Compliance Department Records Management

According to the Department of Health and Human Services (HHS) Office of Inspector General (OIG), it is critical for compliance departments to implement a records management program. Effective compliance programs ensure that the records necessary to protect the integrity of an organization’s compliance process are maintained and current with applicable laws, regulations, and requirements. A well-managed program also provides evidence to confirm records management best practices, such as evidencing employee compliance training, hotline reports, investigation reports, an updated code of conduct and policies, self-disclosures, and results of ongoing monitoring and auditing, etc. Furthermore, the compliance officer should ensure that operational records are properly maintained, protected, and controlled. For example, employee information, patient medical records, billing information, and cost reports are areas that should be guided by clear records management policies and procedures that are often controlled by specific laws and regulations. To ensure everything is done correctly, it is important to have a policy with procedures for the creation, distribution, retention, storage, retrieval, and destruction of compliance-related documents. The following are some suggestions for documentation to include in your organization’s compliance records:

1. A records management compliance checklist;
2. Documentation that evidences that employees were adequately trained;
3. Compliance hotline reports;
4. Documentation evidencing compliance program modification and improvements;
5. Self-disclosures to government agencies;
6. Compliance audit plans and checklists;
7. Results of auditing and monitoring efforts;
8. Corrective actions taken in response to identified problems;
9. Compliance program-related policies and procedures;
10. Compliance briefings for executive and board-level compliance committees;
11. Minutes of executive and board-level compliance committee meetings;
12. Compliance investigation reports and supporting evidence;
13. A database of contracts and agreements with referral sources; and
14. Metrics evidencing compliance program effectiveness.

About the Author

Richard P. Kusserow established Strategic Management Services, LLC, after retiring from being the DHHS Inspector General, and has assisted over 3,000 health care organizations and entities in developing, implementing and assessing compliance programs.