UW Medicine Compliance
Governmental Investigations – COMP.008
The purpose of this policy is to ensure enterprise-wide consistency in responding to government investigations and subpoenas involving healthcare compliance matters. It applies to all UW Medicine entities, departments and individual workforce members.
Applicability: UW Medicine and UW Medicine Affiliated Covered Entity
Policy Title: Government Investigations
Policy Number: COMP.008
Superseded Policies: VMC, Response to Government Investigations
UWMC, 15-5 Response to Government Investigations and Subpoenas
Date Established: October 11, 2017
Date Effective: February 2, 2011
Next Review Date: February 2, 2024
UW Medicine cooperates fully with legally authorized government investigations and subpoenas, involves designated institutional officials throughout the process, produces records in a timely manner and retains appropriate documentation in accordance with established record retention schedules.
UW Medicine is a complex organization with numerous offices that have sole or matrixed responsibilities for certain issues. Responsibility for implementing this policy is shared by entity leadership, managers, workforce members, UW Medicine shared services departments and other designated institutional officials.
A. Each entity is responsible for developing its process to address and advance government investigations and subpoenas in collaboration with the appropriate UW Medicine shared services departments that have scope and jurisdiction over the issue. Each entity shall have a designated institutional official to liaise and assist in the identification of the appropriate parties to manage an issue.
Designated institutional officials responsible for specific issues will:
- Issue required notifications regarding the visit;
- Ensure appropriate documentation and adequate information about the purpose and extent of the visit is obtained before the investigation, review or audit commences;
- Ensure each individual understands their role and responsibility, the authority of the external reviewers and the compliance issues in question;
- Ensure that relevant records are gathered and produced in a timely manner;
- Ensure appropriate communication protocols are established and maintained;
- Provide acceptable accommodations and access to the site visitors; and
- Develop and retain appropriate records of all correspondence, meeting minutes, phone notes and other communications with the external investigators.
B. Any workforce member who is approached by someone claiming to be a government investigator, external auditor or site reviewer, or who receives a subpoena or other written, official governmental request for information (such as a Civil Investigative Demand) must immediately report it in accordance with entity-based reporting requirements.
A. Destroying or altering any document or record in anticipation of a request for material by a government agency or court.
B. Lying or making false or misleading statements to any government investigator.
C. Failing to cooperate with a government investigation.
D. Attempting to persuade any other individual to provide false or misleading information to a government investigator.
Government investigators or persons presenting themselves as government investigators may contact workforce members outside the workplace, during non-work hours or at home. Workforce members may choose to talk to investigators, but also have the right to contact legal counsel or the designated institutional official(s) before responding to any questions.
- UW Medicine Compliance Glossary.
- University of Washington Regulatory Response Guidance.
- Health Sciences Risk Management, Subpoena, Deposition, and Testimony Guidelines for UW Medicine and the School of Dentistry (VMC, see VMC Risk Management).
- VMC, Search Warrant Response Guidelines.
- VMC, Subpoena Response.
- UWNC, Upol057 Management of Media, Governmental Agencies, and Other Third Party Inquiries.
- UWP, Subpoena for Billing Records.
- ALNW, 1106 Staff Member Rights in a Government Investigation
- United States Sentencing Commission, Guidelines Manual, §8B2.1 (Nov. 2016).
- Compliance Program Guidance for Hospitals, 63 Fed. Reg. 8987 (February 23, 1998).
- Supplemental Compliance Program Guidance for Hospitals, 70 Fed. Reg. 4858
(January 31, 2005).