Hotline Auditing and Monitoring Policy and Procedures

HOTLINE AUDITING AND MONITORING POLICY

DEPARTMENT: CREATED ON: FEBRUARY 2009 APPROVAL AUTHORITY: APPROVED ON: POLICY NUMBER: P00183 EFFECTIVE DATE: BOARD APPROVAL: LAST REVIEWED ON: MARCH 2013 POLICY RESPONSIBILITY: LAST REVISED ON: MARCH 2013 PAGE 1 OF 4 SCHEDULED REVISION DATE:

BACKGROUND

The Department of Health and Human Services Office of Inspector General’s compliance guidance calls for ongoing auditing and monitoring of the Compliance Program (CP). The hotline is an integral component of [ORGANIZATION]’s CP. For this reason the hotline requires ongoing auditing and monitoring to ensure it is operating in conformance with established procedures. One of the primary responsibilities of the Compliance Officer (CO) is to ensure that the hotline operates in conformance with its policy and procedures.

PURPOSE

The purpose of this Policy is to ensure that the hotline is operating effectively through a process of ongoing auditing and monitoring.

This policy applies to [ORGANIZATION]’s hotline operations.

KEY TERMS

OF 4 Retaliation: Any adverse action taken against an employee because he or she reported or complained about a potential violation of the Code of Conduct, policies, laws, regulations, or professional standards. Any negative action that would deter a reasonable employee in the same situation from making a complaint qualifies as retaliation.

Retribution: Any act of punishing or taking vengeance for someone reporting a perceived violation of the Code of Conduct, policies, laws, regulations, or professional standards.

POLICY

1. The Compliance Officer (CO) has primary responsibility for the hotline operations and, therefore, will arrange for a review of its function at least annually to ensure adherence to established policy and procedures.

2. The Executive Compliance Committee (ECC) will ensure that the review is conducted in an objective manner.

3. The ECC and Board will receive the independent review report of the hotline function.

4. The CO will take necessary steps to ensure all review findings and recommendations are approved by the ECC are implemented.

PROCEDURES

1. The Compliance Officer (CO) has primary responsibility for the hotline operations and will therefore arrange for annual audits and/or reviews of all aspects of the hotline operation in accordance with this policy and with the concurrence of the Executive Compliance Committee (ECC).

2. The audit or review will focus on ensuring the following elements of the operation of the hotline: a. All calls are answered promptly during established hotline hours. b. A pre-recorded message explaining the ground rules of the Hotline is in place. c. Callers are fully debriefed. d. Callers are provided a report identification number. e. Callers or the number they are calling from are not traceable or identified on the telephone bill. f. Periodic test calls are made to ensure prompt answering and timely/accurate reporting. g. No calls are recorded. h. Call information is kept confidential. i. Calls cannot be overheard or seen by the general population. j. A record retention policy is followed. k. Records are maintained in a secure area. l. Computers used to receive hotline reports or to store hotline reports and information related to the resolution of call reports are password protected.

© 2013. FOR CLIENT USE WITH EXPRESSED WRITTEN PERMISSION ONLY. ALL RIGHTS RESERVED. PAGE 2 OF 4 m. Follow-up on call information is handled promptly and appropriately. n. Call logs are maintained properly. o. Non-retaliation/Non-retribution Policy is followed. p. Hotline is viewed by employees as a viable communications channel. q. The Compliance Issue Resolution Policy is followed with respect to reports made through the hotline.

3. The review must include the review of a representative number of hotline call reports/files in order to determine the following: a. Call issues are being resolved in a timely manner. b. Hotline records reflect the actions taken on caller information. c. Recommendations/corrective actions have been acted upon appropriately. d. Hotline records and follow-up actions are maintained in a secure location. e. Reports are handled consistent with hotline policies and procedures. f. Calls to the hotline are logged and tracked to conclusion, and logs accurately reflect information in the call report and file. g. Hotline reports are maintained in order to facilitate retrieval of information. h. Recommendations and corrective actions have been acted upon promptly. i. Corrective actions taken have been independently verified as complete.

4. The report of the review will include, at a minimum findings, and where appropriate, recommendations for enhancement or corrective action related to all elements of the operation of the hotline set forth in this policy. The CO will provide reports on the results of any hotline audit or review to the ECC that, in turn, will report to the Board.

5. The CO will ensure that all recommendations for improvement of hotline operations that are approved by the ECC are implemented in a timely manner and verified as meeting the objectives of the ECC.