Name of Contact Person: Sarah Ross, Chief Operating Officer Corrective Action: Under the leadership of Open Door’s Chief Operations Officer and Director of Patient Access, we will implement the following actions to address SFDP compliance findings and reduce the risk of future errors. 1. Staff Retra...
Name of Contact Person: Sarah Ross, Chief Operating Officer Corrective Action: Under the leadership of Open Door’s Chief Operations Officer and Director of Patient Access, we will implement the following actions to address SFDP compliance findings and reduce the risk of future errors. 1. Staff Retraining and Competency Validation Retrain all Office Managers and Front Office staff on SFDP requirements, documentation standards, and processing procedures in collaboration with EMR and Learning & Development. Staff will be required to successfully complete a knowledge check prior to independently handling SFDP documentation. SFDP training will also be incorporated into new-hire onboarding and reinforced through ongoing training as needed. 2. Ongoing Monitoring and Accountability Implement a formal monitoring and accountability process to ensure sustained compliance. SFDP accuracy will be reviewed weekly, with Front Office Managers maintaining an error log to track errors, trends, and corrective actions. Continued or repeated errors will be addressed through expectation conversations and progressive disciplinary action, while accurate and consistent performance will be recognized. 3. Monthly Reporting and Targeted Corrective Training Identify trends and common error types, utilizing monthly SFDP reporting, to inform targeted retraining and process improvements. The reporting infrastructure is currently being developed using the Smartsheet Intelligent Work Management Platform to support leadership oversight and continuous improvement. 4. Leadership Oversight and Site-Level Accountability Administrative Directors at all health centers will actively participate in SFDP oversight by meeting with staff to reinforce program expectations and consequences for non-compliance. Monthly site-level SFDP performance reviews will be conducted with the Director of Patient Access, Administrative Directors, and Office Managers to review findings, trends, and corrective actions. 5. Integration into Performance Evaluations SFDP compliance will be formally integrated into staff performance evaluations. Compliance measures are currently included in Office Manager scorecards and will be added to Receptionist performance evaluations to reinforce accountability and sustain compliance. 6. Process Improvement Through Automation To further reduce the risk of human error, Open Door is planning a transition toward increased SFDP automation within the EMR to standardize determinations and improve documentation accuracy over time. Proposed Completion Date: June 30, 2026