UMGC Corrective Action Plan Case Paper

Your health care organization has just learned that it is out of compliance in the problem areas listed below.  You have been asked to researchONE problem and prepare an interoffice research memo that is single-spaced and not more than two 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 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 include the penalty for non-compliance
  • Describe and evaluate how the  COSO  framework, components and principles can improve compliance and correct system-wide problems. See https://www.coso.org/Pages/default.aspx
  • Recommend a strategic corrective action plan  (CAP) that implements components and principles from COSO. 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 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). https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program
  • Your hospital as a score in the 75th percentile for Surgical Site Infection (SSI) during the last six months raising concerns under the Hospital-Acquired Condition Reduction Program (HACRP).  .https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/HAC-Reduction-Program
  • Your long-term care facility has multiple never events in your long-term care facility with multiple patients developing Stage III and IV pressure ulcers during the last year.  

    https://downloads.cms.gov/cmsgov/archived-downloads/smdl/downloads/smd073108.pdf

  • Your long-term care facility has had multiple adverse events from medication errors that led to the deaths of 5 patients at your facility within the last month. You have been so busy investigating, you haven’t reported under the FDA Adverse Event Reporting System (FAERS). https://www.fda.gov/drugs/surveillance/questions-and-answers-fdas-adverse-event-reporting-system-faers
  • Week 4 and 5: Government Programs
    Additional Resources
    Medicare






    Medicare and Medicaid Conditions of Participation: https://www.cms.gov/Regulationsand-Guidance/Legislation/CFCsAndCoPs/index.html?redirect=/CFCsAndCoPs/
    Conditions of Participation for Hospitals https://www.govinfo.gov/content/pkg/CFR2017-title42-vol5/xml/CFR-2017-title42-vol5-part482.xml
    Conditions of Participation for Home Health Services https://www.ecfr.gov/cgi-bin/textidx?node=pt42.5.484&rgn=div5
    Requirements for Long Term Care https://www.ecfr.gov/cgi-bin/textidx?SID=cfbc43a1e632c88ff587201d326f5180&node=42:5.0.1.1.2.2&rgn=div6
    Accountable Care Organizations (ACOs): General
    Information https://innovation.cms.gov/initiatives/ACO
    The Guide to Medicare Preventive Services 4th Edition http://medallionmedical.com/wpcontent/uploads/2015/08/The-Guide-to-Medicare-Preventative-Services-for-PhysicansProviders-and-Suppliers.pdf
    Medicaid









    State Medicaid Plans and Waivers: https://www.cms.gov/Outreach-andEducation/American-Indian-Alaska-Native/AIAN/LTSS-TA-Center/info/state-medicaidpolicies.html
    National Council on Disability: Chapter 1. An Overview of Medicaid Managed Care |
    NCD.gov
    The Urban Institute (2012). Medicaid and CHIP Risk-Based Managed Care in 20
    States: https://www.urban.org/sites/default/files/publication/25646/412617-Medicaidand-CHIP-Risk-Based-Managed-Care-in-States.PDF
    Medicaid A Primer (CRS): http://www.ncsl.org/documents/health/MAPrimer.pdf
    Medicaid and FMAP (CRS): http://www.ncsl.org/documents/health/MAFMAP.pdf
    State Health Departments https://www.usa.gov/state-health
    Maryland Department of Health https://health.maryland.gov/pages/home.aspx
    Medicaid and the Affordable Care Act: https://www.medicaid.gov/affordable-careact/index.html
    Medicaid Expansion: https://www.kff.org/health-reform/issue-brief/a-guide-to-thesupreme-courts-decision/
    Food and Drug Administration (FDA)




    FDA https://www.fda.gov/
    Drug Regulation https://www.fda.gov/drugs
    Medical Device Regulation https://www.fda.gov/medical-devices
    Radiation-Emitting Products https://www.fda.gov/radiation-emitting-products


    Vaccines, Blood & Biologics https://www.fda.gov/vaccines-blood-biologics
    Tobacco Products https://www.fda.gov/tobacco-products
    State Department of Health



    State Health Departments https://www.usa.gov/state-health
    State Health Departments https://www.usa.gov/state-health
    Maryland Department of Health https://health.maryland.gov/pages/home.aspxCDC
    https://www.cdc.gov/Medicaid and the Affordable Care
    Act: https://www.medicaid.gov/affordable-care-act/index.html
    Affordable Care Act






    Affordable Care Act Tax Provisions for Large Employers
    https://www.irs.gov/affordable-care-act/employers/affordable-care-act-tax-provisionsfor-large-employers
    Summary of the Affordable Care Act https://www.kff.org/health-reform/factsheet/summary-of-the-affordable-care-act/
    ACA Information Center for Applicable Large Employers
    (ALE) https://www.irs.gov/affordable-care-act/employers/aca-information-centerfor-applicable-large-employers-ales
    Preventive health care services https://www.kff.org/health-reform/fact-sheet/summaryof-the-affordable-care-act/
    Burwell v. Hobby Lobby Stores (2014) https://www.oyez.org/cases/2013/13-354
    Appealing Health Plan Decisions https://www.hhs.gov/healthcare/about-theaca/cancellations-and-appeals/appealing-health-plandecisions/index.html#:~:text=You%20have%20the%20right%20to,to%20terminate%2
    0your%20health%20coverage.&text=You%20can%20appeal%20your%20insurance,fai
    r%20review%20of%20its%20decision
    CMS RAC Audits




    CMS Recovery Audit Contractors (RAC) https://www.cms.gov/Research-StatisticsData-and-Systems/Monitoring-Programs/Medicare-FFS-CompliancePrograms/Recovery-Audit-Program
    The Recovery Audit Program and Medicare https://www.cms.gov/Research-StatisticsData-and-Systems/Monitoring-Programs/Medicare-FFS-CompliancePrograms/Recovery-Audit-Program/Downloads/The-Recovery-Audit-Program-andMedicare-Slides-051313.pdf
    Approved RAC Topics https://www.cms.gov/Research-Statistics-Data-andSystems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-AuditProgram/Approved-RAC-Topics
    AMA Fact Sheet: Medicare Recovery Audit Contractor (RAC) Program Appeals
    https://www.ama-assn.org/sites/ama-assn.org/files/corp/mediabrowser/public/washington/recovery-audit-contractor-appeals-fact-sheet_0.pdf
    Interoperability and Information Blocking







    CMS Policies and Technology for Interoperability and Burden Reduction
    https://www.cms.gov/Regulations-and-Guidance/Guidance/Interoperability/index
    CMS Interoperability Final Rule https://www.cmspatientaccessrule.com/
    HIMSS Final CMS Interoperability Regulation: What you Need to Know
    https://www.himss.org/news/final-cms-interoperability-regulation-what-you-needknow
    Information Blocking https://www.healthit.gov/topic/information-blocking
    Information Blocking FAQ https://www.healthit.gov/curesrule/resources/informationblocking-faqs
    How do I comply with info blocking and where do I start? https://www.amaassn.org/system/files/2020-11/info-blocking-compliance.pdf
    Understanding the Eight Exceptions to Information Blocking
    https://journal.ahima.org/understanding-the-eight-exceptions-to-information-blocking/
    Children’s Health Insurance Program (CHIP)


    The Children’s Health Insurance Program (CHIP)
    https://www.healthcare.gov/medicaid-chip/childrens-health-insurance-program/
    Children’s Health Insurance Program Overview
    https://www.ncsl.org/research/health/childrens-health-insurance-programoverview.aspx
    Center for Disease Control

    CDC https://www.cdc.gov/
    Food and Drug Administration (FDA)






    FDA https://www.fda.gov/
    Drug Regulation https://www.fda.gov/drugs
    Medical Device Regulation https://www.fda.gov/medical-devices
    Radiation-Emitting Products https://www.fda.gov/radiation-emitting-products
    Vaccines, Blood & Biologics https://www.fda.gov/vaccines-blood-biologics
    Tobacco Products https://www.fda.gov/tobacco-products
    State Department of Health


    State Health Departments https://www.usa.gov/state-health
    Maryland Department of Health https://health.maryland.gov/pages/home.aspx
    COSO


    COSO https://www.coso.org/Pages/default.aspx
    COSO Guidance https://www.coso.org/Pages/guidance.aspx


    COSO: Internal Control – Integrated Framework: An Implementation Guide for the
    Healthcare Provider Industry https://www.coso.org/Documents/COSO-CROWE-COSOInternal-Control-Integrated-Framework.pdf
    COSO: Compliance Risk Management: Applying the COSO ERM Framework
    https://www.coso.org/Documents/Compliance-Risk-Management-Applying-the-COSOERM-Framework.pdf

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