HealthcareHow to Reduce Healthcare Compliance Risks

Depending on the size of your facility, you may employ a healthcare compliance officer or may even have a compliance department. You may have a healthcare compliance program in place with scheduled audits. Furthermore, you are likely monitoring billing accuracy, privacy incidents, and accreditation readiness.

And yet, many healthcare compliance risks slip through the cracks in internal audits, only to be discovered by a surveyor down the line.

The nursing license, the BLS certification, and the continuing education—all of these requirements renew on a schedule unique to each clinician.

Learn how to reduce healthcare compliance risks in your facility from billing to credentialing.

Where Healthcare Compliance Risk Usually Occurs

Regulatory compliance in healthcare breaks into five domains. Four of them are well covered at most organizations. Workforce and credentialing are not, which is where this article goes deepest.

Billing and Coding

The False Claims Act (31 U.S.C. §§ 3729–3733), the Anti-Kickback Statute, and the Stark Law govern this domain. Exposure comes from upcoding, unbundling, and services billed without adequate documentation of medical necessity. The consequences of non-compliance in healthcare are steepest here because penalties attach per item or service rather than per incident, so liability scales with claim volume.

Privacy and Security

HIPAA compliance covers the Privacy Rule, the Security Rule, and breach notification. The weak point is rarely the organization’s own systems. It is the business associate agreement that nobody revisited, and the third-party vendor whose access was never scaled back after a project ended.

Clinical Quality and Safety

The CMS conditions of participation at 42 CFR Part 482 set the federal floor, with accreditation standards layered on top. Adverse-event reporting, medication management, and restraint use all carry documentation requirements that surveyors examine directly.

Workforce and Credentialing

This is the domain worth going deepest on, for a structural reason. In every other area, compliance status changes when someone does something. Here it changes when a date passes. A license that was valid yesterday is no longer valid today, and nothing in the workflow indicates it.

It is also where responsibility is most often misunderstood. In its 2013 Special Advisory Bulletin on the effect of exclusion, the HHS Office of Inspector General (OIG) gives a direct example: if a hospital contracts with a staffing agency for temporary or per diem nurses, the hospital carries overpayment liability and may face civil monetary penalties if an excluded nurse furnishes services to federal beneficiaries.

That settles the question of who is responsible for credentialing agency staff. A facility may rely on the contractor’s screening, but OIG recommends validating that the contractor is actually performing it by requesting and retaining the documentation. The compliance risks associated with temporary healthcare staff remain with the facility.

CMS reinforces this elsewhere. Under 42 CFR 482.13(f), staff with direct patient care responsibilities must demonstrate competence in restraint and seclusion before participating in that care.

Labor and Employment

Worker misclassification exposure is assessed under the IRS common-law analysis, which weighs behavioral control, financial control, and the parties’ relationship. Wage, hour, and overtime documentation for contingent staff sits in the same bucket.

How to Build a Continuous Monitoring Cadence

A compliance risk assessment that stops at the domain level misses all of this.

A workable healthcare compliance checklist answers three questions for every credentialed item: what the authoritative source is, how often it should be checked, and what forces an immediate re-check.

Item	Source of Truth	Frequency	Immediate Re-Check Trigger
State license	State board of nursing, or Nursys, for participating boards	No federal interval (42 CFR 482.23(b)(2) requires a procedure ensuring valid, current licensure; state law sets the rest)	Disciplinary alert, endorsement into a second state, name change
DEA registration	The registrant’s certificate	Renews every 36 months (21 CFR 1301.13)	Change of practice address or state
Board certification	The certifying body (ANCC certifications are valid for five years)	Set by the board, not by a regulator	Lapse in required continuing education
BLS and ACLS	American Heart Association (AHA) eCard verification	Valid for two years through the end of the issue month	Card presented without a verifiable eCard code
Exclusion screening	OIG List of Excluded Individuals and Entities (LEIE)	OIG recommends monthly (See the caveat below)	New hire, new contract, any agency roster change
Respirator fit test	Employer fit-test records	Annually, per 29 CFR 1910.134(f)(2)	New facepiece make, model, style, or size; weight change, dental change, facial scarring
TB screening	Employee health	Baseline at hire (CDC does not recommend annual testing absent known exposure or ongoing transmission)	Known exposure, or transmission at the facility
Immunization records	Employee health	Set by facility policy and state law	New exposure, change in unit assignment
Competency validation	Personnel file	No CMS interval (42 CFR 482.23(b)(5) requires assignments to match competence; facility policy sets the rest). Joint Commission staffing services measures: at hire or rehire, then annually.	New unit, new equipment, scope-of-practice change
Bloodborne pathogens training	Training records	Annually, per 29 CFR 1910.1030(g)(2)	New task with occupational exposure
Emergency preparedness training	Training records	Every two years, per 42 CFR 482.15(d)	Significant update to policies and procedures

Two rows are commonly over-complied with.

1. The CDC’s 2019 recommendations, developed with the National Tuberculosis Controllers Association, state that U.S. healthcare personnel without latent TB infection should not undergo routine serial testing at any interval after baseline.
2. Emergency preparedness training runs on a two-year cycle under 42 CFR 482.15, not annually, though testing exercises occur twice a year.

Set the Alert Window Before the Expiry, Not at It

The question of how often licenses should be re-verified matters less than when the warning arrives, and a 30-day alert assumes 30 days is enough to renew.

The renewal windows are not consistent between issuing bodies, which is why a single fixed lead time is wrong by construction. Under 21 CFR 1301.13(b), a practitioner may apply to be reregistered no more than 60 days before a DEA registration expires. No internal alert policy can create more runway than that.

ANCC operates the opposite way: its 2027 renewal handbook accepts applications up to a year before expiration and allows no grace period or backdating, so a late application creates a permanent gap in the certification dates rather than a brief lapse.

Nursys e-Notify, the national licensure notification system operated by NCSBN, sends institutional expiration reminders on the 1st of the month about licenses expiring that month or the next. That cadence works for a clean online renewal. It does not work when the renewal requires completion of continuing education, a disciplinary disclosure review, or endorsement in a second state. Nursys also posts notices when individual boards fall behind on data submission, meaning a verification that was current last month may no longer reflect the board’s current record.

Tier the alert to the issuing body’s own window and to what the renewal actually requires.

Treat the Expiring Credential as a Scheduling Constraint

Credential expiration tracking that lives in a spreadsheet reviewed monthly will always lag the schedule it governs. The credential gets checked on the compliance team’s cadence rather than on the date someone is assigned to a shift, which is the only moment the status actually matters.

Many healthcare workforce management platforms, for example Nursa, let facilities automatically track credential expirations and proactively block assignments, so a clinician with a lapsed credential is never scheduled for a shift in the first place.

What to Automate First

Not everything in healthcare staffing compliance should be automated, and the order matters.

Automate Anything with an Expiry Date

Dates are mechanical.

This has the highest ratio of risk reduction to implementation effort, and it requires no judgment about what a credential means, only about when it lapses.

Automate Exclusion Screening

The common understanding of OIG exclusion screening is wrong in a specific and useful way.

OIG’s 2013 bulletin states plainly that providers are not required by statute or regulation to check the LEIE. It is a tool OIG makes available, and providers may decide how frequently to use it. OIG recommends monthly screening because the list is updated monthly.

Separately, CMS issued final regulations in 2011, at 42 CFR 455.436, requiring states to screen all enrolled providers monthly. However, this does not obligate states to require providers to screen their own employees and contractors at that interval.

So the strongest available control in workforce compliance has no rule behind it. It has liability behind it, which is a better reason. Screening is mechanical work against a public database, and the exposure it prevents is per-claim.

Automate the Audit Trail, Not Just the Check

You must be able to demonstrate when you verified, not merely assert that you did.

The Joint Commission’s standards interpretation on primary source verification requires organizations to document the date the verification was conducted, who conducted it, what specifically was verified, and the result. It also states that presenting a copy of a license without evidence that the organization has completed primary-source verification does not meet the requirement’s intent. That documentation obligation is the part of the Joint Commission staffing requirements most often failed during a survey, which is why point-in-time evidence is the real deliverable.

Do Not Automate Judgment

Compliance monitoring software handles dates, lists, and evidence retention. It does not handle competence.

The Joint Commission’s guidance on competency assessment in its Health Care Staffing Services standards describes acceptable methods as a combination of information from current and previous employers, peer feedback, verification of certification and licensure, written or oral testing, and direct observation of skills. It states explicitly that a self-assessment, such as a skills checklist, used as the sole method, does not constitute a competency assessment.

The interval comes from the same place.

The Joint Commission’s Health Care Staffing Services measure specifications require a competency assessment at hire or rehire and annually thereafter, which means that for a facility using agency clinicians, the annual expectation falls within the agency’s accreditation program rather than the facility’s conditions of participation.

Streamlining and automating certain tasks (e.g., dates, lists, and evidence retention) allows healthcare administrators and compliance professionals to focus their time where it matters most: making decisions regarding competency, scope of practice, and remediation.

Automate where you can; then rely on your own judgment where it counts.