Compliance Information
Corporate Compliance Officer
Jennie Flanagan, RN BT
315-713-5102 (office)
315-713-5600 (Internal
Anonymous Reporting Hotline)
1-866-493-9451 (External
Anonymous Reporting Hotline)
The
Corporate Compliance Program at CHMC is a mandatory, self-monitoring program to
assure our compliance with all federal, state and local laws applicable to
healthcare.
Our
program is required to:
--Oversee the activities of CHMC and its
employees with regard to compliance with laws, regulations, policies, &
Code of Conduct
--Heighten awareness of compliance and
ethical issues through education
--Provide mechanisms for detection,
correction, and prevention of improper conduct
--Provide employees with avenues for addressing
compliance and ethical issues
We
deal with issues related to:
--Fraud and abuse- (Deficit Reduction Act,
Social Security Act, False Claims Act)
--Regulatory standards and laws-Department of
Health and DNV
--Billing and coding requirements
--HIPAA
--Medical Necessity
--Patient documentation
--Information Requests
--EMTALA - "patient anti-dumping law"
8 Elements of a Compliance Program
(1) The development and distribution of
written standards of conduct, as well as written policies and procedures, that reflect the
institution’s commitment to compliance.
(2) The designation of a compliance officer
and a compliance committee charged with the responsibility for developing,
operating, and monitoring the compliance program, and with authority to report
directly to the head of the organization.
(3) The development and implementation of
regular, effective education and training programs for all affected
employees.
(4) The creation and maintenance of an effective line of
communication between the compliance officer and all employees,
including a process (such as a hotline or other reporting system) to receive
complaints or questions that are addressed in a timely and meaningful way, and
the adoption of procedures to protect the anonymity of complainants and to
protect whistleblowers from retaliation
(5) The clear definition
of roles and responsibilities within the institution’s organization and ensuring the effective assignment of
oversight responsibilities.
(6) The use of audits and/or
other risk evaluation techniques to monitor compliance and identify problem areas.
(7) The enforcement of appropriate
disciplinary action against employees or contractors who have violated institutional policies,
procedures, and/or applicable Federal requirements for the use of Federal
research dollars, and
(8) The development of
policies and procedures for the investigation of identified instances of non-compliance or misconduct.
These should include directions regarding the prompt and proper response to
detected offenses, such as the initiation of appropriate corrective action and
preventive measures.
Accreditation
DNV (Det Norske Veritas) Healthcare Inc.
Claxton-Hepburn Medical Center is
accredited by DNV Healthcare
Inc. DNV Healthcare is committed to improving the quality and safety of
care provided by health care organizations. Accreditation means that the
hospital has demonstrated compliance with organizational, patient care
and safety standards set forth by DNV Healthcare. In addition,
accreditation with DNV standards is the foundation of Claxton-Hepburn's quality management system. Click here to visit the DNV Healthcare Inc. website.
Safety or Quality Concerns? If you have a
concern or complaint about
patient care or safety, please share this directly with those providing
the care or services to you. If you do not feel that your concern has
been adequately addressed, you may contact the manager of that service
area. If you continue to feel that your concern has not been adequately
addressed, please contact Claxton-Hepburn Medical Center's Performance
Improvement Office, located at 214 King Street, Ogdensburg, NY 13669.
You
may contact them by phone at 315-713-5100 , or if you are still
not satisfied with the response, you may report your concern or
register a complaint with the following:
DNV Healthcare
Phone: 1-866-523-6842
Email: hospitalcomplaint@dnv.com
The patient also has the right to file a complaint with the NY Department of Health at 1-800-804-5447.
Standards for Privacy and Protected Health Information
The Deficit Reduction Act (DRA) of 2005
became effective January 1, 2007, and mandates healthcare providers
receiving $5 million in Medicaid reimbursement to have a Compliance
Plan. The Compliance Plan must include policies regarding the False
Claims Act, administrative remedies for false claims and statements;
applicable state false claims provisions and whistleblower protections
under these laws. Claxton-Hepburn Medical Center understands the
importance of having a strong Compliance Plan to prevent fraud, waste,
and abuse in our healthcare system. Claxton-Hepburn is proud to say we
have had an effective compliance program in place since 1999. A specific
requirement of the Deficit Reduction Act is that we communicate our
fraud, waste and abuse policies to our employees, vendors and
contractors. Additionally, the employees, agents, and contractors must,
in performing work for Claxton-Hepburn Medical Center, adopt and abide
by these policies.