Catholic Health. Welcome to the first part of your orientation to Catholic Health. Please review the following slides. If you have questions regarding the material please bring them up when you attend you in class general orientation session. Catholic Health Corporate Compliance. Anne Mason
Promotes Ethical, Professional, and Legal conduct
“Doing what is right”
Supports CHS Standards
Assurance of Quality Care
Attain Compliance by:
Embracing our Mission and Values
Adherence to Policy and Procedures
Found in Compliance 360
Maintaining High Standards of Business and Ethical Conduct
Standards of Conduct
Deal openly and honestly with others
Maintain high standards of conduct in accordance to the CHS mission, directives of the Catholic Church, and applicable federal, state and local laws and regulations
Conflict of Interest
We have a responsibility to act on the best interests of Catholic Health. We need to avoid situations that lead to actual or perceived conflicts of interest
Documentation and Billing
Must be accurate and complete
Associate Compliance Guidebook
provides information on the Standards of Conduct
and is available on CHS website
An observation of failure to follow Standard of Conduct, Policy or Procedures, or observation of an error requires reporting.
Associates can face disciplinary action and even termination for failure to report such events.
All associates are expected to follow standards for:
Legal and Regulatory Compliance
Conflict of Interest
Appropriate Use of Resources
And follow the Code of Ethics
social or entertainment events,
or free meals
associates must consult with their supervisor.
See CHS Policy for further information
If working on behalf of CHS do your actions or activities result in personal gain or advantage, potential adverse effect for CHS, or the potential to interfere with professional judgment, objectivity or ethical responsibilities?
Potential Conflicts of Interest Relationships
include financial relationship for yourself or your immediate family member or secondary employment
Administrative positions with Pharm or DME
Third party payor
Other entities doing business with CHS
All potential Conflicts of Interest must be reported
It is fraudulent to either document services that were not performed or to submit claims for services without appropriately documenting those services.
Missing clinical notes (dates, signatures, orders, care or service rendered) or test results
Incomplete, or illegible documents
Improper billing and coding
can be interpreted as fraud or abuse and lead to a
false claim with the government resulting in penalties.
Reimbursement can only be sought for services or items that have been provided and appropriately documented.
If it’s not documented, it’s not done
It is a crime to knowingly make a false record, file, or submit a false claim with the government for payment
A false claim can include billing for service that:
was not provided or documented
not ordered by a physician
was of substandard quality
Improperly coded or billed
It is also unlawful to improperly retain overpayments
Allows for Qui Tam Relator –notification to government with protection
Individuals or entities can be excluded from participation in Medicare and Medicaid programs.
CHS must not submit any claims to Medicare and/or Medicaid in which a sanctioned individual
or entity provided care or services.
If sanctioned, the person must provide notification immediately to the Compliance Officer.
Follow CHS Policies and Procedures
Offer Language Assistance Services
to those in need
Ensure patient privacy and confidentiality
is maintained (HIPAA and HITECH regulations)
Compliance Policies and Procedures are available
on Compliance 360 (or in an on-site reference manual)
and apply to all CHS associates
Additional compliance policies are also applicable to:
Coding & Billing
Home Health Agency
Language Assistance Program
Language Assistance Program Policy is found in Compliance 360
Mandatory service by law
Family may NOT routinely interpret
Offered upon initial contact AND every time medical information is provided
Documentation is vital to compliance
See Policy for additional information
Health Information Technology for
Economic and Clinical Health Act
Privacy and Security Policies are in Compliance 360
Individually identifiable health information
Also known as
Protected Health Information (PHI)
Transmitted or maintained in any
form or medium
Treatment, Payment or
Health Care Operations
Only access portions of PHI necessary to carry out your duties or to fulfill request
Disclose minimum necessary for your job function based on need for the information
If unable to obtain patient consent, may use professional judgment to share information with a patient’s family and friends
- Be careful with phone
call pertaining to patient
-Pick up faxed or printed PHI immediately
- Use fax cover sheet, verify # & receipt
- Scan PHI only to CHS e-mail accounts
- Make sure to encrypt if being sent outside CHS
- Careful forwarding and replying
- Double check name/address and
material prior to sending
All e-mails sent to a CHS web address are encrypted and therefore secure.
Each e-mail sent outside the CHS system,
will need to be encrypted if it contains sensitive information.
For instructions on a sending external encrypted
email type “encryption” in the search box of Compliance 360.
Curiosity can be a normal human trait
family members, friends, co-workers, persons of
public interest or any others that you are not involved in the care of or …
are...VIOLATIONS of HIPAA
Individuals do NOT have the right
to look up their own health records
Your computer use can be monitored
Lack of integrity
Theft or misuse of services
Improper Political Activity
Breech of Corporate Confidentiality
Improper use of Proprietary Info.
Environmental Health and Safety Issues
Dishonest Communication (spoken or documents)
Improper Business Arrangements
Failure to follow Record Retention policy
Receipt of incentives for patient referrals
The Associate Guidebook or your supervisor can provide additional info.
Immediate supervisor or appropriate department
Higher level manager
Compliance Line 1-888-200-5380 available 24/7
Confidential and Anonymous (if desired)
Report behavior issues, HR policy violations,
and union contract matters to Human Resources
Protects associates from adverse action when they do the right thing and report a genuine concern
Reckless or intentional false accusations by CHS associates are prohibited
Reporting the possible violation does not protect the constituent from the consequences of their own violation or misconduct
Associates have a duty to report
Upholding CHS Mission and Values,
Adhering to Code of Conduct,
Policies & Procedures, and the Law
Completing education and employment requirements
Constant Monitoring for Concerns
Duty to Report Concerns
and Support Non-retaliation
During an Investigation
preserve documentation or records relevant to ongoing investigations
For the Associate and CHS Managers/Supervisors/Administrators
includes termination of employment for violations or failure to report concerns
For Catholic Health System
policies & procedures, and other standards
as soon as aware of situation
apply ethical decision making
Always Seek Knowledge (A.S.K.)
Use Associate Booklet as reference
on CHS website
Compliance/HIPAA Privacy Officer
Anne Mason 821-4469
CHS HIPAA Hotline
HIPAA Security Analyst
Sally O’Brien 862-1938
Corporate Compliance Hotline
1-888-200-5380 (available 24/7)
All reports are confidential
19 Bill of Rights
They are posted in all patient care areas
They are available in Spanish as well as English
If they don’t understand their rights, someone needs to explain them
Receive treatment without discrimination
Receive considerate and respectful care in a clean safe environment free from unnecessary restraints
Receive needed emergency care
Know the names and positions of people caring for them, and refuse their treatment
Know who the MD is who is in charge of your hospital care
A non smoking room
Receive complete information about their diagnosis, treatment and progress
Receive all information for informed consent
Receive all information to give informed consent regarding do not resuscitate
Refuse treatment and be informed of effect
Refuse to take part in research
Privacy in the hospital and confidentiality of all information and records of your care
Participate in decision making about their care, including discharge
Review of their medical record
Receive an itemized bill with explanation of charges
Complain without fear of reprisal
Authorize family members to visit
Make known your wished regarding anatomical gifts
What is “Risk Management”?
Risk Management is the systematic review of events that present a potential for harm and could result in loss for the system.
FOUR ELEMENTS OF RISK MANAGEMENT
Review Occurrence Reports
Review Patient/Visitor Complaints
Participate in Root Cause Analysis
Review concerns expressed by CHS
FOUR ELEMENTS OF RISK MANAGEMENT
Educational Programs through
Department specific inservices
FOUR ELEMENTS OF RISK MANAGEMENT
Investigating & reporting occurrences and claims made to insurance carriers
Assist with discovery requests for lawsuits
Assist with Summons & Complaints and Subpoenas
**NOTIFY RISK MANAGEMENT IMMEDIATELY
UPON RECEIPT OF A
SUMMONS OR SUBPOENA
Within CHS, a process server is to be directed to Administration of the facility in order to serve a Summons or a Subpoena. (HIM may accept subpoenas for hospital records)
***INDIVIDUAL DEPARTMENTS SHOULD NOT ACCEPT,
EVEN IF IT IS FOR SOMEONE IN THE DEPT
FOUR ELEMENTS OF RISK MANAGEMENT
Obtaining & maintaining appropriate insurance coverage:
HPL (Healthcare Professional Liability)
GL (General Liability)
D&O (Directors & Officers)
Property & Casualty
An occurrence is an event that was unplanned, unexpected and unrelated to the natural course of a patient’s disease process or routine care and treatment.
What are sources of an Occurrence?
Patient harm/potential for harm like
falls, med errors
Patient related equipment
What are sources of an Occurrence?
Security issues like elopement, crime,
Lost or damaged property
What is the purpose
of an Occurrence Report?
Who can complete an Occurrence Report?
Any associate or physician who discovers, witnesses or to whom an occurrence is reported, is responsible for documenting the event immediately by means of the Occurrence Report. Anyone who requires assistance should contact the department manager.
DO NOT MAKE COPIES OF AN OCCURRENCE REPORT
What happens to the Occurrence Report?
The completed Occurrence Report is to be forwarded to
the Department Manager
Who will investigate the occurrence and forward to either Quality & Patient Safety Dept or Security as indicated in the
Risk Management process
Risk Management Process
Patient and visitor safety are assessed from both clinical and environmental perspectives
Notify Quality & Patient Safety of patient occurrences
Notify Security of visitor or property occurrences
Risk Management will be notified by QPS or Security
and will participate in evaluation of occurrence
Risk Management will report occurrences to insurance
carrier in cases of potential liability
Risk Management will manage claim as indicated
EMTALA is the Emergency Medical Treatment and Active Labor Act
EMTALA provides a
Guideline for safely and
transferring patients in
The law provides for a medical screening exam (MSE) to all individuals seeking emergency services on hospital property. Hospital property includes the driveway, parking lot, lobby, waiting rooms and areas within 250 yards of the facility.
If an emergency medical condition is found, it will be stabilized within the hospital’s ability to do so, prior to the patient’s transfer or discharge.
If a patient does not have an emergency medical condition, EMTALA does not apply.
*** IMPORTANT: NEVER SUGGEST THAT
A PATIENT GO ELSEWHERE FOR
Fair and Accurate Credit Transactions Act of 2003
“RED Flag Rules”
Hospitals that maintain covered accounts must develop and implement written policies and procedures to identify, detect, prevent, and mitigate identity theft.
You can help reduce opportunities for Identity Theft by keeping PHI confidential and out of public view.
If you believe someone is presenting suspicious documents or acting in a suspicious manner, notify your supervisor who will notify Risk Management
RISK MANAGEMENT DEPARTMENT
Carol Ahrens, RN, BSN 821-4462
Director, Risk Management
Joanne Ricotta, RN, BSN 821-4463
Risk Management Coordinator
Linda McGavin 821-4467
Risk Management Technical Assistant
Valerie Pizarro 821-4468
Legal Services Administrative Assistant
Violence in the Workplace
‘The process of transforming CHS into an organization with a superior ability to deliver patient-centered, quality, compassionate healthcare through outstanding professionals and innovative technology.’
Welcome to Equinox
Catholic Health System
General Orientation Level 1
Quality and Patient Safety
It is a Focused approach to identify, evaluate and improve strategic clinical processes to realize our overall goals of improving patient safety and clinical outcomes
Strategic “Dashboard” Categories Include:
At CHS we believe that the patients and associates safety are our main concern. As a result we have focused our efforts to strengthen our Culture of Safety with the ultimate goal of eliminating medical errors to our patients and injuries to our associates.
How? By raising our expectations of our Board, Leaders, Physicians and Associates.
We expect every ASSOCIATE, LEADER and PHYSICIAN to:
Additional Patient Safety Initiatives:
National Patient Safety Goals
The Catholic Health System fully endorses and supports the Joint Commission (JC) standards wherein any employee who has concerns about the safety or quality of care provided in the hospital may report these concerns to the JC. Furthermore, CHS demonstrates it’s commitment by taking no disciplinary action against any associate who reports a safety or quality of care concern to the JC. Any employee can also feel free to report these concerns to the Quality and Patient Safety Department in their facility
The Infection Control Program is
designed with prevention in mind…
Compliance and guidance is primarily from
New York State Department of Health
Center for Disease Control
Occupational Health and Safety
How are infections transmitted?
Dependent on the type of infection
Respiratory infections are transmitted
through coughing, sneezing and talking by
someone who is ill.
Other infections may occur from:
Direct skin to skin contact
Contaminated inanimate objects
A strong immune system is extremely important in
Transmitted through respiratory secretions
Includes seasonal, H1N1 and others
Practice respiratory etiquette and hand
Meticulous hand hygiene
when taking care of patients with C-diff.
because you need the mechanics of hand washing.
Associates should not work while ill
Prior to returning to work after illness, associates must be ever free for 24hrs and off antipyretics
Annual Health Assessment/PPD
Obtain vaccines (eg. Influenza, Hepatitis B)
Report any potential communicable illness exposure (eg. Chicken Pox) for appropriate guidance
Click on the Bug… Easy as 1, 2, 3!!!!!