MHA 508 Week 5 Auditing and Monitoring for Compliance Example

Weekends Tell the Truth: A Risk-Based Audit and Monitoring Plan for a Nursing Facility Operator, With a Staffing Data Audit as the First Test

[Student Name]

University of Phoenix

MHA/508: The Regulatory Environment in Health Care

Week 5 Assignment

[Instructor Name]

[Date]

The nursing facility operator, its audit plan and findings are composites written for a model paper; national figures come from the federal data set cited, retrieved in September 2026, and guidance and research from the sources listed.

At the quarterly meeting of the board's quality and compliance committee, a director asked the compliance officer of a composite nonprofit operator of fourteen nursing buildings a simple question: the program looks good on paper, but how do you know it works? The compliance officer answered that she would show the committee the audit plan and the results of its first audit. This paper describes both.

Auditing Versus Monitoring

People swap the two words freely, yet they name different tools. Monitoring is routine, ongoing checking of known risks, usually by the people who run a process, such as a director of nursing reviewing falls each week. Auditing is a periodic, structured review, conducted independently of the process, that tests whether requirements are actually met and whether controls work.

What OIG Recommends

OIG's general compliance guidance advises that the compliance committee build a work plan with a schedule of audits based on risks identified in an annual risk assessment, keep capacity for additional audits when new risks appear and include clinical review of medical necessity in claims audits. It lists routine monitoring examples such as monthly screening of exclusion lists and recommends periodic review of whether the program as a whole is effective, reported directly to the board (Office of Inspector General, 2023).

Where the Plan Came From

The previous year, the operator built a risk matrix with eight rows. The audit plan takes its topics from the rows rated red or amber, together with the payment and legal risks that auditors, rather than managers, are best placed to test.

The Annual Audit Plan

Six audits are scheduled for the year. Staffing data submitted to CMS, in the first quarter. Resident assessment coding, with a clinical reviewer, in the second quarter and again in the fourth. Abuse allegation reporting timelines, in the second quarter. Infection prevention practices, by direct observation, in the third quarter. Referral-source contracts against fair market value, in the third quarter. Each audit states its question, sample, method, standard and auditor.

Routine Monitoring

Monitoring continues between audits: monthly screening of every employee and contractor against federal and state exclusion lists, weekly falls and infection reviews by nursing leaders, daily review of abuse allegations by administrators and monthly review of staffing reports by human resources.

Independence

Audits are conducted by the compliance department's auditor, a registered nurse with coding credentials, or by an outside firm for coding and contracts. No building audits itself, and auditors report to the compliance officer, not to operations.

Why Staffing Data First

Staffing data went first for three reasons. Each building's hours are submitted to CMS from payroll, publicly reported and used in star ratings. Errors can mislead residents and families. And the risk matrix had rated staffing data accuracy amber, with a known weakness in how agency hours were recorded.

What National Data Show About Weekends

Payroll-based data have changed what the public can see. A study of the first federal payroll-based staffing data found large day-to-day fluctuations in staffing, much lower staffing on weekends and many days below CMS expectations, and concluded that the data give a more complete picture than earlier self-reported figures (Geng et al., 2019). Current federal data confirm the pattern: across 14,288 facilities with reported staffing, median total nurse staffing was 3.68 hours per resident day, but only 3.26 on weekends, and median registered nurse hours fell from 0.58 to 0.39 on weekends. About 60% of facilities reported weekend staffing at least 10% below their overall level (Centers for Medicare & Medicaid Services, 2026). A resident who falls on a Sunday is cared for by the weekend staff, not the average.

The Audit Question and Method

The audit question was whether hours submitted to CMS for two quarters matched payroll and agency invoices and were assigned to the correct job categories. The auditor sampled 28 days per building, including 8 weekend days, and compared submitted hours with timecards, agency invoices and schedules for every nursing employee on those days.

Finding One: Agency Hours

Four buildings had agency nurse hours missing from submissions on some days, because invoices arrived after the submission deadline and were never added. Across the sample, 3.1% of agency hours were missing, understating staffing.

Finding Two: Job Categories

Two buildings coded the director of nursing's administrative hours as direct care registered nurse hours, which federal instructions exclude. This overstated registered nurse hours at those buildings by about 0.08 hours per resident day.

Finding Three: Weekends

Accurate data revealed a real problem. On sampled weekend days, registered nurse hours averaged 0.36 per resident day, compared with 0.61 on weekdays, and three buildings had weekend days with fewer than eight consecutive registered nurse hours, which federal rules require every day unless a waiver applies.

What the Auditor Did Not Find

The audit also reported what was working. Ten buildings had submissions within 1% of payroll on every sampled day, and no building had hours for people who did not work. Reporting clean results matters: it tells leaders which controls work and keeps the audit from being seen as a hunt for wrongdoing.

Root Causes

The auditor traced each finding to its cause. Missing agency hours came from a timing gap between invoices and submission deadlines, not from any intent to understate. The job category errors came from a payroll setup made years earlier that no one had revisited. The weekend gaps came from a staffing model that relied on registered nurses volunteering for weekend shifts, which fewer were willing to do after two resigned.

Reporting the Results

The compliance officer reported findings to the compliance committee within two weeks and to the board committee at its next meeting, with a one-page summary: what was audited, what was found, what it means and who owns the fix.

Corrective Actions

Agency invoices now arrive weekly and are reconciled before each submission. Director of nursing hours were recoded, and corrected data were resubmitted where the window allowed. For weekends, the chief nursing officer created weekend registered nurse supervisor positions shared across nearby buildings and added a weekend differential. Each action has an owner and a due date.

Follow-Up

A follow-up audit of the same measures six months later will test whether the fixes worked. Weekend registered nurse coverage is now monitored weekly by the chief nursing officer until the follow-up audit confirms the change.

Measuring the Program Itself

Following OIG's advice, the board will commission an outside review of the whole compliance program's effectiveness every two years, reported directly to the board committee.

Answering the Director

The compliance officer's answer to the director was the audit itself: a risk-based question, a clear method, findings that included problems no one had seen and fixes with owners and dates. That, she said, is how you know the program works: it finds things.

Conclusion

A compliance program is only as good as its ability to detect problems. Separating monitoring from independent auditing, drawing audits from a risk assessment and following OIG's guidance produced a plan the board could understand. The first audit corrected reporting errors and, with accurate data, exposed a weekend staffing gap consistent with national patterns, leading to real changes in care.

References

Centers for Medicare & Medicaid Services. (2026). Provider information [Data set]. Provider Data Catalog. https://data.cms.gov/provider-data/dataset/4pq5-n9py

Geng, F., Stevenson, D. G., & Grabowski, D. C. (2019). Daily nursing home staffing levels highly variable, often below CMS expectations. Health Affairs, 38(7), 1095-1100. https://doi.org/10.1377/hlthaff.2018.05322

Office of Inspector General. (2023). General compliance program guidance. U.S. Department of Health and Human Services. https://oig.hhs.gov/compliance/general-compliance-program-guidance/