May 2018 Volume 13, Issue 2 Compliance Courier New Office of Healthcare and Regulatory Compliance Recently, the Office of Audit, Compliance and Ethics (OACE) underwent a reorganization. After careful review of OACE?s function and structure, the department was divided into three distinct departments: the Office of University Compliance, the Office of Audit and Management Advisory Services and the Office of Privacy Protection and Management. In addition to the new University Compliance structure, there remains an Athletic Compliance Department, Research Compliance Department and the new Office of Healthcare and Regulatory Compliance at UConn Health. In February 2018 Debra Abromaitis was appointed the Interim Compliance Officer for the Office of Healthcare and Regulatory Compliance. The office has four focus areas - Clinical, Finance, Regulatory, and Education. Clinical - Rikel Lightner is the Associate Clinical Compliance Officer. Rikel?s primary responsibilities include promoting compliance with regulations governing the provision of clinical services. Rikel joined the Office in May 2018. Prior to joining our office, Rikel worked at Correctional Managed Healthcare (CMHC) as a Health Services Administrator. Rikel is a registered nurse and holds a Juris Doctor from Western New England University School of Law. Finance - Kimberly (Kim) Bailot is the Associate Finance Compliance Officer. Kim?s primary responsibilities include educating, monitoring and providing guidance on regulations that impact charging, billing or payment for clinical services. Kim joined the Office in 2008. Prior to joining our office, Kim worked at St. Francis Hospital as the Corporate Compliance Manager. Kim holds a Bachelor of Science in Healthcare Management from Ithaca College. Regulatory - Joanna Mackie is the Associate Regulatory Compliance Officer. Joanna?s primary responsibilities are maintaining regulatory compliance and preparing for regulatory surveys. She is a liaison to external surveyors such as the Department of Public Health, The Joint Commission and Centers for Medicare and Medicaid Services (CMS). Joanna joined the Office in April 2018. Prior to joining our office, Joanna worked as the Clinical Documentation RN Auditor Specialist in UConn?s Revenue Integrity Department. Joanna is a registered nurse and holds a BSN from Western Connecticut State University and a Master of Health Administration from Saint Joseph's University. She is certified by the Association on Clinical Documentation Specialists. Education - Virginia (Ginny) Pack is the Associate Educational Compliance Officer. Ginny?s primary responsibilities include developing and implementing compliance education and training programs. Ginny joined the Office in 2005. Prior to joining our office, Ginny worked as the Program Manager for Education and Training for Correctional Managed Health Care (CMHC). She holds a Master?s of Science degree in Nursing from the University of Saint Joseph. Shannon Kelmelis is the Administrative Officer. Shannon?s primary responsibilities include maintaining the department?s budget, the administrative functions of the institution?s monthly Exclusions Checking Programs and assisting with training needs. Shannon joined the Office in 2017. Prior to joining our office, Shannon worked for the UConn Health Department of Human Resources as an Administrative Program Coordinator. Shannon holds a Master of Education in Higher Education Administration from Post University. Michelle Mendocha is the Administrative Program Coordinator. Michelle?s primary responsibilities include supporting the Compliance Officer, Healthcare Compliance Staff and the University Policy Committee. Michelle joined the Office 2013. Prior to joining our office, Michelle worked in the Pediatric Dentistry department of Craniofacial Sciences as an Administrative Program Coordinator. Michelle holds an Associate Degree in Business Management from Mattatuck Community College. Kaitlyn Rewenko is the Regulatory Administrative Program Coordinator. Kaitlyn?s primary responsibilities are assisting with the coordination of all regulatory surveys. Her focus is on regulatory compliance for all agencies as they survey UConn Health. Kaitlyn joined the Office in April 2018. Prior to joining our office, she worked in the Quality and Infection Control Departments. Kaitlyn graduated from Central Connecticut State University with a BA in Psychology. REPORTLINE 888.685.2637
Transcript
May 2018 Volume 13, Issue 2
Compliance
Courier New Office of Healthcare and Regulatory Compliance
Recently, the Office of Audit, Compliance and Ethics (OACE) underwent a reorganization. After careful review of OACE?s function and structure, the department was divided into three distinct departments: the Office of University Compliance, the Office of Audit and Management Advisory Services and the Office of Privacy Protection and Management. In addition to the new University Compliance structure, there remains an Athletic Compliance Department, Research Compliance Department and the new Office of Healthcare and Regulatory Compliance at UConn Health. In February 2018 Debra Abromaitis was appointed the Interim Compliance Officer for the Office of Healthcare and Regulatory Compliance. The office has four focus areas - Clinical, Finance, Regulatory, and Education.
Clinical - Rikel Lightner is the Associate Clinical Compliance Officer. Rikel?s primary responsibilities include promoting compliance with regulations governing the provision of clinical services. Rikel joined the Office in May 2018. Prior to joining our office, Rikel worked at Correctional Managed Healthcare (CMHC) as a Health Services Administrator. Rikel is a registered nurse and holds a Juris Doctor from Western New England University School of Law.
Finance - Kimberly (Kim) Bailot is the Associate Finance Compliance Officer. Kim?s primary responsibilities include educating, monitoring and providing guidance on regulations that impact charging, billing or payment for clinical
services. Kim joined the Office in 2008. Prior to joining our office, Kim worked at St. Francis Hospital as the Corporate Compliance Manager. Kim holds a Bachelor of Science in Healthcare Management from Ithaca College.
Regulatory - Joanna Mackie is the Associate Regulatory Compliance Officer. Joanna?s primary responsibilities are maintaining regulatory compliance and preparing for regulatory surveys. She is a liaison to external surveyors such as the Department of Public Health, The Joint Commission and Centers for Medicare and Medicaid Services (CMS). Joanna joined the Office in April 2018. Prior to joining our office, Joanna worked as the Clinical Documentation RN Auditor Specialist in UConn?s Revenue Integrity Department. Joanna is a registered nurse and holds a BSN from Western Connecticut State University and a Master of Health Administration from Saint Joseph's University. She is certified by the Association on Clinical Documentation Specialists.
Educat ion - Virginia (Ginny) Pack is the Associate Educational Compliance Officer. Ginny?s primary responsibilities include developing and implementing compliance education and training programs. Ginny joined the Office in 2005. Prior to joining our office, Ginny worked as the Program Manager for Education and Training for Correctional Managed Health Care (CMHC). She holds a Master?s of Science degree in Nursing from the University of Saint Joseph.
Shannon Kelmelis is the Administrative Officer. Shannon?s primary responsibilities include maintaining the department?s budget, the administrative functions of the institution?s monthly Exclusions Checking Programs and assisting with training needs. Shannon joined the Office in 2017. Prior to joining our office, Shannon worked for the UConn Health Department of Human Resources as an Administrative Program Coordinator. Shannon holds a Master of Education in Higher Education Administration from Post University.
Michelle Mendocha is the Administrative Program Coordinator. Michelle?s primary responsibilities include supporting the Compliance Officer, Healthcare Compliance Staff and the University Policy Committee. Michelle joined the Office 2013. Prior to joining our office, Michelle worked in the Pediatric Dentistry department of Craniofacial Sciences as an Administrative Program Coordinator. Michelle holds an Associate Degree in Business Management from Mattatuck Community College.
Kaitlyn Rewenko is the Regulatory Administrative Program Coordinator. Kaitlyn?s primary responsibilities are assisting with the coordination of all regulatory surveys. Her focus is on regulatory compliance for all agencies as they survey UConn Health. Kaitlyn joined the Office in April 2018. Prior to joining our office, she worked in the Quality and Infection Control Departments. Kaitlyn graduated from Central Connecticut State University with a BA in Psychology.
REPORTLINE 888.685.2637
Training and Educat ion Updates Annual Training
The 2017 Annual Compliance Training closed on January 8, 2018. The overall completion percentage for UConn Health employees is 99.4%.
Best Wishes to Ginny Pack
After 33 years at UConn Health, Ginny will be retiring on July 1, 2018. She has been a great resource to UConn Health in the areas of Clinical Care, Education, Ethics and Privacy. Many thanks to Ginny for her dedication and contributions to UConn Health. We wish her well.
Joint Commission surveyors visit accredited health care organizations a minimum of once every three years to evaluate standards compliance. This visit is called a survey. UConn John Dempsey Hospital is currently in the window of our survey. All regular Joint Commission accreditation surveys are unannounced and begin at 8am. We have been informed that the following surveyors will be assigned to our survey:
- Behavioral Health Care Program (Generalist - 1 day) - Hospital Program (Ambulatory Specialist- 2 days ,
Engineer - 2days, Physician - 4 days, Nurse - 4 days and Administrator - 3 days)
The Hospital is surveyed on the 18 Chapters in the Hospital Survey.
- ?Accreditat ion Part icipat ion Requirements? (APR): Consists of specific requirements for participation in the accreditation process and for maintaining an accreditation award.
- ?Environment of Care®? (EC): Describes how to maintain a safe, functional, and effective environment for patients, staff, and other individuals in the organization.
- ?Emergency Management? (EM): Ensures that the organization has a disaster plan in place.
- ?Human Resources? (HR): Outlines processes for staff management.
- ?Infect ion Prevent ion and Control? (IC): Helps organizations identify and reduce the risk of acquiring and transmitting infections.
- ?Informat ion Management? (IM): Directs organizations to obtain, manage, and use information to provide, coordinate, and integrate care, treatment, and services.
- ?Leadership? (LD): Reviews structure and relationships of leadership and the maintenance of a culture of safety, quality, and operational performance.
- ?Life Safety? (LS): Covers fire protection systems, fire detection systems, and key fire safety building features that are challenging for hospitals.
- ?Medicat ion Management? (MM): Addresses the stages of medication use, including selection, storage, and safe management of medications, ordering, preparing and dispensing, administration, monitoring of effect, and evaluation of the processes.
- ?Medical Staff? (MS): Addresses the structure, role, and processes of the medical staff, including the process for credentialing and privileging and for evaluation of practitioners.
- ?Nat ional Pat ient Safety Goals? (NPSG): Includes specific actions that organizations are expected to take to prevent medical errors such as those caused by inaccurate patient identification, medication errors, health care?associated infections, harm associated with clinical alarm systems, and safety risks in patient populations.
- ?Nursing? (NR): Reflects the leadership role of the nurse executive including directing organization wide nursing services, establishing guidelines for nursing care delivery, and providing nursing care, treatment, and services.
- ?Provision of Care, Treatment , and Services? (PC): Covers four basic areas: planning care, implementing care, special conditions, and discharge or transfer.
- ?Performance Improvement? (PI): Focuses on using data to monitor performance, compiling and analyzing data to identify improvement opportunities, and taking action on improvement priorities.
- ?Record of Care, Treatment , and Services? (RC): Covers the planning function (components of clinical records, authentication, timeliness, and record retention) as well as documentation of items in the patient record.
- ?Rights and Responsibilit ies of the Individual? (RI): Addresses informed consent, participating in decision making, and respecting patient rights.
- ?Transplant Safety? (TS): Focuses on the development and implementation of policies and procedures for safely acquiring, receiving, storing, and issuing tissues and organs.
- ?Waived Test ing? (WT): Covers policies, identifying staff responsible for performing and supervising waived testing, competency requirements, quality control, and record keeping.
At the end of each day a report of our findings is given based of the SAFER (Survey Analysis For Evaluating Risk) MATRIX. The Joint Commission renders accreditation decisions two weeks to two months after the survey.
We appreciate the effort everyone puts in daily to keep our patients safe and remain in a constant state of regulatory preparedness.
What Happens During a Joint Commission Survey
We've Moved!The Of f ice of Healt hcare and Regulat ory Com pliance has m oved t o:
