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CHILDREN’S HOSPITAL & MEDICAL CENTER CORPORATE COMPLIANCE PLAN - page 5 / 15

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Once a concern report has been made, the Staff member has a continuing obligation to update the report if they obtain new information.

The Compliance Officer will have an open door policy regarding reports of concerns of any violations or suspected violations of the law or questions on the adherence to the law and

components of the Plan.

Staff may report a concern by a

written

report,

phone

call,

email,

or

stop by the Compliance Officer’s office to report in person.

Compliance Hotline: To encourage reporting of compliance concerns or questions, the Hospital has established a Compliance Hotline. The Hospital’s Compliance Hotline telephone number (402-955-3250) is posted on the Hospital Website and throughout the Hospital. This hotline is attached to a secured voice mail system accessible only by the Compliance Officer or designee.

Staff is encouraged to disclose their identity, recognizing that anonymity may hamper complete and timely investigations. However, anonymous reports will not be refused or treated less seriously because the reporter wishes to remain anonymous. All compliance concern reports will be kept confidential to the extent possible and will be investigated by the Compliance Officer or designee. However, complete anonymity can not be guaranteed especially in situations where governmental authorities may be involved.

No Staff who reports a compliance concern will be retaliated against or otherwise disciplined solely for reporting the concern (see Whistleblower Policy). The Hospital strictly prohibits retaliation against employees who raise concerns honestly and forthrightly, and retribution in any form will not be tolerated. Staff found to have retaliated against another Staff member will be disciplined in accordance with Hospital’s disciplinary guidelines, or with medical staff by- laws if applicable, up to and including termination. The Compliance Officer does not have the authority to extend protection or immunity from disciplinary action or prosecution to individuals who have engaged in misconduct regardless of whether they reported the misconduct. No Staff will be punished solely for mistakenly reporting what they in good faith believed to be an act of misconduct, but an individual may be subject to disciplinary action if the report was knowingly misstated. Any Staff who knowingly misuses the hotline will be subject to disciplinary action up to and including termination of their employment/ affiliation.

Compliance inquiries will be included in confidential exit interviews conducted on behalf of Human Resources. Departing employees will be asked if they had knowledge of or suspected potential misconduct or violations of laws, standards or policies and procedures while at Children’s and whether they reported their concerns. Compliance concerns identified via exit interviews will be investigated to the extent possible.

VIII. INVESTIGATION AND CORRECTIVE ACTION

Upon receipt of a hotline report, questionable audit or monitoring results or other information that suggests a compliance issue, the Compliance Officer will take all reasonable steps to promptly investigate the situation for purposes of assessing legal risks or obligations as well as Plan compliance. The Compliance Officer will enter the concern in the compliance concern log and open a written report. Based upon the information given and the nature of the concern, the Compliance Officer will conduct an initial assessment to determine whether the report has merit and warrants additional investigation. The Compliance Officer either alone or in consultation with legal counsel will make a determination as to who should conduct the investigation - the Compliance Officer, legal counsel or an outside expert retained by legal counsel. Investigations will start as soon as possible

CORPORATE COMPLIANCE PLAN 5/6/10

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