12 procedure namecourse professordate

1. 1
2
Procedure
Name
Course
Professor
Date
Monitoring tool procedure for: Infection Prevention and Control
Assessment Framework (IPCAF)
Infection prevention and control assessment framework is one
of the monitoring tools which has been developed to be used for
the COVID compliance plan. Having a monitoring tool is one
thing and using it appropriately is another thing. To make better
use of IPCAF, the following procedure will be used:
1. Compliance officer responds to questions on three aspects.
On the first aspect, the compliance officer will assess the
infection rate at the facility. An increase in the infection will
require the compliance officer to evaluate whether medical staff
complies with the COVID compliance plan. On the second
aspect, a compliance officer will assess the rate of compliance

2. to standard precaution practices. On this part, compliance will
respond to numerous question which pertains accessibility and
availability of PPEs, hand hygiene skills to medical staff and its
implementation and correct use of face masks and gloves by the
medical staff. On the third aspect, the compliance officer will
respond to questions that evaluate the effectiveness of
communication on prevention and control to COVID 19.
2. Compliance officer determine shortcomings to COVID
compliance plan based response to three aspects in step 1.
Shortcomings help compliance officer establish actions which
should be taken to improve compliance to plan.
3. Compliance officer communicate to medical staff on the
findings of compliance score, improvements to the plan and
disciplinary actions to those that fail to comply with
compliance. This ensures that the monitoring tool achieves
desired outcome because after assessment and detection of
shortcomings, the action is taken to improve compliance to
plan.
My Wood
by E. M. Forster (1879-1970)
A few years ago I wrote a book which dealt in part with the
difficulties of the
English in India. Feeling that they would have had no
difficulties in India
themselves, the Americans read the book freely. The more they
read it the better it
made them feel, and a check to the author was the result. I
bought a wood with the

3. check. It is not a large wood--it contains scarcely any trees, and
it is intersected,
blast it, by a public foot-path. Still, it is the first property that I
have owned, so it is
right that other people should participate in my shame, and
should ask themselves,
in accents that will vary in horror, this very important question:
What is the effect
of property upon the character? Don't let's touch economics; the
effect of private
ownership upon the community as a whole is another question--
a more important
question, perhaps, but another one. Let's keep to psychology. If
you own things,
what's their effect on you? What's the effect on me of my wood?
In the first place, it makes me feel heavy. Property does have
this effect. Property
produces men of weight, and it was a man of weight who failed
to get into the
Kingdom of Heaven. He was not wicked, that unfortunate
millionaire in the
parable, he was only stout; he stuck out in front, not to mention
behind, and as he

4. wedged himself this way and that in the crystalline entrance and
bruised his well-
fed flanks, he saw beneath him a comparatively slim camel
passing through the eye
of a needle and being woven into the robe of God. The Gospels
all through couple
stoutness and slowness. They point out what is perfectly
obvious, yet seldom
realized: that if you have a lot of things you cannot move about
a lot, that furniture
requires dusting, dusters require servants, servants require
insurance stamps, and
the whole tangle of them makes you think twice before you
accept an invitation to
dinner or go for a bathe in the Jordan. Sometimes the Gospels
proceed further and
say with Tolstoy that property is sinful; they approach the
difficult ground of
asceticism here, where I cannot follow them. But as to the
immediate effects of
property on people, they just show straightforwar d logic. It
produces men of
weight. Men of weight cannot, by definition, move like the
lightning from the East

5. unto the West, and the ascent of a fourteen-stone bishop into a
pulpit is thus the
exact antithesis of the coming of the Son of Man. My wood
makes me feel heavy.
In the second place, it makes me feel it ought to be larger. The
other day I heard a
twig snap in it. I as annoyed at first, for I thought that someone
was blackberrying,
and depreciating the value of the undergrowth. On coming
nearer, I saw it was not
a man who had trodden on the twig and snapped it, but a bird,
and I felt pleased.
My bird. The bird was not equally pleased. Ignoring the relation
between us, it
took flight as soon as it saw the shape of my face, and flew
straight over the
boundary hedge into a field, the property of Mrs. Henessy,
where it sat down with
a loud squawk. It had become Mrs. Henessy's bird. Something
seemed grossly
amiss here, something that would not have occurred had the
wood been larger. I
could not afford to buy Mrs. Henessy out, I dared not murder

6. her, and limitations
of this sort beset me on every side. Ahab did not want that
vineyard--he only
needed it to round off his property, preparatory to plotting a
new curve--and all the
land around my wood has become necessary to me in order to
round off the wood.
A boundary protects. But--poor little thing--the boundary ought
in its turn to be
protected. Noises on the edge of it. Children throw stones. A
little more, and then a
little more, until we reach the sea. Happy Canute! Happier
Alexander! And after
all, why should even the world be the limit of possession? A
rocket containing a
Union Jack, will, it is hoped, be shortly fired at the moon. Mars.
Sirius. Beyond
which . . . But these immensities ended by saddening me. I
could not suppose that
my wood was the destined nucleus of universal dominion--it is
so small and
contains no mineral wealth beyond the blackberries. Nor was I
comforted when
Mrs. Henessy's bird took alarm for the second time and flew

7. clean away from us
all, under the belief that it belonged to itself.
In the third place, property makes its owner feel that he ought to
do something to
it. Yet he isn't sure what. A restlessness comes over him, a
vague sense that he has
a personality to express--the same sense which, without any
vagueness, leads the
artist to an act of creation. Sometimes I think I will cut down
such trees as remain
in the wood, at other times I want to fill up the gaps betw een
them with new trees.
Both impulses are pretentious and empty. They are not honest
movements towards
moneymaking or beauty. They spring from a foolish desire to
express myself and
from an inability to enjoy what I have got. Creation, property,
enjoyment form a
sinister trinity in the human mind. Creation and enjoyment are
both very, very
good, yet they are often unattainable without a material basis,
and at such moments
property pushes itself in as a substitute, saying, "Accept me
instead--I'm good

8. enough for all three." It is not enough. It is, as Shakespeare said
of lust, "The
expense of spirit in a waste of shame": it is "Before, a joy
proposed; behind, a
dream." Yet we don't know how to shun it. It is forced on us by
our economic
system as the alternative to starvation. It is also forced on us by
an internal defect
in the soul, by the feeling that in property may lie the germs of
self-development
and of exquisite or heroic deeds. Our life on earth is, and ought
to be, material and
carnal. But we have not yet learned to manage our materialism
and carnality
properly; they are still entangled with the desire for ownership,
where (in the
words of Dante "Possession is one with loss."
And this brings us to our fourth and final point: the
blackberries. Blackberries are
not plentiful in this meager grove, but they are easily seen from
the public footpath
which traverses it, and all too easily gathered. Foxgloves, too--

9. people will pull up
the foxgloves, and ladies of an educational tendency even grub
for toadstools to
show them on the Monday in class. Other ladies, less educated,
roll down the
bracken in the arms of their gentlemen friends. There is paper,
there are tins. Pray,
does my wood belong to me or doesn't it? And, if it does, should
I not own it best
by allowing no one else to walk there? There is a wood near
Lyme Regis, also
cursed by a public footpath, where the owner has not hesitated
on this point. He
has built high stone walls each side of the path, and has spanned
it by bridges, so
that the public circulate like termites while he gorges on the
blackberries unseen.
He really does own his wood, this able chap. Dives in Hell did
pretty well, but the
gulf dividing him from Lazarus shall come to this in time. I
shall wall in and fence
out until I really taste the sweets of property. Enormously stout,
endlessly
avaricious, pseudo-creative, intensely selfish, I shall weave

10. upon my forehead the
quadruple crown of possession until those nasty Bolshies come
and take it off
again and thrust me aside into the outer darkness.
(1926)
First published in 1926, E.M. Forster's "My Wood" appears in
the collection
Abinger Harvest (1936, reprinted in 1996 by Andre Deutsch
Ltd.).
1
4
Monitoring Tools for Compliance Plans
Name
Course
Professor
Date

11. Background to the project
Originally, it was established that the medical facility was
violating compliance policies that have been established by the
management on the account of two areas. In the first case, it
was established that medical staff does not wash hands between
patients as is recommended by the medical facility. This is
extremely considering the prevailing health situation in the
country. In April 2020, approximately 0.9 million citizens had
been infected with COVID and more than 52,000 Americans had
succumbed to the virus (Tam, Walker & Moreno, 2020). The
situation is dire with new cases continuing to be reported in the
country putting more risk to healthcare personnel that
constantly interact with COVID patients. Hand washing and
social distancing have been recommended as the most effective
ways to contain the spread of COVID. However, it is
challenging and threatening when medical personnel fails to
wash hands not only to prevent the spread of COVID but rather
it is standard precaution measures to prevent transmission of
infectious diseases (CDC, 2018). It is the background of this
COVID compliance plan has been developed, related
compliance policies and also compliance procedure and in this
project, monitoring tools for this compliance will be developed.
Similarly, health facilities identified cases where medical staff
charged clients twice. This is not allowed and replicates to
fraudulent billing practices which if not tamed, can ruin the
reputation of the facility. Complicated coding and prone to
errors billing systems are some reasons given for the rise of
rampant billing frauds in medical facilities. However, in some
cases: patients are overcharged, charges are made for services
not rendered and in other cases, doctors charge for wrong
services fatten their pocket tell reasons for growing fraudulent
billing practices (Bothwell, 2018). To curtail facility rising to
billing scandals, a billing compliance plan was created,

12. compliance policies and procedures and in this project,
monitoring tools are developed.
Monitoring Tools for COVID Compliance Plan
The impact of COVID cannot be underestimated. It brought the
global economy to a standstill and hardly hit the healthcare
system. The United States is not exceptional but remains one of
the most hard-hit economies with the highest number of
confirmed cases. In the U.S, according to available data
released by CDC, for reported cases from February to June in
2020, 571,708 (22% of total cases) healthcare personnel had
been infected with the virus (Hughes, M2020). Access to PPE,
face mask, social distancing and hand hygiene to HCP and those
attended remain critical elements to protecting healthcare
workers (Hughes, 2020). Surprisingl y, even with glaring
statistics on the serious impact of COVID amid other infections,
medical staff fail to practice hand hygiene between patients
advised.
COVID compliance plan has been developed that seek to
address observed violation for hand washing practices by the
medical staff. On the same effect, two compliance policies were
developed which are standard precaution practice and
communication policy on prevention. To ensure compliance
policies are executed accordingly by the medical, a compliance
procedure was developed which comprises of five steps.
However, as though these efforts are not adequate, two
monitoring tools are developed which seek to determine the
efficiency of the compliance plan, the progress that has been
and also helps identify areas that need improvement. Ideally,
monitoring tools track compliance of medical staff to COVID
compliance plan.
Monitoring tool 1: Infection Prevention and Control Assessment
Framework (IPCAF)
This is a standard monitoring tool developed by WHO to assess
the implementation of protocols and guidelines in the acute care
facility (WHO, n.d). However, even though this tool was
developed by WHO, it is a relevant tool that can be used to

13. monitor COVID compliance plan.
IPCAF will monitor the COVID compliance plan in four
aspects. In the first case, it will assess infection prevention
control in the medical facility (WHO, n.d). Data that is
generated on the rate of infection in the medical facility will be
used by the compliance officer to track and assess compliance
COVID compliance plan. For example, when infections number
in the medical facility are on the rise, it would be an indicator
that COVID compliance policies and procedures are not
complied with by the medical staff. However, this will require
investigation to establish the reliability of such assumptions.
On the second aspect, IPCAF will be used to identify relevant
shortcomings that need improvement in the COVID compliance
plan (WHO, n.d). This shows that IPCAF is powerful which not
only monitors and also seeks to detect possible problems in the
compliance plan which require adjustment to make it stronger
and increase compliance to the plan.
On the third aspect, IPCAF will help check areas that meet
international standards and requirements (WHO, n.d). For
example, IPCAF will determine whether PPEs that are made
available to medical staff are adequate and are of recommended
quality. Further, will seek to determine whether medical staff
and all people served by the medical are furnished with quality
and updated information on prevention and containment as
released by the ministry of health, CDC, WHO and other
relevant bodies on infectious control.
In aspect four, IPCAF gives a score that helps to determine the
progress that has been made on the compliance journey to the
policies and procedure. This is essential because the course of
action is generated from the results. It is the score that is
generated which helps the medical facility to determine actions
that need to take to improve compliance with the COVID
compliance plan.
Monitoring tool 2: Compliance Officer
The medical facility will use the office of the compliance

14. officer to monitor compliance to the COVID compliance tool. A
compliance officer is competent, versatile and well informed
with all details of a Compliance plan, policies and procedure
therein as well as the expected outcome. Regularly, compliance
will be required to track actions of medical staff and
management to establish whether responsibilities assigned to
each individual are implemented. For example, management
should buy PPEs and medical devices required to enforce
standard practices. The compliance officer assesses whether
management has its bit and whether the medical staff is putting
PPEs and maintain hand hygiene. Therefore, the compliance
officer is a critical component in the monitoring process and
recommendation of legal action to those found non-compliant to
plan.
Monitoring Tools for Billing Compliance Plan
Fraudulent billing cases are rampant. The facility would want to
maintain integrity stand by having a clean and ethical billing
system. Lately, the facility has identified that billing officers
are engaging in unethical malpractices by billing clients twice
in some cases. This is unacceptable to the facility and it is
putting all measures in place to avoid its billing system
becoming an avenue for criminal enterprise. Because of this
development, the facility has developed a billing compliance
plan. Two compliance policies have been developed-procedure
emphasizes the ethical and professional conduct of billing
officers and second- auditing to the billing system. Further, a
compliance procedure has been developed which detail five
steps followed to implement compliance policies. To effectively
ensure billing compliance plan is implemented and desired
results attained, four monitoring tools adopted from Strategic
Management Services, LLC (2018) are suggested.
Tool 1: Risk assessment and evaluation
This tool helps to detect tools that exist in the billing
compliance plan. Some of the risks could be billers that lack
integrity, a billing system that is easily manipulated and cases
where billers develop codes and at the same bill clients.

15. Therefore, risk assessment and evaluation will significantly
help to identify vulnerabilities in billing compliance which
would prompt action taking approach.
Tool 2: Compliance work plans.
This is a tool that provides a roadmap on how auditing to the
billing compliance plan is to be conducted. It equips the
auditing firm with necessary informa tion on what to look for
when auditing the billing compliance plan, history of
malpractices to the billers and emerging malpractices that need
to be considered.
Tool 3: Sampling protocols
This is a tool that would be used to establish variations on the
monitoring that is taking place. It is a critical monitoring tool
because variations identified form the basis for a possible
problem in the billing system.
Tool 4: Computer-assisted Audit Techniques
A compliance officer will use this tool to get an in-depth
analysis of the billing system, transaction and internal controls.
This helps the compliance officer to determine whether billing
officers comply with billing compliance policies and
procedures, determine the efficiency of the billing compliance
plan and areas that need improvement.

16. References
Bothwell, M. (2018, October 9). Why Medicare Billing Fraud
Cases Are Running Rampant and What You Can Do About It.
Retrieved from https://whistleblowerlaw.com/medicare-billing-
fraud-cases/
CDC. (2018, June 18). Standard Precautions. Retrieved from
https://www.cdc.gov/oralhealth/infectioncontrol/summary-
infection-prevention-practices/standard-precautions.html
Hughes, M. M. (2020). Update: characteristics of health care
personnel with COVID-19—United States, February 12–July 16,
2020. MMWR. Morbidity and mortality weekly report, 69.
Strategic Management Services, LLC. (2018). Health Care
Auditing and Monitoring Tools for an Effective Compliance
Program. Retrieved from
https://www.compliance.com/resources/health-care-auditing-
and-monitoring-tools-for-an-effective-compliance-program/
Tam, K. M., Walker, N., & Moreno, J. (2020). Effect of
mitigation measures on the spreading of COVID-19 in hard-hit
states in the US. Plos one, 15(11), e0240877.
WHO. (n.d). Infection Prevention and Control Assessment
Framework at the Facility Level. Retrieved from
https://www.who.int/infection-prevention/tools/core-
components/IPCAF-facility.PDF?ua=1
1
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17. Compliance Policies
Name
Course
Professor
Date
Compliance Policies
In the previous project, two compliance plans were developed
and a job description developed for safety and compliance
manager. However, strength for any compliance programs
depends on compliance policy and procedurals which outlines
applicable laws, regulations and standards that should be
followed to implement developed plans. Compliance policies
should be clear and simple to eliminate confusion or difficulties
which may be experienced by implementers of compliance
plans. Considering there are two compliance plans, to enhance
clarity on the developed compliance, each compliance plan
would be considered individually constituting two sections for
two compliance policies under each compliance plan.
Compliance Plan For Covid protocols
The impact of Covid-19 has been felt in all sectors of
economies and health sectors is not exceptional. Even though
numerous professionals have been affected by the virus,
significant healthcare providers have succumbed to the virus on
the line of the duty. According to a study conducted that assess
the impact of Covid-19 on the health sector, as of April 2020,
countries that reported the significant number of healthcare
providers that had succumbed to the virus are Italy with 44%,
Iran with 15%, Philippines with 8%, Indonesia with 6%, and

18. China, Spain, U.S each with 4% (Iyengar et al…,2020).
Healthcare providers are the first line of defense at high risk of
infection because they constantly engage and interact with
Covid protocols. Given there is no cure for the virus, hospitals
are implementing prevention measures to contain the spread of
the virus, protect clients and also its staff. However, it has been
noticed that staff members have been violating Covid protocols
such as washing hands between patients necessitating the
development of a Compliance plan for COVID. In the following
two sections, compliance policies for the compliance plan for
COVID are outlined.
Section 1: Compliance Standards for COVID Protocols
Healthcare providers should comply with standard precaution
practices when treating patients regardless of the nature of
diagnosis (Beyamo, Dodicho & Facha, 2019). In the healthcare
facility, healthcare workers are at high risk of infection. Covid-
19 is an infectious disease which means healthcare workers ar e
at high risk of being exposed to the virus. For example, it is
reported that more than 570,000 healthcare personnel had been
infected with the virus in America (PAHO, 2020). This
underscores need to take standard precaution which constitutes
of policies which aimed at reducing the risk of transmitting
infection in the healthcare (facility Beyamo et al…, 2019).
Standard precautions are not selective to particular diseases
because medical personal handles clients with a variety of
infections.
To minimize the spread of Covid in the healthcare facility,
standard precaution policies entail hand hygiene which requires
healthcare providers to wash their hands with soap and water
before and after attending to clients, use hand antisepsis and
also to apply surgical hand scrub. According to the World
Health Organization (2020), hand washing is the most effective
way to contain the spread of COVID-19. Therefore, hand
hygiene is an integral part of standard precaution that healthcare
providers should seek to implement to minimize the spread of
the virus.

19. Protective Personal equipment (PPE) which includes uses of
surgical face masks, aprons, goggles and closed boots is another
ingredient of standard precaution that should be implemented in
the healthcare facility (Beyamo et al…, 2019). To prevent the
spread of COVID-19, healthcare providers need to cover key
entry points (nose, eye and mouth) which pathways for viral
droplets hence the need for healthcare facilities to ensure all
healthcare workers have effective PPEs (Hung et al….,2020).
Healthcare facilities procure adequate PPEs which are
recommended by the ministry of health as one of the standard
precaution policies that not only protect healthcare providers
but also the patients.
Section 2: Communication Policy on Prevention Information
Communication is a powerful tool which when exhausted, the
violation of COVID rules and protocols can be avoided. Lack
of information could be the reason for the violation of COVID
protocols. Under the communication policy, the safety and
compliance manager should provide accurate and timely
information on the COVID protocols to the medical staff.
Further, safety and compliance officers should deliver the
message to the employers on what they need to do to protect
their families from contracting the diseases. Communication
policy outlines channels of communication to medical staff and
visiting clients. A medical facility should seek to ensure it has
effective communication systems and structures to pass COVID
prevention information.
Billing Compliance Plan
Billing fraudulent cases have been reported severally and
control such incidences, Medicaid Fraud Control Unit prosecute
healthcare providers that charge people healthcare services that
should be provided freely (Flasher & Lamboy-Ruiz, 2019).
Auditors need to be furnished latest fraud insights so that when
auditing systems and transactions, can easily identify fraudulent
billing activities. However, fraudulent billing activities do not
only happen in public health facilities but they do happen across
the board. This calls for a need for private health care facilities

20. to be extra cautious and institute monitoring programs that can
help them detect fraudulent activities.
It is noted that the up coding and misrepresentation of clinical
information is rampant with a total value of about $100 billion
(Drabiak & Wolfson, 2020). Physicians are using unorthodox
methods to make a profit and the amount of money reimbursed
in the concerted effort to optimize profit (Drabiak & Wolfson,
2020). This demonstrates the seriousness of fraudulent activities
in the health sector which sometimes lead to wrong prescription
and treatment to siphon more from the clients.
In the case of the medical facility of our concern, it has been
established that medical staff charge clients for application, a
cost that already has been paid on the cast. This questions
knowledge of the medical staff on the billing system that is
applied by the facility whether they have information on the
distribution, composition and nature of charges. It is believed
that medical staff are not strangers to the billing system and
double billing could collusion to fraudulently extort money
from the client. It is on this background billing compliance plan
has been developed that constitutes two compliance policies
outlined in sections three and four as shown below.
Section three: Procedure
The person that undertakes the billing exercise must
demonstrate ethical and professional standards. This requires
personnel to consistently comply with ethical and professional
standards by being honest and fair in charging the clients.
Violation of integrity and fairness principles is tantamount to
violation of personal responsibility that attracts disciplinary
action against the officer.
Medical staff must comply with the billing process and system
that has been developed by the healthcare facility. This requires
medical staff to familiarize themselves with the billing system,
applicable charges for all treatment and treatment procedures,
reimbursement programs and inclusive and non-inclusive
charges to avoid double charging clients.
Section four: Auditing

21. The medical facility will recruit an internal auditor that will
regularly determine compliance of billing officers with a legal
requirement. Further, the internal auditor will monitor
transactions in the medical facility to ascertain adherence to the
billing compliance plan.
Annually, the medical facility will recruit an external auditor to
carry out control and substantive test. The control test
establishes whether the facility has enhanced a strong internal
control system (Mahaluça et al…, 2019). On the other hand,
substantive test checks the accuracy of transactions and whether
there is a material error in the financial statement (Mahaluça et
al…, 2019). Auditing is an important policy in billing
compliance plan for monitoring purposes.
References
Beyamo, A., Dodicho, T., & Facha, W. (2019). Compliance with
standard precaution practices and associated factors among
health care workers in Dawuro Zone, South West Ethiopia,
cross sectional study. BMC health services research, 19(1), 381.
CDC. (2020). COVID-19 Communication Plan for Select Non-
healthcare Critical Infrastructure Employers. Retrieved from
https://www.cdc.gov/coronavirus/2019-
ncov/community/communication-plan.html
Drabiak, K., & Wolfson, J. (2020). What Should Health Care
Organizations Do to Reduce Billing Fraud and Abuse?. AMA
Journal of Ethics, 22(3), 221-231.
Flasher, R., & Lamboy-Ruiz, M. A. (2019). Impact of
enforcement on healthcare billing fraud: Evidence from the
USA. Journal of Business Ethics, 1-13.

22. Hung, O., Lehmann, C., Coonan, T., Murphy, M., & Stewart, R.
(2020). Personal protective equipment during the COVID-19
pandemic (Letter #2). Canadian journal of anaesthesia = Journal
canadien d'anesthesie, 67(11), 1649–1650.
https://doi.org/10.1007/s12630-020-01785-3
Iyengar, K. P., Ish, P., Upadhyaya, G. K., Malhotra, N.,
Vaishya, R., & Jain, V. K. (2020). COVID-19 and mortality in
doctors. Diabetes & metabolic syndrome, 14(6), 1743–1746.
https://doi.org/10.1016/j.dsx.2020.09.003
Mahaluça, F., Chissengue, G., Uamba, J., Pereira, I., Mabjaia,
E., & Vilanculos, A. (2019). Importance of Applying
Statistical Sampling to Increase Confidence in Financial
Statements. Int J Account Res, 7(198), 2.
World Health Organization. (2020). Handwashing an effective
tool to prevent COVID-19, other diseases. Retrieved from
https://www.who.int/southeastasia/news/detail/15-10-2020-
handwashing-an-effective-tool-to-prevent-covid-19-other-
diseases
1
6
Module 2 - Statistics and Quality Methods
Jamie Raines
Rasmussen College
H340/HSA3422 Section 01 Regulation and Compliance in
Healthcare
Rebecca Mangali
January 12, 2021

23. Job Description
In human resource management, hiring and recruitment is one of
the main functions that is performed by the human resource
managers. During the recruitment process, human resource
managers are required to develop a job description for vacant
positions outlining requirements, duties and roles that would be
performed by the applicants that wish to be considered in the
recruitment drive. It has been established that staff members
have not been observing COVID-19 protocols and also have
been charging those applying initial cast twice. Violation of
COVID protocols creates a lot of concern because more than
557,000 healthcare workers have been infected with a virus and
more than 3,000 have succumbed to the diseases (Lewis, 2020;
PAHO, 2020). Full-Circle Medical facility is in the process of
recruiting a safety and compliance manager hence develops a
job description for the said position that would address
compliance violation issues that have been identified.
Vacancy: Safety and Compliance Manager
Job Type
3-year contract subject to renewal based on performance
Qualification
Master’s degree in Health Management
Location
New York
Department
Health and Legal Compliance
Reference
234/NYC77/001575
Application Duration

24. 4/1/2021-31/1/2021
Major duties
· Ensure all staff members comply with Covid-19 protocols in
the facility.
· Conduct compliance risk assessment training for staff
members.
· Regularly update staff members of emerging compliance
guidelines.
· Follow up Compliance issues that require investigation.
· Recommend actions the medical facility should take against
defiant staff members.
· Assess ethical compliance with billing and general operational
standards.
· Follow up charge sheet for patients to ensure outline payment
plans are followed.
· Enhance legal medical compliance in the facility.
· Motivate employees to comply with established Covid
regulations
Requirements and Skills
· Must have a master’s degree in Health management.
· At least 2 years’ experience in enforcement
legislation/guidance.
· Awareness of health and safety issues.
· Good understanding of health billing practices.
· Excellent communication skills.
Compliance Plans
Having a brand new vehicle does not necessarily mean the
destination would be reached safely but depends on whether the
driver on the steering is qualified. This means the safety of the
journey is inseparable from skills, competence and experience
possessed by the driver. Practically, organizations spend a
substantial amount of time searching for talented employees
that have the right skills and competencies (Czarniewski, 2016).
In human capital management, knowledge, skills and abilities
(KSAs) are optional but rather a priority because the success
and innovative nature of an organization depend on its talent

25. management and right human resources (Lawler III & Boudreau,
2012). Ideally, it is factual that the medical facility has been
experiencing compliance violations. However, to successfully
implement compliance plans, a medical facility requires a good
captain that understands the value of compliance, an individual
with the necessary skills and experience to steer compliance
implementation plan.
Coercive compliance theory which entails threats and
punishment has been practiced but has not borne effective
results. Similarly, catalytic compliance theory which entails
dialogue and suggestion has been applied and has neither
delivered optimal results (Weske et al…, 2018). However, a
compliance plan with pre-existing motivation for compliance
has been identified to be most effective (Weske et al…, 2018).
It is based on the approach, a job description for safety and
compliance manager states motivation skills, training and
expertise on enforcement as key elements which are essential in
motivating employees to comply with compliance plans.
With the outbreak of Covid-19, evidence shows that different
countries took varying containment measures such as the
closure of schools, travel restrictions, gathering restrictions and
emphasis on the washing of hands with soap and running water
for at least 20 seconds (Chan et al…,2020). Many individuals
observed and complied with measures taken some due to
extrinsic motivations such as social pressure while others were
forced to comply out of intrinsic motivations such as moral and
social norms (Chan et al…, 2020). To successfully implement
Covid rules and ensure all employees comply with laid down
protocol and at same ensure billing system operate as per rates
determined by the management, safety and compliance officer is
sought with management skills. Further, the applicant should
have a high level of integrity to promote an ethical culture in
the organization.
In the nutshell, critically evaluating the job description, the
medical facility would wish to recruit a safety and compliance
manager that would motivate employees to implement

26. compliance plans. The office bearer should have experience
and skills to successfully help medical staff members to
navigate compliance violations and instead develop in-built
compliance culture. Knowledge, skills and abilities outlined in
the job description are pivotal to implementing compliance
plans.
References
Chan, H. F., Brumpton, M., Macintyre, A., Arapoc, J., Savage,
D. A., Skali, A., ... & Torgler, B. (2020). How confidence in
health care systems affects mobility and compliance during the
COVID-19 pandemic. PloS one, 15(10), e0240644.
Czarniewski, S. (2016). Conditions for the Effective
Management of Human Capital-The Trends and Mechanisms Of
Power In The Organization. European Journal of Research and
Reflection in Management Sciences Vol, 4(3).
Lawler III, E. E., & Boudreau, J. W. (2012). TALENT
MANAGEMENT-Creating an Effective Human Capital
Strategy-Use questions—And findings—From survey research
to help gauge your progress on the road to becoming a strategic
HR business partner. HR Magazine-Alexandria, 57(8), 57.
Lewis, R. (2020, December 23). Did they have to die? How
America's Covid response left 3,000 health workers dead.
Retrieved from https://www.theguardian.com/us-
news/2020/dec/23/us-healthcare-workers-died-covid-
coronavirus

27. PAHO. (2020). COVID-19 has infected some 570,000 health
workers and killed 2,500 in the Americas, PAHO Director says.
Retrieved from https://www.paho.org/en/news/2-9-2020-covid-
19-has-infected-some-570000-health-workers-and-killed-2500-
americas-paho
Weske, U., Boselie, P., van Rensen, E., & Schneider, M. (2018).
Using regulatory enforcement theory to explain compliance with
quality and patient safety regulations: the case of internal
audits. BMC health services research, 18(1), 62.
https://doi.org/10.1186/s12913-018-2865-8
1
7
Compliance Procedures
Name
Course
Professor
Date
Compliance Procedures
In module 3, compliance policies were developed for two
compliance plans. Normally, policies set out rules and
parameters of what needs to be done. However, what needs to

28. be done and how should be done are two different concepts. It is
possible medical facilities could be having progressive
compliance policies but the effect will be determined by how
these policies are implemented. Process or steps which outline
how compliance policies are implemented in the medical facility
for two compliance plans is known as compliance procedure.
Compliance Procedure for Covid Protocols.
It has been established that the health sector is one most hit by
COVID-19 in the United States with approximately 4% of
healthcare professionals succumbing to the virus. However,
even with such a glaring dangerous infectious which continues
to destabilize the healthcare system, cases of violation to
handwashing were noted in our medical facility. It is on the
background of this compliance policies were written in project
3- that is standard protocols that entail precaution practices
such as hand washing and PPE and, communication policy to
relay information on prevention to medical staff and clients
(Beyamo, Dodicho & Facha, 2019). However, having
compliance policies is not adequate and that is why compliance
procedure has been developed.
Compliance procedure to implement standard COVID protocols
and communication policy comprises of five steps/processes.
These processes are outlined below and every medical staff is
invited to read and familiarize themselves with the laid down
procedure.
Step 1: The compliance officer develops standard precautions
that medical staff should comply with to minimize the spread of
the virus. Compliance officer needs to research and consult with
the ministry of health, world health organization and CDC to
establish standard precaution that relates to COVID protocols.
Step 2: Compliance officer shares with management on standard
Covid protocols that is a standard precaution which facility
need to implement to prevent the spread of the virus. This will
enable management to procure medical devices such as an
apron, gloves, surgical face mask, and sanitizers and hand
washing points to be put in the medical facility (World Health

29. Organization, 2020; Beyamo et al…, 2019). This is very
important because it helps to ensure necessary medical devices
required to implement precaution measures are available.
Step 3: Compliance officer avail publication to medical staff
which outlines standard precaution measures that have been
recommended by management. In the publication, another
standard precaution which medical staff should implement, a
statement of administrative and disciplinary action statement
which is meant to reinforce standard precaution. Additionally,
the publication states that medical staffs have the right to
demand to be provided with effective and adequate PPEs before
they attend to the clients (Sheldon, 2019). Therefore,
management must ensure that the medical facility has adequate
and recommended PPEs to offer medical staff protection and
minimize the spread of the virus among colleagues, family
members and clients.
Step 4: Training session for medical staff. A compliance officer
will organize a training session that will incorporate
management officials and guests from the ministry of health.
The training session will seek to educate medical staff on how
to put PPEs and other standard precautions measures that should
be observed when attending to patients. Further, training will
create awareness of the importance of observing standard
COVID protocols that relate to precaution measures.
Step 5: The compliance manager will develop a communication
framework that is tailored to educate clients on COVID
regulations which are implemented in the medical facility. At
the entrance of the medical facility, clients will be made aware
of the existence of COVID, prevention measures that have been
put in the facility and obligations of clients in containment
effort.
Procedure for Billing Plan
A billing compliance plan was developed for the medical
facility after it was revealed some staff that bill clients charge
them twice. This is unacceptable and against the code of ethics
for Medical facilities. The facility is against the exploitation of

30. clients and is committed to remaining a truthful and trusted
institution. However, this cannot be attained when some
employees want to take advantage of clients who possibly do
not have knowledge of systems used to charge clients. Such
practices are not only rampant in our medical facility and also
in public health facilities. It is for this reason Medicaid Fraud
Control Unit instituted a system to prosecute healthcare
personnel that fraudulently exploit clients by charging
healthcare services that otherwise are provided freely (Flasher
& Lamboy-Ruiz, 2019). Cognizant of billing violations in the
medical facility, related compliance policies were developed,
which entails ethical standards of professionals in the billing
process and also auditing. However, to ensure that compliance
policies are complied with and implemented to the latter, a
compliance procedure for billing compliance plan has been
developed.
Procedure 1: Compliance officer liaises with diagnosis medical
officers to develop codes that will be used coding. It is the
medical officers that see patients determine what to charge
depending on the service rendered. Therefore, it will be
necessary for the compliance officer to connect with healthcare
personnel that attends to patients and comes up with codes that
will be submitted to the billers.
Procedure 2: Compliance officer shares with billers developed
codes. To enhance clarity to the biller, codes that have been
developed will be shared by the individuals that bill clients,
prepare and submit claims to Medicaid, Medicare, private health
care insurance providers and third parties. This will help to
ensure billing is systematic and consistent and issues of
duplications in the billing are avoided.
Procedure 3: Training on compliance with billing codes. A
compliance officer will undertake a training exercise that seeks
to educate billing officers on the need to comply with billing
codes that have been developed.
Procedure 4: Auditor's requirement. A compliance officer will
outline the requirements of auditors and the job description of

31. auditors recruited by the medical facility. The medical facility
is determined to enforce internal control systems to strengthen
its billing system and also enhance transparency and fairness of
the system. This compels the facility to institute a monitoring
system through recruiting internal and external auditors. For
internal auditors, the company will recruit individuals with a
high code of ethics for auditors, qualified auditors with
knowledge of international auditing standards and also, an
individual conversant with the billing process in a healthcare
setting. Internal auditors will regularly monitor billing systems
and establish whether billers are complying with coding systems
that have been developed as well as management policies.
For external auditors, the medical facility will recruit auditing
firms that have demonstrated a strong stand for audit
independence. External auditors will annually audit billing
systems and establish whether internal controls are adequate
and implemented and two, will help detect whether there are
fraudulent activities committed by billers (Younas & Kassim,
2019).
Procedure 5: Legal action will be taken against billers that do
not comply with the billing compliance plan. Reports of both
internal and external auditors will be evaluated and when
malpractices are identified amongst billers, a medical facility
under leadership and direction of compliance will determine
disciplinary and legal action to be taken against billers that
violate the billing compliance plan.

32. References
Beyamo, A., Dodicho, T., & Facha, W. (2019). Compliance with
standard precaution practices and associated factors among
health care workers in Dawuro Zone, South West Ethiopia,
cross sectional study. BMC health services research, 19(1), 381.
Flasher, R., & Lamboy-Ruiz, M. A. (2019). Impact of
enforcement on healthcare billing fraud: Evidence from the
USA. Journal of Business Ethics, 1-13.
Sheldon, L. K. (2019). The Importance of PPE Use. AJN The
American Journal of Nursing, 119(4), 10.
World Health Organization. (2020). Handwashing an effective
tool to prevent COVID-19, other diseases. Retrieved from
https://www.who.int/southeastasia/news/detail/15-10-2020-
handwashing-an-effective-tool-to-prevent-covid-19-other-
diseases
Younas, M. A., & Kassim, A. A. M. (2019). Essentiality of
internal control in Audit process. Int J Bus Appl Soc Sci
[Internet], 1-6.
1
3
Compliance Plan
Name
Course
Professor
Date

33. Compliance Plan
Following the outbreak of COVID-19, the institution took
numerous measures to mitigate the spread of the virus among
the staff and also the patients. It is sad to note that country has
lost thousands of healthcare personnel which calls for each
healthcare facility to remain vigilant and enforce all Covid-19
protocols without reservation. Reliable sources indicate that
more than 570,000 healthcare workers have been infected while
more than 3,000 have succumbed to diseases (Lewis, 2020;
PAHO, 2020). This is not exceptional in our facility hence need
strict compliance with protocols that have been issued by the
ministry of health and also facility management to keep the
virus at bay in the concerted effort to protect vulnerable clinical
staff members as well as dear parents. It is worrying to note that
some of the clinical staff members violate COVID protocols and
measures that have been put in place by failing to wash hands
between patients. Management of facility has severally
pronounced itself on this matter and would wish to restate that
clinical staff members must wash hands between members. This
does not only apply because of the existence of a pandemic but
is a cardinal principle for our operation. Considering the severe
impact of Covid-19 and the fact that no cure has been
established, developing a compliance plan will necessary to
protect the spread of the virus in the facility among health
workers and also to the members of the public. Further, this will
also help to protect the families of healthcare workers and also
to ensure the facility remains operational.
Finally, it has been established that medical staff members
charge extra for the application of the initial cast. However, the

34. application of the initial cast is included in the cost of the visit.
This might ruin the reputation of the facility because patients
could feel that they are being exploited. As a result of this, a
compliance plan is necessary that guides medical staff members
on what each charge entails to avoid overcharging patients.
References
Lewis, R. (2020, December 23). Did they have to die? How
America's Covid response left 3,000 health workers dead.
Retrieved from https://www.theguardian.com/us-
news/2020/dec/23/us-healthcare-workers-died-covid-
coronavirus
PAHO. (2020). COVID-19 has infected some 570,000 health
workers and killed 2,500 in the Americas, PAHO Director says.
Retrieved from https://www.paho.org/en/news/2-9-2020-covid-
19-has-infected-some-570000-health-workers-and-killed-2500-
americas-paho