GOOD SHEPHERD SERVICES, LTD.
Corporate Compliance Policy
Introduction
Under the direction of our Board of Directors, Good Shepherd Services developed a Corporate Compliance Program in January of 1999. The intent was to affirm the commitment of our organization to abide by high legal and ethical standards with the delivery of health care services and the operation of the organization.
We have developed the following policies and procedures for the implementation of the program as it relates to Good Shepherd employees, vendors and providers (contractors). Specifically, these policies and procedures provide guidance to all employees, vendors and providers regarding the operation of the Corporate Compliance Program and the available mechanisms through which compliance issues can and should be reported.
This document is the abbreviated version of the program. The complete program document is available in public areas at Good Shepherd Services or by request.
Each employee, contractor and vendor is responsible for adhering to the standards of this program. The program is discussed with employees during their employment orientation and every January at our mandatory all-staff compliance meeting.
Compliance Committee Composition
This committee consists of three members and the Compliance Officer. The committee and the officer are appointed by the Executive Director and approved by the Good Shepherd Board of Directors. Once appointed, the officer serves in that position until the Executive Director and the board determine that a replacement is necessary in order to maintain the effectiveness of the program.
Compliance Committee Responsibility
The committee has overall responsibility for managing and overseeing the compliance program. Under the direction of the Compliance Officer, the committee is responsible for operating the program on a daily basis and has the appropriate resources to perform its responsibilities within the program. The committee assumes responsibility for investigating any compliance violation, in accordance with the procedures outlined in the program manual.
Compliance Officer Role and Responsibility
The Compliance Officer serves as an ombudsman to whom employees and contractors should report suspected violations of standards of conduct described in the program.
Good Shepherd instructs its employees and contractors to report to the Compliance Officer any suspected compliance violation. To facilitate such disclosure, we prominently display throughout our campus the announcement of the Compliance Officer appointment and the necessity of promptly reporting suspected misconduct or questionable practices. The Compliance Officer makes all reasonable efforts to maintain the anonymity of the reporting individual and the confidentiality of the report.
The Compliance Officer and the Executive Director are responsible for training efforts of the program. In this capacity, they may be assisted by outside experts and/or legal counsel.
Reporting Compliance Issues
If a Good Shepherd employee or contractor has a concern regarding any ethics or compliance issue, including the standards of conduct or policies and procedures described in program, that person should immediately contact his/her supervisor and/or the Compliance Officer. All reports are immediately investigated by the Compliance Officer in a confidential manner.
Types of Issues to Report
Anyone who acquires information that gives him/her reason to believe that another employee, contractor or any other person or entity associated with Good Shepherd, is engaged in or plans to operate in a manner prohibited by the compliance program or Good Shepherd policies and procedures, should promptly report such information to the Compliance Officer.
Anyone who is directed to engage in conduct prohibited by the compliance program should immediately report such information to the Compliance Officer.
Good Shepherd does not tolerate any supervisor or another employee retaliating against an employee or contractor for reporting compliance issues. If such a situation were to occur, disciplinary action may be taken.
Licenses, Certifications, Approvals and Accreditations
Good Shepherd Services maintains all licenses, certifications, approvals and accreditations necessary for the operation of each health care facility, service, agency or department within Good Shepherd's system of operations.
Inappropriate Business Entertainment or Gifts
Employees of Good Shepherd cannot provide or accept business entertainment and gifts above ordinary and reasonable items deemed to be of nominal value, provided those items do not violate local, state or federal law. Any questions in this section should be directed to the Compliance Officer for interpretation.
Cash or other gifts to physicians and other referral sources are absolutely prohibited. Non-cash items given to physicians or other referral sources greater than nominal value must be approved by the Executive Director of Good Shepherd Services. Such approval must be confirmed prior to giving the item, along with the stated reason for the gift documented in writing.
Improper Payments
Good Shepherd and its employees do not make payments or provide anything of value to anyone to induce the use of our health care services. The only exception is in full compliance with laws authorizing such payments in specific circumstances.
Employees of Good Shepherd may not make or offer to make any payment or provide anything of value to another person with the understanding or intention that payment or items of value will influence any government official, resident/tenant/client/patient, physician or other source of referrals. Such payment cannot be used for improper or unlawful purposes. If it were publicly disclosed, this type of action would embarrass the employee and Good Shepherd and may result in legal action.
Guidelines for Appropriate Referrals by Employees and Non-Employees
When employees and non-employees associated with Good Shepherd are in a position to make referrals, they must make such referrals based on the preferences of the individual seeking care, or if the individual does not express a preference, what is best for the individual.
In any case, referrals must be made without regard to the number of referrals any physician or other health care provider has made to Good Shepherd.
Marketing of Services
Good Shepherd presents itself to the communities it serves through its marketing activities in a manner consistent with its mission and capabilities. We will not tolerate and do not practice engaging in unethical, abusive or illegal marketing or advertising practices in connection with offering or providing services.
No Compensation for Referrals
We do not pay incentives to employees or contractors based on the number of persons they refer to us for services. The decision to provide services referred to Good Shepherd is a medical decision that is made by qualified health care professionals.
Release of Individual Health Information
Our organization maintains the right to privacy and confidentiality of all medical information in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Implementation of Compliance Program
The Compliance Officer and Executive Director are responsible for the program's implementation and for ensuring that all employees and contractors are fully informed about and comply with the compliance program and any changes made to it.
Training and Distribution of Compliance Handbooks
Training and implementation of the Corporate Compliance Program was initially conducted in January of 1999 and is reconfirmed every January with our employees and contractors. New employees are oriented to the program expectations within 90 days of their hiring.
On an annual basis, all management employees and all employees in the business offices are required to sign an agreement that they have received the employee version of our compliance program, that it was reviewed with them, they understand it, and agree to follow it. These agreements are kept in the employee's personnel file in the human resources department.
Service Agreements with Contractors
All service agreements between Good Shepherd Services and vendors and providers that furnish resident/ tenant/client/patient/child care services to the people we serve through our organization must sign a statement that they agree to follow the compliance program. These individuals/entities must receive a copy of the compliance program, review it and sign the agreement that they will comply with the expected standards, policies and procedures. Any individual/entity conducting business on behalf of contractors is expected to follow the standards of this program.
Purpose and Responsibility of Education and Training
To insure that employees are familiar with the compliance program, we conduct on-going communication with them in regard to reinforcement and updates with the program. The Compliance Officer is responsible for these communication efforts.
Whenever it occurs, the initial exposure an employee has to the compliance program shall include a review of applicable state and federal regulatory requirements relating to the provision of health care services by Good Shepherd.
The compliance committee may require that a contractor who has a service agreement with Good Shepherd, or anyone who provides services on behalf of the contractor, participate in training programs relating to the compliance program.
Communication of Changes
The Compliance Officer distributes in writing and/or posting in obvious places within our organization any modifications to the compliance program or manual. Written explanations of changes may be provided. If it is determined that written or posted changes are not sufficient, then an interim training will be conducted.
Employees are provided with periodic notification and information about the compliance program through Good Shepherd's staff newsletter, compliance manuals located in employee break rooms and compliance manuals placed at staff work stations.
Investigations and Corrective Action
Upon receiving a report of a known or suspected violation of the Corporate Compliance Program, the procedure for investigation is for the Compliance Officer to notify the Executive Director, then call a meeting of the compliance committee. The committee will investigate the matter to determine whether a violation of the program standards or other misconduct has occurred.
If the Executive Director is the subject of the report, the Compliance Officer will notify the President of the Good Shepherd Services Board of Directors, who will convene a committee of the board to investigate the matter. Such an investigation will be conducted in the same manner as outlined for the compliance committee, except that all communication regarding the matter will be made to the President of the board instead of the Executive Director. Any corrective action taken will be the responsibility of the President of the board.
For any questions regarding our Corporate Compliance Program, email or call our Compliance Officer or the Executive Director of Good Shepherd Services. To report any compliance concerns regarding our employees or vendors and providers we do business with, call our Corporate Compliance Officer at (920)833-6856 or email info@goodshepherdservices.org.
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NOTICE OF GOOD SHEPHERD SERVICES PRIVACY PRACTICES |
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THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. USE AND DISCLOSURE OF HEALTH INFORMATION Good Shepherd Services may use your health information, that is, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996, for purposes of providing you treatment, obtaining payment for your care and conducting health care operations. Your health information may be used or disclosed only after Good Shepherd Services has obtained your written consent. Good Shepherd Services has established a policy to guard against unnecessary disclosure of your health information. THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AFTER YOU HAVE PROVIDED YOUR WRITTEN CONSENT: To Provide Treatment. Good Shepherd Services may use your health information to provide care to you and disclose your health information to others who provide care to you, such as your attending physician and other health care professionals who are involved in your care. For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications. To Obtain Payment. Good Shepherd Services may include your health information in invoices to collect payment from third parties for the care you may receive from Good Shepherd Services For example, Good Shepherd Services may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or Good Shepherd Services To Conduct Health Care Operations. Good Shepherd Services may use and disclose health information for its own operations in order to facilitate the function of Good Shepherd Services and as necessary to provide quality care to all of Good Shepherd Service’s residents. Health care operations include activities such as: - Quality assessment and improvement activities. - Activities designed to improve health or reduce health care costs. - Protocol development, case management and care coordination. - Contacting health care providers and residents with information about treatment alternatives and other related functions that do not include treatment. - Professional review and performance evaluation. - Training programs including those in which students, trainees or practitioners in health care learn under supervision. - Training of non-health care professionals. - Accreditation, certification, licensing or credentialing activities. - Review and auditing, including compliance reviews, medical reviews, legal services and compliance programs. - Business planning and development including cost management and planning related analyses and formulary development. - Business management and general administrative activities of Good Shepherd Services Fundraising for the benefit of Good Shepherd Services and certain marketing activities. For example, Good Shepherd Services may use your health information to evaluate its staff performance, combine your health information with other Good Shepherd Services residents in evaluating how to more effectively serve all of Good Shepherd Service’s residents, disclose your health information to Good Shepherd Services staff and contracted personnel for training purposes, use your health information to contact you or your family as part of general fundraising and community information mailings (unless you tell us you do not want to be contacted). For the Good Shepherd Services Directory. Good Shepherd Services may disclose certain information about you including your name, your religious affiliation and where you are located in a Good Shepherd Services directory while you are in Good Shepherd. Good Shepherd Services may disclose this information to people who ask for you by name. However, religious affiliation will only be disclosed to clergy. If you do not want Good Shepherd Services to include your information in the directory, you must notify the Privacy Officer at (920) 833-6856. For Fundraising Activities. Good Shepherd Services may use information about you including your name, address and telephone number to contact you or your family to raise money for Good Shepherd Services If you do not want Good Shepherd Services to contact you or your family, you must notify Privacy Officer at (920) 833-6856 and indicate that you do not wish to be contacted. For Treatment Alternatives. Good Shepherd Services may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED WITHOUT YOUR WRITTEN CONSENT OR AUTHORIZATION: When Legally Required. Good Shepherd Services will disclose your health information when it is required to do so by any Federal, State or local law. When There Are Risks to Public Health. Good Shepherd Services may disclose your health information for the following public activities and purposes: - To prevent or control disease, injury or disability, report disease, injury, vital events such as birth or death and the conduct of public health surveillance, investigations and interventions. - To report adverse events, product defects, to track products or enable product recalls, repairs and replacements and to conduct post-marketing surveillance and compliance with requirements of the Food and Drug Administration. - To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease. - To an employer about an individual who is a member of the workforce as legally required. To Report Abuse, Neglect Or Domestic Violence. Good Shepherd Services is allowed to notify government authorities if Good Shepherd Services believes a resident is the victim of abuse, neglect or domestic violence. Good Shepherd Services will make this disclosure only when specifically required or authorized by law or when the resident agrees to the disclosure. To Conduct Health Oversight Activities. Good Shepherd Services may disclose your health information to a health oversight agency for activities including audits; civil, administrative or criminal investigations; inspections; licensure or disciplinary action. Good Shepherd Services, however, may not disclose your health information if you are the subject of an investigation and the investigation does not arise out of and is not directly related to your receipt of health care or public benefits. In Connection With Judicial And Administrative Proceedings. As permitted or required by State law, Good Shepherd Services may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request or other lawful process, but only when Good Shepherd Services makes reasonable efforts to either notify you about the request or to obtain an order protecting your health information. For Law Enforcement Purposes. As permitted or required by State law, Good Shepherd Services may disclose your health information to a law enforcement official for certain law enforcement purposes, including, under certain limited circumstances, if you are a victim of a crime or in order to report a crime. To Coroners And Medical Examiners. Good Shepherd Services may disclose your health information to coroners and medical examiners for purposes of determining your cause of death or for other duties, as authorized by law. To Funeral Directors. Good Shepherd Services may disclose your health information to funeral directors consistent with applicable law and if necessary, to carry out their duties with respect to your funeral arrangements. If necessary to carry out their duties, Good Shepherd Services may disclose your health information prior to and in reasonable anticipation, of your death. For Organ, Eye Or Tissue Donation. Good Shepherd Services may use or disclose your health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue for the purpose of facilitating the donation and transplantation. For Research Purposes. Good Shepherd Services may, under very select circumstances, use your health information for research. Before Good Shepherd Services discloses any of your health information for such research purposes, the project will be subject to an extensive approval process. Good Shepherd Services will almost always request your written authorization before granting access to your individually identifiable health information In the Event of A Serious Threat To Health Or Safety. Good Shepherd Services may, consistent with applicable law and ethical standards of conduct, disclose your health information if Good Shepherd Services, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public. For Specified Government Functions. In certain circumstances, the Federal regulations authorize Good Shepherd Services to use or disclose your health information to facilitate specified government functions relating to the military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations and inmates and law enforcement custody. For Worker's Compensation. Good Shepherd Services may release your health information for worker's compensation or similar programs. AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION Other than is stated above, Good Shepherd Services will not disclose your health information other than with your written authorization. If you or your representative authorizes Good Shepherd Services to use or disclose your health information, you may revoke that authorization in writing at any time.YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION You have the following rights regarding your health information that Good Shepherd Services maintains:Right to Request Restrictions. You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on Good Shepherd Service’s disclosure of your health information to someone who is involved in your care or the payment of your care. However, Good Shepherd Services is not required to agree to your request. If you wish to make a request for restrictions, please contact Privacy Officer at (920) 833-6856. Right to Receive Confidential Communications. You have the right to request that Good Shepherd Services communicate with you in a certain way. For example, you may ask that Good Shepherd Services only conduct communications pertaining to your health information with you privately with no other family members present. If you wish to receive confidential communications, please contact Privacy Officer at (920) 833-6856. Good Shepherd Services will not request that you provide any reasons for your request and will attempt to honor your reasonable requests for confidential communications.Right to Inspect and Copy Your Health Information. You have the right to inspect and copy your health information, including billing records. A request to inspect and copy records containing your health information may be made to Privacy Officer at (920) 833-6856. If you request a copy of your health information, Good Shepherd Services may charge a reasonable fee for copying and assembling costs associated with your request.Right to Amend Your Health Information. You or your representative has the right to request that Good Shepherd Services amend your records, if you believe your health information records are incorrect or incomplete. That request may be made as long as the information is maintained by Good Shepherd Services. A request for an amendment of records must be made in writing to the Privacy Officer at Good Shepherd Services, 607 Bronson Rd., Seymour, WI 54165. Good Shepherd Services may deny the request if it is not in writing or does not include a reason for the amendment. The request also may be denied if your health information records were not created by Good Shepherd Services, if the records you are requesting are not part of Good Shepherd Services records, if the health information you wish to amend is not part of the health information you or your representative are permitted to inspect and copy, or if, in the opinion of Good Shepherd Services the records containing your health information are accurate and complete. Right to an Accounting. You or your representative have the right to request an accounting of disclosures of your health information made by Good Shepherd Services for purposes, which may include disclosures authorized by law and disclosures made for research. The request for an accounting must be made in writing to Privacy Officer at Good Shepherd Services, 607 Bronson Rd., Seymour, WI 54165. The request should specify the time period for the accounting starting on April 14, 2003. Accounting requests may not be made for periods of time in excess of six (6) years. Good Shepherd Services will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee. Right to a Paper Copy of this Notice. You or your representative has a right to a separate paper copy of this Notice at any time even if you or your representative has received this Notice previously. To obtain a separate paper copy, please contact Privacy Officer at (920) 833-6856. DUTIES OF GOOD SHEPHERD SERVICES Good Shepherd Services is required by law to maintain the privacy of your health information and to provide to you and your representative this Notice of its duties and privacy practices. Good Shepherd Services is required to abide by the terms of this Notice as may be amended from time to time. Good Shepherd Services reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all health information that it maintains. If Good Shepherd Services changes its Notice, Good Shepherd Services will provide a copy of the revised Notice to you or your appointed representative. You or your representative has the right to express complaints to Good Shepherd Services and to the Secretary of Health and Human Services if you or your representative believe that your privacy rights have been violated. Any complaints to Good Shepherd Services should be made in writing to Privacy Officer at (920) 833-6856. Good Shepherd Services encourages you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.CONTACT PERSON Good Shepherd Services has designated the Privacy Officer as its contact person for all issues regarding resident privacy and your rights under the Federal privacy standards. You may contact this person at 607 Bronson Rd., Seymour, WI 54165, or phone (920) 833-6856 or email info@goodshepherdservices.org. EFFECTIVE DATE This Revised Notice is effective May 24, 2006. |