Action Plan to Address Policy Updates and Implementation (Finding 2018-001):
a. Review and Update Policies: Begin by conducting a comprehensive review of existing policies,
particularly those related to procurement, suspension, and debarment. Ensure these policies align with
the latest HRSA requirem...
Action Plan to Address Policy Updates and Implementation (Finding 2018-001):
a. Review and Update Policies: Begin by conducting a comprehensive review of existing policies,
particularly those related to procurement, suspension, and debarment. Ensure these policies align with
the latest HRSA requirements and federal regulations.
b. Engage a Policy Consultant: Seek the expertise of a policy consultant or legal counsel well-versed in
healthcare compliance and HRSA regulations to assist in policy revision.
c. Policy Training: Develop a training program to educate staff, especially key personnel like the CEO and
CFO, on the updated policies. This training should emphasize the significance of compliance and the
potential consequences of non-compliance.
d. Implementation Oversight: Appoint a Compliance Officer responsible for overseeing the
implementation of updated policies and procedures. This officer should regularly audit and monitor
adherence to these policies.
e. Documentation and Reporting: Implement a robust documentation system to track policy adherence and
any deviations. Ensure that timely and accurate reports are generated for review by internal committees
and the board.
f. Board and Committee Involvement: Enhance board and committee involvement in the oversight of
policy compliance. Provide regular updates and reports to these entities to keep them informed and
engaged in the compliance process.
g. Continuous Monitoring: Establish a continuous monitoring process to identify any policy-related
deficiencies promptly. Regularly assess the effectiveness of policies and make necessary adjustments.
h. External Audit: Schedule an external audit ahead of time by an independent auditor or agency to ensure
objectivity and compliance with HRSA standards.
i. Communication: Promote a culture of compliance through effective communication channels.
Encourage employees at all levels to report potential violations or concerns without fear of retaliation.
j. Periodic Review: Commit to a periodic review of policies, at least annually, to ensure they remain
current and aligned with any evolving HRSA regulations or federal mandates.