HORIZON WEST HEALTHCARE COMPLIANCE PROGRAM

Horizon West HealthCare has a culture that emphasizes responsibility and accountability.  As such, we are committed to being in compliance with all federal, state and local laws.    A compliance program is one way to protect against the risks and consequences of regulatory violations. 

The healthcare industry faces many challenges.  We must follow a growing number of healthcare laws and regulations that govern how we provide care and how we are reimbursed for our services.  These laws have become increasingly complicated, and they change constantly.  The compliance program assists us in meeting our legal, ethical and professional responsibilities under a very complex environment.

The compliance program includes at a minimum:

• Standard of Conduct
• Compliance Awareness through Compliance Training
• A Confidential Compliance Hotline Number:  1-866-535-4643
• A Confidential Disclosure Program
• Monitoring and auditing of compliance risk areas
• A resource for compliance guidance

Anytime you are aware of an actual or potential violation, you are encouraged to contact the Confidential Compliance Hotline at 1-866-535-4643. 

CONFIDENTIAL DISCLOSURE PROGRAM - REPORTING COMPLIANCE ISSUES

Any employee who knows of or suspects any violation of the Compliance Program or any other fraudulent conduct must promptly report such a violation to his or her supervisor, the Community Compliance Liaison Officer, the Compliance Officer, or any member of the Compliance Committee.

It is the absolute policy of the community that there will be no retaliation or retribution of any type against any employee who makes a report of any actual or suspected violation where the information is timely received in order that corrective measure can be taken and that do not involve patient health and safety concerns.

The Community has in place a Confidential Disclosure Program whereby any individual may anonymously report any concern.

The Community Compliance Liaison Officer will forward any and all report/envelopes found in the Confidential Disclosure Box to the Compliance Officer within two business days of discovery of the envelope in the Confidential Disclosure Box.  The Confidential Disclosure Box is checked by the Community Compliance Liaison Officer at least twice a week.

A report or request for clarification or investigation may be made by submitting:

• A written Compliance Report, which are available in a box located near the Confidential Disclosure Box, near the Consumer Board area in the community.  (FHW-CRF-001).

The Compliance Officer shall maintain a Confidential Disclosure Log wherein every written compliance report received by the Compliance Officer shall be logged.  In addition, a report will be completed on each compliance matter that is submitted to the Compliance Officer on form FHW-CRF-001, (hereinafter Compliance Report).  The Compliance Officer is responsible for maintaining the log and will coordinate the investigation to its conclusion and disposition. 

• The Corporate Compliance Officer is responsible for maintaining the Confidential Disclosure Log.
• The Corporate Compliance Officer will number and log each and every compliance report that is submitted.
• The Corporate Compliance Officer will complete a Compliance Report Investigation Form, FHW-CRIF-001 for all compliance reports.
• The Corporate Compliance Officer will coordinate the investigation to its conclusion and disposition.
• The Disclosure log will be located in the Corporate Compliance Officers office, and the compliance report investigation forms will be maintained with the log.

You may also call the Confidential Hotline at: 1-866-535-4643 to report your concerns.

HIPAA PRIVACY AND CONFIDENTIALITY:

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that defines residents’ rights to privacy and controls how their personal healthcare information is used.  You may find these rules at 45 Code of Federal Regulations, Parts 160 and 164. This healthcare information is commonly referred to as protected healthcare information or PHI. The law specifies who can access patients’ protected, identifiable health information and when disclosure of this information is permitted.

HIPAA’s privacy rule restricts the way personal health information can be used and disclosed; gives patients greater access to their medical records; and provides greater protection for residents’ medical and financial records. It applies to all healthcare providers, including nursing homes, hospitals, pharmacies, laboratories, rehabilitation agencies, home health agencies, as well as healthcare clearinghouses and health plans.

Federal law protects the confidentiality of residents’ medical, financial and personal information.  Resident information is exchanged in verbal, written and electronic forms.  HIPAA regulations require that we protect resident information from being seen, heard or read by anyone who is not authorized to do so.  Only specified individuals are permitted to access resident records:  the resident or his or her authorized representative, the individual’s physician and the staff members who need the information.  No medical, financial or personal information about a resident may be disclosed to anyone else without the individual’s permission.

The right to privacy means that we cannot answer questions from friends, relatives or the news media without a written consent. 

STANDARD OF CONDUCT

Your community has a culture that emphasizes responsibility and accountability.  As such, the community is committed to being in full compliance with all federal, state and local laws.  It is important that all staff understand and adhere to the policies and procedures of the compliance program including the Standard of Conduct and the Confidential Disclosure Program. 

Introduction
 
When you do not comply with healthcare laws and regulations criminal indictments and staggering fines can threaten your community’s credibility.  Healthcare organizations are judged by quality of care and standards of ethical responsibility.
A compliance program is one way to protect against the risks and consequences of regulatory violations and deliver the highest quality of care.  It ensures that your community demonstrates the highest standards of professionalism and competence.

What is the Compliance Program?
 
The Compliance Program is an outline of policies and procedures to follow to stay in compliance with federal and state laws.

The scope may vary with direct responsibility for some areas like Medicare/Medi-Cal, (Medicaid) and indirect responsibility for others.

The goal is to prevent violations of these laws and make sure if errors do occur, your community can respond immediately to resolve problems.

In general, the formal program covers compliance with government health program regulations to prevent violations of the False Claims Act, as well as the Fraud and Abuse Laws (Stark and Antikickback) that prohibit improper relationships, in addition to licensure and OSHA regulations. 

As a condition of continued employment with the community, staff is expected to comply with the community’s Standard of Conduct as well as any related policies and procedures.  Supervisors are responsible for enforcing the Standard of Conduct as well as company policies and procedures.  Due diligence to prevent and detect violations of the law is everyone’s responsibility.  It is the duty of any staff that discovers a violation of the Standard of Conduct to report the violation.  Note that failure to report a breach is a violation of the Standard of Conduct and could be grounds for disciplinary action up to and including termination. 

How Did Compliance Programs Start?
 
The development of healthcare compliance programs came after the passage of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  This established healthcare fraud as a federal criminal offense with stiff penalties, fines and jail sentences.  It also increased the authority and responsibility of the Centers for Medicare/Medicaid Services office of the Inspector General (OIG) to fight healthcare fraud and abuse.

The Purpose of the Standard of Conduct
 
The purpose of the Standard of Conduct is to assist all staff in maintaining high ethical standards in all business dealings.  The Standard of Conduct is designed to guide individuals in making decisions that conform to the legal, ethical and moral standards expected.  Your compliance shall ensure the community is in full compliance with the laws, rules and regulations.

Summary of the Compliance Program
 
The Compliance Officer is entrusted to oversee and ensure activities are conducted in compliance with federal, state and local laws and applicable policies and procedures.  The Community Compliance Liaison Officer and the Compliance Committee assist in applying those principles. 

Compliance Committee:

The Compliance Committee are members of senior management and generally make up the following composition:

Compliance Officer
CEO/President
Accounts Receivable Manager
Director of Financial Management
Director of Operations
Human Resources
Clinical

The community is committed to providing quality resident care in full compliance with all federal, state and local laws.  It is important that all staff understand and adhere to the policies and procedures of the compliance program including the Standard of Conduct and Summary of the Compliance Program and the Confidential Disclosure Program described below.

The Executive Director has been appointed the Community Compliance Liaison Officer.  The Community Compliance Liaison Officer is entrusted to ensure all activities are conducted in compliance with federal, state and local laws and applicable policies and procedures.

Consistent with the service agreement, the Compliance Officer, Compliance Committee and the Community Compliance Liaison Officer are available to consult and advise about compliance issues, and ensure that the program is updated and reviewed on a regular basis.

The Compliance Officer is responsible for obtaining reports of noncompliance, and complaints reported to a Community Compliance Liaison Officer; Research and investigation, resolve, retraining, and providing timely reports to the Board of Directors and CEO related to Compliance matters; Coordinate consulting with outside Counsel regarding compliance obligations; Make recommendations for the retention of outside consultants; Oversight of continuing education of all staff on a regular basis; and prepare and circulate periodicals and/or a compliance newsletter periodically.    .

The Compliance Committee is responsible for overseeing the compliance program.  Addressing questions, issues and suggestions brought to the Compliance Committee from any source including the Compliance Officer, Community Compliance Liaison Officers, officers, directors, staff, vendors and consultants and from the Communities’ staff, nurses, residents, healthcare providers, families of residents, suppliers, and consultants.  The committee will respond to questions; identify and resolve all compliance issues; and assist the Compliance Officer to ensure that the program is updated and reviewed for conformity with new and modified laws and regulations on a regular and timely basis.

The Community Compliance Liaison Officer is responsible for ensuring the continuing education of all staff as to relevant policies and procedures; create and encourage an environment which meets the Standard of Conduct; facilitate communication about the Compliance Program and any questions, concerns, or potential areas of non-compliance and appropriate reporting; and participate in investigations.

Training

Within one week of commencing employment, each new employee shall be provided access to this Standard of Conduct and Summary of the Compliance Program.  Within thirty days of commencement of employment, each new employee will receive an hour of general training regarding the Compliance Program including the Standard of Conduct and the Confidential Disclosure Program and will sign a Certification attesting that they have received the training and understand the Compliance Program, and the applicable policies and procedures relevant to their job.  After the one (1) hour general training, every employee must sign a Standard of Conduct form (FHW-CUIA-001), and Employee Certification form (FHW-ECIS-001).

Employer Vendor and Staff Screening

The service company has implemented a written policy whereby the service center or the Communities it has entered into a service agreement with, shall not employ, with or without pay, an individual or entity for any position defined as an “affected employee” in the compliance plan that is listed on the OIG’s Cumulative Sanctions Report and the General Services Administration’s (GSA’s) List of Parties Excluded from Federal Procurement and Non-Procurement Programs, (hereinafter “List”) as excluded, suspended or ineligible for participation in federal health programs.  In order

Reporting Compliance Issues

Any employee who knows of or suspects any violation of the Compliance Program or any other fraudulent conduct must promptly report such a violation to his or her supervisor, the Community Compliance Liaison Officer, the Compliance Officer, or any member of the Compliance Committee.

It is the absolute policy of the community that there will be no retaliation or retribution of any type against any employee who makes a report of any actual or suspected violation where the information is timely received in order that corrective measure can be taken and that do not involve patient health and safety concerns.

The Community Compliance Liaison Officer will forward any and all report/envelopes found in the Confidential Disclosure Box to the Compliance Officer within two business days of discovery of the envelope in the Confidential Disclosure Box.  The Confidential Disclosure Box is checked by the Community Compliance Liaison Officer at least twice a week.

A report or request for clarification or investigation may be made by submitting:

• A written Compliance Report, which are available in a box located near the Confidential Disclosure Box, near the Consumer Board area in the community.  (FHW-CRF-001).

The Compliance Officer shall maintain a Confidential Disclosure Log wherein every written compliance report received by the Compliance Officer shall be logged.  In addition, a report will be completed on each compliance matter that is submitted to the Compliance Officer on form FHW-CRF-001, (hereinafter Compliance Report).  The Compliance Officer is responsible for maintaining the log and will coordinate the investigation to its conclusion and disposition. 

• The Corporate Compliance Officer is responsible for maintaining the Confidential Disclosure Log.
• The Corporate Compliance Officer will number and log each and every compliance report that is submitted.
• The Corporate Compliance Officer will complete a Compliance Report Investigation Form, FHW-CRIF-001 for all compliance reports.
• The Corporate Compliance Officer will coordinate the investigation to its conclusion and disposition.
• The Disclosure log will be located in the Corporate Compliance Officers office, and the compliance report investigation forms will be maintained with the log.

You may also call the Confidential Hotline at: 1-866-535-4643 to report your concerns.

Enforcement and Disciplinary Action

The purpose of the Compliance Program is to detect, deter and respond to compliance issues.  Failing to detect non-compliance with applicable policies and legal requirements, where reasonable diligence would have led to the discovery of any problems or violations and would have given the community opportunity to correct them is grounds for disciplinary action. 

• Staff shall be evaluated to see if they carry out compliance requirements routinely.
• When non-compliance issues occur, action shall be taken to avoid similar misconduct in the future, or correct harm.
• When complaints are received and documented, an investigation is conducted to identify if a resident care process or behavior is causing the problem.
• Most problems occur due to human error, however, are investigated as rigorously as fraud or abuse.
• Depending on the circumstances an investigation may be an information inquiry, or involve a more formal inquiry such as a review of claims.

Your community’s policies and procedures outline corrective actions for any failure to comply with the regulations:

• Disciplinary policy for non-compliance
• Disciplinary actions for failure to report non-compliance
• Those responsible for taking disciplinary actions

Corrective action may include:

• Verbal warnings, loss of privileges or suspension
• Discipline or termination of staff who intentionally violate the law
• Returning identified overpayments to the government
• Voluntary disclosure of non-compliance to law enforcement or regulatory officials

Response and Prevention

When the cause of non-compliance is determined, your community takes steps to correct risky processes and prevent future errors.

Response and prevention include:

• Identifying and resolving problems in your area that may have caused or contributed to non-compliance
• Creating or updating policies or procedures to address high-risk or deficiencies in the compliance program
• Adding educational requirements for staff in areas that contributed to the problem
• Monitoring regularly to make sure preventive measures eliminate non-compliance

Protocols for Avoidance of Conflicts of Interest:    

A.          Business Ethics -

In furtherance of the Service Center’s and Community’s commitment to the highest ethics and integrity, staff will accurately and honestly represent to the Service Center and the Community and will not engage in any activity or scheme intended to defraud anyone of money, property or honest services.  The Service Center and the Community require candor and honesty from staff in the performance of their responsibilities and their communications.  No employee shall make false or misleading statements to anyone.

B.          Conflicts of Interest -

Directors, officers, committee members and key staff owe a duty of undivided and unqualified loyalty to the Service Center and Community.  Persons holding such positions may not use their position to profit personally or to assist others in profiting in any way at the expense of the Service Center and Community.  Such persons are expected to regulate their activities so as to avoid actual impropriety or the appearance of impropriety which might arise from the influence of those activities on business decisions of the Service Center and Community, or from disclosure or private use of business affairs or plans of the Service Center and Community.

The following will service as a guide as to the types of activities which might cause conflicts of interest:

1. Ownership in or employment by any outside agency which does business with the Service Center and Community.  The Service Center and Community may, following a review of the relevant facts, permit ownership if management concludes such ownership interest will not adversely impact the Service Center’s and Community’s interest or the judgment of the person.
2. Conducting any business not on behalf of the Service Center and Community, with any vendor, supplier, contractor or agency, or any of their officers or staff.
3. Representing the Service Center and Community in any transaction in which you or a household member as a substantial personal interest.
4. Disclosure or use of confidential information of or about the Service Center and Community for personal profit or advantage.
5. Competition with The Service Center and Community, directly or indirectly, in the purchase, sale or ownership of property or property rights or interests, or business investment opportunities.

C.         Business Relationships -

Business transactions with vendors, contractors and other third parties shall be transacted free from offers or solicitation of gifts and favors or other improper inducements in exchange for influence or assistance in a transaction.

The Standards described below are intended to guide staff in determining the appropriateness of the listed activities or behaviors within the context of the Service Center’s and Community’s business relationships, including relationships with vendors, providers, contractors, third party payors and government entities.  It is the intent of the Service Center and Community that this policy be construed broadly to avoid even the appearance of improper activity.  If there is any doubt or concern about whether such specific conduct or activities are ethical or otherwise appropriate, you should contact your supervisor, Community Compliance Liaison Officer, Compliance Committee Member or the Compliance Officer for clarification.

1. Gifts and gratuities.  It is the Service Center’s and Community’s desire to, at all times, preserve and protect its reputation and to avoid the appearance of impropriety.

Gifts of Nominal Value:  Courtesy gifts of nominal value - including reasonable paid meals ancillary to business meetings for the company and unsolicited promotional items such as pens and calendars that are not intended to invite any form of reciprocation - are permissible as long as public scrutiny of the gift would not cause the company embarrassment.

No gifts - not even gifts of nominal value - should be accepted from or offered to anyone who refers or might refer residents or other reimbursable business to or from the company.

• Gifts from residents/patients:  Staff are prohibited from soliciting tips, personal gratuities or gifts from residents and/or their families and from accepting monetary tips or gratuities.
• Gifts influencing decision making:  Staff shall not accept gifts, favors, services, entertainment or other things of value to the extent that decision making or actions affecting the Service Center and/or Community might be influenced.  Similarly, the offer or giving of money, services or other things of value with the expectation of influencing the judgment or decision making process of any purchasing vendor, provider, supplier, customer, government official or other person by the Service Center and Community is absolutely prohibited.  Any such conduct must be reported immediately either to your supervisor, Community Compliance Liaison Officer, Compliance Committee or Compliance Officer.
• Gifts from existing vendors:  These gifts should be shared with the staffs’ co-workers.  Staff shall not accept gifts, meals, expensive entertainment or other offers of good or services, nor may they solicit from vendors, suppliers, contractors or other persons.
• Business inducements:  Staff shall not seek to gain any advantage through the improper use of payments, business courtesies or other inducements.  Offering, giving, soliciting or receiving any form of bribe or other improper payment is prohibited.

D.         Protection of Assets -

All staff will strive to preserve and protect the Service Center’s and Community’s assets by making prudent and effective use of the Service Center’s and Community’s resources and properly and accurately reporting its financial condition.  The Service Center and Community has established control standards and procedures to ensure that assets are protected and properly used and that financial records and reports are accurate and reliable.  All staff share the responsibilities for maintaining and complying with required internal controls.

All financial reports, accounting records, research reports, expense accounts, time sheets and other documents must accurately and clearly represent the relevant facts or the true nature of a transaction.  Improper or fraudulent accounting documentation or financial reporting is contrary to the policy of the Service Center and the Community and may be in violation of applicable laws.

Travel and entertainment expenses should be consistent with the staff’s job responsibility and the Service Center and Communities needs and resources.  A staff member should not suffer a financial loss nor a financial gain as a result of business travel and entertainment.  Staff members are expected to exercise reasonable judgment in the use of the Service Center’s and Communities assets as carefully as they would spend their own.

Staff are prohibited from the unauthorized use or taking of the Service Center’s or Communities equipment, supplies, materials or services.  Staff should obtain the approval of the appropriate supervisor before engaging in any activity on The Service Center and Community time which will result in remuneration to the employee or the use of the Service Center’s or Communities equipment, supplies, materials, or services for personal or non-work related purposes.

E.         Kickbacks -

Every staff member will absolutely refuse kickbacks or other payments in exchange for referrals.  Providers shall not offer residents/patients incentives to utilize services.  For example, it is improper for a physician to offer to waive co-payments and deductible for residents/patients unless the resident/patient is indigent or meets certain poverty guidelines.  Offering free needles, supplies or services to induce the resident/patient to utilize the provider or purchase other services or supplies may also be improper.
  

INFORMATION SECURITY (HIPAA)

Information contained the Service Center’s and Community’s computers systems, as well as information contained in the policy manuals information systems, is confidential and proprietary.  Information security refers to safeguarding this confidential information from damage, loss, unauthorized access, or unauthorized modification.

Computer System Security -

Certain staff members are granted access to the Service Center’s or Community’s computer systems.  Responsibilities that accompany this access include:

• Each staff member must keep his or her computer access password(s) confidential.
• Only The Service Center or Community provided software may be installed on computers.
• Software must not be removed from the computers (i.e., removal of anti-virus software creates a security vulnerability).
• Each staff member must inform his or her supervisor whenever the staff member