C. Compliance education and competency assessment will be provided on a periodic basis. Education and communication emphasizes that the compliance plan includes an internal mechanism for reporting potential violations, and that compliance violations will result in disciplinary action. D. Staff who reports violations is assured they may do so without fear of retribution. E. Exit interviews are to include a compliance-related question. All departments are expected to develop and implement systematic processes to assess compliance issues, take corrective measures, and continually monitor compliance.
Audits are to be designated to provide reliable assessment of current practices.
Records are to be maintained on audit findings and periodically reported to the Compliance Committee. There are several internal report mechanisms available for all staff to report possible violations. D. The Compliance Committee reviews and evaluates the potential problems reported. E. Periodic audits by internal and external sources will target selected areas throughout the hospital to ensure compliance and to determine if proper controls are in place. Audit findings will be reviewed by the Compliance Committee.