Your health care organization has just learned that it is out of compliance in the problem areas listed below. You have been asked to research ONE problem and prepare an interoffice research memo that is double-spaced and not more than four pages. The Memo should be addressed to the VP of Finance and include the following sections with a heading in bold for each section. Use APA 7 for in-text citations and references.
- Memo Heading
- Memo To:
- Memo From:
- Re: (Regarding – Name the topic)
- Brief description of the problem
- State the Law and agency guidelines or regulations that govern the issue include the penalty for non-compliance
- Describe and evaluate how the COSO framework, components and principles can improve compliance and correct system-wide problems. See COSO Internal Control – Integrated Framework: An Implementation Guide for the Healthcare Provider Industry PDF
- Recommend a strategic corrective action plan (CAP) that implements components and principles from COSO. Name and describe at least three managerial actions you recommend to correct the specific problem and bring the organization into compliance using the COSO compliance tool.
- Give reasons to support selection of these actions. Indicate which COSO components and principles you relied on and why.
Problems (Select One)
- Your hospital has had multiple repeat hospital admissions of patients with pneumonia within 30 days of discharge in violation of the Hospital Readmissions Reduction Program (HRRP). CMS.gov Website: Hospital Readmissions Reduction Program (HRRP) Landing Page
- Your hospital as a score in the 75th percentile for Surgical Site Infection (SSI) during the last six months raising concerns under the Hospital-Acquired Condition Reduction Program (HACRP). CMS.gov Website: Hospital-Acquired Condition (HAC) Reduction Program Landing Page and AHRQ Website: Patient Safety Network – Never Events Landing Page
- Your long-term care facility has multiple never events in your long-term care facility with multiple patients developing Stage III and IV pressure ulcers during the last year. CMS State Medicaid Payments HAC Letter PDF
- Your long-term care facility has had multiple adverse events from medication errors that led to the deaths of 5 patients at your facility within the last month. You have been so busy investigating, you havent reported under the FDA Adverse Event Reporting System (FAERS). FDA Website: Questions and Answers of FDA’s Adverse Event Reporting System (FAERS) Link