Overview
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 double-spaced and not more than four 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 7 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, including the penalty for non-compliance. Include the code or regulatory citation. How does the law apply to the problem? Tip: Look for both state and federal laws.
- Describe and evaluate how the COSO framework, components, and principles can improve compliance and correct system-wide problems. How does COSO apply to the problem? See COSO Internal Control - Integrated Framework: An Implementation Guide for the Healthcare Provider Industry PDF.
- Recommend a strategic corrective action plan (CAP) that implements components and principles from COSO to correct the specific problem. 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 the 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). CMS.gov Website: Hospital Readmissions Reduction Program (HRRP) Landing Page
- Your hospital has scored in the 75th percentile for Surgical Site Infection (SSI) during the last six months raising concerns under the Hospital-Acquired Condition Reduction Program (HACRP). CMS.gov Website: Hospital-Acquired Condition (HAC) Reduction Program Landing Page and AHRQ Website: Patient Safety Network - Never Events Landing Page
- Your long-term care facility has multiple never events, with multiple patients developing Stage III and IV pressure ulcers during the last year. CMS State Medicaid Payments HAC Letter PDF
- Your long-term care facility has had multiple adverse events from medication errors that led to the deaths of five patients at your facility within the last month. You have been so busy investigating that you haven’t considered voluntary reporting under the FDA Adverse Event Reporting System (FAERS). FDA Website: Questions and Answers about the FDA's Adverse Event Reporting System (FAERS) Link
TIPS TO COMPLETE THE MEMO
Use a memo format with citations and references in APA 7 format. The memo should be double-spaced and include headings. The memo format should include the following:
- Memo Heading,
- Problem Description
- State of the Law
- Describe the COSO framework and evaluate how it would apply
- Recommend a strategic action plan suing COSO. State 3 actions to take to resolve the problem.
Use the assignment links as well as the classroom law library, compliance library, textbooks, and course web links to complete the assignment.
Choose a problem that would be in a useful setting or useful situation that you might encounter as a health care manager.
Also review laws and guidelines in the textbook, Classroom law library and textbooks as well as course web links.
Name the law and give a U.S.C. citation to the code section related to the law you are discussing. This should be in the format of 26 U.S.C. 442 (2021).
There are links to the U.S.C. in the Classroom Law Library. Here is another link to the U.S.C. at https://www.law.cornell.edu/uscode/text
State code sections should indicate the state you are referring to and he code citation.
There are also code sections in the textbook.
What is COSO?
COSO stands for the Committee of Sponsoring Organizations of the Treadway Commission. It has guidelines for an enterprise risk management (ERM) system to control organizational risk.
You can find COSO information at https://www.coso.org/SitePages/Home.aspx
Include a short description of the COSO enterprise risk management ERM) system in your memo.
What does it mean to create a corrective action plan (CAP)?
A corrective action plan (CAP) is a multiple step plan to correct the problem. A good corrective action plan should be specific to correct the stated problem, should state specific actions to take to correct things.
Consider actions that incorporate the compliance and risk management strategies we have discussed.
What is the difference between a corrective action plan (CAP) and a compliance plan?
A corrective action plan (CAP) corrects a specific problem. This may include investigation of the issue, government reporting, employment action with an employee who made an error, etc.
A compliance plan is a plan to comply with a specific law. The plan focuses on preventing problems by putting strategies in place to avoid problems.
What does it mean to state three actions to correct the problem?
The corrective action plan should state three things you can do to correct the problem. Each thing you do should be an action.
Make sure the actions are specific to correct the problem you have focused on. Look for innovative ways to resolve the issue.
How do I integrate COSO into the corrective action plan?
COSO sets forth ways to make system wide changes for enterprise risk management (ERM). Take the COSO principles and adapt them to the specific problem you have selected to create a corrective action plan based on COSO and specific to the problem. Explain how your plan relates to COSO and its principles.
This means that you will explain COSO and its principles and then consider how to use them to correct the specific problem.
For example, if the problem was fraudulent billing of the government. Consider which COSO principles will correct the billing problem and keep the problem from occurring again. Make sure your corrective action is specific and corrects the specific problem.
Be sure to talk about and apply COSO principles in your memo.