but in no event more than fourteen (14) days following the receipt of the report suggesting a potential compliance issue.
Investigation activities may include, but not be limited to, the following:
A review of applicable laws, regulations and standards;
Interviews with the person reporting the concern and others who may be involved or have
information to support the investigation;
A review of relevant documents including both financial and clinical records.
If the Compliance Officer believes that the integrity of the investigation is at stake due to the presence of the employee under investigation, the employee may be relieved of their position at the discretion of the Compliance Officer in consultation with the Vice President of Human Resources. The Compliance Officer shall take necessary steps to prevent the destruction of documents or other evidentiary material relevant to an investigation.
If, upon conclusion of the investigation and review by legal counsel, it is determined that there is a substantiated material compliance concern, the Compliance Officer shall immediately formulate and implement a corrective plan of action. The corrective plan of action will ensure that the issue is addressed, eliminated or mitigated to reduce the chance that the situation recurs. Corrective action may include, but not be limited to, adopting new policies and procedures and monitoring their implementation, imposing restrictions on the duties of Staff, education and training, discipline of Staff up to and including termination, and disclosure to governmental authorities as required by law.
If the compliance problem relates to billing, similar billing will be discontinued until the problem is corrected and education on appropriate billing processes is provided. If improper payments were received, the Compliance Officer in concert with legal counsel will determine the amount of repayment to be made and the required disclosures. If there is reason to believe that the misconduct may have violated criminal, civil or administrative law, the misconduct will be reported to the appropriate authority within a reasonable period of time but ordinarily no more than sixty (60) days.
A summary report of the compliance concern, the investigation and the outcome will be prepared by the Compliance Officer and forwarded to the President & Chief Executive Officer. As appropriate, the Compliance Officer will discuss the outcome of the compliance investigation with the individual reporting the concern. The Compliance Officer will maintain records of investigations including documentation of the alleged violation, a description of the investigative process, interview notes and copies of key documents, interviewed witness and documents reviewed log, the results of the investigation and the corrective action. The Compliance Officer will report periodically to the Compliance Committee and the Board of Directors Audit and Compliance Committee on identified compliance concerns and on the investigations undertaken as a result of these concerns.
Any issue for which a corrective action plan has been implemented will be targeted for focused on- going monitoring and incorporation into audits of that area in the future. Information gathered during an investigation may be incorporated into future Staff education and training.
ENFORCEMENT AND DISCIPLINARY ACTION
Any Staff member who fails to comply with applicable laws, regulations, standards and policies may be subject to disciplinary action, up to and including termination of employment/affiliation. Failure to report known or suspected noncompliance may subject Staff to disciplinary action. Management or other supervisory staff may be subject to disciplinary action in the event that they unreasonably fail to detect a known or suspected compliance violation.
CORPORATE COMPLIANCE PLAN 5/6/10
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