Dear Compliance Officer

Although TJC no longer requires you to collect proof of vaccination, they do require you to track data around why people are NOT getting vaccinated. Additionally, you should be reviewing this data before Flu season each year. Your Annual Flu program should plan to provide education to staff, using the declination reasons to empower and encourage them to get vaccinated. 

Ultimately, you need to see what your State regulations say about Influenza and COVID19 vaccinations and TB screens. States such as NJ have clear requirements that very specific requirements around TB, MMR, and Physical Examinations. 

Each State requires similar incidents to be reported, such as abuse, exploitation, and neglect.  However reportable incidents can vary significantly. These requirements are often found in the SUD/MH regulations.

Where States differ vastly is how you can submit a report. Don’t wait to the last minute to figure this out. In many states, you have to enroll in their incident reporting system which could take days or even weeks, causing you to miss the reporting window and potentially end up with an inspection or fines. 

On the Hatch Incident Reporting form, we have clearly outlined: 

• What is a reportable incident? 
• When does it need to be reported?
• How do I report an incident?

You should track incidents whether they are required to be reported or not, and some states do require that you track all incidents. This is a great way to collect lots of objective data about your program, and improve performance. 

This is regulated by each state. Check your regulations!

A training can be interactive or completed solely by the user, for example, they take a training through an LMS. You can assess competency by administering a quiz after the quiz to see if the staff member’s knowledge is sufficient (think C level proficiency), but you will need to ensure that you are ‘testing’ for a comprehensive understanding of the topic. 

A competency is administered by someone with experience and assesses the skills of a staff member. A competency should be an interactive event.

Remember that all of the above should be documented, and a part of the employee’s HR file. 

If the State or accrediting body does not require a written policy, then no.

We recommend that you do, because it is a good idea to have a written process surrounding something you are required to do. 

In the words of Brene Brown: Clear is kind. Unclear is unkind! 

Obtaining an OTP certification is a lengthy process, similar to spinning plates, and the plates are on fire. 

You have to deal with multiple agencies (State, SOTA, SAMSHA, DEA, and an accrediting body) simultaneously, sometimes running from one plate to the other to make sure they stay spinning.  

This depends on your State. Most states have regulations around SUD treatment, some states have them around MH treatment, very few with ED specific regulations, while some states don’t have regulations for MH levels of care at all. 

If we look at TJC/CARF, they do have varied, additional standards around the populations served.

So long story short, YES! 

• Review all of the data you have collected.
  • If you are not collecting data, you’re going to be busier than a moth in a mitten.
• The data should be discussed with your team.
  • The team will help the data trends tell a story so you can determine areas of improvement.
• Each area of your program should be monitored for performance improvement, and each area should have several performance improvements initiatives. I recommend between 3-5 initiatives.
• For instance, if I’m looking to create initiatives around Emergency Management, I would at how it correlates with areas such as:
  • Clinical Support/Activities
  • Emergency Drills
  • Incident Response Team
  • Recovery & Resilience
  • Internal Resources & Assets 
  • Staff Roles/Responsibilities in an Emergency

This depends on the state and what population is being served.

With that being said, some telehealth operators are neither licensed nor accredited. This opens them up to certain liabilities, and additionally they cannot bill as a facility. If you are going the unlicensed/unaccredited route – ask your attorney or a Hatch consultant if you need to set up a friendly PC model. 

Something is bound to happen in your facility. It may not be a critical incident, but it could become one if not addressed.

As soon as an event or repetitive events occur, such as seeing that 3 slip/falls happened last month, or an issue with medication orders such as finding that the wrong medication is continually being administered due to incorrect reading of doctors orders – you need to get started on planning your corrective actions. 

To craft a stellar CAP we recommend you look at several factors:

1. What is the Root Cause of the event(s) occurring?
2. What Departments will be involved and who will be responsible for overseeing the plan? 
3. What policies or processes will change, and who will oversee change management?
4. Determine how you will prevent the occurrence from happening again? 
5. What data will you look at over the next few weeks or months to determine improvement?
6. Who will track this data, who will review it and how often? 
7. And ultimately – What will you do if you don’t see improvement? 

You can, but you probably won’t get paid. Some insurance companies have internal policies that disallow holistic services. They don’t share these policies with you. Criminals like Optum have cherry-picked the ASAM to determine that certain tried and true groups are not billable. 

That’s right Optum, we don’t like you. 

Patient satisfaction, Staff satisfaction, Staff safety, AMA/ ATA rates, and average length of stay are some of the ways Compliance assists in driving revenue. Maximizing length of stay and patient care allows less patient admissions and documentation, which is part of compliance, ultimately assists in increasing revenues.

Additionally, if staff are not trained properly, or if you are paying overtime to prepare for an inspection or survey, you are wasting precious resources. 

Policies should be written and created by someone who understands your business internally from workflows and processes, to staff skills, to your mission and vision, to treatment protocols and philosophies.

Exceptional policy creation drives better patient outcomes, allows for more efficient use of your staff’s time, and promotes consistent processes. This contributes to a smoothly running organization and better results, as compared to having a policy just to check the boxes.

If you hired a consultant to write you policies, and they did not interview your staff at length, you policies most likely do not represent what you are actually doing. 

And you know what they say, it’s better to NOT have a policy than it is to have a policy that is incorrect.