ACE ALERT: Is your compliance program up to date?

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ACE Alert, May 12, 2021, Volume 20

Is your compliance program up to date?

 Lynette Peterson, CHC, CHA

An effective compliance and ethics program is outlined in the Federal Sentencing Guidelines, Organizational Guidelines Chapter 8, and is frequently summarized in seven steps.  However, a compliance plan is intended to be much more than a book that sits on a shelf. 

There have been several updates to the laws that govern anesthesia and pain management practices such as the Stark Law and Anti-Kickback law.  These changes may require updates to your compliance program. Compliance programs are to be living documents and should reflect changes and updates based on current law and practice management initiatives.

 As stated in the Application Notes section of the Sentencing Guidelines, “An organization’s failure to incorporate and follow applicable industry practices or the standards called for by any applicable governmental regulation weighs against a finding of an effective compliance and ethics program.”

Many organizations struggle with how to demonstrate an active compliance and ethics program.  Your practice should have the policy to review the compliance program annually, at a minimum, with additional reviews when significant changes occur. 

Below are some sample questions you can use to help determine if you have an up-to-date compliance plan. 


Feel free to share the ACE Alert with your network. 

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