Corporate Compliance Administrative Policy
The Center for Nursing and Rehabilitation at Hoosick Falls
and affiliated entities
Administrative Compliance Policy Manual
Title: Corporate Compliance
Policy: It is the policy of HFHC to promote compliance with all federal, state and local statues, regulations and program requirements pertinent to the accomplishment of our corporate mission. Corporate compliance has been embraced as a central theme for all current and future affiliates of HFHC, and every reasonable attempt will be made to prevent, detect and address errors, omissions, fraud and abuse in our daily operations.
1. The commitment to Corporate Compliance is mandated by the Board of Directors and applies to all employees, medical staff and independent contractors within HFHC.
2. The foundation of the Corporate Compliance Policy is the network of internal controls, policies and procedures in place within HFHC. The success of the plan is predicated on the continuous monitoring of effective managerial systems and investigation and correction of real and potential problems.
3. All employees are required by this policy to discuss potential errors or irregularities with their chain of command and/or directly with the HFHC Compliance Officer. Under no circumstances will retaliation be permitted against employees who voice legitimate concerns to management.
4. The Corporate Compliance Policy follows the HHS Office of Inspector General’s Compliance Program Guidance for Nursing Facilities, but is equally applicable to the requirements of all other governmental entities.
Procedure for Administration of the Corporate Compliance Program:
1. The Purchasing Director of HFHC will function as the Corporate Compliance Officer, with the Administrator of the HFHC as an alternate. The Compliance Officer will coordinate system wide compliance initiatives and be responsible for the following tasks:
a. Reviewing and updating the HFHC Compliance Program on a regular basis.
b. Maintaining all records and documentation of compliance related activities.
c. Reporting on compliance matters to the full Board of Directors on at least a quarterly basis, usually in conjunction with the standard CQI report.
d. Reporting on compliance matters at the department head meetings, which will serve as the management compliance committee. The Compliance Officer will also attend the Continuous Quality Improvement Meeting when required.
e. Conducting ad hoc training on compliance related issues and helping to develop compliance elements for the standard orientation and inservicing program.
f. Serving as the point of contact for employees with questions or concerns about potential compliance problems within HFHC. Facility training and literature will reinforce this option for employees and stress that their inquiries will be kept confidential to the extent possible and that they will be protected from retaliation.
g. Reviewing all monitoring and auditing functions within the various internal control systems of HFHC to ensure that potential problems are identified and dealt with in a timely manner, and for developing and implementing systems as needed.
h. Working with the Administrator to ensure that employees who have compliance related violations are appropriately disciplined according to the standards contained in the HFHC Employee Handbook and for monitoring compliance issues with independent contractors and vendors.
i. Conducting and/or coordinating internal investigations into potential compliance issues and working with the Administrator on developing appropriate courses of action.
2. All staff members are required to read and abide by the HFHC Standards of Conduct and Standards of Compliance as contained in the Employee Handbook. All board members, medical staff and managers in a position to affect facility billing and purchasing decisions are further required to read and execute an annual conflict of interest statement as described in a separate administrative policy. Violations of the terms and conditions stated in these documents expose the individual to disciplinary actions up to and including dismissal or removal.
3. All vendors and independent contractors will be held to the same standard of compliance as HFHC staff. Contractors will be reviewed by legal counsel as needed for potential issues; and any instances of non-compliance will be considered grounds for severing the business relationship.
4. The Administrator, DNS, Purchasing Director and all department managers and supervisors are responsible for continually reviewing and updating the policies, procedures and systems of internal controls within their areas of responsibility. It is contingent upon them to remain current and informed on all changes and modifications to the regulatory environment in which they operate. To this end, HFHC is committed to supporting continuing professional education through tuition reimbursement, seminars, industry publications and online research.
5. The Administrator, DNS, CFL and all department managers and supervisors are responsible for enforcing adherence to the policies, procedures and systems of internal controls within their areas of responsibility. Training staff members, monitoring their work directly or through managerial systems, and timely correction of problems that come to light are critical to the prevention and detection of errors, omissions, fraud and abuse.
6. The Inservice Education Director is responsible for conducting and/or coordinating all new employee orientation, certification classes and mandatory inservicing in conjunction with other involved department managers. Specific training for individual risk areas will be organized or outsourced as needed.
Procedure for Ensuring Quality of Care Compliance:
1. It is the policy of HFHC to provide the highest quality of care to its residents. HFHC believes that state and federal regulations provide a minimum baseline of standards which all staff will strive to exceed in the provision of care and services.
2. The HFHC Medical Staff conducts monitoring and evaluation activities relating to the quality and appropriateness of resident care and handles all issues pertaining to staff appointment and delineation of privileges. The bylaws and policies of the Medical Staff are incorporated by reference into this Compliance Plan.
3. The HFHC Comprehensive Care Planning Committee reviews and draws conclusions about the quality and appropriateness of resident care in conjunction with the Medical Staff. The committee maintains its own data files, analytical reports and minutes of meetings. The records, internal controls, policies and procedures of the team are incorporated by reference into this compliance plan.
4. The HFHC Continuous Quality Improvement Committee reviews quality issues in a broader perspective. The records, internal controls, policies and procedures of the team are incorporated by reference into this compliance plan.
Procedure for Ensuring Resident Rights Compliance:
1. It is the policy of HFHC, as required by state and federal law, not to discriminate in the admission, retention and care of residents because of race, color, blindness, national origin, sex, sexual preference, religion, sponsorship or source of payment.
2. The Administrator, together with Social Work, Recreation Therapy and other clinicians, monitors adherence to all federal and state guidelines and addresses all resident and family complaints and concerns.
Procedure for Ensuring Billing and Financial/Regulatory Reporting Compliance:
1. HFHC has an obligation to its residents, third party payers and the state and federal government to exercise diligence, care and integrity when submitting claims for payment or statutory reports.
2. The HFHC standing system of internal controls and software controls, are incorporated by reference into this compliance plan. The Purchasing Director will continuously monitor compliance with the fiscal systems, making modifications and corrections as needed.
3. Monthly financial statements will be prepared and presented by management to the Board of Directors. Utilization of services, cash position and operational performance compared to the approved budget will be reviewed and discussed.
4. The year end financial statements will be audited by an independent accounting firm possessing significant healthcare expertise. The accounting firm will present the audited financial statements to the Board of Directors, along with a management letter detailing observations about the policies, procedures, systems of internal control and other fiscal management practices of HFHC.
5. The Purchasing Director, along with the auditors, will prepare the Medicare Cost Report in strict compliance with HIM-15 and Fiscal Intermediary guidelines.
6. The Purchasing Director, along with the auditors, will prepare the Medicaid Cost Report in strict compliance with NYSDOH guidelines. The independent accounting firm is required to certify key components of the Medicaid Cost Report prior to its submission.
7. The Purchasing Director will prepare the annual federal and state non-profit tax returns for HFHC, ensuring reporting and disclosure requirements are met.
8. Periodically, an outside entity will review a sample of Medicare Part A and Part B claims to ensure the following:
a. Eligibility of resident for benefits
b. The presence of all necessary physician orders
c. Appropriate care plans and clinical notes
d. Census or attendance records and descriptions of procedures/treatments performed
e. Supporting MDS and RUG-III documentation
f. Accuracy of information on the UB-04 or ANSI 837 electronic billing forms
9. Other payer claims will be reviewed by this entity during the engagement on an as needed basis.
10. The Quarterly Medicare Credit Balance Report will be reviewed and filed by the Purchasing Director and Administrative Assistant.
11. All ADR’s and focused medical reviews will be discussed by the Purchasing Director and QA nurse.
12. All NYS Department of Health draft audits will be reviewed by the Purchasing Director.
13. Complaints and concerns of private paying residents will be reviewed by the Purchasing Director.
Procedure for Ensuring Employee Screening Compliance:
1. It is the policy of the HFHC to exercise due care in the recruitment and hiring of employees.
2. Department Managers and the Administrative Assistant share joint responsibility for the screening and processing of new employees.
3. Any new hire or rehire is required to complete the HFHC employment application and certify its accuracy. Any disclosure of criminal offense or healthcare related non-compliance will be reviewed and may serve as grounds for refusal to hire. Falsification of the employment application will serve as grounds for immediate termination.
4. All prospective employees will have a CHRC performed by NYS guidelines.
5. All prospective employees will be checked against the CNA data bank for sanctions.
6. Professional certifications or licensures will be checked on line or by other means
7. References will be checked for all positions.
8. Periodically, the Purchasing Director will review a sample of new hires to ensure compliance with the above standards.
Procedure for Detecting Kickbacks, Inducements and Self-Referrals:
1. Federal and state law prohibit HFHC and its employees from offering or accepting anything of value in exchange for resident referrals or orders for goods and services which involve payments from either Medicare or Medicaid. These circumstances can be quite complex and require close scrutiny from all involved staff.
2. All new contracts will be reviewed by the Compliance Officers and/or legal counsel for potential conflicts with federal and state statues and regulations. Existing contracts which come under question will also be subject to review and possible termination or renegotiation.
3. All medical staff and independent contractors/vendors who have compliance exposure will be required to disclose any compliance violations and will be checked against the OIG’s List of Excluded Individuals and Entities annually at the time of submission of the Medicare Cost Report. Any disclosure of criminal offense or healthcare related non-compliance will be reviewed and may serve as grounds for non-renewal, cancellation or loss of privileges.
Procedure for Confidentiality, Documentation and Records Retention:
1. It is the policy of HFHC to properly safeguard and manage all sensitive and privileged information pertaining to residents, clients and employees. This philosophy pertains to facility operations in general and compliance related tasks in particular.
2. All pertinent federal and state guidelines for confidentiality and record retention, as well as the HFHC HIPAA Compliance Plan and departmental policies and procedures, are incorporated by reference into this Compliance Plan.
3. All potential compliance issues noted by staff and management will be documented in writing and submitted to the Compliance Officer, who will maintain the central files on compliance issues.
4. Privacy and confidentiality of resident and employee data will be ensured, to the extent possible, by all parties to compliance investigations. Information on residents and staff may have to be provided to federal and state authorities in the course of their investigations.
Procedure for Evaluating Employee Performance Relating to Compliance:
1. HFHC is committed to training all staff in regulatory issues and keeping them current with developing trends. Compliance with all applicable laws, regulations, ethical standards and policies is an expectation for all staff and violations of the same will not be tolerated.
2. Training records will be maintained along with other mandated orientation and inservice records and will be component of the employee’s annual appraisal.
3. Failure to follow HFHC policies and procedures or report instances of misconduct will be cause for an unfavorable performance appraisal and/or progressive discipline, as outlined in the Employee Handbook.
4. Gross misconduct, fraudulent or abusive behavior uncovered as part of a compliance investigation will result in immediate termination and potential legal ramifications.
5. Management and supervisory personnel will be evaluated in part based on their department’s adherence to compliance related policies and procedures. Failure to train and monitor staff or to detect obvious compliance issues within the scope of their authority will result in disciplinary action against the manager or supervisor.
Procedure for Ensuring Risk Management and Employee Incident Compliance:
1. It is the policy of HFHC to promote the safest environment possible for residents, staff and visitors.
2. The HFHC Safety Team monitors residents, visitor and employee incidents for trends and causes and develops corrective actions. The records, internal controls, policies and procedures of the team are incorporated by reference into this Compliance Plan.
3. The Safety Team reviews all pertinent federal and state regulations and coordinates systemic changes, building modifications and staff training as necessary.
4. The Administrator and/or Purchasing Director will monitor all reporting to and from insurance companies and will coordinate involvement of legal counsel where warranted.