Your health care organization has just learned that it is out of compliance in the problem areas listed below. You have been asked to research ONE problem and prepare an interoffice research memo that is single-spaced and not more than two pages. The Memo should be addressed to the VP of Finance and include the following sections with a heading in bold for each section. Use APA for in-text citations and references.
Memo Heading
Memo To:
Memo From:
Date:
Re: (Regarding – Name the topic)
Brief description of the problem
State the Law and agency guidelines or regulations that govern the issue include the penalty for non-compliance
Describe and evaluate how the COSO framework, components and principles can improve compliance and correct system-wide problems. See https://www.coso.org/Pages/default.aspx
Recommend a strategic corrective action plan (CAP) that implements components and principles from COSO. Name and describe at least three managerial actions you recommend to correct the specific problem and bring the organization into compliance using the COSO compliance tool.
Give reasons to support selection of these actions. Indicate which COSO components and principles you relied on and why.
Problems (Select One)
Your hospital has had multiple repeat hospital admissions of patients with pneumonia within 30 days of discharge in violation of the Hospital Readmissions Reduction Program (HRRP). https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program
Your hospital as a score in the 75th percentile for Surgical Site Infection (SSI) during the last six months raising concerns under the Hospital-Acquired Condition Reduction Program (HACRP). .https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/HAC-Reduction-Program
Your long-term care facility has multiple never events in your long-term care facility with multiple patients developing Stage III and IV pressure ulcers during the last year. https://downloads.cms.gov/cmsgov/archived-downloads/smdl/downloads/smd073108.pdf
Your long-term care facility has had multiple adverse events from medication errors that led to the deaths of 5 patients at your facility within the last month. You have been so busy investigating, you havent reported under the FDA Adverse Event Reporting System (FAERS). https://www.fda.gov/drugs/surveillance/questions-and-answers-fdas-adverse-event-reporting-system-faers
Week 4 and 5: Government Programs
Additional Resources
Medicare
Medicare and Medicaid Conditions of Participation: https://www.cms.gov/Regulationsand-Guidance/Legislation/CFCsAndCoPs/index.html?redirect=/CFCsAndCoPs/
Conditions of Participation for Hospitals https://www.govinfo.gov/content/pkg/CFR2017-title42-vol5/xml/CFR-2017-title42-vol5-part482.xml
Conditions of Participation for Home Health Services https://www.ecfr.gov/cgi-bin/textidx?node=pt42.5.484&rgn=div5
Requirements for Long Term Care https://www.ecfr.gov/cgi-bin/textidx?SID=cfbc43a1e632c88ff587201d326f5180&node=42:5.0.1.1.2.2&rgn=div6
Accountable Care Organizations (ACOs): General
Information https://innovation.cms.gov/initiatives/ACO
The Guide to Medicare Preventive Services 4th Edition http://medallionmedical.com/wpcontent/uploads/2015/08/The-Guide-to-Medicare-Preventative-Services-for-PhysicansProviders-and-Suppliers.pdf
Medicaid
State Medicaid Plans and Waivers: https://www.cms.gov/Outreach-andEducation/American-Indian-Alaska-Native/AIAN/LTSS-TA-Center/info/state-medicaidpolicies.html
National Council on Disability: Chapter 1. An Overview of Medicaid Managed Care |
NCD.gov
The Urban Institute (2012). Medicaid and CHIP Risk-Based Managed Care in 20
States: https://www.urban.org/sites/default/files/publication/25646/412617-Medicaidand-CHIP-Risk-Based-Managed-Care-in-States.PDF
Medicaid A Primer (CRS): http://www.ncsl.org/documents/health/MAPrimer.pdf
Medicaid and FMAP (CRS): http://www.ncsl.org/documents/health/MAFMAP.pdf
State Health Departments https://www.usa.gov/state-health
Maryland Department of Health https://health.maryland.gov/pages/home.aspx
Medicaid and the Affordable Care Act: https://www.medicaid.gov/affordable-careact/index.html
Medicaid Expansion: https://www.kff.org/health-reform/issue-brief/a-guide-to-thesupreme-courts-decision/
Food and Drug Administration (FDA)
FDA https://www.fda.gov/
Drug Regulation https://www.fda.gov/drugs
Medical Device Regulation https://www.fda.gov/medical-devices
Radiation-Emitting Products https://www.fda.gov/radiation-emitting-products
Vaccines, Blood & Biologics https://www.fda.gov/vaccines-blood-biologics
Tobacco Products https://www.fda.gov/tobacco-products
State Department of Health
State Health Departments https://www.usa.gov/state-health
State Health Departments https://www.usa.gov/state-health
Maryland Department of Health https://health.maryland.gov/pages/home.aspxCDC
https://www.cdc.gov/Medicaid and the Affordable Care
Act: https://www.medicaid.gov/affordable-care-act/index.html
Affordable Care Act
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?
?
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Affordable Care Act Tax Provisions for Large Employers
https://www.irs.gov/affordable-care-act/employers/affordable-care-act-tax-provisionsfor-large-employers
Summary of the Affordable Care Act https://www.kff.org/health-reform/factsheet/summary-of-the-affordable-care-act/
ACA Information Center for Applicable Large Employers
(ALE) https://www.irs.gov/affordable-care-act/employers/aca-information-centerfor-applicable-large-employers-ales
Preventive health care services https://www.kff.org/health-reform/fact-sheet/summaryof-the-affordable-care-act/
Burwell v. Hobby Lobby Stores (2014) https://www.oyez.org/cases/2013/13-354
Appealing Health Plan Decisions https://www.hhs.gov/healthcare/about-theaca/cancellations-and-appeals/appealing-health-plandecisions/index.html#:~:text=You%20have%20the%20right%20to,to%20terminate%2
0your%20health%20coverage.&text=You%20can%20appeal%20your%20insurance,fai
r%20review%20of%20its%20decision
CMS RAC Audits
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?
?
?
CMS Recovery Audit Contractors (RAC) https://www.cms.gov/Research-StatisticsData-and-Systems/Monitoring-Programs/Medicare-FFS-CompliancePrograms/Recovery-Audit-Program
The Recovery Audit Program and Medicare https://www.cms.gov/Research-StatisticsData-and-Systems/Monitoring-Programs/Medicare-FFS-CompliancePrograms/Recovery-Audit-Program/Downloads/The-Recovery-Audit-Program-andMedicare-Slides-051313.pdf
Approved RAC Topics https://www.cms.gov/Research-Statistics-Data-andSystems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-AuditProgram/Approved-RAC-Topics
AMA Fact Sheet: Medicare Recovery Audit Contractor (RAC) Program Appeals
https://www.ama-assn.org/sites/ama-assn.org/files/corp/mediabrowser/public/washington/recovery-audit-contractor-appeals-fact-sheet_0.pdf
Interoperability and Information Blocking
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?
?
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?
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CMS Policies and Technology for Interoperability and Burden Reduction
https://www.cms.gov/Regulations-and-Guidance/Guidance/Interoperability/index
CMS Interoperability Final Rule https://www.cmspatientaccessrule.com/
HIMSS Final CMS Interoperability Regulation: What you Need to Know
https://www.himss.org/news/final-cms-interoperability-regulation-what-you-needknow
Information Blocking https://www.healthit.gov/topic/information-blocking
Information Blocking FAQ https://www.healthit.gov/curesrule/resources/informationblocking-faqs
How do I comply with info blocking and where do I start? https://www.amaassn.org/system/files/2020-11/info-blocking-compliance.pdf
Understanding the Eight Exceptions to Information Blocking
https://journal.ahima.org/understanding-the-eight-exceptions-to-information-blocking/
Childrens Health Insurance Program (CHIP)
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The Childrens Health Insurance Program (CHIP)
https://www.healthcare.gov/medicaid-chip/childrens-health-insurance-program/
Childrens Health Insurance Program Overview
https://www.ncsl.org/research/health/childrens-health-insurance-programoverview.aspx
Center for Disease Control
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CDC https://www.cdc.gov/
Food and Drug Administration (FDA)
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FDA https://www.fda.gov/
Drug Regulation https://www.fda.gov/drugs
Medical Device Regulation https://www.fda.gov/medical-devices
Radiation-Emitting Products https://www.fda.gov/radiation-emitting-products
Vaccines, Blood & Biologics https://www.fda.gov/vaccines-blood-biologics
Tobacco Products https://www.fda.gov/tobacco-products
State Department of Health
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State Health Departments https://www.usa.gov/state-health
Maryland Department of Health https://health.maryland.gov/pages/home.aspx
COSO
COSO https://www.coso.org/Pages/default.aspx
COSO Guidance https://www.coso.org/Pages/guidance.aspx
COSO: Internal Control Integrated Framework: An Implementation Guide for the
Healthcare Provider Industry https://www.coso.org/Documents/COSO-CROWE-COSOInternal-Control-Integrated-Framework.pdf
COSO: Compliance Risk Management: Applying the COSO ERM Framework
https://www.coso.org/Documents/Compliance-Risk-Management-Applying-the-COSOERM-Framework.pdf
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