HA 625 Unit 8 compliance program plan example

Seven Elements for a Four-Office Hospice: A Compliance Program Plan That Starts With the Board's Grant of Authority and Ends With Eligibility Audits

Student Name

Health Care Administration, Herzing University

HA 625: Healthcare Law and Ethics

Instructor Name

March 5, 2026

Seven Elements for a Four-Office Hospice: A Compliance Program Plan That Starts With the Board's Grant of Authority and Ends With Eligibility Audits

The Organization and Why It Needs a Rebuilt Program

The composite hospice operates four offices in two adjoining counties, with an average daily census of about 310 patients, 260 employees, and about $42 million in annual revenue, nearly all of it from Medicare. It has had a compliance policy manual since 2014 and a part-time compliance function held by the director of quality. Two events prompted this plan: a Medicare contractor's targeted review last year that denied 9 of 40 sampled claims for lack of documentation supporting terminal prognosis, and a hotline call alleging that a marketing representative was giving gift cards to assisted living staff who referred patients. Hospices are a focus of federal oversight for exactly these risks, including eligibility, level of care, and inducements to referral sources (U.S. Department of Health and Human Services, Office of Inspector General [OIG], 2018). This plan rebuilds the program around the seven elements in the federal compliance guidance (OIG, 2023), with the hospice-specific risk areas the OIG identified in its earlier guidance for hospices (OIG, 1999).

Authority

The program's authority comes from the board. The plan asks the board of directors to adopt a resolution that establishes the compliance program, names a compliance officer, charters a board compliance committee, and commits the organization to fund the program. The resolution should state that the compliance officer reports to the chief executive officer and has direct, unrestricted access to the board compliance committee, including the right to meet with it without management present. It should state that the compliance officer may review any record and interview any employee or contractor, and may not be dismissed without notice to the board. Federal guidance recommends that the compliance officer not be subordinate to the general counsel or the chief financial officer, because those roles may face conflicts when a finding involves legal exposure or revenue (OIG, 2023). The resolution also establishes a management compliance committee, chaired by the compliance officer, with the chief executive, medical director, director of clinical operations, finance director and human resources director as members.

Element 1: Written Policies and Procedures

A code of conduct, two pages long and written in plain language, will be adopted by the board and signed by every employee, contractor, and board member on hire and each year. Beneath it, the plan revises or writes policies for the areas of highest risk: hospice eligibility and certification, including the physician narrative and the face-to-face encounter required before the third benefit period and each later period (42 C.F.R. § 418.22); level of care, especially general inpatient care; live discharges; relationships with referral sources; marketing; the aggregate cap; and documentation. Each policy names an owner and a review date.

Element 2: Compliance Leadership and Oversight

The compliance officer will be a full-time position, filled by recruitment, with hospice or home health compliance experience and no operational duties. The quality director returns to quality work. The management compliance committee meets monthly for the first year and quarterly after that; the board compliance committee meets quarterly and receives a written report at each meeting covering hotline activity, audit results, open investigations, and corrective actions. Budget: salary and benefits for the compliance officer, an annual external eligibility audit, hotline service, and training materials, about $265,000 in the first year, roughly 0.6% of revenue.

Element 3: Training and Education

All staff complete general compliance training at hire and annually, covering the code of conduct, how to report concerns, and the prohibition on retaliation. Role-specific training adds more: physicians and nurse practitioners on eligibility documentation and prognosis; admission nurses on eligibility criteria and on what they may and may not say to families about benefits; marketing staff on the Anti-Kickback Statute and the hospice's gift policy; billing staff on level-of-care coding and the cap. Completion is tracked, and a completion rate under 95% by the deadline is reported to the board committee.

Element 4: Lines of Communication and Reporting

A hotline run by an outside vendor will be available at all hours by telephone and web, with an option to report anonymously. Its number will be posted in every office, printed on badge cards, and given to contracted nursing facilities and assisted living communities, whose staff often see problems first. The compliance officer will also hold open office hours at each office quarterly. Every report receives a tracking number, and the reporter can check its status without revealing identity.

Element 5: Enforcing Standards Through Consequences and Incentives

Discipline for compliance violations will follow a written scale, from coaching to termination, applied consistently regardless of the person's role or revenue contribution. Managers will be held accountable for compliance in their areas through their annual evaluations. Incentive pay for admissions staff and marketers will be restructured so that no bonus depends on the number of admissions or on patient length of stay, since pay tied to volume creates the pressure that leads to enrolling patients who are not eligible. The hospice will check every employee, contractor and board member for federal program exclusion when they join and every month after.

Element 6: Risk Assessment, Auditing and Monitoring

The compliance officer will lead an annual risk assessment with the management committee, and the audit plan will follow from it. For the first year, the plan sets four audits. Eligibility: an external clinical reviewer examines 30 records a quarter of patients in their third or later benefit period, testing the physician narrative, the face-to-face encounter, and whether the clinical record supports a prognosis of six months or less. General inpatient care: 20 episodes a quarter reviewed for documented symptoms that could not be managed at home. Live discharges: every live discharge reviewed monthly for reason and pattern, since high rates of patients discharged alive can signal enrollment of ineligible patients. Referral relationships: all marketing expenses and gifts reviewed quarterly against the gift policy. Monthly monitoring reports will track length of stay, live discharge rate, general inpatient days, and cap position by office.

Element 7: Responding to Offenses and Corrective Action

Every credible allegation is investigated under a written procedure, with the compliance officer deciding when to involve outside counsel. The gift card allegation will be the program's first investigation: counsel will direct a review of marketing expense records for the past three years and interviews with the representative and the assisted living staff named, because payments to referral sources raise questions of intent under the Anti-Kickback Statute that should be analyzed under privilege. Any overpayment identified, including claims for patients later found ineligible, will be reported and returned within the federal 60-day period, and the compliance officer will recommend to the board whether a self-disclosure is warranted. Every finding leads to a written corrective action plan, assigned to a named person and due by a set date, which the board committee tracks to closure.

Timeline and Measures of Success

Months 1 to 2: board resolution adopted, compliance officer recruited, hotline launched. Months 2 to 4: priority policies revised, incentive plans restructured, all-staff training completed. Month 4 onward: quarterly eligibility and inpatient audits. Month 12: first annual program review by an outside reviewer. The program will judge itself on outcomes rather than activity: a denial rate on the next contractor review below 5%, hotline reports rising in the first year as staff learn to use the line, and every corrective action closed on time. The hospice and figures are composite.

References

Hospice care: Certification of terminal illness, 42 C.F.R. § 418.22 (2025).

U.S. Department of Health and Human Services, Office of Inspector General. (1999). Publication of the OIG compliance program guidance for hospices. Federal Register, 64(192), 54031-54049.

U.S. Department of Health and Human Services, Office of Inspector General. (2018). Vulnerabilities in the Medicare hospice program affect quality care and program integrity: An OIG portfolio (OEI-02-16-00570).

U.S. Department of Health and Human Services, Office of Inspector General. (2023). General compliance program guidance. https://oig.hhs.gov/compliance/general-compliance-program-guidance/