To: Sonoma County Board of Supervisors
Department or Agency Name(s): Department of Health Services
Staff Name and Phone Number: Tina Rivera 707-565-4774; Jennifer Pimentel, 707-565-5311; Sharmalee Rajakumaran, 707-565-3738
Vote Requirement: Majority
Supervisorial District(s): Countywide
Title:
Title
Department of Health Services Compliance Program Biennial Report
End
Recommended Action:
Recommended action
Receive the Sonoma County Department of Health Services Compliance Program Biennial Report for Calendar Year 2022 - Calendar Year 2023.
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Executive Summary:
The Department of Health Services (DHS) Compliance Unit is responsible for directing and administering a comprehensive healthcare compliance program, ensuring compliance with federal, state, and local healthcare regulations and requirements. The Board of Supervisors is responsible for providing oversight to ensure DHS has an adequate and effective compliance program and through delegated authority ensures the Director of Health Services provides the administrative oversight and leadership of the program through the direction of the Compliance Officer. The Board of Supervisors also ensures the Compliance Officer has unfettered access through an effective reporting system that assures the appropriate information relating to compliance with applicable laws will come to its attention timely and accurately.
This item requests the Board receive the Sonoma County Department of Health Services Compliance Program Biennial Report for Calendar Year (CY) 2022 - CY2023.
Discussion:
Per the U.S. Department of Health and Human Services Office of Inspector General’s Practical Guidance for Health Care Governing Boards on Compliance Oversight, it is imperative that the Board of Supervisors understands its role and the function of the compliance program focusing on the following: (1) roles of, and relationship between, the organization’s audit, compliance, and legal departments; (2) mechanisms and process for issue-reporting within an organization; (3) approach to identify regulatory risk; and (4) methods of encouraging enterprise-wide accountability to achieve compliance goals <https://oig.hhs.gov/documents/root/162/Practical-Guidance-for-Health-Care-Boards-on-Compliance-Oversight.pdf>
On January 17, 2017 the Office of Inspector General and Health Care Compliance Association (HCCA) released Measuring Compliance Program Effectiveness: A Resource Guide. <https://oig.hhs.gov/documents/toolkits/928/HCCA-OIG-Resource-Guide.pdf>
In March 2023, the Criminal Division of the U.S. Department of Justice (DOJ) released updated guidance to its prosecutors on how to evaluate the design, implementation, and effective operation of corporate compliance programs in determining whether, and to what extent, the DOJ considers a corporation’s compliance program to have been effective at the time of the offense and to be effective at the time of a charging decision or resolution. <https://www.justice.gov/criminal-fraud/page/file/937501/download>
The Compliance Program Biennial Review for CY 2022 & CY 2023 was conducted for the DHS by Hilliard Compliance Consulting in December 2023 which is the focus of the Compliance Program Workplan for the CY 2024 & CY 2025.
From CY 2022 - CY 2023, DHS continued to maintain a Compliance Program by working collaboratively with Department staff and adhering to the United States Sentencing Commission’s Federal Sentencing Guidelines seven elements of an effective compliance program:
Element #1: Compliance Policies and Procedures and Standards of Conduct
Element #2: Compliance Officer and Compliance Committee
Element #3: Training and Education
Element #4: Auditing and Monitoring
Element #5: Reporting and Investigation
Element #6: Enforcement and Discipline
Element #7: Response and Prevention
In accordance with the seven elements of an effective compliance program, DHS conducted CY 2023 risk assessment and developed a workplan for CY 2024-CY 2025. The Risk Assessment identified strengths and areas of improvement. The Workplan outlines risk mitigation activities for areas of improvement and ensures consistent growth.
Examples of Compliance Program strengths:
1. Significant progress has been made by the Compliance Officer (“CO”) and Unit staff, working collaboratively with their Department colleagues.
2. The majority of the seven structural and process elements of the Compliance Program have been developed, implemented, and have demonstrated positive outcomes.
The Department has taken a number of system-wide measures to improve compliance, especially in federally funded health programs, and mitigate risk to the County. The work plan for CY 2024 and CY 2025 reflects the Department’s goal of addressing identified gaps and the intent to work collaboratively across the Department.
Strategic Plan:
N/A
Racial Equity:
Was this item identified as an opportunity to apply the Racial Equity Toolkit?
No
Prior Board Actions:
On May 9, 2023 the Board received the Sonoma County Department of Health Services Compliance Program CY 2022/2023 Mid-Plan Progress Report for CY 2022.
On March 1, 2022 the Board received the Sonoma County Department of Health Services Compliance Program annual report for CY2018 - CY2021.
On December 4, 2018 the Board received an orientation on health care compliance and the Board’s oversight role from national compliance expert Lynda Hilliard. The Board directed the Compliance Officer to prepare an annual healthcare compliance report to the Board beginning in Spring 2019.
On March 2, 2010 the Board received the 2009 Healthcare Compliance Program Annual Report.
On February 24, 2009 the Board received the 2008 Healthcare Compliance Program Annual Report.
On May 13, 2008 the Board received the 2007 Healthcare Compliance Program Annual Report.
On March 6, 2007 the Board received the 2006 Healthcare Compliance Program Annual Report.
On May 17, 2005 the Board received a report of the 2003 - 2004 Compliance Program Evaluation from the Department of Health Services.
On April 6, 2004 the Board adopted a resolution approving the Department of Health Services Compliance Program and directing the Director of Health Services to implement it and to amend it from time to time as necessary (Resolution No. 04-0296).
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Narrative Explanation of Fiscal Impacts:
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Narrative Explanation of Staffing Impacts (If Required):
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Attachments:
None
Related Items “On File” with the Clerk of the Board:
None