Practice evaluation — more compliance challenges

Part two examines five additional areas in which practices often fall short.

In the March issue of Ophthalmology Management, I explained that, in my role of ensuring medical practices are compliant before entertaining prospective investors, I have learned many practices fall short on compliance measures ( ).

To help practices avoid this, I previously detailed five areas in which the compliance ball is often dropped. This month, in part two, I address five more.


A compliance plan for a medical practice summarizes and communicates standards of appropriate conduct for all who are part of the practice. Primary components of a compliance plan include the naming of a compliance officer, standards of conduct, instructions to conduct internal monitoring and auditing, practice standards and conformance. The plan should also include prohibited business practices, education and training records and instructions for the audit committee. In the event of an audit, a well-designed compliance plan can help demonstrate a practice’s intention to conduct itself ethically regarding business operations, government regulations and patient services and care.

  • Issue: In recent visits, I have found that practices either do not have a compliance plan in place or they have a generic version downloaded from the internet.
  • Solution: If your practice is missing a compliance plan, consider working with an auditing professional to help you create a customized document.


Many states have recently passed updated legislation regarding what is permissible to ask prospective employees during interviews. For example, employers in some states are not permitted to ask candidates about their salary history or complete reference checks until they have extended a conditional offer of employment.

  • Issue: In some practices, I have found applications that contain fields that could be misconstrued as discriminatory, such as requesting information about a candidate’s health history or graduation dates for education.
  • Solution: Practices should consult with their labor attorney(s) to verify their application for employment and hiring protocols meet state and federal guidelines.


In a busy practice, it can be easy to forget to periodically review employee files. Practices should consult their state’s Department of Labor website, talk with their attorney(s), or both, to establish what documents to include in personnel files.

  • Issue: During my recent audits, I have discovered incorrect or incomplete employee forms, hiring documents or interview notes that could be misconstrued as discriminatory, and employee write-ups (or lack thereof) that could be challenged by a disgruntled employee.
  • Solution: Practices should establish an employee file retention policy and provide managers with guidelines as to what should be kept in employee files. Furthermore, the practice’s labor attorney(s) should approve the retention policy.

9. I-9 FORMS

The I-9 form is used to verify the identity and legal authorization to work for all paid U.S. employees. According to the Society for Human Resource Management’s website (under the section “Are You Prepared for an I-9 Compliance Audit,” at ), the U.S. Department of Homeland Security’s Immigration and Customs Enforcement (ICE) dictates that “[I-9 forms] for former employees is only needed for one year after separation or three years from date of hire (whichever is later).”

  • Issue: When I visit practices, I often find I-9 forms are missing or stored (incorrectly) in employee files.
  • Solution: Employers are required to maintain I-9 forms separately from personnel files and retain records based on the aforementioned parameters. With those requirements in mind, I suggest employers file I-9 forms (for current and terminated employees) in a separate binder under alphabetical order.


Most practices I work with have an employee handbook to outline practice policies, such as overtime, employee code of conduct and employee relations (eg, harassment).

  • Issue: While most practices I visit have an employee handbook, I find that many are often outdated, or the policies outlined are not really how things are done.
  • Solution: Consider setting a practice standard to review and update the employee handbook every one or two years. Have your attorney(s) review the handbook before distributing updates to staff.


So, how did your practice fare? Did you find yourself less than perfectly compliant in any of the 10 areas I covered? Regardless of whether your practice is considering a PE transaction, set aside time to review compliance initiatives throughout your organization.

These staff trainings and policies are designed to protect your business, staff and patients. By ensuring your group stays up to date, you can rest assured that your practice is well suited to pursue any future business opportunity that may present itself. OM