First Healthcare Compliance CONNECT August 2020

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 

4 


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 


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 

6 


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 


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. 

8 


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 


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 

10 


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 


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! 

12 


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 


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 

14

First Healthcare Compliance CONNECT August 2020

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