Corporate Compliance Training

Purpose of P&S Corporate Compliance

An effective compliance and ethics program must:

• Exercise due diligence to prevent and detect wrong-doing

• Promote an organizational culture that encourages ethical conduct 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 Compliance

To meet the objectives of the 7 elements of a corporate compliance program as outlined by the Federal Sentencing Guidelines (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 & Procedures

P&S Surgical Hospital is Required to:

• Develop and implement policies, procedures, and practices designed to ensure compliance with state & federal regulations and programs.

• Adhere to the requirements set forth in its policies & the Code of Conduct as outlined by federal and state regulations. (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 the highest quality procedural care in a patient focused environment. P&S Surgical Hospital is committed to 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 of the organization will conduct themselves.

• Conduct must be in a manner that protects and promotes organizational-wide integrity and enhances P&S Surgical Hospital’s ability to achieve its objectives and mission.

• This applies to all employees, officers, administrators, board members, medical staff, vendors, contracted employees, consultants, students, and volunteers.

• Staff members must certify annually that they have received, read, understand, and agree to abide by the Code of Conduct.

The Compliance Officer & Committee Must:

• Continue to design, implement, oversee, and monitor the compliance program.

• Report on a regular basis to the CEO, Compliance Committee, and to the governing body.

• Develop, coordinate, and participate in a multifaceted education & training program.

• Ensure that independent contractors and agents are aware of the organization’s compliance program requirements.

• Assist with internal compliance review and monitoring activities.

Training & Education

Understand communication processes to report any compliance issues 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 of the laws, regulations and policies, or any other questionable conduct.

Effective Lines of Communication

Reporting 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 good faith, but appropriate disciplinary action will be taken against those who commit misconduct.

• All reported allegations will have to be verified before any actions are taken.

Effective Lines of Communication

Discipline / Background Checks

• All employees undergo a background check/ drug screening upon hiring.

• A monthly Sanction Check is reviewed on all employees, medical staff, 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 that supports the Code of Conduct and outlines disciplinary actions in the event of misconduct.

Auditing & Monitoring • Unethical or

inappropriate care of patients

• Lack of correct and sufficient documentation in admitting / discharging patients

• Medical Necessity • Billing for services or

supplies that were not provided

• Altering claims for higher payment

• 2 Annual (External) Billing/Coding Audits

• MCR inpatient one-day stays

• Conflict of Interest /Inappropriate vendor relationships

• Inappropriate access and/or release of (PHI)

• Bribes or

kickbacks• Business

Associate Agreements (BAA)

• Physician Ownership Disclosure

Responding & Corrective Action

• The Compliance Officer reviews all allegations in a serious manner and takes the necessary 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 the CEO, Compliance Committee, and Board.

• All allegations, audits (internal & external), and monitoring tools are addressed in the allotted 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 for review

We want to provide a safe patient centered environment for Patients & Employees!!

Quick Facts

• All employees are held responsible and accountable for compliance and can be charged with fraud.

• The Compliance Officer investigates every complaint of noncompliance.

• There will be no retaliation for reporting concerns in good faith, but appropriate disciplinary action will be taken against those who commit misconduct.

• Accepting gifts to induce or reward referrals of federal health care 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’s care

• Never treat or act differently to someone because they identified a compliance or ethical issue

• Accepting gifts from vendors, providers, or third parties is prohibited as outlined in the conflict of interest policy at P&S. All gifts (>$10.00 per person 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 you believe 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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