Compliance and Ethics Plan
Uintah Health Care Special Service District
COMPLIANCE AND ETHICS PROGRAM
I. Code of Conduct
Uintah Health Care Special Service District (“the Facility”) is committed to the prevention and detection of criminal, civil, ethical and administrative violations and promotes quality of care consistent with Federal and State and internal regulations. The Facility is also committed to providing the care and services necessary to attain or maintain each resident’s highest practicable physical, mental and psychosocial well-being. This Compliance and Ethics Program (“Program”) is designed to implement these goals.
Additional guidelines can be found in the Employee Conduct Policies attached in Appendix C.
This Code of Conduct will be provided to each current employee and agent upon adoption, and will be provided to each new employee and agent upon hire. Upon receipt of this Code of Conduct and Program, all employees and agents will acknowledge receipt and understanding of the Code of Conduct and Program by signing the document in Appendix A. A copy of Appendix A will be kept in the employee’s or agent’s file. This Code of Conduct will also be made available to residents and their families upon request.
II. Compliance Standards and Procedures
This Program establishes the following compliance standards and procedures to be followed by employees and agents of Uintah Health Care Special Service District. The Facility has determined these standards and procedures are reasonably capable of reducing the prospect of criminal, civil and administrative violations.
A. Quality of Care
In regard to quality of care, the Facility will pay particular attention to 42 CFR 483, and will instruct all employees to comply with all regulations included in that section.
Sufficient Staffing
The Facility will utilize adequate staffing levels and sufficiently trained or supervised staff to provide medical, nursing and related services, in accordance with applicable laws. Medical care of each resident will be supervised by a physician, who will see the resident at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. The Facility will also retain the services of a registered
nurse for at least 8 consecutive hours a day, 7 days a week, and will have 24-hour licensed nursing services. The Facility will also have a registered nurse who serves as the director of nursing on a full-time basis. The Facility will also retain a qualified dietician. Other staffing decisions will be made as required by law.
Comprehensive Resident Care Plans
In order to provide each resident the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, the Facility will complete for each resident a comprehensive, accurate assessment of each resident’s functional capacity and a comprehensive care plan that includes measurable objectives and timetables to meet the resident’s medical, nursing and mental and psychosocial needs. This includes recommendations for and documentation of discharge and transfer of a resident. All disciplines involved in each resident’s care will participate in the care planning. These disciplines include the resident’s physician, a registered nurse with responsibility for the resident, and any other disciplines involved in the resident’s care. Each resident will have an attending physician, and that attending physician will participate in the care planning. When completing care plans, the interdisciplinary team will schedule meetings, rather than hold perfunctory meetings. The full interdisciplinary team will participate and complete all clinical assessments before the meeting is convened. If the attending physician is not at the Facility daily, the physician may participate in care planning meetings via consultation, post-meeting debriefing, or remote-electronic participation. Regardless, the meetings will focus on serving the best interests of the resident and complying with State and Federal regulations.
For residents with mental illness or mental retardation, the interdisciplinary team will ensure that the Facility has a Preadmission Screening and Resident review screen. For residents who do not require specialized services, the interdisciplinary team will ensure the Facility is providing mental health or mental retardation services which are of a lesser intensity than specialized services to all residents who need such services.
Unless the resident has been declared incompetent or otherwise found to be incapacitated under State law, each resident has the right to participate in his or her care planning and treatment. When possible, residents and their family members or legal guardians will be included in the development of care and treatment plans.
Appropriate Treatment
The Facility will provide appropriate and sufficient treatment and services as required by law to address each resident’s clinical conditions, including but not limited to pressure ulcers, dehydration, malnutrition, incontinence of the bladder and mental or psychosocial problems.
Accommodation of Needs
The Facility will accommodate individual resident needs and preferences as possible except when the health or safety of the individual or other residents would be endangered.
The Facility will also provide appropriate services to assist residents with activities of daily living, and will also provide an ongoing activities program to meet the individual needs of all residents.
Restorative and Personal Care Services
The Facility will provide, as possible, at least the following services to residents, if applicable to the resident:
· Assistance in avoiding pressure ulcers;
· Assistance in attaining active and passive range of motion;
· Assistance with ambulation;
· Fall prevention;
· Incontinence management;
· Bathing;
· Dressing;
· Grooming activities.
The Facility will document these services, and will document refusals of these services by residents.
Medication Management
Facility staff will administer medication to residents only as prescribed and allowed by law. Drug switches will only be made upon authorization of the attending physician, medical director or other licensed prescriber, or as allowed by law. The Facility and employees and agents will properly prescribe administer and monitor prescription drug usage. Specifically, the Facility will facilitate as possible residents receiving pharmaceutical services, including acquiring, receiving, dispensing and administering all drugs to meet the needs of each resident. The Facility will also provide routine and emergency drugs and to residents or obtain them under an agreement with a qualified professional. The Facility will meet this obligation even if a pharmacy charges a Medicare Part D copayment to a dual-eligible beneficiary who cannot afford to pay the copayment.
The Facility will maintain drug records and track all medications administered. The Facility will also periodically consult with a pharmacist to identify, evaluate and address
medication issues that may affect resident care, medical care and quality of life. The pharmacist will also consult on all aspects of the provision of pharmacy services in the facility. The pharmacist can be employed or utilized through a contractual agreement, but compensation cannot reflect the volume or value of drugs prescribed for or administered to residents.
The Facility will engage in only appropriate use of psychotropic medications for residents. All psychopharmalogical practices of the Facility will comply with Federal and State regulations. The Facility will not use any medication as a chemical restraint for purposes of discipline or convenience, and not required to treat the resident’s medical symptoms. In addition, resident drug regimens will be free from unnecessary drugs. For residents who require antipsychotic medications, the Facility will, unless contraindicated, ensure that residents receive gradual dose reductions and behavioral interventions aimed at reducing medication use.
As part of training under this Plan, the Facility will train care providers regarding appropriate monitoring and documentation practices. The Compliance Officer will also audit drug regimen reviews and resident care plans to determine if they incorporate an assessment of each resident’s medical, nursing, and mental and psychosocial needs, including the need for psychotropic medications for a specific medical condition. At care planning meetings, the care providers will collaborate to analyze the outcomes of care using the results of the drug regimen reviews, progress notes and monitoring of the resident’s behaviors.
All residents with Medicare have a right to choose their Part D plans. The Facility will make efforts to work with pharmacies to assure they recognize the Part D plans chosen by the Facility’s Medicare beneficiaries, or to add additional pharmacies to achieve the objective. As necessary, the Facility will provide and objective information and education to residents on all available Part D plans. The Facility will not require, request, coach or steer any resident to select or change a plan for any reason, nor will it knowingly or willingly allow a pharmacy servicing the Facility to do the same.
Therapy Services
The Facility will provide appropriate services, by not providing unnecessary therapy and not underutilizing medically necessary therapeutic services. The Facility will not utilize therapy services to improperly inflate the severity of RUG classifications to obtain additional reimbursement. The Facility will also not over-utilize therapy services billed on a fee-for-service basis to Part B under consolidate billing, and will not stint on therapy services provided to patients covered by the Part A PPS payment.
The Facility will require therapy contractors to provide complete and contemporaneous documentation of each resident’s services. The Facility will periodically review physician’s orders and reconcile whether the orders reconcile with services provided. As necessary, the Facility will interview residents and family members to be sure services are delivered. And care planning members will assess the continued medical necessity of services provided.
Resident Safety
The Facility will report all incidents of mistreatment, neglect or abuse as required by law, including but not limited to the Elder Justice Act.
The Facility will comply with abuse policies included in Appendix C.
The Facility will also, as part of compliance training, periodically discuss issues regarding resident-on-resident abuse.
B. Resident Rights
Discrimination
The Facility will not discriminate against residents in regard to admission or improper denial of access to care in any manner prohibited by law. The Facility will offer care to all residents eligible as required by Federal and State laws governing admissions. The Facility will also not condition admission on a prospective resident’s agreement to hold the Facility harmless for injuries or poor care provided to the resident.
Abuse
The Facility will not tolerate verbal, mental or physical abuse of residents, nor will the Facility improperly deny access to care. Facility staff will report all abuse in accordance with State and Federal laws. The Facility will also not engage in inappropriate use of physical or chemical restraints.
Privacy
The Facility will disclose resident information and records only in compliance with HIPAA and other Federal and State laws and regulations. If the Facility discovers a breach of protected information, the Facility will notify each resident or resident’s family, as required by law. When required by law, the Facility will also notify prominent media outlets and the Health and Human Services Secretary.
The Facility will also respect each resident’s right to privacy by allowing all residents to send and receive unopened mail and use a telephone where calls can be made in privacy.
Self-Determination
All residents have the right to self-determination and right to participate in care and treatment decisions, including the right to choose a personal physician, to be fully informed of his or her health status, and participate in advance of treatment decisions, including the right to refuse treatment, unless the resident is adjudged incompetent or incapacitated.
Financial Affairs
The Facility will safeguard residents’ financial affairs as allowed by the resident and the law. The Facility will engage in a periodic sample review of medical records to detect billing errors.
C. Billing and Cost Reporting
The Facility will do the following in regard to billing and cost reporting:
· Bill only for items or services actually rendered or provided as claimed.
· Only submit claims for equipment, medical supplies and services that are medically necessary.
· Submit claims to Medicare Part A only for residents who are actually eligible for Part A coverage.
· Bill only once for each item or service provided. In the event the Facility mistakenly submits duplicate billing, the Facility will correct the error as provided by applicable law.
· Periodically check for, identify and timely refund credit balances.
· Submit claims only for items or services ordered.
· Not knowingly bill for inadequate or substandard care.
· Not provide misleading information about a resident’s medical condition.
· Not up code the level of service provided.
· Not bill for items or services included in the per diem rate or are of the type of item or service that must be billed as a unit and may not be unbundled.
· Not bill residents for items or services included in the per diem rate or otherwise covered by the third-party payor.
· Not alter documentation or forge physician signature on documents used to verify that services were ordered or provided.
· Maintain sufficient documentation to support the diagnosis, justify treatment, document the course of treatment and results and promote the continuity of care.
· Not falsify cost reports.
The Facility will also collect and analyze case-mix data. The facility will ensure data reported to the Federal Government is accurate. The Facility will utilize this data to ensure accuracy and identify and address potential quality of care issues.
For services and items billed under Medicare or Medicaid, the Facility will not “supplement” payment rates, and will accept the applicable Medicare or Medicaid payment, including any beneficiary coinsurance or copayments authorized, for covered items and services as complete payment.
D. Employee Screening
Background and Reference Checks
The Facility will conduct a background check and reference check on each individual employed by the Facility. This includes checking with all applicable licensing and certification authorities to verify that requisite licenses and certifications are in order. For each employee the Facility will also check the List of Excluded Individuals/Entities List at https://exclusions.oig.hhs.gov to verify that employees are not excluded from participating in the Federal health care programs and retain on file the results of all queries. For each entity the Facility will check the U.S. General Services Administration list of debarred entities at https://exclusions.oig.hhs.gov to verify that entities are not excluded from participating in the Federal health care programs and retain on file the results of all queries. For all health care practitioners, providers and suppliers the Facility contracts with or employs, the Facility will check the National Practitioner Data Bank and Healthcare Integrity and Protection Data Bank at www.npdb.hrsa.gov to verify these individuals are not excluded from participating in the Federal health care programs, are qualified to work and pose no threat of risk to the Facility or residents. The Facility will retain on file the results of all queries. The Facility will periodically renew and verify all these checks and keep results on file. For nurse aides, the Facility will upon hire check every state nurse aide registry it believes may have information on the individual. This will include every state in which the Facility knows the individual has worked.
Application Disclosures
All employment applications will require the applicant to disclose, on the employment application, any criminal conviction or exclusion from Federal or State health care programs. This includes but is not limited to any offense that would preclude employment in a nursing facility.
Temporary Employment Agencies
The Facility will require temporary employment agencies to ensure all temporary staff assigned to the Facility has undergone background checks that verify the same information as outlined in Paragraph D.
Employment Termination and Prohibitions
The Facility will prohibit the employment of any individual who has been convicted of a criminal offense related to health care or who is debarred, excluded, or otherwise ineligible for participation in Federal health care programs. If the Facility receives notice that an employee or contractor is currently charged with a criminal offense related to the delivery of health care services or is proposed for exclusion during his or her employment or contract, the Facility will take all appropriate actions to ensure that the responsibilities of that employee or contractor do not adversely affect the quality of care rendered to any resident, or the accuracy of any claims submitted to any Federal or State health care program. If resolution of the matter results in conviction, debarment or exclusion, the Facility will terminate the employee’s or contractor’s employment or contract.
Conviction Reporting
All current employees and contractors are required to report to the Facility if, subsequent to employment, they are convicted of an offense that would preclude employment in a nursing facility or are excluded from participation in any Federal health care program.
E. Kickbacks, Inducements and Self-Referrals
Anti-Kickbacks
The Facility will not knowingly offer, pay, solicit or receive bribes, kickbacks or other remuneration in order to induce business reimbursable by Federal health care programs. The Facility will make best efforts to ensure that all Facility contracts and arrangements with actual or potential sources of referrals comply with applicable statutes and requirements.
Physician Self-Referrals
The Facility will not accept a referral from a physician for the furnishing of designated health services if the Facility has a financial relationship with the physician or a member of the physician’s immediate family, as outlined in the Stark physician self-referral law. The Facility will analyze potential physician self-referral situations by engaging in the following three-part inquiry:
· Is there a referral (including, but not limited to ordering a service for a resident) from a physician for a designated health service? If not, there is no self-referral issue. If yes, the next inquiry is:
Does the physician (or an immediate family member) have a direct or indirect financial relationship with the Facility? A financial relationship can be created by ownership, investment or compensation. If there is no financial relationship, there
· is no physician self-referral issue. If there is a financial relationship ,the next inquiry is:
· Does the financial relationship fit in an exception? If not, the Facility will reassess the situation and change as necessary to avoid any violation of laws.
In order to prevent violations, the Facility will enter into appropriate written agreements with physicians. All agreements will involve fair-market compensation. The Facility will also document all non-monetary compensation to physicians and periodically analyze to ensure such compensation does not exceed legal limits.
Coinsurance and Deductible Waivers
The Facility will not waive coinsurance or deductible amounts without a good faith determination that the resident is in financial need, or absent reasonable efforts to collect the cost-sharing amount.
Agreements with Other Health Care Providers
The Facility will not enter into any unauthorized or unlawful agreements with a hospital, home health agency or hospice that involve the referral or transfer of any resident to or by the Facility. In regard to hospice care, the Facility will not accept free goods or goods below fair market value from the hospice as inducement for the Facility to refer residents to the hospice. The Facility will also not allow a hospice company to pay for room and board in excess of the amounts the Facility would normally charge or receive from Medicaid. The Facility will not allow a hospice company to pay for additional services that should be already included in the room and board payment. The Facility will not accept referrals of residents from a hospice in return for the Facility’s referrals to the hospice.
The Facility may enter into reserved bed arrangements with hospitals, if the arrangements comply with law. The arrangements cannot include payments that result in double-dipping by the Facility, payments for more beds than the hospital legitimately needs, and excessive payments. Reserved bed agreements cannot violate statutes and regulations which govern Medicare provider agreements, which prohibit a provider from charging a beneficiary or other party for covered services, prohibit a provider from discriminating against Medicare beneficiaries, as a class, in admission policies, or prohibit certain types of payments in connection with referring residents for covered services. Reserved bed arrangements will only be entered into when there is a bona fide need to have the arrangement in place. The arrangements will serve the limited purposed of securing needed beds, not future referrals.
The Facility will not enter into an arrangement with a hospital under which the Facility will only accept a Medicare beneficiary on the condition that the hospital pays the Facility an amount over and above what the Facility would receive through Prospective Payment Systems.
The Facility will periodically review contractor and staff arrangements to ensure the following:
· There is a legitimate need for the services or supplies;
· The services or supplies are actually provided and adequately documented;
· The compensation is at fair-market value in an arm’s-length transaction;
· The arrangement is not related in any manner to the volume or value of Federal health care program business.
The Facility will document the preceding prior to the payment to the provider of the supplies or services.
Agreements with Vendors
The Facility will not enter into any arrangements with vendors that result in the Facility receiving non-covered items at below market prices or for no charge, provided the Facility orders Medicare-reimbursed products.
The Facility will not solicit or receive items of value in exchange for providing the supplier access to residents’ medical records or other information necessary to bill Medicare. The Facility will also not enter into joint ventures with entities supplying goods or services. And the Facility will not “swap” (receive discounts from suppliers on Medicare Part A items and services in return for the referrals of Medicare Part B business). If any direct or indirect link exists between a price offered by a supplier or provider to a Facility for items or services that the Facility pays for out-of-pocket and referrals of Federal business for which the supplier or provider can bill a Federal health care program, the Facility will reassess the agreement and adjust to ensure the Facility does not violate and laws or regulations.
Gifts
The Facility and its employees will comply with the Gifts, Gratuities, and Payments Policy in Appendix C.
Free Goods and Services
The Facility will evaluate acceptance of free goods and services to ensure the Facility does not violate any laws or regulations. The Facility will pay particular attention to the following:
· Pharmaceutical consultant services, medication management, or supplies offered by a pharmacy;
· Infection control, chart review, or other services offered by laboratories or other suppliers;
· Equipment, computers or software applications that have independent value to the Facility;
· DME or supplies offered by DME suppliers for residents covered by Part A benefits;
· A laboratory phlebotomist providing administrative services;
· A hospice nurse providing nursing services for non-hospice residents;
· A registered nurse provided by a hospital.
Neither the Facility nor any employees or agents will accept anything of value from a pharmacy or pharmaceutical manufacturer to influence the choice of drug or to switch a resident from one drug to another.
Guarantees
The Facility will not condition admission or an expedited admission or continued stay at the Facility on a third-party guarantee of payment or soliciting payment for services covered by Medicaid, in addition to any amount required to be paid under the State Medicaid plan.
Discounts
The Facility will disclose all discounts and rebates and ensure they are accurately reflected on cost reports and in any claims as appropriate filed with a Federal program. Any discounts received from a group purchasing organization contract will also be properly disclosed and accurately reported on the Facility’s cost reports.
Physician Contracts
When entering a contract or financial agreement with a physician, the Facility will specifically review the contract or agreement to look for violations of any anti-kickback, self-referral and other relevant Federal and State laws. Specifically, the Facility will periodically review physician contracts to ensure the following:
· There is a legitimate need for the services;
· The services are provided;
· The compensation is at fair-market value in an arm’s-length transaction; and
The arrangement is not related in any manner to the volume or value of Federal health care program business. The Facility will also maintain documentation of all physician arrangements, including the compensation terms, time logs or other accounts of services rendered and the basis for determining compensation. The Facility will also ensure they have not engaged more medical directors or other physicians than necessary for legitimate business purposes, and will ensure that compensation is commensurate with the skill level and experience reasonably necessary to perform the contracted services.
Compliance
The Facility will review each contract and agreement with all actual or potential sources of referrals specifically with the intent to ensure the contract or agreement applies with all applicable statutes and requirements. If feasible, the Facility will have legal counsel review all contracts and agreements with all actual or potential sources of referrals specifically with the intent to ensure the contract or agreement applies with all applicable statutes and requirements.
The Facility will also ask the following questions to help determine compliance:
· Does the Facility (or affiliates or representatives) provide anything of value to persons or entities in a position to influence or generate Federal health care program business for the Facility (or affiliates) directly or indirectly?
· Does the Facility (or affiliates or representatives) receive anything of value from persons or entities for which the Facility generates Federal health care program business, directly or indirectly?
· Could one purpose of an arrangement be to induce or reward the generation of business payable in whole or in part by a Federal health care program?
· Does the arrangement or practice have a potential to interfere with or skew clinical decision making?
· Does the arrangement or practice have a potential to increase costs to Federal health care programs or beneficiaries?
· Does the arrangement or practice have a potential to increase the risk of overutilization or inappropriate utilization?
· Does the arrangement or practice raise patient safety or quality of care concerns?
If the answer to any of these questions is yes, anti-kickback statutes may be implicated, and the Facility will reassess the agreement. The Facility will also determine if the arrangement falls into the following safe harbors:
· Investment interests safe harbor
· Space rental safe harbor
· Personal services and management contracts safe harbor
· Discount safe harbor
· Employee safe harbor
· Electronic health records items and services safe harbors
· Managed care and risk sharing arrangements safe harbors.
The Facility will also evaluate potentially problematic arrangements with referral sources and referral recipients that do not fit into a safe harbor by reviewing the totality of the facts and circumstances, including the intent of the parties. The Facility will also look at the following factors:
· Nature of the relationship – What degree of influence do the parties have, directly or indirectly, on the generation of business for each other?
· Manner in which participants were selected – Were parties selected to participate in an arrangement in whole or in part because of their past or anticipated referrals?
· Manner in which the remuneration is determined – Does the remuneration take into account, directly or indirectly, the volume or value of business generated? Is the remuneration conditioned in whole or in part on referrals or other business generated between the parties? Is the arrangement itself conditioned, directly or indirectly, on the volume or value of Federal health care program business? Is there any service provided other than referrals?
· Value of the remuneration – Is the remuneration fair-market value in an arm’s-length transaction for legitimate, reasonable and necessary services that are actually rendered? Is the Facility paying an inflated rate to a potential referral source? Is the Facility receiving free or below-market-rate items or services from a provider or supplier? Is compensation tied, directly or indirectly, to Federal health care program reimbursement? Is the determination of fair-market value based upon a reasonable methodology that is uniformly applied and properly documented?
· Nature of items or services provided – Are items and services actually needed as rendered, commercially reasonable, and necessary to achieve a legitimate business purpose?
· Potential Federal program impact – Does the remuneration have the potential to affect costs to any of the Federal health care programs or their beneficiaries? Could the remuneration lead to overutilization or inappropriate utilization?
· Potential conflicts of interest – Would acceptance of the remuneration diminish, or appear to diminish, the objectivity of professional judgment? Are there resident safety or quality-of-care concerns? If the remuneration relates to the dissemination of information, is the information complete, accurate and not misleading?
· Manner in which the arrangement is documented – Is the arrangement properly and fully documented in writing? Are the Facility and outside providers and suppliers documenting the items and services they provide? Is the Facility monitoring items and services provided by outside providers and suppliers? Are arrangements actually conducted according to the terms of the written agreements?
F. Creation and Retention of Records
The Facility will maintain appropriate and thorough medical records on each resident. In addition, the Facility will maintain all records and documentation (including billing documentation) required for participation in Federal, State and private health care programs, including resident assessment instruments, comprehensive plans of care, and all corrective actions taken in response to surveys. All medical record documentation should support the medical necessity of services provided as well as the level of service billed.
The Facility will retain all medical records for at least ten years after the last date of resident care. The records of a minor, if any, will be kept until the age of 18 plus 4 years, but in no case less than seven years. Inactive medical records that extend beyond the above requirements will be destroyed, such destruction being witnessed by persons designated by the Administrator. The Facility will keep a log of medical records destruction, which includes the date and time destroyed, medical record number, how records were destroyed, where records were destroyed, signature of personnel destroying records and other information as appropriate or necessary.
The Facility will maintain all records documentation and audit data that support and explain cost reports and other financial activity, including any internal or external compliance monitoring activities, and all records necessary to demonstrate the integrity of the nursing facility compliance process and to confirm the effectiveness of this Program.
The Facility will document all compliance activities and efforts to comply with applicable statutes, regulations and Federal health care programs. This will include a log of oral inquiries between the Facility and third parties regarding compliance efforts.
All current medical records of in-house residents are filed in the medical records department and are maintained by the medical records clerk. Medical records are stored in a locked room and protected from fire, water damage, insects and theft.
The Facility will maintain hard copies of all electronic or database documentation. The Facility will not tolerate falsification and backdating of records. Physicians, Physicians Assistants, Nurse Practitioners, Certified Nursing Assistants, Nursing Assistants, Dietary, Activities, Business Office, Administration, Resident Advocate, Therapy aides, Physical Therapy, Occupational Therapy, Pharmacist Consultant, LCSW, CSW, Northeastern Counseling, SRS Consultant, Hospice Companies and any others allowed by law are authorized to make entries in medical records. Administrator, Director of Nursing, Business Office Manager, Admissions Coordinator, Payroll Manager, Physicians, Physicians Assistants, Nurse Practitioners, Certified Nursing Assistants, Nursing Assistants, Dietary, Activities, Resident Advocate, Therapy aides, Physical Therapy, Occupational Therapy, Pharmacist Consultant, LCSW, CSW, Northeastern Counseling, SRS Consultant, Hospice Companies and any others allowed by law have access to medical records.
G. Discrimination
The Facility will not discriminate in any manner prohibited by Federal or State law.
H. Other Policies and Procedures
Other Facility policies and procedures that employees must follow are attached as Appendix C.
III. Responsibility and Oversight
The following individuals within high-level personnel of The Facility have the overall responsibility to oversee compliance with the above standards and procedures in Paragraph II and have sufficient resources and authority to ensure such compliance.
The Administrator will act as Compliance Officer. The Compliance Committee is compromised of the Administrator and department heads.
The Compliance Officer’s key duties are:
· Overseeing and monitoring implementation of the Program;
· Reporting on a regular basis to the Uintah Health Care Special Service District Board of Directors on the progress of implementation, and assisting these components in establishing methods to improve the Facility’s efficiency and quality of services, and to reduce the Facility’s vulnerability to fraud, abuse and waste;
· Periodically revising the Program in light of changes in the organization’s needs, and in the law and policies of government and private payor health plans;
· Developing, coordinating and participating in education and training that focuses on the elements of this Program, and seeking to ensure that all employees and management understand and comply with pertinent Federal and State laws, rules and regulations;
· Ensuring that independent contractors and agents who furnish physician, nursing or other health care services to the residents are aware of the residents’ rights as well as requirements of this program that apply to the services the contractors and agents provide;
· Coordinating personnel issues with the Facility’s Human Resources staff to ensure that (1) the Facility has checked the National Practitioner Data Bank for all medical staff and independent contractors (as necessary), and (2) the Facility has checked the Office of Inspector General’s List of Excluded Individuals/Entities for all employees, medical staff and independent contractors;
· Assisting the Facility’s financial management in coordinating internal compliance review and monitoring activities, including annual or periodic reviews of departments;
· Independently investigating and acting on matters related to compliance, including the flexibility to design and coordinate internal investigations and any resulting corrective action with all Facility departments, subcontracted providers and health care professionals under the Facility’s control;
· Participating with legal counsel in the appropriate reporting of self-discovered violations, if necessary;
· Continuing the momentum of the Program after the initial years of implementation.
The Compliance Officer has authority to review all documents and other information relevant to compliance activities, including, but not limited to, medical and billing records, and documents concerning the marketing efforts of the nursing facility and its arrangements with other health care providers, including physicians and independent contractors. This review authority enables the compliance officer to examine contracts and obligations (seeking the advice of legal counsel, where appropriate) that may contain referral and payment provisions that could violate the anti-kickback statute or regulatory requirements.
The Compliance Committee is established to advise the Compliance Officer and assist in the implementation of the Program. The Committee’s functions include:
· Analyzing the legal requirements with which the Facility must comply, and specific risk areas;
· Assessing existing policies and procedures that address these risk areas for possible incorporation into the Program;
· Working with appropriate departments to develop standards of conduct and policies and procedures to promote compliance with legal and ethical requirements;
· Recommending and monitoring, in conjunction with the relevant departments, the development of internal systems and controls to carry out the Facility’s policies;
· Determining the appropriate strategies and approaches to promote compliance with program requirements and detection of any potential violations;
· Developing a system to solicit, evaluate, and respond to complaints and problems;
· Monitoring internal and external audits and investigations for the purpose of identifying deficiencies and implementing corrective action.
The Compliance Officer and Compliance Committee will each year review any new OIG and HCFA regulations, Work Plan, Special Fraud Alerts, Advisory Opinions, Bulletins and Other Guidance from the Office of Inspector General at www.hhs.gov/oig and provide training and modifications to this Program as necessary.
The Compliance Officer and Compliance Committee will also periodically meet with the Director of Nursing, Medical Director, and, as necessary, direct care staff to review annual state surveys, verify the Facility has effectively addressed any deficiencies cited by the surveyors, provide training as necessary, and amend this Program as necessary. The individuals at these meetings should also at that time identify issues affecting the quality of care provided to the residents and develop and implement appropriate corrective actions. They may also decide to analyze outcomes of prior modifications to this Program to ensure that modifications achieve desired results and actually improves care.
IV. Non-Delegation
The Facility will use due care in order to not delegate substantial discretionary authority to individuals it knows, or should know through the exercise of due diligence, have a propensity to engage in criminal, civil and administrative violations. The Facility will run background checks and verify all licenses (if applicable) for all individuals who have substantial discretionary authority, as outlined in Paragraph II.D.
V. Communication
The Facility will take steps to communicate effectively the standards and procedures of this Program to all employees and agents. The Facility will do so by providing a copy of this Program to all current employees and agents upon completion of this document, and will provide a copy of this Program to all new employee and agents. Employees and agents should particularly review the Compliance Standards and Procedures in Paragraph II and other policies and procedures in Appendix C which explain in a practical matter what is required. The Facility will also hold individual or group training programs on compliance standards and procedures periodically as necessary. All employees will receive compliance training for at least one hour annually. This training is a mandatory requirement for continued employment.
Supervisors will discuss the following with each new employee, each current employee at the time the Facility adopts this program, and each employee at the time of periodic training:
· Compliance policies and legal requirements applicable to their function, as outlined in this Program;
· Strict compliance with these policies and procedures is a condition of employment;
· The Facility will take disciplinary action, up to and including termination, for violation of these policies.
Upon receipt of this Program, all employees and agents will acknowledge receipt and understanding of the Program by signing the document in Appendix A. A copy of Appendix A will be kept in the employee’s or agent’s file. Upon any training, an employee will sign the document in Appendix B acknowledging receipt of training. A copy of Appendix B will be kept in the employee’s file.
The Facility provides new employee orientation, monthly SilverChair online courses that cover state-required subjects and department training.
Officers, managers and office staff, upon hire, will receive training from supervisors, the Compliance Officer, the Compliance Committee or other individual as appropriate on the following topics:
· Compliance with Medicare participation requirements relevant to their respective duties and responsibilities;
· Appropriate and sufficient documentation;
· Prohibitions on paying or receiving remuneration to induce referrals;
· Proper documentation in clinical or financial records;
· Residents’ rights;
· The duty to report misconduct.
The following are contacts for Facility agents and employees:
Office of Inspector General
U.S. Department of Health and Human Services
200 Independence Ave S.W.
Washington D.C. 20201
877-696-6775
Bureau of Health Facility Licensing, Certification and Resident Assessment
Utah Department of Health & Human Services
288 North 1400 West
Salt Lake City, UT 84116
801-538-6158
800-999-7339
Utah Division of Aging Ombudsman
Utah Department of Health & Human Services
195 North 1950 West
Salt Lake City, UT 84116
801-371-7897
Adult Protective Services
Utah Department of Health & Human Services
288 N 1460 W
Salt Lake City, UT 84116
800-371-7897
Utah Medicaid Provider Fraud
Utah Office of Inspector General
5272 College Drive Suite 200
Salt Lake City, UT 84123
855-403-7283
Utah Division of Occupational and Professional Licensing (DOPL)
Utah Department of Commerce
PO Box 146741
Salt Lake City, UT 84114-6741
801-530-6628
866-275-3675
VI. Monitoring and Auditing
The Facility will take reasonable steps to achieve compliance with these standards and utilize the following monitoring and auditing systems reasonably designed to detect criminal, civil and administrative violations by employees and other agents.
The Compliance Officer and Compliance Committee will monitor Facility activities to remain in compliance with local, state and federal requirements. The Quality Assurance Committee will provide additional monitoring processes.
The Compliance Officer, with the assistance of the Compliance Committee, will annually assess whether the Facility has met this Program’s compliance elements. The Compliance Officer will then implement corrective action as necessary. The Compliance Officer may use (but is not limited to) the following methods as part of the review process:
· On-site visits and inspections;
· Interviews;
· Testing the billing and claims reimbursement staff on their knowledge of applicable program requirements and claims and billing criteria;
· Unannounced mock surveys and audits;
· Examination of the organization’s compliant logs and investigative files;
· Legal assessment of all contractual relationships with contractors, consultants and potential referral sources;
· Re-evaluation of deficiencies cited in past surveys for State requirements and Medicare participation requirements;
· Checking personnel records to determine whether individuals who previously have been reprimanded for compliance issues are now conforming to facility policies;
· Questionnaires developed to solicit impressions of a broad cross-section of the nursing facility’s employees and staff concerning adherence to the Code of Conduct and policies and procedures, as well as their work loads and ability to address the residents’ activities of daily living;
· Validation of qualifications of Facility physicians and other staff, including verification of applicable license renewals;
· Trend analysis, or longitudinal studies, that uncover deviations in specific areas over a given period;
· Analyzing past survey reports for patterns of deficiencies to determine if the proposed corrective plan of action identified and corrected the underlying problem.
The Compliance Officer will
· Have the qualifications and experience necessary to adequately identify potential issues with the subject matter that is reviewed, or utilize the assistance of a reviewer who has the necessary qualifications and experience;
· Be objective and independent of line management to the extent reasonably possible;
· Have access to existing audit and health care resources, relevant personnel, and all relevant areas of operation;
· Present written documentation on all compliance activities and ongoing monitoring efforts to the Uintah Health Care Special Service District Board of Directors and the Compliance Committee, at least annually;
· Specifically identify areas where corrective actions are needed.
The Compliance Officer will make investigations when there are indications of potential fraud and present written documentation of the investigation to the Uintah Health Care Special Service District Board of Directors and the Compliance Committee. This documentation should include documentation of the alleged violation, a description of the investigative process (including the objectivity of the investigators and methodologies utilized), copies of interview notes and key documents, a log of the witnesses interviewed and the documents reviewed, and the results of the investigation.
If the Facility undertakes an investigation of an alleged violation and the Compliance Officer believes the integrity of the investigation may be at stake because of the presence of employees under investigation, the facility should remove those individuals from their current responsibilities until the investigation is completed (unless there is an ongoing internal or government-led undercover operation known to the Facility). The Compliance Officer should also take appropriate steps to secure or prevent the destruction of documents or other evidence relevant to the investigation.
The Facility will have the following reporting system whereby employees and other agents can report violations by others within the Facility. Neither the Facility nor Facility employees may retaliate against other employees for reporting violations.
The Facility will encourage employees to report violations by reporting to supervisors, the Executive Director or the Chairman. If the employee requests confidentiality, the Facility will make efforts to comply with that request if possible. Employees may submit anonymous reports in writing.
All employees will have access to the Compliance Officer to discuss Facility policies and this Program. The Compliance Officer will document all questions and responses.
The Compliance Officer will document all reports and investigate them promptly to determine their veracity. The Compliance Officer will document all investigations as
outlined above. At the completion of an investigation based on a report, the Compliance Officer will redact any individual identifying information, and provide a report to the Uintah Health Care Special Service District Board of Directors and the Compliance Committee.
The Facility will attempt to maintain the confidentiality of an employee’s identity, although there may be circumstances when the individual’s identity may become known or may have to be revealed.
VII. Enforcement
The standards outlined above will be consistently enforced through appropriate disciplinary mechanisms. Individuals who violate these standards will be disciplined.
Individuals who reasonably know or should know of violations of these standards and who fail to detect and report such violations will be disciplined.
Supervisors who fail to adequately instruct subordinates or fail 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 given the Facility an opportunity to correct them earlier will be disciplined.
Discipline will occur according to Employee Conduct Policies included in Appendix C.
If a Facility warrants any discipline is warranted, discipline will be administered promptly.
VIII. Response and Prevention
After an offense has been detected, the Facility will take all reasonable steps to respond appropriately to the offense and prevent further similar offenses, including making any modifications to this program to prevent and detect other criminal, civil and administrative violations. The Facility will do the following in response to all offenses:
· Conduct reasonable inquiry into whether any misconduct violates criminal, civil or administrative law;
· If so, promptly (but no more than 30 days after learning of the offense, unless a shorter time period required by law or rule) report the offense to outside agencies or organizations as required by law or rule. The Facility will use the method of self-disclosure outlined by each agencies or organization, if available;
· Discipline the individual who committed the offense as outlined in Paragraph VII;
· If applicable, make any repayments as required by law or rule to any affected payor;
· Take any other decisive steps to correct the problem, which will be determined on a case-by-case basis.
· Modify this Program as necessary to prevent further similar offenses;
· Any other items required by law.
IX. Reassessment
The Facility will undertake reassessment of this compliance program on a regular basis to identify changes necessary to reflect changes necessary within the organization and its facilities. The Compliance Officer and Compliance Committee will reassess this program at least annually, and make appropriate changes at that time, or as necessary. During an annual review, the Compliance Officer will review and analyze at least the following:
· Designation of the Compliance Officer and Compliance Committee;
· Development of compliance policies and procedures including standards of conduct;
· Developing open lines of communication;
· Appropriate training and teaching;
· Internal monitoring and auditing;
· Response to detected deficiencies;
· Enforcement of disciplinary standards;
· Allocation of resources to compliance initiatives;
· Timetables for implementation of compliance measures;
· Whether compensation structures create undue pressure to pursue profit over compliance.
The Compliance Officer and Compliance Committee will also reassess and revise this Program as necessary based on any offenses.
X. Qualifications
Nothing in this Program is intended to create civil liability obligations on the part of the Facility. This Program is intended only to assist the Facility and its employees and contractors comply with Federal and State laws and regulations. This Program does not create liability above what the Facility is already required to do under applicable laws and regulations.
APPENDIX “A”
I understand that it is my responsibility to refer to https://www.uintahhealthcaressd.org under Employment, Compliance and Ethics and read and understand this policy. You may reach out to the compliance officer with any questions.
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Print Name
_________________________________________
Signature Date
_________________________________________
Print Name of Compliance Officer
_________________________________________
Signature Date
APPENDIX “B”
I hereby acknowledge that I received training on issues in the Compliance and Ethics Program or other policies and procedures, including the following:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________
Print Name
_________________________________________
Signature Date
_________________________________________
Print Name of Compliance Officer
_________________________________________
Signature Date
APPENDIX “C”
Other Facility Policies and Procedures
Abuse
UHCSSD does not tolerate abuse to its clients, be it verbal, mental or physical. Any suspected abuse will be immediately reported to employee’s supervisor, Director, and Executive Director. It is the law. An employee accused or suspected of abuse will immediately be suspended, without pay, while the allegations are investigated. An investigation will be initiated by the Director and the appropriate agencies (department of health, long term care ombudsman, adult protective services, law enforcement, if appropriate) notified immediately. Substantiated abuse will result in the employee’s termination. If the employee is licensed or certified then the Division of Occupational and Professional licensing or the Utah CNA registry shall be notified. Failure of anybody to immediately report abuse will result in disciplinary action up and to termination.
Policy Statement
Our company shall prohibit any employee from receiving or giving any gift, gratuity, or payment for services rendered; the making of any promise(s) on behalf of the company; or engaging in any activity, practice, or act which conflicts with the interest of the company or its residents.
Policy Interpretation and Implementation
1. No employee of this company, or any member of his/her immediate family, may give or accept cash, gifts, special accommodations, favors, or use of property or facilities to or from anyone with whom this company does business or is negotiating business on behalf of the company.
2. The giving or accepting of anything of value by our employees to or from any of our suppliers, residents, family members, visitors, or other employees in any form whatsoever is prohibited. Such conduct may be criminal under certain laws.
3. This policy does not preclude gifts of items of nominal value (not to exceed $50.00 per year). Gifts bearing a supplier logo, which are distributed generally and cost no more than five dollars ($5.00), may be excluded from the fifty dollar ($50.00) annual limitation.
4. Employees and members of their immediate families may not accept any discount on personal purchases of products from a supplier that does business with our company. Discounts made available to all employees as a general practice may be accepted.
5. Any employee(s) who receives a gift which is prohibited by this policy must report it to the administrator.
6. Inquires concerning gifts, services, etc., should be referred to the administrator.