Tips for Setting Up a Compliance Calendar

Calendar with Teal background

Identifying key components to add to your day-to-day processes

By Nicole Kluckhohn, PT, DPT, PhD*

Required and recommended compliance training has increased significantly over the past decade.

Patient Privacy/Security, Workplace Safety, Insurance Credentialing, and Medical Records Training can be a substantial burden for clinic owners, and it may seem impossible to find the time to ensure staff are up to date on training without consistently cutting into patient care time. A written/formal compliance plan is a requirement for all private practices. In addition to the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH) law requirements, there are OSHA requirements and potentially state and local requirements. Once you have a list of your annual compliance requirements, it is important to schedule them and track completion. The purpose of this article is to outline a simple and comprehensive compliance calendar for the year that you can use to break down your list of compliance requirements into small bites that are more palatable.

1. Establish Annual Training Topics

The first step is to identify the major educational topics that need to be reviewed. Next, identify how best to educate your staff on these topics and track completion with the resources you have. There are many great educational resources available that provide video modules and tracking of completion. This may not be financially viable for your practice, so perhaps topics that are reviewed or discussed in person, or independent reading with a short quiz, is a more feasible choice for ensuring all staff have completed these annually. You may choose to set a specific month annually to require all staff to have these completed—ideally, a slower month seasonally for your business, or you may choose to highlight one “Topic of the Month” to review as part of a routine monthly staff meeting. Either option is effective, and should allow for easy tracking of completion rates.

Annual Training Topic Examples
  • Policy Review Including Code of Conduct Attestation
  • Compliance Plan Review
  • HIPAA
  • Documentation Education
  • Billing and Coding Education and Review
  • OSHA/Infection Control
  • Sexual Harassment
  • Workplace Violence
  • CPR Training

2. Safety Drills

Identify the Safety Drills that are established (or should be established) in your geographic market. Set up a practice schedule for the Emergency Drills to get through each one at least one time per year, perhaps on a quarterly rotation if you have four to do; for example, Fire, Tornado/Hurricane/Earthquake, Bomb, Active Shooter. The goal is for your staff not to have to respond to these scenarios without ever having considered or practiced the protocol in advance.

Tracking and Audits

In addition to training topics and safety drills, your administrative team should be tracking the following on a regular basis. Included in that list is monthly checking of the Office of Inspector General (OIG) exclusion list to ensure all active providers are in good standing, updating the National Plan and Provider Enumeration System (NPPES), and ensuring licenses for all clinical staff are in good standing and not expired. Checking licenses should be done as staff is hired and then with each renewal. Finally, regular tracking of credentialing revalidation for staff will minimize risk of lost revenue.

Tracking/Updating New Hires and Each Licensure Period
  • Revalidation Timing (quarterly check of Medicare website)
  • Licensure Expiration (annually/biannually depending on state)
  • NPPES Updates
  • CPR Renewals (depending on setting requirements)
  • OIG Exclusion list for all licensed staff (monthly)
  • Any additional requirements specific to your market and setting

4. Documentation and Chart Audits

Whether these chart audits are done by specific members of the clinical team or as peer reviews, there needs to be a process to ensure that charts are complete and meet the requirements of the payer. This includes demonstrating evidence of the necessary skills and accurate billing. This is much more easily managed with regular reviews throughout the year; that is, a specified number of charts per month instead of trying to manage a year’s worth of charts just before annual performance reviews. Managing these each month also allows for faster feedback and coaching to correct errors.

Now that you have identified the key components of your compliance plan, you can begin to layer these into a calendar that allows for these to become intertwined in day-to-day processes instead of a large looming project. Following is an example of how this could look depending on your clinic needs and personal preferences. Make this your own and manage it to meet the needs of your clinic and staff.


Nicole Kluckhorn

Nicole Kluckhohn is a PPS member and Senior Consultant with 8150 Advisors. She can be reached at nicole@8150advisors.com.

*This author has a professional affiliation with this subject.