1. RIDER 33/CHAPTER 261 COMPLIANCE AUDITS

2. What is it? The legal requirement to report abuse (sexual or other abuse) of children The rules include reporting all children under the age of 14 who have been sexually active, who have an STD or are pregnant. The rules include reporting all children between 14 and 16 who have been sexually active in certain circumstances.

3. Why is it important to us? Reporting child abuse is the right thing to do. Our state laws mandate reporting child abuse. Our grants from DSHS (Family Planning, Child Health and STD) provide an opportunity for the State to monitor our performance.

4. What are we doing to make sure we comply? All 4 C’s staff have responsibilities. Registration and Medical records staff highlight minors’ medical records by placing stickers on them. Medical aides and nurses assess (screen) patients and make sure the right forms are available for documenting and reporting.

5. Providers and nurses assess patients for abuse and complete documentation. If needed, they report to Child Protective Services. If a patient is married, or if a patient 14- 16 states that they are sexually active with a partner less than 3 years older than they are, reporting is not mandated, but the “affirmative defense” must be documented in the record.

6. If we report, what happens? The object of reporting is to notify the authorities of an abusive situation that may be dangerous to our patient. We are reporting the abuse, not the patient. An investigation may be made.

7. How do we monitor our performance? Every month the Compliance Auditor gets a computer report showing minors that have received services for prenatal care, STD treatment or Family Planning Services. WIC is audited separately. The medical records are carefully audited to see if a checklist should have been completed and if a report to CPS should have been made.

8. If responsible staff has not made a necessary report or has not made proper documentation in the medical record, a letter is sent to them requiring them to complete the records immediately.

9. If staff have multiple instances of non-compliance, corrective actions (discipline) may be initiated.

10. Audit Data From May – October, 57 4 C’s clinic records have been audited, all were children 14-16 No clinic services were given to children <14

11. Audit Data Of the 57 records, 14 had errors in reporting or documentation Of the 14, 9 were substantial errors: no checklist done (7), checklist done incorrectly(1) or was not reported to CPS when it should have been(1).

12. Audit Data 2 of the 14 records were reported to CPS late (more than 48 hours after the patient had been seen) 3 of the 14 records had minor procedural errors

13. How are we doing? Documentation has improved over the past six months and most cases are reported correctly. Those instances that are not reported correctly are caught and reports are made. Staff receive education if needed.

14. The Result? Internal compliance auditing is working to assure compliance with the law and secure funding of services for residents who need family planning, OB, STD and WIC. A recent WIC audit by the State revealed no findings. We strive for 100% compliance and will demonstrate compliance if audited.