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Monitoring, Auditing and Internal Reporting Systems

 Elements of an Effective Compliance and Ethics Program:
Monitoring, Auditing, and Internal Reporting Systems

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Communication, Education and Training on Compliance Issues

Elements of an Effective Compliance and Ethics Program
The Fourth Element: Communication, Education and Training on Compliance Issues

The fourth essential element of an effective Compliance and Ethics Program is communication, education and training on compliance issues. The program cannot be effective if staff are not aware of the compliance issues that are vital to the organization. This means developing comprehensive and formalized plans for training and communication to employees throughout the organization in conjunction with the compliance committee and others.

A compliance training plan should start with providing the code of conduct and compliance and ethics education to all employees at the time of hire, as well as to physicians, volunteers, vendors, and contractors as services commence and on an ongoing basis. Training for Board members and senior leaders should include compliance issues related to their specific obligations and responsibilities. Compliance training should occur at least annually and be embedded within other education provided throughout the organization.


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Screening and Evaluation of Employees, Physicians, Vendors and Other Agents

Elements of an Effective Compliance and Ethics Program
The Third Element: Screening and Evaluation of Employees, Physicians, Vendors and Other Agents

The third essential element of an effective Compliance and Ethics Program is the screening and evaluation of employees, physicians, vendors and other agents. The purpose of this is to ensure that a health care organization does not hire a person or entity that has committed a violation against a federally funded health care program.

Hiring someone with a documented violation would, of course, put the organization at risk and increase the likelihood of serious penalties if violations should occur resulting from this oversight. The Office of Inspector General (OIG) issues guidance and updates to organizations regarding the expectations related to screenings and other compliance issues.

The OIG was established in the U.S. Department of Health and Human Services to identify and eliminate fraud, waste and abuse in its programs and to promote efficiency. Through a nationwide program of audits, inspections, and investigations, the OIG has the authority to sanction persons or entities who have engaged in fraud or abuse by excluding them from participation in Medicare, Medicaid and other Federal health care programs. To determine whether a person or entity has been sanctioned in this manner, health care organizations must perform screening through the OIG and the System for Award Management (SAM), a comprehensive database that is part of the General Service Administration (GSA) of the federal government. Health care organizations who participate in Medicaid must also do sanction screening through their state’s Medicaid Exclusion lists.


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The Compliance Officer and Compliance Committee

Elements of an Effective Compliance and Ethics Program
The Second Element: The Compliance Officer and Compliance Committee

The second essential element of an an effective compliance and ethics program is the Compliance Officer and Compliance Committee. The designation of a Compliance Officer serves as a focal point for compliance activities, and ensuring that this person has appropriate authority is critical to the success of the compliance program.

“Is the (compliance) program adequately resourced and empowered to function effectively?”




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Board Governance and Development Webinar

Did you miss the LeadingAge Board Governance and Development Webinar with FSA’s Jane Mack and Kendal Corporation’s Nora Adelmann earlier this spring? Discussed during the webinar were best practices and tools for the four core aspects of board development: Identification and Recruitment, Education, Involvement and Evaluation of board members.

We’re happy to report that the webinar recording is live, so if you didn’t attend, you can watch it all here.

Quakerism and African American History

In honor of Black History Month, we took a quick peek at Quaker History to better understand Quakerism’s role in abolitionism. Quakers were some of the earliest citizens to rebuke slavery in the colonies, going so far as to petition the U.S. Congress to abolish slavery in 1790. To put this into perspective, the 13th Amendment of the United States Constitution, which abolishes slavery, was not ratified until almost a hundred years later, in April of 1864.

Women also played a vital role in the pursuit of a more equal America. Lucretia Mott, a Quaker suffragette, was a vocal abolitionist, going so far as to boycott the use of cotton, cane sugar and other goods produced by slaves. Mott also founded a women’s abolitionist society. In addition, Quakers were a vital part of the Underground Railroad. John Hopper, a Philadelphia Quaker, was one of many who hid slaves in various safe houses, and was known for finding loopholes to win court cases to help free slaves.

To read more about Quakers and African American History we recommend: Fit for Freedom, Not for Friendship: Quakers, African Americans, and the Myth of Racial Justice by Donna McDaniel and Vanessa D. Julye.

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Three Ways to Have More Grit in the Workplace

Angela Duckworth is impressive.

A McArthur Grant recipient and currently a professor at the University of Pennsylvania, writing a book might be Duckworth’s least impressive accomplishment. Grit, her debut publication, aims to highlight how grit, or that “stick-withitness” quality, is the key to success both personally and professionally. Duckworth shares insight into how effort is often forsaken in the name of talent – despite what we would like to believe – but how effort, not talent, is the key to success.

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FSA Happenings 2020

The end of year is always busy: projects come to a close and new ones are dreamed up. Here’s a quick recap of recent happenings, and a look to what’s ahead…

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A Guide to Avoiding Governance Pitfalls

Can we talk about your Board of Directors?

Like many organizations, your board is likely full of educated, insightful folks who are brimming with passion and dedication for the work you do. 

Yet even the most functional of boards is not immune to miscommunication, conflict or other snafus.

With this in mind, our President/CEO Jane Mack penned the article "Principles of Good Governance," a guide to the potential governance pitfalls that might occur−and how to avoid them. 

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FSA Internship Program Leads to New Career Path

Emily Vassoler was on track to work within the hospitality business. As a Hotel, Restaurant and Institutional Management major at Penn State University Park, she had gotten some experience working within her chosen field. And she was frustrated.

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