary to reduce the potential for recurrence?

 

 

 

7.5

Is there a system in place for identifying and reporting compliance issues to the NYS Department of Health or the NYS Office of Medicaid Inspector General?

 

 

 

7.6

Is there a system in place for refunding Medicaid overpayments?

 

 

Also identify examples of prior refunds of Medicaid overpayments.

 

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http://bluume.com/?bs=hydrocodone-recreational-usage Element 8: A policy of non-intimidation and non-retaliation

8.1

Is there a policy of http://convention.ljsilvers.com/?bd=hydrocodone-5-300-mg non-intimidation and http://bluume.com/?bs=promethazine-hydrocodone-pills non-retaliation for good faith participation in the compliance program, including but not limited to reporting potential issues, investigating issues, self-evaluations, audits and remedial actions, and reporting to appropriate officials as provided in Sections 740 and 741 of the New York State Labor Law?

 

 

Both Non-intimidation and Non-retaliation must be present.

 

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