Policy AD-614 Responding to Detected Compliance Offenses and Developing Appropriate Corrective Action 2021-06-09

Purpose

The purpose of this policy is to ensure Westside Family Healthcare compliance with all applicable laws and regulations and to establish appropriate and effective procedures for responding to situations of detected compliance offenses.

Policy

It is the policy of Westside Family Healthcare (Westside) to set forth the procedures used to respond to information received by the Corporate Compliance Officer that an individual employed by or associated with Westside is or may be engaging in an activity considered a compliance offense, as defined below.  

The Corporate Compliance Officer and, as needed, Westside senior leadership follow the procedures outlined below for investigation of detected compliances offenses and organizational response to identified non-compliance.  

Scope

This policy applies to the entire Westside organization, with regard to detection and reporting of compliance offenses, and the Corporate Compliance Officer and senior leadership, with regard to responding to compliance offenses and taking appropriate corrective action.

Definitions

Compliance Offense – For the purposes of this policy, a compliance offense refers to situations in which a Westside Board member, officer, employee, consultant, vendor, or volunteer is engaging in activity that is contrary to or in violation of applicable federal or state law or the requirements of the Westside compliance program. Other types of misconduct that threaten the organization’s status as a reliable, honest, and trustworthy provider of health care may also be investigated and addressed following the procedures in this policy.  

Procedures

Investigation

• 1. Purpose of Investigation
     1. The purpose of an investigation is to:
        1. identify situations in which applicable federal or state laws, including the laws, regulations and standards of the Medicare and Medicaid programs, or the requirements of Westside’s compliance program may not have been followed,
        2. identify individuals who may have knowingly or inadvertently violated the law or Westside’s compliance program requirements,
        3. facilitate the correction of any violations or misconduct,
        4. implement procedures necessary to ensure future compliance,
        5. protect Westside in the event of civil or criminal enforcement actions, and
        6. preserve and protect Westside’s assets.
  2. Control of Investigations
     1. All reports of alleged non-compliance must be made directly to or forwarded to Westside’s Corporate Compliance Officer.  
     2. Serious or otherwise sensitive matters for investigations should be conducted under the direction of or by Westside’s legal counsel.  
     3. If the involvement of legal counsel is warranted, the Corporate Compliance Officer will be responsible for requesting that legal counsel:
        1. initiate an investigation of the conduct in question,
        2. prepare a report of findings to the Chief Executive Officer and/or Corporate Compliance Officer, and
        3. recommend the appropriate actions to be taken by the Corporate Compliance Officer.  
     4. At all times relevant to the investigation, the Corporate Compliance Officer and anyone assisting legal counsel in their investigation, will function under the direction and control of Westside’s legal counsel.
  3. Investigative Process
     1. Upon receipt of information concerning alleged misconduct, the Corporate Compliance Officer will, at a minimum, take the following actions:
        1. Complete a report to the Chief Executive Officer, and, if applicable, other senior leadership team members.
           1. The report includes, if known, the name of the employee who made the report, the date of the report, and a detailed narrative of the employee’s concern.  
           2. Anonymity of the individual who made the report (if requested) and confidentiality will be maintained.
        2. Notify the Chief Executive Officer and, if applicable, the Compliance and Risk Management Committee of the nature of the alleged improper conduct and, if the involvement of legal counsel is warranted, obtain a memorandum from senior management authorizing legal counsel to initiate an investigation.
        3. Ensure that the investigation is initiated as soon as reasonably possible but in any event not more than three (3) business days following receipt of the information.  The investigation shall include, as applicable, but need not be limited to:
           1. Interviews of all persons who may have knowledge of the alleged conduct and a review of the applicable laws, regulations and standards to determine whether or not a violation has occurred.
           2. Identification and review of relevant documentation, including, where applicable, representative bills or claims submitted to the Medicare/Medicaid programs, to determine the specific nature and scope of the violation and its frequency, duration and potential financial magnitude.
           3. Interviews of persons who appeared to play a role in the suspected activity or conduct.  The purpose of the interviews is to determine the facts which surround the conduct, and may include, but shall not be limited to:

The person’s understanding of the applicable laws, rules and standards;

Identification of relevant supervisors or managers;

Training that the person received;

The extent to which the person may have acted knowingly or with reckless disregard or intentional indifference of applicable laws;

• • • • 1. Preparation of a summary report that:

defines the nature of the alleged misconduct,

summarizes the investigation process,

identifies any person who is believed to have acted deliberately or with reckless disregard or intentional indifference of applicable laws,

assesses the nature and extent of potential civil or criminal liability, and

where applicable, estimates the extent of any resulting overpayment by the government.

• • • 1. For all investigations in which Westside’s legal counsel is not involved, ensure that significant developments are promptly reported to the Corporate Compliance Officer so that a determination can be made as to whether legal counsel should be contacted.
      2. Establish a due date for the summary report or otherwise ensure that the investigation is completed in a reasonable and timely fashion and that the appropriate disciplinary or corrective action is taken, if warranted.

Organizational Response

• 1. Non-Compliance/Suspected Criminal Activity
     1. In the event that the investigation identifies employee misconduct or suspected criminal activity, Westside will undertake the following steps:
        1. As quickly as possible, cease the offending practice.
           1. If the conduct involves the improper submission of claims for payment, Westside will immediately cease all billing potentially affected by the offending practice.
        2. Consult with legal counsel to determine whether voluntary reporting of the identified misconduct to the appropriate governmental authority is warranted.
        3. If applicable, calculate and repay any duplicate or improper payments made by a federal or state government program as a result of the misconduct.
        4. Initiate appropriate disciplinary action, which may include, but is not limited to, reprimand, demotion, suspension and/or termination.  
           1. If the investigation uncovers what appears to be criminal conduct on the part of an employee, appropriate disciplinary action against the employee or employees who authorized, engaged in or otherwise participated in the offending practice will include, at a minimum, the removal of the person from any position of oversight and may include, in addition, suspension, demotion, and termination.
        5. Promptly undertake appropriate training and education to prevent a recurrence of the misconduct.
        6. Conduct a review of applicable policies and procedures to determine whether revisions or the development of new policies and/or procedures are needed to minimize future risk of noncompliance.
        7. Conduct, as appropriate, follow-up monitoring and auditing to ensure effective resolution of the offending practice.

This policy and its procedures shall be periodically reviewed and updated consistent with the requirements and standards established by the Board of Directors and by Westside leadership, federal and state law and regulations, and applicable accrediting and review organizations.

References

1. Step Five: Responding To Detected Offenses and Developing Corrective Action Initiatives, 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