Purpose of P&S Corporate ComplianceAn effective compliance and ethics program must:• Exercise due diligence to prevent and detect wrong-doing• Promote an organizational culture that encourages ethicalconduct and a commitment to compliance with the law.• Raise awareness• Provide a positive impact to corporate reputation/culture• Provide a “safe” mechanism(s) for reporting and seeking help
Objectives of P&S Corporate ComplianceTo meet the objectives of the 7 elements of a corporatecompliance program as outlined by the Federal SentencingGuidelines (FSG), P&S Surgical Hospital must:• Review Written Policies & Procedures• Select a Compliance Officer & Committee• Train & Educate employees• Provide effective Lines of Communication• Provide Discipline & Background Checks• Include Auditing and Monitoring• Respond & take Corrective Action
Written Policies & ProceduresP&S Surgical Hospital is Required to:• Develop and implement policies, procedures, andpractices designed to ensure compliance with state &federal regulations and programs.• Adhere to the requirements set forth in its policies & theCode of Conduct as outlined by federal and stateregulations.(e.g., licensure, Medicare/Medicaid requirements, HIPAA/HITECH requirements, etc.).
P&S Code of Conduct:• Deter, Detect, Correct & Prevent Misconduct• P&S Surgical Hospital strives to provide thehighest quality procedural care in a patient focusedenvironment. P&S Surgical Hospital is committedto our core values of:• Service• Respect• Compassionate Care• Friendliness• Stewardship
P & S Code of Conduct:• The Code of Conduct provides standards by which all members ofthe organization will conduct themselves.• Conduct must be in a manner that protects and promotesorganizational-wide integrity and enhances P&S Surgical Hospital’sability to achieve its objectives and mission.• This applies to all employees, officers, administrators, boardmembers, medical staff, vendors, contractedemployees, consultants, students, and volunteers.• Staff members must certify annually that they havereceived, read, understand, and agree to abide by the Code ofConduct.
The Compliance Officer & Committee Must:• Continue to design, implement, oversee, and monitor the complianceprogram.• Report on a regular basis to the CEO, Compliance Committee, and to thegoverning body.• Develop, coordinate, and participate in a multifaceted education & trainingprogram.• Ensure that independent contractors and agents are aware of theorganization’s compliance program requirements.• Assist with internal compliance review and monitoring activities.
Training & EducationUnderstand communication processes to report any complianceissues or concerns :• New Hire Orientation• Code of Conduct Training – Annually• 7 Elements of an Effective Compliance Program – Annually• Conflict of Interest Statements• Safe guarding PHI/ePHI• All employees are responsible to report suspected violations ofthe laws, regulations and policies, or any other questionableconduct.
Effective Lines of CommunicationReporting Compliance Issues or Concerns: Your manager Executive Team Member Director of Human ResourcesChenire Craig- 998-7307 Corporate Compliance OfficerDirk Rhodes- 998-6135 ComplianceLine “Anonymous Hotline” - 1-866-570-2523
• Dirk Rhodes, Corporate Compliance Officer• Phone: (318)- 998-6135• Contact via E-mail: DirkRhodes@pssurgery.com• P&S Corporate “Hotline” ComplianceLine:1-866-570-2523• 100% anonymous; Available 24 hours a day/ 7 days a week• There will be no retaliation for reporting concerns in goodfaith, but appropriate disciplinary action will be taken againstthose who commit misconduct.• All reported allegations will have to be verified before anyactions are taken.Effective Lines of Communication
Discipline / Background Checks• All employees undergo a background check/ drug screening uponhiring.• A monthly Sanction Check is reviewed on all employees, medicalstaff, and vendors to show that P&S is compliant with federal &state regulations and programs in which we participate.• Employees receive a copy of the Sanction Policy annually thatsupports the Code of Conduct and outlines disciplinary actions inthe event of misconduct.
Auditing & Monitoring• Unethical or inappropriate careof patients• Lack of correct and sufficientdocumentation in admitting /discharging patients• Medical Necessity• Billing for services or suppliesthat were not provided• Altering claims for higherpayment• 2 Annual (External)Billing/Coding Audits• MCR inpatient one-daystays• Conflict of Interest/Inappropriate vendorrelationships• Inappropriate accessand/or release of (PHI)• Bribes or kickbacks• Business AssociateAgreements (BAA)• Physician OwnershipDisclosure
Responding & Corrective Action• The Compliance Officer reviews all allegations in a serious manner and takes thenecessary steps to deter, detect, correct, & prevent any wrong-doing or misconduct.(All reported allegations will have to be verified before any actions are taken.)• All allegations, audits (internal & external), and monitoring is reported directly to theCEO, Compliance Committee, and Board.• All allegations, audits (internal & external), and monitoring tools are addressed in theallotted time frame per the institution.• In regards to the P&S ComplianceLine “Hotline”• ≤ 72 hours to respond to any issue or concern (Severity I to III)• May take longer considering certain factors and seeking P&S Legal Counsel forreviewWe want to provide a safe patient centered environment forPatients & Employees!!
Quick Facts• All employees are held responsible and accountable for complianceand can be charged with fraud.• The Compliance Officer investigates every complaint ofnoncompliance.• There will be no retaliation for reporting concerns in good faith, butappropriate disciplinary action will be taken against those whocommit misconduct.• Accepting gifts to induce or reward referrals of federal healthcare program business is prohibited.
Examples of Compliance Issues• Never read another employee’s confidential records without permission• Never use another person’s password to access confidential information• Only discuss a patient’s condition with those involved in the patient’scare• Never treat or act differently to someone because they identified acompliance or ethical issue• Accepting gifts from vendors, providers, or third parties is prohibited asoutlined in the conflict of interest policy at P&S. All gifts (>$10.00 perperson per transaction) need prior administration approval before accepting.• Only bill for visits, procedures and/or tests actually performed• Always provide complete documentation for ALL services performed
Remember!DO THE RIGHT THING:• When you become aware of or observe something youbelieve to be improper, report it.• Keep yourself trained and informed.• There will be no retaliation for reporting in good faith!No Pointing Fingers!!
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