2. Purpose of P&S Corporate Compliance
An effective compliance and ethics program must:
• Exercise due diligence to prevent and detect wrong-doing
• Promote an organizational culture that encourages ethical
conduct and a commitment to compliance with the law.
• Raise awareness
• Provide a positive impact to corporate reputation/culture
• Provide a “safe” mechanism(s) for reporting and seeking help
3. Objectives of P&S Corporate Compliance
To meet the objectives of the 7 elements of a corporate
compliance program as outlined by the Federal Sentencing
Guidelines (FSG), P&S Surgical Hospital must:
• Review Written Policies & Procedures
• Select a Compliance Officer & Committee
• Train & Educate employees
• Provide effective Lines of Communication
• Provide Discipline & Background Checks
• Include Auditing and Monitoring
• Respond & take Corrective Action
4. Written Policies & Procedures
P&S Surgical Hospital is Required to:
• Develop and implement policies, procedures, and
practices designed to ensure compliance with state &
federal regulations and programs.
• Adhere to the requirements set forth in its policies & the
Code of Conduct as outlined by federal and state
regulations.
(e.g., licensure, Medicare/Medicaid requirements, HIPAA/HITECH requirements, etc.).
5. P&S Code of Conduct:
• Deter, Detect, Correct & Prevent Misconduct
• P&S Surgical Hospital strives to provide the
highest quality procedural care in a patient focused
environment. P&S Surgical Hospital is committed
to our core values of:
• Service
• Respect
• Compassionate Care
• Friendliness
• Stewardship
6. P & S Code of Conduct:
• The Code of Conduct provides standards by which all members of
the organization will conduct themselves.
• Conduct must be in a manner that protects and promotes
organizational-wide integrity and enhances P&S Surgical Hospital’s
ability to achieve its objectives and mission.
• This applies to all employees, officers, administrators, board
members, medical staff, vendors, contracted
employees, consultants, students, and volunteers.
• Staff members must certify annually that they have
received, read, understand, and agree to abide by the Code of
Conduct.
7. The Compliance Officer & Committee Must:
• Continue to design, implement, oversee, and monitor the compliance
program.
• Report on a regular basis to the CEO, Compliance Committee, and to the
governing body.
• Develop, coordinate, and participate in a multifaceted education & training
program.
• Ensure that independent contractors and agents are aware of the
organization’s compliance program requirements.
• Assist with internal compliance review and monitoring activities.
8. Training & Education
Understand communication processes to report any compliance
issues or concerns :
• New Hire Orientation
• Code of Conduct Training – Annually
• 7 Elements of an Effective Compliance Program – Annually
• Conflict of Interest Statements
• Safe guarding PHI/ePHI
• All employees are responsible to report suspected violations of
the laws, regulations and policies, or any other questionable
conduct.
9. Effective Lines of Communication
Reporting Compliance Issues or Concerns:
Your manager
Executive Team Member
Director of Human Resources
Chenire Craig- 998-7307
Corporate Compliance Officer
Dirk Rhodes- 998-6135
ComplianceLine “Anonymous Hotline” - 1-866-570-2523
10. • Dirk Rhodes, Corporate Compliance Officer
• Phone: (318)- 998-6135
• Contact via E-mail: DirkRhodes@pssurgery.com
• P&S Corporate “Hotline” ComplianceLine:
1-866-570-2523
• 100% anonymous; Available 24 hours a day/ 7 days a week
• There will be no retaliation for reporting concerns in good
faith, but appropriate disciplinary action will be taken against
those who commit misconduct.
• All reported allegations will have to be verified before any
actions are taken.
Effective Lines of Communication
11. Discipline / Background Checks
• All employees undergo a background check/ drug screening upon
hiring.
• A monthly Sanction Check is reviewed on all employees, medical
staff, and vendors to show that P&S is compliant with federal &
state regulations and programs in which we participate.
• Employees receive a copy of the Sanction Policy annually that
supports the Code of Conduct and outlines disciplinary actions in
the event of misconduct.
12. Auditing & Monitoring
• Unethical or inappropriate care
of patients
• Lack of correct and sufficient
documentation in admitting /
discharging patients
• Medical Necessity
• Billing for services or supplies
that were not provided
• Altering claims for higher
payment
• 2 Annual (External)
Billing/Coding Audits
• MCR inpatient one-day
stays
• Conflict of Interest
/Inappropriate vendor
relationships
• Inappropriate access
and/or release of (PHI)
• Bribes or kickbacks
• Business Associate
Agreements (BAA)
• Physician Ownership
Disclosure
13. Responding & Corrective Action
• The Compliance Officer reviews all allegations in a serious manner and takes the
necessary steps to deter, detect, correct, & prevent any wrong-doing or misconduct.
(All reported allegations will have to be verified before any actions are taken.)
• All allegations, audits (internal & external), and monitoring is reported directly to the
CEO, Compliance Committee, and Board.
• All allegations, audits (internal & external), and monitoring tools are addressed in the
allotted time frame per the institution.
• In regards to the P&S ComplianceLine “Hotline”
• ≤ 72 hours to respond to any issue or concern (Severity I to III)
• May take longer considering certain factors and seeking P&S Legal Counsel for
review
We want to provide a safe patient centered environment for
Patients & Employees!!
14. Quick Facts
• All employees are held responsible and accountable for compliance
and can be charged with fraud.
• The Compliance Officer investigates every complaint of
noncompliance.
• There will be no retaliation for reporting concerns in good faith, but
appropriate disciplinary action will be taken against those who
commit misconduct.
• Accepting gifts to induce or reward referrals of federal health
care program business is prohibited.
15. Examples of Compliance Issues
• Never read another employee’s confidential records without permission
• Never use another person’s password to access confidential information
• Only discuss a patient’s condition with those involved in the patient’s
care
• Never treat or act differently to someone because they identified a
compliance or ethical issue
• Accepting gifts from vendors, providers, or third parties is prohibited as
outlined in the conflict of interest policy at P&S. All gifts (>$10.00 per
person per transaction) need prior administration approval before accepting.
• Only bill for visits, procedures and/or tests actually performed
• Always provide complete documentation for ALL services performed
16. Remember!
DO THE RIGHT THING:
• When you become aware of or observe something you
believe to be improper, report it.
• Keep yourself trained and informed.
• There will be no retaliation for reporting in good faith!
No Pointing Fingers!!
17. End of Presentation
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