Element #1- Chief Compliance Officer (CCO), Compliance Program and Executive Compliance Committee (ECC)
In keeping with JHS’ overall commitment to support the operation of its Compliance Department for this complex health system, JHS continues to maintain a comprehensive and dynamic Compliance function under the leadership of Mr. Migoya, the JHS CEO and President, the Executive leadership and The PHT FRB. Other developments are listed and explained throughout this report.
JHS continues to maintain Compliance 360 (C360), a robust web-based compliance and risk assessment application, providing a one platform solution to track and monitor compliance issues across the system as well as all JHS Policy administration and management, and finally as the physician arrangements database.
Diana Salinas, Esq., CHC continues in her role as Chief Compliance Officer of JHS. Luis Martinez, Esq., continues in his role as Chief Privacy Officer and James Rowan, Esq. as Corporate Compliance Manager overseeing STARK and Anti-Kickback issues as well as providing support to JNMC and JSCH on compliance related matters. The Compliance Audit Manager, Alison Ingram, CHC, resigned to pursue an external promotion. Renee Baine has been promoted to fill the vacancy of the Audit Manager. We continue to recruit for vacancies within the CCP, such as the RAC Coordinator and the Compliance Audit Supervisor roles. The Compliance program leadership continues to serve as members of the ECC.
The ECC is comprised of the Chief Compliance Officer, Chief Executive Officer and President, Chief Operating Officer, Chief Financial Officer, Chief Medical Officer, Chief Nursing officer, Chief Human Resource Officer and the
Chief Administrative Officer for all JHS hospital centers
. The ECC meets on a monthly basis and addresses subjects that may include (1) discussing pending compliance issues, (2) announcing and discussing new initiatives, (3) reviewing rules, regulations and policies and procedures, (4) developing compliance work plans, and (5) assigning responsibilities for meeting compliance policies and procedures requirements.An Equal Opportunity Employer 4
Element #2 - JHS Standard and Code of Conduct and Compliance Policies and Procedures
The Compliance Program maintains a Code of Conduct and a series of Compliance Policies and Procedures (600 series of the JHS Policy Manual) that were developed and implemented in an effort to ensure compliance with federal health care program requirements. Further, the policies are tailored to each one of the seven elements in an effort to communicate to employees the standards and procedures to which they must adhere. Additionally, the Standard and Code of Conduct are provided to all employees, agents and contractors. On an ongoing basis, the Compliance Department reviews and updates the policies to address any new requirements or guidance that emerge within the healthcare industry by regulatory bodies.
The JHS system wide Policy Manual administration function also lies within the Compliance Department. The Policy Administrator, Annisa Laguna, works closely with policy owners, stakeholders, legal and executives across the system to assure comprehensive review and dissemination of JHS policies and other mission-critical policies.
Element #3 - Compliance General and Specific Training
The JHS Compliance Program continues to develop and provide system wide comprehensive, timely and resource-efficient General and Specific Compliance training as well as HIPAA Privacy and Security education to ensure thorough comprehension of policies, procedures, laws, regulations and legal requirements that identify compliance priorities. Training is provided through new hire orientation, face to face and via the JHS web based learning system (JEN). During 2010, in order to facilitate meeting the compliance training obligations, the CCP identified the “training year” to coincide with the JHS Joint Commission Hospital mandatory education which is measured on the calendar year. For calendar year 2010, one hundred percent of the 11,625 active employees completed the general compliance training and 1,094 the specific compliance training. All new employees received compliance and HIPAA education within the first thirty days of employment, generally during their hospital orientation session.
The Compliance Program also provides training, education and in-services year round on a variety of related matters. Further, the Compliance team continues to work with other departments towards a fully electronic system to determine training accuracy and reporting. The compliance training program is reviewed and updated on an annual basis according to changes and updates related to Federal healthcare program regulations, as well as, billing and coding updates. Lastly, continuous department specific research, communication and training of Federal program regulations and requirements are provided, as well as dissemination of OIG audit findings to develop compliance awareness of national compliance efforts.
Element #4 - Monitoring and Auditing
The Compliance Program includes an Audit team made up of compliance and medical auditors. The JHS Compliance annual audit plan was developed and based on the review of the annual OIG work plan, the RAC approved vulnerabilities and internal institutional risk assessments. The audit plan was re- evaluated monthly based on investigation triggered audits and special projects. Audits generally focus on medical necessity, proper documentation, coding, billing and reimbursement in relation to Medicaid and Medicare and other Federal Health Care programs.
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The FY2011 Audit Plan was completed with the exception of one audit that was transferred to Internal Audit and completed by that team, and three audits that were rolled over to the FY2012 Audit Plan due to process changes under way within the subject area. A total of 49 audits were completed for FY11. Overall the audit findings ranged in error rates. But most importantly with all audits corrective action measures were taken either at the departmental level or by developing work groups. The highest risk area identified from the FY11 audit plan lies in the RAC approved issue related to medical necessity on inpatient status versus observation status where significant work is still taking place across departments including but not limited to Quality, Case Management, HIM, Billing Office, IT, etc. Element #5 - Reporting; effective lines of communication
The JHS Compliance Program maintains effective lines of communication to empower every
employee as a member of the Compliance team to bring forward information of suspected improper governmental activity, or other non-compliant conduct, without fear of retaliation or retribution. The JHS reporting mechanisms include the Compliance Hotline via an independently-operated vendor but managed on a daily basis from the Compliance Department for reporting and investigation purposes. During FY11 five hundred and thirty-seven calls were logged into the hotline; one hundred and fifty-five of these calls generated an investigation. One hundred forty-two investigations have been closed; twenty- five were substantiated and one hundred and seventeen were unsubstantiated. The remaining investigations are presently open and being worked on. Additionally, employees also have the opportunity to voice concerns and raise compliance issues without fear of retaliation via email and walk- ins to the Compliance Department.
Element #6 - Enforcement and Discipline
The Compliance program responds to detected deficiencies such as improper activities or
violations of Compliance policies regardless of the employee’s stature within JHS. This response includes monitoring and coordinating all efforts related to investigation requests that occur via the Hotline, emails, walk-ins, and phone calls to the Compliance Department. A strong collaborative effort with Human Resources’ Labor Relations & Workforce Compliance Department on all these matters continues to exist.
Element #7 - Response and Prevention
Background checks and sanctions screenings of all applicants and prospective vendors for ineligible persons is conducted prior to hiring any individual for a position at JHS. Additionally, the Compliance Program conducts an annual OIG Sanction Exclusion list screening of all employees and vendors to ensure sanctioned individuals were not employed or doing business at JHS. Potential matches are routinely identified (based on similarity of name only). When an employees’ name matched a name on the Exclusion List, JHS reviewed and obtained renewed attestations from all employees, with the exception of two employees that were identified to be the actual persons on the list. One employee was separated immediately and the second employee’s circumstance warrant further inquiry and
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consideration. Compliance, legal and labor relations are jointly addressing both incidents. No excluded vendors were identified for the same period.
The Compliance team coordinated, tracked and conducted investigations (where applicable) as well as managed complaints of suspected improper governmental activity, workplace misconduct, and other ethical breaches made under JHS policies. This process ensures compliance with federal and state laws including whistleblower laws. The team also addressed investigations and remediation of identified systemic problems by driving work groups and taskforces as needed such as the Infusion workgroup, etc.