First Healthcare Compliance CONNECT August 2020

FirstHealthcareCompliance

CONNECT

August 2020

A Monthly Publication for the Healthcare Compliance Community

Combat COVID-19 in the

Healthcare Setting with Hand

Hygiene Compliance

Q&A: COVID 19: Testing,

Reimbursement, and Provider

Relief Funds

3 Important Traits According to

a Corporate Compliance Officer

in Healthcare

1st Talk Compliance: The Do’s

and Don’ts of Designing an

Aging Physician Policy

Infographic: 4 Purposes of

Hand Hygiene in the Healthcare

Setting

FAQ Corner

Upcoming and On-Demand

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HIPAA PRIVACY

AND SECURITY

SUMMIT 2020

NOVEMBER 12, 2020

In This Issue:

FAQ Corner

Combat COVID-19 in the Healthcare Setting with Hand Hygiene Compliance

Q&A: COVID 19: Testing, Reimbursement, and Provider Relief Funds

2

First Healthcare Compliance, LLC © 2020


Compliance Super Ninja

Laura Troyer, Practice Manager

Jeffrey S. Masin MD

How would you describe your

experience with First Healthcare

Compliance?

My experience has been great. The

portal is so easy to use and the weekly

updates are so helpful.

What do you enjoy most about working with Jeffrey S. Masin

MD?

Dr. Masin is so easy to work for. He is so laid back and has been such a

pleasure to work for. When I was diagnosed with cancer he said I

should take all the time I needed and we would be just fine. I am

now cancer free.

Would you rather have x-ray vision or magnified

hearing? Why?

I think I would rather have magnified hearing but would

definitely need to be able to turn it off. It would get annoying!

3 Important Traits According to a Corporate Compliance Officer in Healthcare

Infographic: 4 Purposes of Hand Hygiene in the Healthcare Setting

1st Talk Compliance: The Do’s and Don’ts of Designing an Aging Physician Policy

Upcoming and On-Demand Webinars

Contact Toll Free: 888-54-FIRST 3


FAQ Corner

Can a hospital provide access to its HIPAA-compliant, web-based

telehealth platform for free to independent physicians on its medical

staff to furnish medically necessary telehealth services during the

time period subject to the COVID-19 Declaration?

According to the facts presented in the question received by the OIG, the hospital would provide free access to a

web-based telehealth platform to independent physicians on its medical staff. Such physicians could access the

platform from various settings outside of the hospital’s campus. The hospital would receive no payment from any

(i) independent physician to whom it grants free access to the platform, or (ii) payor for services furnished through

its telehealth platform by the independent physicians. In addition, independent physicians who use the hospital’s

telehealth platform for free (i) receive no remuneration for use of the platform from the hospital (other than free

access to the platform); (ii) must be responsible for appropriately maintaining any required records for patients

who receive services using the platform; and (iii) independently bill and receive reimbursement from payors for

professional services furnished via the platform.

OIG’s longstanding guidance makes clear that, depending on the facts and circumstances, the provision of free

or below fair market value goods or services to an actual or potential referral source may violate the Federal antikickback

statute. OIG recognizes that access to the platform would provide independent value to the physicians-who

may refer Federal health care program business to the hospital-and therefore would implicate the Federal antikickback

statute. Nonetheless, in the unique and exigent circumstances resulting from the COVID-19 outbreak, we

believe that free access to a hospital’s telehealth platform by physicians on its medical staff would present a low risk

of fraud and abuse under the Federal anti-kickback statute and could improve beneficiaries’ access to telehealth

services, so long as the platform is (i) provided for free to physicians to furnish medically necessary telehealth

services; (ii) provided only when necessary as a result of the COVID-19 outbreak and during the period subject to

the COVID-19 Declaration; (iii) not conditioned on the physician’s past or anticipated volume or value of referrals to,

or other business generated for, the hospital for any items or services that may be reimbursable in whole or in part

by a Federal health care program; and (iv) offered to all physicians on the medical staff on an equal basis (but not

necessarily accepted by every member to whom it is offered).

Provider’s should review the recent guidance published by the Office for Civil Rights titled “Notification of

Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health

Emergency.”

Explore more OIG FAQs here.

Explore the FAQs tab in your compliance solution to find

answers to your compliance questions!

CLIENT

ALERT

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First Healthcare Compliance, LLC © 2020


4 Purposes of Hand Hygiene

in the Healthcare Setting

Compliance with hand hygiene is more important than ever. A hand

hygiene program in a healthcare facility is an important step that conveys

competency, professionalism and respect. Proper hand hygiene affords

patients and healthcare providers protections and the

focus is even more important due to COVID-19.

Prevent

nosocomial

infection of

patients

1

2

Prevent

cross-transmission

of microorganisms

between patients

3

4

Prevent

contamination of

the environment

with pathogens

Prevent healthcare

providers from

contracting diseases

in the occupational

setting

Comprehensive Healthcare Compliance

Management Solutions

CONFIDENCE INCLUDED

Creating confidence among compliance

professionals through education,

resources, and support

888.54.FIRST 1sthcc.com

Contact Toll Free: 888-54-FIRST 5


3 Important Traits According to a

Corporate Compliance Officer in

Healthcare

Julie Sheppard, BSN, JD, CHC

Now more than ever, our world is in need of leadership to help

navigate the difficult environment and changing rules and

regulations. Healthcare systems and businesses particularly rely

on the skills and attributes of a talented

Chief Compliance Officer. The individual

serving in this role is certain to interact

with every employee at some juncture

and impact the overall culture of the

organization. As with all leadership roles,

there are obvious skills and traits that

will help fulfill the position. In addition

to being intelligent and analytical, a

compliance officer must be of high

integrity and possess the ability to

communicate with diverse personalities.

A strong person serves the role of the

compliance officer with confidence and

helps an organization face unavoidable

challenges.

Multiple duties and responsibilities comprise a compliance

officer’s job description making it difficult to determine exactly

the most important skills and traits for a specific organization.

However, there are exemplary professionals serving in the role

of healthcare compliance officer around the United States. One

such individual is Christine Babenko, MJ, MSN, RN, CHC, CCEP,

CHPC, Corporate Compliance Officer of ChristianaCare. Ms.

Babenko’s experience in this role is extensive as she has been

with the health system for 23 years and through many changes.

Here, Ms. Babenko shares her insight and expertise on the three

most important traits of a healthcare compliance officer.

What are the three most important traits of a

healthcare compliance officer?

1. Building trust through effective

communication

I don’t want people to think of compliance as

a punishment or a roadblock that they work

to avoid. I want people to feel that they can

come to me and discuss their concern or ask

any questions. I want them to trust that I will

actively listen to learn. I’m on their team and

together, we are stronger!

2. Having a true thirst for knowledge

The regulatory landscape today is very

complex and constantly transforming. Every

Compliance Officer must stay abreast of these

relentless changes. In addition, the healthcare

industry is also rapidly changing as providers are tasked with

finding innovative ways to re-imagine health care delivery. The

Compliance Officer must have a strong understanding of how

the health system is using innovation to conduct its business.

Integrating innovation into the current and ever-changing

regulatory setting is complicated at best. Intellectual curiosity is

essential!

3. Strong leadership skills

It’s not easy having crucial conversations, delivering bad news,

or reconciling differences. Unfortunately, sometimes it’s part

of the job. Compliance Officers must be courageous and lead

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First Healthcare Compliance, LLC © 2020


y example. I’m in the final stretch of obtaining my doctorate

degree in Organizational Leadership, Learning and Innovation.

One of my favorite learning moments came from reading

Stephen Covey’s book titled The 7 Habits of Highly Effective

People. Having the ability to critically analyze yourself, and

the insight to know how your behavior impacts others, is an

important leadership skill every Compliance Officer needs.

Strong leadership skills will help Compliance Officers become

successful change agents for their organization.

The most

comprehensive

healthcare

compliance course

COVID-19 Healthcare

Compliance Updates

The Fundamentals is a user-friendly, four-module

online course designed to help healthcare professionals

understand the essential principles and practices of

compliance.

Written by our “dream team” of healthcare providers and

attorneys, The Fundamentals course is packed with useful,

easy-to-understand information that covers HIPAA, OSHA,

employment law and enforcement of federal healthcare

laws.

The course takes less than four hours to complete, and the

modules can be viewed in any order. A certificate of course

completion is provided following successful completion of

the online course and exam.

In response to the global outbreak of the novel coronavirus

disease (COVID-19), the Secretary of Health and Human

Services declared a public health emergency on January 31,

2020. Federal agencies have taken action by issuing updates

and guidance to navigate the crisis. This ebook provides

healthcare providers with important developments and

resources that impact federal healthcare laws.

The Compliance Certification Board (CCB)® has approved

this event for up to 4.0 nonlive CCB CEUs. Continuing

Education Units are awarded based on individual

attendance records. Granting of prior approval in no way

constitutes endorsement by CCB of this event content or

of the event sponsor.

Download Now

Buy Course Today

Contact Toll Free: 888-54-FIRST 7


Combat COVID-19 in the

Healthcare Setting with Hand

Hygiene Compliance

Julie Sheppard, BSN, JD, CHC

The importance of hand hygiene compliance has never

been greater as it’s a vital part of the U.S. response to the

COVID-19 pandemic. All individuals are instructed to wear

a mask, practice social distancing and exercise frequent

hand washing. In medical offices and hospitals hand hygiene

takes on even greater significance. Practicing hand hygiene,

which includes the use of alcohol-based hand rub (ABHR) or

handwashing, is a simple yet effective way to prevent the

spread of pathogens and infections in healthcare settings.

Hand hygiene is especially important in the

healthcare environment

On any given day, about one in 31 hospital patients has at

least one healthcare-associated infection. Nosocomial or

hospital acquired infections may be difficult to treat and

are often life threatening. Compliance with hand hygiene

is one of the most important ways to prevent spread of

infection. Transmission of pathogens can potentially occur

at many points of contact with the healthcare provider and

hand washing mechanically removes pathogens while ABHR

properly used as recommended by CDC inactivates SARS-

CoV-2. ABHR effectively reduces the number of pathogens

that may be present on the hands of healthcare providers

after brief interactions with patients or the care environment.

The need for hand hygiene applies to all healthcare personnel

(HCP). HCP refers to all paid and unpaid persons serving

in healthcare settings who have the potential for direct or

indirect exposure to patients or infectious materials, including

body substances (e.g., blood, tissue, and specific body fluids);

contaminated medical supplies, devices, and equipment;

contaminated environmental surfaces; or contaminated

air. HCP include, but are not limited to, emergency medical

service personnel, nurses, nursing assistants, physicians,

technicians, therapists, phlebotomists, pharmacists,

students and trainees, contractual staff not employed by

the healthcare facility, and persons not directly involved in

patient care, but who could be exposed to infectious agents

that can be transmitted in the healthcare setting (e.g., clerical,

dietary, environmental services, laundry, security, engineering

and facilities management, administrative, billing, and

volunteer personnel).

How often should HCPs wash their hands?

According to the CDC, studies show that some healthcare

providers practice hand hygiene less than half of the times

they should. Healthcare providers might need to clean their

hands as many as 100 times per 12-hour shift, depending on

the number of patients and intensity of care. In fact, multiple

opportunities for hand hygiene may occur during a single

care episode.

HCP should perform hand hygiene before and after all patient

contact, contact with potentially infectious material, and

before putting on and after removing PPE, including gloves.

Hand hygiene after removing PPE is particularly important to

remove any pathogens that might have been transferred to

bare hands during the removal process.

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First Healthcare Compliance, LLC © 2020


What are the hand hygiene guidelines?

CDC recommends using ABHR with greater than 60%

ethanol or 70% isopropanol in healthcare settings. Unless

hands are visibly soiled, an alcohol-based hand rub is

preferred over soap and water in most clinical situations

due to evidence of better compliance compared to soap and

water. Hand rubs are generally less irritating to hands and

are effective in the absence of a sink.

Hands should be washed with soap and water for at least

20 seconds when visibly soiled, before eating, and after

using the restroom. Wash with soap and water:

• Immediately before touching a patient

• When hands are visibly soiled

• Before performing an aseptic task (e.g., placing

an indwelling device) or handling invasive medical

devices

• After caring for a person with known or suspected

infectious diarrhea

• Before moving from work on a soiled body site to a

clean body site on the same patient

• After known or suspected exposure to spores (e.g.

B. anthracis, C difficile outbreaks)

• After touching a patient or the patient’s immediate

environment

• After contact with blood, body fluids or

contaminated surfaces

• Immediately after glove removal

Resources for hand hygiene compliance

Hand hygiene supplies must be readily available and

healthcare facilities must educate patients, visitors, and

HCP about the importance of performing hand hygiene

immediately before and after any contact with their

facemask or cloth face covering. Employees should be

trained about hand hygiene necessity and their role in

reducing preventable infections.

Many high quality resources are available to learn more

about hand hygiene in healthcare settings. There’s an

informational video available from the New England Journal

of Medicine. The World Health Organization provides a

hand hygiene self-assessment framework. First Healthcare

Compliance offers a poster set that addresses hand

washing along with Personal Protective Equipment (PPE)

and infection control.

Navigating Workplace Violence

Prevention Under OSHA

Workplace violence is a serious issue, especially in healthcare facilities. In 2013

alone, over 25,000 occupational assault injuries occurred, most of which were

in the health care and social services industries. The Occupational Safety and

Health Administration (OSHA) responded in 2015 by updating and publishing

their guidelines on how to best prevent workplace violence. The OSHA workplace

violence prevention guidelines help employees and employers alike by providing

the necessary steps to maintain a safe work environment.

DOWNLOAD NOW

Contact Toll Free: 888-54-FIRST 9


Q&A: COVID 19: Testing,

Reimbursement, and Provider

Relief Funds

By Catherine Short

Emily A. Johnson and Courtney Tito, Members, at

McDonald Hopkins LLC recently presented the

webinar “COVID 19: Testing, Reimbursement,

and Provider Relief Funds” and the recording

is available on our YouTube Channel. Emily and

Courtney returned to answer many commonly

asked questions from the webinar.

What is the difference between diagnostic and

antibody testing?

Diagnostic testing identifies people who are currently infected,

whereas antibody (otherwise known as serology) testing looks

for antibodies to the virus, which can help identify individuals

who have developed an adaptive immune response to the

virus as part of either an active infection or a prior infection.

Antibody test results are important for detecting previous

infections in individuals who had few or no symptoms.

How reliable is antibody testing?

The utility of antibody test results is unknown as scientists

are still exploring the possibility of COVID-19 reinfection.

Specifically, it remains uncertain whether the antibodies that

result from a COVID-19 infection will provide someone with

immunity from getting infected again. If antibodies do provide

immunity, it is unknown how long the immunity will last.

However, the information yielded from the antibody testing

can potentially be used to determine the percentage of a

geographic area previously infected with COVID-19 in order

to determine which communities have higher rates of herd

immunity.

What documentation should an employer

have with labs and employees to commence

return to work COVID testing?

An employer should have a laboratory services agreement with

the performing laboratory that identifies the services to be

provided by the laboratory and the method of compensation for

such services. Additionally, employee consent forms should be

used so that the employee understands how the test results

may be used by an employer. Also, the laboratory should

require the employee to sign an authorization permitting

the laboratory to release the employee’s test results to the

employer, particularly if the laboratory is subject to HIPAA.

Other issues that may come up in these arrangements include

permitting requirements if specimen collection will occur on

the employer’s premises, identifying who will be supplying

protective face masks to the employee who presents for

specimen collection (the employer, the lab, or the employee),

among other issues.

How often should return to work testing be

performed?

For most employers, there is no set framework and the

employer should establish a frequency that works best for

the particular workplace. This should be documented in the

employer’s policies and procedures. For healthcare employers

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First Healthcare Compliance, LLC © 2020


such as nursing homes, hospitals, and assisted living facilities,

there may be a state-issued executive order defining the

testing that is required to be performed on employees of such

entities and the frequency that such testing must be performed.

It is important to regularly monitor the applicable state’s

communications and orders on this issue.

Emily A. Johnson is a Member at McDonald Hopkins LLC,

Chicago and practices in its Health Law group. Ms. Johnson

counsels and represents clients in the healthcare industry,

with an emphasis on laboratories and pathology groups.

Ms. Johnson provides advice on wide range of healthcare

regulatory issues, including but not limited to Stark Law, Anti-

Kickback Statute, licensure, reimbursement and contractual

matters. Ms. Johnson has also counseled clients with

HIPAA compliance, including

drafting HIPAA policies and

procedures, breach response and

notification, Office for Civil Rights

investigations, and advising on

proactive HIPAA compliance and

breach prevention. She has also

advised clients regarding direct to

consumer testing issues.

Ms. Tito is a Member of McDonald Hopkins, LLC and practices

in its Health Law group in the West Palm Beach office. Ms.

Tito counsels and represents clients in the health law industry,

including, federal and private payor audits and disputes,

reimbursement, contract, corporate, enrollment revocations,

payment suspensions, internal investigations, compliance and

regulatory, and in responding to federal subpoenas and civil

investigative demands. She advises clients in both federal and

state matters. She has counseled

clients on regulatory, licensing,

compliance, reimbursement,

corporate, CLIA standards, state

and federal fraud and abuse rules

and regulations and telehealth

matters. She has also advised clients

regarding direct to consumer issues.

Check out a recording of this webinar and others by Emily

A. Johnson, Courtney Tito, and Elizabeth Sullivan, Members

at McDonald Hopkins, LLC with First Healthcare Compliance:

Payor Disputes And Audits Observations Strategies, and

Eliminating Kickbacks in Recovery Act (EKRA): Summary and

Status, and listen to Courtney and Catherine on our radio

program and podcast 1st Talk Compliance. Take a look at our

new book: HIPAA Privacy and Security; our recent blog articles

including Q&A: Payor Disputes and Audits: Observations &

Strategies and CMS Updates Compliance Program Training

Requirements for FDRs and our online compliance training

courses such as The UPIC is Coming: CMS Auditors 2.0, and

MACRA – Medicare Access & Chip Reauthorization Act of 2015.

HIPAA Privacy and Security

First Healthcare Compliance HIPAA Privacy and Security is a user-friendly

resource designed to help healthcare, administrative, and compliance

professionals, whether they serve as a covered entity or a business associate,

better understand their compliance responsibilities under the Health Insurance

Portability and Accountability Act. The book explains HIPAA privacy, security,

enforcement and breach notification in plain language, and provides a

comprehensive checklist that entities can use to get their compliance efforts

off the ground.

BUY BOOK NOW

Contact Toll Free: 888-54-FIRST 11


hosted by Catherine Short

Catherine Short speaks with Dr. Mary Hoppa, MD, MBA, senior consultant with The Greeley Company

which provides solutions through consulting, education, interim staffing, credentialing management,

and external peer review to healthcare organizations nationwide, about “The Do’s and Don’ts of

Designing an Aging Physician Policy.” We will discuss how to identify and address competency issues

among senior physicians and best practices to prevent potential safety incidents that could have longterm

consequences for both patients and practitioner. We will also learn how to recognize age related

impairments that affect a healthcare professional’s ability to safely administer care, look at how to design

a fair aging policy to protect both practitioners and patients, as well as focusing in on how to address

competency issues and when privileging needs to be reassessed or revoked.

Listen weekdays at

7:30am, 3:30pm, 11:30pm ET

Check out our Show Page!

Looking for the latest compliance insights?

Subscribe to our feed and don’t miss a thing!

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WORD SEARCH

A N P O G Q G R Z D H D R D V D J E F I

T E D Y C T N E M P I U Q E A A A H E M

Y R E G U L A T I O N U Z O C N X C O D

I A M L R I W W S Z F O P K T Q N Y E I

N C X S U T K C G M M Y M I N A W D B A

A H V C T N E M E S R U B M I E R L B G

D T P I M I W P W K O O K L H O I A X N

C L R E J P A X Y I D C P Y Y P D I Z O

K A A N M M Y S R Y C M W F G M L M H S

T E R T A W L E E A O M P J I G I O G T

J H Z I N E E C H C Z D K C E S U C I I

G L V S A A A R T T E O U I N D C O V C

Z G Q T G G D U Z W S R L F E Q E S S L

W N F S E D E O T H A U B P B Y X O O F

T Z W L M M R S Y N F R V L M A E N B W

D J O W E O S E I R Z K H A Z S R P L X

V N E C N O H R J Y Y S C E I C C Q G N

R W K L T O I I J F V A T B U K I G O G

V Y Y Z W E P V G Z W M V Y Q H S B I U

R B K H I F I E Y F N X W V Q J E A W K

HYGIENE MASK EXERCISE

HEALTHCARE NOSOCOMIAL MANAGEMENT

COMPLIANCE EQUIPMENT ANTIBODY

DIAGNOSTIC SCIENTISTS REIMBURSEMENT

REGULATION LEADERSHIP RESOURCES

Contact Toll Free: 888-54-FIRST 13


Upcoming and On-Demand Webinars

Training

AUG 18, 2020

SEPT 9, 2020

SEPT 22, 2020

OCT 6, 2020

ON DEMAND

ON DEMAND

Diagnosis Coding: The Cost of One and Done

Federal Healthcare Fraud and Abuse Framework

How Workplace Communication Mitigates

Harassment

Why are Security & Governance for Health Data

Analytics Vital?

COVID 19: Testing, Reimbursement, and Provider

Relief Funds

Active Shooter in a Healthcare Facility-Planning for

Responding to & Recovering from the Unthinkable

Register

Register

Register

Register

All Upcoming Webinars

All On Demand Webinars

NEW FEATURES!

Training Zone - New required training modules have been added titled “Fraud

Waste and Abuse Training” and “General Compliance Training”. These modules replace the

CMS training materials.

Employee Zone - A Notes button has been added to the HepB Vaccination Status section.

OSHA Zone - To assist with successfully completing your assessment embedded links to

Resources have been added.

New COVID-19 Resource section available from the dashboard for 1st Performance, 1st

Professional, and 1st Premium.

CLIENT

ALERT

Join us on Social Media!

Contact our Client Services Team with your questions!

888.54.FIRST or clientservices@1sthcc.com

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