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CHILDREN’S HOSPITAL & MEDICAL CENTER CORPORATE COMPLIANCE PLAN - page 3 / 15

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IV.

  • -

    Recommend and monitor the development of internal systems, policies and controls to carry out the compliance program,

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    Determine the appropriate strategies to promote compliance, and

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    Monitor the results of external and internal investigations for the purpose of identifying deficiencies and implementing corrective action.

Hospital Managers and Supervisors Managers and supervisors have a responsibility to know and understand the laws and regulations that apply to their area of responsibility and to exhibit a strong commitment to compliance. Managers and supervisors will encourage open communication among Staff concerning compliance matters. Managers and supervisors will evaluate the compliance performance of Staff during their annual review and will use due diligence in hiring and retaining employees.

DUE DILIGENCE IN THE HIRING OR CREDENTIALING STAFF

The Hospital has developed a screening process to prevent the hiring or credentialing of individuals who pose a risk of involvement in illegal activities. New hires and medical staff applicants will have references checked and will be subject to complete background investigations utilizing: the HHS/OIG Cumulative Sanctions, the General Services Administration List of Parties Excluded from Federal Procurement and Non-Procurement Programs, and the National Practitioner’s Data Bank. In addition, all prospective Staff will be required to disclose whether they have been convicted of a health care-related crime, or excluded or otherwise rendered ineligible for participation in a governmental funded health care program. The Hospital will not employ, credential, retain, contract, or otherwise affiliate with anyone excluded from participation in governmental funded health care programs.

V.

COMPLIANCE TRAINING AND EDUCATION

Successful implementation and functioning of the Plan will require effective training and education of Staff. The Hospital will make appropriate educational training programs and resources available to ensure Staff familiarity with organizational policies and procedures and those areas of law that affect the conduct of their job duties. The compliance training and education program will provide Staff with awareness regarding the importance of compliance, an understanding of the structure of

the Plan and responsibility

needed technical and functional for the development of compliance

training to carry out education lies with the

their responsibilities. Compliance Officer.

The

The Plan including training sessions.

the Corporate Code of Conduct was presented to Staff This initial training introduced Staff to compliance

in initial mandatory and reaffirmed the

Hospital’s standards.

commitment to an ethical, Initial general compliance

professional training is a

work environment and compliance with mandatory orientation subject for newly

legal hired

Staff. General compliance education general compliance education may be

is provided at least annually. developed as needs arise.

Additional

organization-wide

In addition to the general compliance education, Staff will receive job or departmental specific compliance education as needed. This education will focus on technical and functional training to allow staff to carry out their job responsibilities in a fully compliant manner. The departmental compliance education will be based upon identified compliance educational needs as determined by the supervisor together with the Compliance Officer. This specialized training will focus on complex or high compliance risk areas and will be modified over time in response to regulatory

developments

and

newly

identified

compliance

risk

areas.

Compliance

risk

areas

may

be

CORPORATE COMPLIANCE PLAN 5/6/10

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