Non-Subscription Audit 1.0

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Survey Number

• Name and position of person ultimately responsible for the hospital non-subscription program.

• Date the facility begin the non-subscription program (opted out of Workers Compensation insurance)?

  Date

• Summarize the experience of facility personnel within the Texas non-subscription program.

• What is the role of the non-subscription attorney in the hospital program.

• Is there regularly scheduled conversation/meetings with the attorney involved with the non-subscription program?

  Yes

  No

  N/A

• Is there an Appeals Committee?

  Yes

  No

  N/A

• Describe the role of the Appeals Committee.

• Describe the process of communication regarding the denial of an occurrence.

• What are the acceptance policy and procedures.

• What communication is sent to the injured employee following a denial of an occurrence?

• How is the appeal rate calculated for denial of a claim?

• What is the percentage of appealed claims to the total?

• How is the win/lose appeal calculated?

• How is the closure rate determined?

• Who tracks the closure rate from the facility?

• How are hospital policy violations that are due to unsafe acts communicated?

Required Data

• Is the DWC Form-005 filed each year between February 1 and April 30 each year?

  Yes

  No

  N/A

• Is the DWC Form-005 filed electronically each year?

  Yes

  No

  N/A

• Is the DWC Form-005 filed by a hard copy (not electronically)?

  Yes

  No

  N/A

• Is the DWC Form-007 completed and sent to the TDI Division of Workers Compensation EACH Month?

  Yes

  No

  N/A

• Does the DWC For-007 include the following:

  Select A work related or on-the-job death An employee absent from work more than1 day as the result of on-the-job injury Knowledge of occupational disease

  • A work related or on-the-job death
  • An employee absent from work more than1 day as the result of on-the-job injury
  • Knowledge of occupational disease

• When filing the DWC Form-007, is an injury data sheet completed on EACH employee injured during the reporting period?

  Yes

  No

  N/A

• Does the DWC Form-007 include all Full time, Part time and Temporary employees?

  Yes

  No

  N/A

Program Procedures

• Is there a posted notice of that the facility has no workers compensation coverage where the employee can see it regularly?

  Yes

  No

  N/A

• Is the posted notice of non-coverage provided in Spanish or other appropriate language?

  Yes

  No

  N/A

• Is the written notice of non-coverage provided to each new employee?

  Yes

  No

  N/A

• Is a copy of non-coverage signed and dated by the new employee and a facility representative and filed in the new employee's personnel file?

  Yes

  No

  N/A

• For each employee accident or illness, is there an internal report completed?

  Yes

  No

  N/A

• Describe the hospital safety program and the portion of the program that focuses on accident identification and loss prevention.

• Where is the report sent within the hospital when there is an accident or illness?

• What is the established time frame that the accident/illness report must be completed?

• Name of department and position that reviews each injury report.

• If the accident or illness reported is reviewed and questioned regarding on-the-job event is work related, what are the procedures taken?

• Is there current information available regarding who to contact when there is a potential for denial of the claim?

  Yes

  No

  N/A

• Is there an IMMEDIATE follow up by a supervisor following an accident or illness specifically in regard to causes.

  Yes

  No

  N/A

• Is there a Return-to-Work program that is available to each employee following an accident offered to those on restricted duty or unable to work at full capacity?

  Yes

  No

  N/A

• Is there a third party administrator available to the hospital when there is a question regarding the validity of the accident/illness report?

  Yes

  No

  N/A

• Is there a corporate contact person that is available to discuss accident/illness issues?

  Yes

  No

  N/A

• Name of Corporate contact to discuss issues of occurrences.

Training/education

• Are all new hires provided safety training with specifics of the non-subscription program PRIOR to beginning their position?

  Yes

  No

  N/A

• Is ALL training for new hires documented and FILED for future references?

  Yes

  No

  N/A

• Is safety training provided to ALL employees and documentation regarding the type of training for all employees maintained for future references and includes dates of training?

  Yes

  No

  N/A

• Is annually safety training to ALL employees based on accident trends?

  Yes

  No

  N/A

• Is there a safety or hazard reporting system available to all employees with follow up?

  Yes

  No

  N/A

• Person that reviews safety hazards reported by the staff.

• Does the equipment management program include DOCUMENTED training on the safe use of all equipment and includes patient and non-patient equipment for EACH employee?

  Yes

  No

  N/A

• Is there a committee (EOC) or SUBCOMMITTEE that meets monthly and safety issues or safety hazards addressed?

  Yes

  No

  N/A

• Is there any outside assistance used to enhance the facility employee safety program?

  Yes

  No

  N/A

• Is the Texas Department of Insurance (TDI) used for safety training?

  Yes

  No

  N/A

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