C5 Compliance Program Effectiveness Renée W. Jaenicke, CPA CIA CFE Director of Internal Audit Renown Health - PDF

1 C5 Compliance Program Effectiveness Renée W. Jaenicke, CPA CIA CFE Director of Internal Audit Renown Health AHIA 31 st Annual Conference August 26-29, 2012 Philadelphia PA What we will cover

Please download to get full document.

View again

of 36
All materials on our website are shared by users. If you have any questions about copyright issues, please report us to resolve them. We are always happy to assist you.

Pets & Animals

Publish on:

Views: 10 | Pages: 36

Extension: PDF | Download: 0

1 C5 Compliance Program Effectiveness Renée W. Jaenicke, CPA CIA CFE Director of Internal Audit Renown Health AHIA 31 st Annual Conference August 26-29, 2012 Philadelphia PA What we will cover 2 Renown Health and Internal Audit Why evaluate compliance program effectiveness? Initial efforts FY 2012 audit Next steps Lessons learned Handouts Renown Health 2 acute care facilities (884 licensed beds) Children s hospital 1 inpatient rehab (62 licensed beds) 1 skilled nursing facility 6 urgent care locations 16 medical group locations 12 imaging locations 10 draw locations Various joint ventures Institutes for neuroscience, pain, heart & vascular, robotic surgery, cancer Internal Audit Department - Productive Time Breakdown 80% 70% 60% 50% 40% 30% 20% 10% 0% FY 2009 FY 2009 FY 2010 FY 2011 FY 2012 Financial Operational Consulting Fraud IT FTE = 4.6 Why? PPACA, Section 11281(b)(1): On or after the date that is 36 months after the date of the enactment of this section, a facility shall with respect to the entity that operates the facility have in operation a compliance and ethics program that is effective in preventing and detecting ti criminal, i civil, il and administrative violations under this Act Why? PPACA, Section 11281(b)(2)(A): No later than the date that is 2 years after such date of the enactment, the Secretary, working jointly with the Inspector General of the Department of Health and Human Services, shall promulgate regulations for an effective compliance and ethics program for operating organization, which may include a model compliance program. Why? 2010 U.S. Sentencing Guidelines Section 8B2.5(f)(1) If the offense occurred even though the organization had in place at the time of the offense an effective compliance and ethics program as provided in Section B2.1, subtract 3 points. (This section relates to culpability score for sentencing of organizations.) Why? United States Federal Register, Vol. 70, No. 19, Monday, January 31, 2005, Notices, pp Hospitals should regularly review the implementation and execution of their compliance program elements. This review should be conducted at least annually and should include an assessment of each of the basic elements individually, as well as the overall success of the program. Why? AICPA, SAS 99, AU316.86: The cornerstone of an effective antifraud environment is a culture with a strong value system founded on integrity. This value system often is reflected in a code of conduct. Why? IIA Standard 2110.A1: The internal audit activity must evaluate the design, implementation, and effectiveness of the organization s ethics-related objectives, programs, and activities. IIA Standard 2120.A1: The internal audit activity must evaluate risk exposures relating to the organization s governance, operations, an if information systems regarding compliance with laws, regulations, and contracts. Initial Efforts Planning Consulting Project (to gain buy-in) Consisted of only Based on guidelines, articles, best practices Initial Efforts Fieldwork Policies and Procedures Designation of a Compliance Officer and Compliance Committee Effective ing and Education Effective Lines of Communication Well-Published Disciplinary Guidelines Auditing and Monitoring Risk assessments Monitoring Corrective Action Initiatives Initial Efforts Fieldwork Code of Ethics Development Contents Implementation Conflict of Interest Policy Existence of policy Hotline communication Hotline implementation Hotline call disposition Initial Efforts Fieldwork Tone at the Hiring and Promoting Appropriate Employees Training (in general) Disciplinary efforts (in general) Initial Efforts Reporting Summary of recommendations Review compliance program effectiveness annually Update Code of Ethics and Compliance P&P Provide Code of Ethics to various constituents Include Code of Ethics question in exit survey Implement Compliance Committee of Board of Directors charter Revitalize Compliance Steering Committee Initial Efforts Reporting Summary of recommendations Develop on-line learning modules Provide physician training Enhance Compliance Officer and communication Prepare and implement compliance risk assessment Expand background screening Initial Efforts Reporting Report format Leading practice, source Current state Recommendations Responsibility, due date CEO asked for -up to recommendations Some recommendations rejected Most not implemented Report to CEO, CFO, CCO only No report to Board FY 2012 Audit Planning Audit program based on regulations, primarily 2010 Federal Sentencing Guidelines Manual Chapter 8, Part B2.1 PPACA Section 6102 Federal Register, Vol. 63, No. 35, Monday, February 23, 1998, pp Federal Register, Vol. 70, No. 19, Monday, January 31, 2005, pp Based on 7 elements of an effective compliance program FY 2012 Audit Planning 33 leading practices based on: Compliance Week or HCCA articles Society of Corporate Compliance and Ethics publications AHIA sessions AICPA s SAS 99 PCAOB OIG Ponemon Institute report Sample charters, policies, and procedures from others IIA Knowledge Report Other compliance articles Utilized to determine how others are applying regulations. FY 2012 Audit Planning Source Regulatory Requirement Leading Practice Source and Summary Regulations Reference Code Exact quote from regulations Leading Practice Reference Code Leading Practice Summary Audit Step Number A through G, # Audit Step Description How to perform Performed by Assigned to Some steps performed together, even from separate sections FY 2012 Audit Fieldwork Used prior year ICQ s and enhanced based on audit program Detail ing Most work performed by director with assistance Validated results FY 2012 Audit Fieldwork Regulatory Requirement: Reference code and quote Leading Practice: Reference code and summary Procedure Performed: From Audit Program Results Regulatory Results Leading Practices Conclusions Regulatory General compliance, not in compliance, unable to test Conclusions Leading Practices Using leading practice or not; whether to apply, recommendations Performed by, date Reviewed by, date Validated with, date FY 2012 Audit Fieldwork Recommendations implemented during audit Updates to position description, charter, risk ranking If I were the OIG and asked you for this, what you tell me or give me to prove we are in compliance? You are the expert on what you do. We just put the materials together. How can we help you take the compliance program to the next level? What restructuring may be needed? Training, administrative tasks How can we work together to make this more meaningful to you? Provide examples how Internal Audit does it Risk ranking, reporting, follow-up tracking FY 2012 Audit Reporting Element Ad Hoc Repeatable Defined Managed Optimized A X B X C D X X E X F G X X FY 2012 Audit Reporting Common themes together regardless of which compliance program element Separate tables under each for: Should, shall, recommend May wish to consider Indicated outstanding action plans from previous years Some areas not reviewed this year Need to be developed FY 2012 Audit Reporting Background Regulations used Results Summary Maturity Level Broad issue Quotation from regulation and page reference Current state Recommendation Action plan, responsible party, due date FY 2012 Audit Reporting Other leading practices recommended Areas not reviewed Area ( from regulation) Disposition Areas audited with no issues by element FY 2012 Results Summary of action plans Update and train on compliance tracking, enhance use Utilize training grid, update content Electronic training acknowledgements Track for compliance with training Update code of ethics, P&P Code of ethics affirmations FY 2012 Results Summary of action plans Perform background for more constituents Approve Compliance Committee charter Revitalize Compliance Steering Committee Develop FY 2013 audit plan based on risk assessment and present to Compliance Committee Educate on compliance role and hotline availability FY 2012 Audit Results Restructuring responsibilities Initial and ongoing regular meetings with CEO, CFO, CCO, and VP of HR Monthly meeting with CEO regarding outstanding items Compliance regulations grid Regulation, Issue (Y/N), responsibility, other Owned by Compliance and HR Easy to develop based on audit program Executive summary to go to Board in September 2012 Next Steps Perform annually Required Requested Planning Director to update plan for FY 2013 based on: What couldn t be evaluated in FY Issues identified in FY Results of action plan completion. Fieldwork Senior to lead audit; director to review Reporting Evaluate format Project progression Planning Fieldwork Reporting Results and Fll Follow-Up Initial FY 2012 FY 2013 Informal, based on guidelines, articles, leading Structured, repeatable, based on guidelines, articles, and leading To update FY 2012 based on additional practices practices leading practices ICQ only, Detailed testing, working Now repeatable Loosely based paper template, by others on 7 elements performed by director Only to CEO, Program maturity Will show CFO, CCO evaluated, action plans progress required, report to Board Recommendation Action plan TBD only, most not implementation ti underway implemented Lessons Learned Just something Governance doesn t mean anything until you show them Give a compelling reason Tread carefully Provide frequent updates Let the Board know Handouts Please refer to your handouts ? Renée W. Jaenicke Director of Internal Audit Renown Health (775) Save the Date: August 25-28, nd Annual Conference Chicago, IL
Related Search
Similar documents
View more...
We Need Your Support
Thank you for visiting our website and your interest in our free products and services. We are nonprofit website to share and download documents. To the running of this website, we need your help to support us.

Thanks to everyone for your continued support.

No, Thanks