Skip to main content

Compliance Audit

As a healthcare compliance company, Empower HCP is responsible for ensuring that your medical practice adheres to all relevant laws, regulations, and standards in the healthcare industry. To do this, Empower HCP will conduct a Compliance Program Effectiveness Audit (CPE), which is a comprehensive review of the practice's operations and procedures to assess its level of compliance. The following is a general outline of how we would go about conducting this audit for a medical practice.


Planning and Preparation

The first step in conducting a compliance audit is to plan and prepare. Empower HCP would start by reviewing the medical practice's policies and procedures, as well as any relevant laws and regulations. They would also identify the key areas of the practice that need to be audited and determine the scope of the audit.


On-Site Review

The next step is to conduct an on-site review of the medical practice. During this step, Empower HCP will analyze the practice’s compliance risk, observe the practice's operations and procedures, conduct interviews with employees, and review any relevant records and documents. Additionally, we will review billing process data and the internal audit reporting system. The goal is to get a comprehensive understanding of the practice's operations and to identify any compliance gaps.


Identification of Non-Compliant Areas

Once the on-site review is complete, Empower HCP would identify any areas of non-compliance and document their findings. This might include issues such as improper record-keeping, failure to follow appropriate privacy and security protocols, or lack of proper training for staff members.


Reporting and Recommendations

After identifying areas of non-compliance, Empower HCP will make recommendations for how the medical practice can remedy these issues and bring itself into compliance. This might include providing training to staff members, revising policies and procedures, or implementing new technology or systems to improve record-keeping and data management. The proposed action plan will identify any educational needs and identify stakeholders for implementation. We will also assist in the selection and training of a Compliance Officer and develop a compliance reporting process.



The final step in the compliance audit is to follow up and ensure that the medical practice has taken the necessary steps to come into compliance. Empower HCP will conduct another on-site review to confirm that the recommended changes have been implemented and that the practice is now in compliance with all relevant laws, regulations, and standards.

In conclusion, the purpose of a Compliance Program Effectiveness Audit (CPE) for a medical practice is to conduct a comprehensive review of the practice's operations to assess its level of compliance with relevant laws, regulations, and standards. The audit process involves planning and preparation, an on-site review, identification of non-compliant areas, recommendations and remediation, and follow-up. The goal is to ensure that the medical practice is operating in a manner that is compliant and protects both patients and the practice itself.

Compliance Ethics & Program

It is critical for medical practices to ensure that all of their activities and procedures adhere to the highest standards of ethics and compliance As such, Empower HCP helps practices build and implement effective compliance and ethics programs.

Following a Compliance Program Effectiveness Audit (CPE), Empower HCP works with an organization’s dedicated Compliance Officer(s) and internal team to develop a comprehensive compliance and ethics program for the healthcare provider. This compliance program typically includes the following components:


The compliance program and organizational compliance code of conduct will include a review of associated human resource policies and procedures. This written policy is clear and concise, and should outline the organization’s commitment to upholding ethical standards.


Before implementing a compliance program, a compliance committee will be developed and overseen by Empower HCP. We will work with this committee to develop the organizational workflows necessary to operationalize the compliance program policies and procedures, and develop a compliance awareness program to support the culture of compliance in the workplace.


The policies and procedures outlined in the compliance program should be periodically reviewed and updated to reflect new laws and regulations. We will also put a system of monitoring and auditing in place to ensure that all policies and procedures are being followed. This system will include regular reviews and reports to ensure that the compliance program is effective and that any issues are identified and addressed in a timely manner.

Our goal is to help medical practices create a compliant and ethical environment in which all team members have a clear understanding of policies and procedures, and are held accountable for their actions. A healthcare compliance company can help ensure that a practice is in compliance with all applicable laws and regulations, while also promoting a culture of ethical behavior. By utilizing the services of Empower NCP, medical practices can be confident that their compliance and ethics programs are effective and up-to-date. This will help to reduce the risk of legal and ethical violations, as well as protect the practice’s reputation and bottom line.

Co-Sourced Compliance Officer (CCO)

Empower HCP functions as the ongoing Co-Sourced Compliance Officer (CCO) for your organization. We will work in conjunction with your designated internal compliance officer or compliance team to build, implement, manage, and maintain the compliance program. We provide guidance to develop and integrate all the elements of the compliance program, including but not limited to:

  • Providing overall compliance program direction
  • Developing a culture of compliance and maintaining compliance awareness
  • Developing and implementing compliance operations policy and procedures
  • Preparing annual risk assessment and audit work plan
  • Overseeing auditing and monitoring activities
  • Confirming contract compliance
  • Developing and maintaining a compliance reporting system and investigations
  • Providing changes and updates on the regulatory environment to executives and compliance personnel
  • Reporting on program progress to corporate officials including the board and the compliance committee
  • Exclusion checking
  • Monitoring new services and workflow changes for risk
  • Business Associates - Vendor tracking/BAA
  • Monitoring billing compliance activities
  • FWA, HIPAA, OSHA and harassment training for new employees and as annual training

Our CCO program has the dual benefits of using recognized experts to bring a compliance program up to standard quickly and ensure it operates consistent with regulatory and program standards.

OSHA Safety & Compliance Program

OSHA safety and compliance is one of the most important aspects of any healthcare organization, and it is essential for a healthcare organization to ensure that their employees are safe and compliant with OSHA regulations and standards. Compliance with OSHA regulations is not only important to protect employees, but also to protect the organization from potential fines, penalties, and other legal repercussions.

At Empower HCP, we understand the importance of OSHA safety and compliance and the impact it can have on an organization’s operations. We are committed to providing our clients with the most up-to-date advice and resources to help them remain compliant with OSHA regulations. We develop OSHA safety and compliance programs tailored to meet the needs of each practice we work with. This program includes an annual assessment of the workplace environment, with a gap analysis for OSHA compliance with the health and safety standards promulgated by the Occupational Safety and Health Administration (OSHA), the United States Centers for Disease Control (CDC), and other regulatory and industry standards and guidelines for each facility. The OSHA Safety Program will also include assistance in developing and maintaining facility specific OSHA compliance manuals and documentation including OSHA’s Hazard Communication, Bloodborne Pathogens and General Safety standards individualized to your facilities’ plus abstracts and reference materials for relevant regulations.

Empower HCP provides detailed training sessions for staff on OSHA safety and compliance, including topics like hazard identification and control, proper use of safety equipment, and emergency preparedness. Our team is available around the clock to identify and address any potential compliance issues.

Compliance Training

Healthcare organizations face a variety of compliance requirements to ensure that they are delivering quality care to their patients in a safe and compliant manner. Compliance training makes certain staff understand and stay up-to-date on all relevant regulations, requirements, and best practices that help a medical practice run. At Empower HCP, we strive to make compliance training as engaging and effective as possible. Our experienced trainers create customized training content and programs to fit the specific needs of each practice or system, and our continuing education credits ensure that healthcare personnel remain compliant.

We offer both classroom-based and online training programs. Our classroom-based programs provide a hands-on learning experience, allowing healthcare personnel to ask questions and practice the skills they’ve learned. Our online programs provide a convenient, self-paced learning experience, allowing healthcare personnel to access the material at any time and learn at their own pace. We also provide continuing education credits to ensure that all healthcare personnel are up to date on their compliance training. Empower HCP is here to help you ensure that your organization meets all of its compliance requirements.

Modules available:

Compliance and Ethics

  • The fundamental expectations for a compliance program (7 key elements of a compliance program), disclosure, transparency and quality of care.
  • The relevant laws include FWA, FCA, Anti Kickback Statute, Beneficiary Inducement Statute, Stark Law, Excluded Entities and Individuals, and CMP’s .
  • Best Practices for Fraud Prevention: Detection, Correction, Prevention and Reporting.


  • Privacy Rule
  • Security Rule
  • SRA/Security Risk Management
  • Encryption
  • Patient right to access and copy their medical records
  • E-PHI minimal use of identifier
  • Patient right to request amendment of their medical records
  • Portable Devices
  • Ransomware, Phishing, Snooping, Malware
  • Patient right to restrictions on uses and disclosures
  • Business Associates
  • Patient right to confidential communications
  • texting, email, faxing, medical messaging, voice data
  • Patient right to accounting of uses and disclosures
  • Breach Response


  • OSHA Overview
  • Hazard Communication Standard
  • Bloodborne Pathogens Standard
  • General Industry Requirements
  • General Duty Clause


  • Definitions of harassment
  • Sensitivities and awareness
  • Complaints and how they should be made and handled
  • Investigation of complaints
  • Remedies, Consequences and Corrective action protocols
  • Discrimination
  • Employee Rights and Responsibilities
  • New sources of civil, criminal, personal and administrative liability

Customer Service

  • Knowing the difference between what to say and what not to say
  • Recognizing problems before they start
  • Listening and engaging
  • Effectively communicating
  • Coping with difficult situations
  • Being courteous and conscientious
  • Exceeding expectations

Organization-Specific Training Content

At Empower HCP, we specialize in creating organization-specific training content that is tailored to the needs of each organization we work with. Our training content is designed to help educate and inform employees on the latest changes in healthcare compliance and how that relates to the operations of your specific organization.

Our team of experts will work with you to create a customized training program that meets the specific needs of your organization. Specific training can be developed either onsite or by telephone conference with our professional trainers. You can utilize our topic specific content, or we can develop site-specific content and curriculum for unique needs. We can also license access to authoring tools, so you may create your own programs and content. No matter which alternative, or combination of solutions, you choose, the result is a facility and organization specific curriculum that efficiently handles most or all of your new hire and existing staff training and education needs.

Confidential Compliance Hotline Call & Message Center

Healthcare compliance is a complex and often confusing process, but organizational leaders can’t solve problems surrounding ethics and compliance until they are aware of them. A compliance and ethics hotline can help foster a sustainable work culture where everyone is encouraged to demonstrate ethical behavior and report any non-compliance they encounter. The Empower HCP Compliance Hotline Call & Message Center is a dedicated phone line available to all employees for any compliance-related issue. This confidential hotline provides an anonymous way to report any incidents or violations of applicable laws, regulations, and standards.

Empower HCP’s experts are available to listen to the concerns of your team and answer any questions they may have. We take all reports seriously and will take action when necessary to ensure compliance on your organization's behalf. Employees have the option to engage with the hotline on various platforms - phone, email, text, etc. - and all submissions remain confidential. Our call and message center is designed to provide teams with the guidance and support they need to be successful in an organization’s compliance efforts, and we are committed to helping ensure that your organization is in compliance with all relevant laws, regulations, and standards.

Employee Handbook

The success of any organization depends in large part on its employees. An employee handbook can be an invaluable tool in establishing standards of employee expectation and conduct. Empower HCP’s employee handbook services will provide your business with a comprehensive guide for your team that is clear, concise, and tailored to your organization’s needs. The handbook will contain information on the company’s history, mission, policies, code of conduct, and overall expectations. It will also include details on employee responsibilities, rights, and benefits. This handbook is given to your employees, subcontractors, vendors, volunteers and interns to clarify their rights and responsibilities during their relationship with your company. Empower HCP will also develop a Federal and State specific handbook which describes your practice’s expectations and commitment to ethics and compliance.

As your organization continues to grow, the need may arise from time to time to revise, supplement, or change when appropriate. Empower HCP provides annual and quarterly updates as needed to the employee handbook in order to stay in compliance so you can focus on your other organizational objectives.

To Top