Policy AD-610 Corporate Compliance Officer Authority and Duties 2021-06-09

Purpose

The purpose of this policy is to ensure Westside Family Healthcare’s compliance with all applicable federal, state, and local laws and regulations, as well as with the requirements of the organization’s grant funders and accreditation agencies.

Additionally, this policy recognizes the benefits of a strong compliance program, including but not limited to increasing the potential for proper coding and billing practices, avoidance of fraud, waste, and abuse, promoting patient safety, protecting patient privacy, ensuring delivery of high quality patient care, protecting employee rights, and reducing liability and other risks for the organization.

Policy

It is the policy of Westside Family Healthcare (Westside) to designate an employee as its Corporate Compliance Officer to oversee the development and implementation of the organization’s compliance program and to ensure appropriate handling of instances of suspected or known illegal or unethical conduct.  The procedures set forth in this policy describe the authority, duties, and responsibilities of the Corporate Compliance Officer.

Scope

This policy applies to Westside and the individual identified as the Corporate Compliance Officer.

Definitions

None

Procedures

1. Authority  
   1. The Corporate Compliance Officer has principal authority and responsibility for the development, implementation, oversight, and evaluation of all aspects of the organization’s corporate compliance program.  
   2. The Corporate Compliance Officer reports to the Director of Quality Improvement and is assured direct access to Westside’s Chief Executive Officer,  Board of Directors, and legal counsel, as needed or requested, for the purpose of making reports and recommendations on compliance matters.  
   3. The Corporate Compliance Officer serves as co-chair of the Compliance and Risk Management Committee with the Chief Operations Officer/Risk Manager, as detailed in policy AD-613 Functions of the Compliance and Risk Management Committee.
   4. The Corporate Compliance Officer serves as chair of the Continuous Survey Readiness Committee, which reviews and monitors ongoing compliance with requirements of the HRSA Health Center and FTCA programs and with The Joint Commission standards for Ambulatory Health Care and Primary Care Medical Home (PCMH) accreditation.
   5. The Corporate Compliance Officer is authorized to investigate all instances of suspected illegal or unethical conduct to determine the necessary facts and may, upon obtaining appropriate authorization consistent with Westside budget constraints, seek the advice of legal counsel and hire outside investigators and/or consultants.

Duties  

• 1. The Corporate Compliance Officer has all of the duties and responsibilities that are ordinarily delegated to corporate compliance officers.  
  2. The Corporate Compliance Officer maintains current knowledge of and ensures ongoing compliance with applicable federal, state, and local laws and regulations.
  3. The Corporate Compliance Officer develops and maintains a comprehensive corporate compliance program in recognition that:
     1. The Department of Health and Human Services (HHS) Office of the Inspector General (OIG) has published voluntary guidelines titled Compliance Program for Individual and Small Group Physician Practices that include highly recommended best practices, and
     2. Establishment of a compliance program is mandated as a condition of enrollment for Medicare and Medicaid providers, as established in the Patient Protection and Affordable Care Act of 2010 (PPACA), once HHS has published required core elements.
  4. As part of their duties and responsibilities, the Corporate Compliance Officer is responsible for the following compliance program activities on behalf of the organization:
     1. Overseeing and monitoring the development, implementation, and ongoing operations of Westside’s compliance program.
     2. Ensuring that Westside’s corporate compliance program includes the following seven components of an effective compliance program, as outlined in the HHS OIG guidance:
        1. A compliance officer;
        2. Written standards and policies to implement compliance and organizational standards and govern operations;
        3. Appropriate training and education on standards and procedures;
        4. Open lines of communication;
        5. Internal monitoring and auditing;
        6. Investigation of detected offenses and developing corrective action; and
        7. Publicized and enforced disciplinary standards.
     3. Implementing a corporate compliance program that includes the following activities, as detailed in the HHS OIG compliance program guidance:
        1. Establishing methods - such as conducting periodic audits, developing effective lines of communication on compliance issues, and preparing written practice standards and procedures - to improve the organization’s efficiency and quality of services and to reduce its vulnerability to fraud and abuse;  
        2. Evaluating the compliance program to ensure that it meets its objectives and periodically revising the program, or recommending such revisions to the Compliance and Risk Management Committee, in light of changes in the needs of organization or changes in the law and/or in the standards and procedures of government and private payer health plans;
        3. Developing, coordinating, and participating in a training program that focuses on the components of the compliance program and seeks to ensure that all appropriate employees and management are knowledgeable of, and comply with, pertinent Federal and State standards and that independent contractors and consultants (and volunteers, if applicable) who furnish medical and other services to Westside are aware of the requirements of the organization’s Compliance Program;
        4. Ensuring that the HHS OIG’s List of Excluded Individuals and Entities, and the General Services Administration’s (GSA’s) List of Parties Debarred from Federal Programs have been checked with respect to all board members, employees, medical staff, and independent contractors;  
        5. Independently investigating and acting on any report or allegation of unethical or improper conduct or business practices, and implementing and monitoring appropriate corrective action and/or subsequent compliance; and
     4. Developing, reviewing, and updating written standards and policies for key corporate compliance areas (refer to Attachment A: Key Corporate Compliance-Related Policies for relevant Westside policies) including but not limited to:
        1. The Corporate Compliance Officer;
        2. The Compliance Committee;
        3. Standards of Conduct;
        4. Conflict of Interest;
        5. Confidentiality;
        6. Fraud, Waste, and Abuse, including compliance with:
           1. The Anti-Kickback Statute,
           2. The False Claims Act, and
           3. The Stark Law;
        7. Document Retention;
        8. Screening – Exclusions and Background Checks;
        9. Whistleblower Protection and Non-Retaliation;
        10. Detecting and Responding to Compliance Offenses; and
        11. Areas of High Risk to the organization.
     5. Overseeing Policy Management for the organization, including:
        1. Developing standardized processes for policy creation, review, and updating;
        2. Reviewing policies for inclusion of appropriate compliance-related content and procedures; and
        3. Supporting policy owners, as needed.
     6. Monitoring, documenting, and supporting Westside’s compliance with regard to grant funding and grant-related program requirements, including but not limited to:
        1. HRSA’s Health Center Program (Section 330);
        2. HRSA’s FTCA medical malpractice program;
        3. HRSA’s 340B Drug Discount Program;
        4. Delaware Department of Health and Social Services (DHSS) sub-grants (ex. Title X/Family Planning); and
        5. Other relevant federal, state, or private foundation grants.
     7. Monitoring, documenting, and supporting Westside’s compliance with regard to meeting The Joint Commission (TJC) accreditation standards for the:
        1. TJC Ambulatory Health Care (AHC) program, and
        2. TJC Primary Care Medical Home (PCMH) program.
     8. Monitoring, documenting, and supporting Westside’s compliance with relevant regulations enforced by federal and state entities, including but not limited to:
        1. Department of Health and Human Services (HHS),
        2. HHS Office of the Inspector General (OIG),
        3. HHS Centers for Medicare and Medicaid Services (CMS),
        4. HHS Office for Civil Rights (OCR),
        5. HHS Substance Abuse and Mental Health Services Administration (SAMHSA),
        6. Department of Labor (DOL),
        7. DOL Occupational Safety and Health Administrator (OSHA),
        8. DOL Equal Employment Opportunity Commission (EEOC),
        9. Delaware Department of Health and Social Services (DHSS),
        10. DHSS Division of Public Health (DPH),
        11. DHSS Division of Medicare and Medicaid Services (DMMS),
        12. Delaware Division of Waste and Hazardous Substances (DNREC), and
        13. eBrightHealth Accountable Care Organization (ACO).
     9. Supporting the Chief Operating Officer/Risk Manager in implementing the Risk Management Program and assessing and reducing compliance-related risk.
     10. Supporting the Director of Quality Improvement in implementing the Continuous Quality Improvement Plan and addressing and resolving identified areas of non-compliance.
     11. Reporting on a regular basis to the Board of Directors and Chief Executive Officer on the progress of the compliance program’s implementation and of the methods adopted to improve the organization’s efficiency and quality of services and to reduce its vulnerability to fraud and abuse.
     12. Receiving reports of alleged non-compliance or detected compliance offenses directly from Westside staff or via the anonymous Compliance Hotline.
     13. Responding to identified or reported compliance offenses and taking appropriate action following the procedures outlined in Westside policy AD-614 Responding to Detected Compliance Offenses and Developing Appropriate Corrective Action.

References

1. Compliance Program for Individual and Small Group Physician Practices.  Department of Health and Human Services (DHSS) Office of Inspector General (OIG). Federal Register / Vol. 65, No. 194 / Thursday, October 5, 2000 / Notices.   https://oig.hhs.gov/authorities/docs/physician.pdf
2. Section 6401 of the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act). http://housedocs.house.gov/energycommerce/ppacacon.pdf
3. NACHC Corporate Compliance Toolkit – Compliance Officer Position Description: Sample
4. Health Services Resource Administration (HRSA) Bureau of Primary Care (BPHC) manuals
   1. Health Services Resource Administration (HRSA). Health Center Program Compliance Manual, August 2018.  https://bphc.hrsa.gov/programrequirements/compliancemanual/
   2. Health Services Resource Administration (HRSA). Health Center Program Site Visit Protocol (SVP), February 27, 2020.  https://bphc.hrsa.gov/programrequirements/svprotocol
5. The Joint Commission (TJC) manuals
   1. The Joint Commission (TJC) Comprehensive Accreditation Manual for Ambulatory Health Care (CAMAC), January 1, 2021.  Entire manual including compliance program-related standards:
      1. APR.01.01.01: The organization submits information to The Joint Commission as required.
      2. APR.02.01.01: The organization permits the performance of a survey at The Joint Commission's discretion.
      3. LD.04.01.01: The organization complies with law and regulation.

ATTACHMENT A:

KEY CORPORATE COMPLIANCE-RELATED POLICIES

Corporate Compliance Officer

AD-610 Corporate Compliance Officer Authority and Obligations

Compliance Committee

AD-613 Functions of the Compliance and Risk Management Committee

Standards of Conduct

Employee Handbook (contained within)

Confidentiality

AD-101 Confidentiality

Conflict of Interest

AD-102 Conflicts of Interest

Fraud, Waste, and Abuse

AD-106 False Claims Recovery Education

Document Retention

AD-710 Document Retention and Destruction

Screening – Exclusions and Background Checks

New policy and procedures under development. (ongoing checks conducted)

Whistleblower Protection and Non-Retaliation.

HR-102 Whistleblower Protection (State)

HR-103 Whistleblower Protection (Federal)

Detecting and Responding to Compliance Offenses

AD-614 Responding to Detected Compliance Offenses and Developing Appropriate Corrective Action

High Risk Areas

AD-450 Risk Management Plan

A range of Westside policies, as listed in Attachment A to AD-450