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CHILDREN’S HOSPITAL & MEDICAL CENTER CORPORATE COMPLIANCE PLAN - page 4 / 15

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identified by departmental monitoring activities, reported compliance concerns, governmental enforcement initiatives or by other means available. The Compliance Officer, the supervisors and Staff share the responsibility to identify compliance related information to be presented to Staff through education and training.

Participation in compliance training will be mandatory and only the Compliance Officer is authorized to excuse a staff member. Attendance at and participation in compliance educational programs is a factor in each employee’s annual evaluation and is a condition of continued employment.

Compliance training and educational programs will utilize a variety of teaching methods and will be customized to the targeted groups recognizing the skills, experience, knowledge and educational level of the group. Outside experts may be enlisted by the Compliance Officer to

conduct specialized or highly

technical compliance training.

The Compliance

regularly and not less than annually report to the Board of Directors Audit and

Officer will Compliance

Committee on compliance educational initiatives.

VI.

MONITORING AND AUDITING SYSTEMS

In recognition of the need for the establishment of an on-going evaluation process to assure the success of the compliance program, the Compliance Committee will develop a monitoring and audit process. The monitoring and audit process will assess compliance with laws, regulations, standards and policies and procedures. The scope and frequency of compliance monitoring and auditing activities in a particular area will be based on an assessment of risk and the effectiveness of existing operational controls and on-going monitoring activities. The Compliance Officer will establish guidelines to assure monitoring and audit coverage for all high-risk areas identified by the Compliance Committee.

All compliance monitoring and audit activities will be under the direction of the Compliance Officer. In addition to the use of internal resources, outside parties with specific compliance review expertise with federal and state health care statutes, regulations and program requirements may be used for auditing in specific areas. When possible, claim and billing accuracy monitoring will be completed on a prospective basis to identify potential problems before claims are submitted. Audit procedures may be conducted with the assistance of legal counsel to maintain the attorney client privilege. Monitoring and audit results will be used to assist in correcting past problems and putting systems into place to prevent them from recurring. Compliance monitoring and audit records will be kept confidential and maintained by the Compliance Officer in a secure location for seven (7) years.

Results of routine compliance monitoring and audit activities will be reported to the President &

Chief Executive Officer and the Board of Directors Audit and Compliance Committee on

basis.

If

monitoring

and

audit

activities

identify

a

potential

non-compliant

situation

a regular or other

compliance

concern,

the

investigative

procedures

set

forth

in

Section

VIII

will

be

followed.

VII.

COMPLIANCE CONCERNS REPORTING STRUCTURE

Staff has a duty and obligation to immediately report any concerns of suspected or actual violation of laws, regulations, standards or any other part of this Plan to their supervisor. If Staff member is uncomfortable making such report to their supervisor, a report must be made to the Compliance Officer. If the Compliance Officer is unavailable, Staff should contact the President & Chief Executive Officer, the administrator on call or the Vice President of Human Resources.

CORPORATE COMPLIANCE PLAN 5/6/10

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