NETWORK POLICY & PROCEDURE Page 1 of 7

Transcription

1 NETWORK POLICY & PROCEDURE Page 1 of 7 APPROVED FOR: COMMUNITY HEALTH NETWORK FOUNDATION, INC. COMMUNITY HEALTH NETWORK, INC. COMMUNITY HOME HEALTH SERVICES, INC. COMMUNITY HOSPITAL SOUTH, INC. COMMUNITY HOWARD REGIONAL HEALTH, INC. COMMUNITY PHYSICIAN NETWORK (A TRADE NAME OF COMMUNITY PHYSICIANS OF INDIANA, INC.) COMMUNITY WESTVIEW HOSPITAL (A TRADE NAME OF INDIANAPOLIS OSTEOPATHIC HOSPITAL, INC.) (EFFECTIVE 7/1/15 A FACILITY OF COMMUNITY HOSPITAL EAST) INDIANA PROHEALTH NETWORK, LLC. COMMUNITY HEART AND VASCULAR HOSPITAL (A TRADE NAME OF INDIANA HEART HOSPITAL) (EFFECTIVE 10/1/14 A FACILITY OF COMMUNITY HOSPITAL EAST) VISIONARY ENTERPRISES, INC. FORMULATED BY: Chief Risk and Compliance Officer EFFECTIVE/REVIEWED/REVISED: [Formerly Corp. ADM H-010] 3/31/11 Reviewed/ Revised 7/14/14 Reviewed/ Revised 9/1/15 Reviewed/ Updated STATEMENTS OF PURPOSE: One element of an effective compliance program is regular and effective training programs for all employees. To ensure that employees of the Community Health Network (CHNw) are knowledgeable about changes in federal and state laws, rules and regulations; payer guidelines; CHNw standards and ethical guidelines, the Network Compliance Committee (Committee) shall coordinate the communication of changes to the appropriate personnel within the CHNw on a timely basis. The purpose of this policy is to describe elements of compliance education and consequences of failing to meet compliance education requirements. DEFINITIONS: Provider Provider includes employed physicians, oral surgeons, dentists, podiatrists and allied health professionals (including, but not limited to, MDs, DOs, nurse practitioners, clinical nurse specialists, certified nurse midwives, physician assistants and licensed independent clinical psychologists).

2 NETWORK POLICY & PROCEDURE Page 2 of 7 POLICY: 1. Delegation of Network Compliance Education Responsibility A. The Committee has delegated responsibility for developing and implementing annual, periodic and other compliance education to the Chief Risk and Compliance Officer. B. The Chief Risk and Compliance Officer, or his/her designee, will determine appropriate topics for compliance education. 2. Compliance Education Content A. Compliance Education will consist of: 1. New Employee Orientation: Network Responsibility and Compliance Program (NRCP) and HIPAA; 2. Annual NRCP and HIPAA training; 3. NRCP News newsletter, sent to all CHNw employees by every other month; 4. HIPAA Highlights, sent to all CHNw employees by monthly; 5. Targeted in-depth training; and 6. Ad hoc compliance and HIPAA alerts and information. B. Compliance education topics may be determined through input from the Committee, Compliance Liaisons; senior leadership; the Health and Human Services Office of Inspector General (OIG) annual work plan; OIG focus areas (e.g., subjects of OIG Fraud Alerts;) changes in compliance-related laws or regulations; payer guidelines; the annual risk assessment conducted by Internal Audit; employee questions; compliance incidents or privacy incidents that put the CHNw at risk of non-compliance with federal or state laws or regulations and that lend themselves to learning opportunities, etc. C. Orientation and annual NRCP training will be tracked electronically, using MySuccess Center, NetLearning, or similar system.

3 NETWORK POLICY & PROCEDURE Page 3 of 7 3. New Employee and Provider Orientation A. Compliance education for new employees and providers is developed by the Chief Risk and Compliance Officer, or designee and distributed to Compliance Liaisons and others responsible for employee and provider orientation. B. An overview of the NRCP and HIPAA Privacy will be completed by all new employees, including employed providers, on or before the first day of orientation. Role-based education on additional compliance and privacy concepts for new employees will be completed within thirty (30) days after hire. C. Code of Conduct and Business Ethics Distribution: each new employee and provider will receive a copy of the Code of Conduct and Business Ethics on or before the first day of orientation. D. Completing the training outlined above is a condition of employment. Should an employee or provider fail to receive the information and documents outlined above within 30 calendar days of being hired: 1. the employee or provider must receive the training immediately; and 2. the fact that the employee or provider did not receive the training in a timely fashion, the name of the employee s supervisor, and an action plan for resolution must be reported to the appropriate Human Resources representative. E. Failure to complete such training in accordance with this policy will result in corrective action up to and including discharge from employment. 4. Annual Compliance Education A. Annual Compliance education will include HIPAA Privacy training as well as related compliance topics. B. All active CHNw employees and providers will be required to complete annual Compliance education, using materials provided by the Chief Risk and Compliance Officer or designee. 1. For purposes of this policy, an employee or provider is defined as any person whose name is maintained on a CHNw Human Resources roll / database and is in active status.

4 NETWORK POLICY & PROCEDURE Page 4 of 7 2. Employees or providers who are not in active status (e.g., on leave of absence or severance) are not required to complete the annual Compliance education while they are in an inactive status. 3. Any employee who does not complete the annual Compliance education by the established date, due to being on a leave of absence, must complete the current year s Compliance education within 14 calendar days of his/her return to work. 4. Newly hired employees and providers, attending orientation and completing approved Compliance orientation education, are also required to complete the annual Compliance education to the extent the annual Compliance education is different from that provided during orientation. C. In support of the CHNw initiative to transition to electronic communication and documentation, the annual Compliance education will be available in an electronic format, except in those areas in which electronic resources are unavailable. D. Employees completing the annual Compliance education will sign an acknowledgement form on an annual basis, indicating that the employee is aware of and agrees to follow the CHNw Code of Conduct and Business Ethics and compliance policies and procedures. 1. Any employee who refuses to sign the acknowledgement or disagrees with the statements in the acknowledgement will be contacted by the Chief Risk and Compliance Officer, or designee, to determine the employee s objections; and to provide additional information or clarification of the statements in the acknowledgement. 2. The signed acknowledgement form will be maintained electronically and/or in hard copy in the employee s personnel file. E. Corrective Action for failure to complete annual Compliance education. 1. Completion of the annual Compliance education and signing the acknowledgment form is a condition of employment. 2. Should any active employee fail to complete the annual Compliance education or sign the acknowledgement form by the established date, the employee must be immediately removed from the schedule until such time as he or she completes the training requirements and will be subject to corrective action.

5 NETWORK POLICY & PROCEDURE Page 5 of 7 3. Any active employee who does not complete the annual Compliance education requirement within fifteen days of the due date will be discharged. 5. Periodic Newsletters In addition to orientation and annual Compliance education, periodic newsletters are utilized as additional educational resources. Such newsletters will provide additional information on compliance and HIPAA topics between formal training programs. A. NRCP News 1. The Chief Risk and Compliance Officer or designated staff develop and distribute a bi-monthly newsletter, NRCP News. 2. NRCP News contains articles that focus on important compliance issues, updates on federal and state laws and regulations and areas that cause confusion among employees and/or which expose the CHNw to potential risk of non-compliance. 3. NRCP News is distributed by to all CHNw employees and is posted on the NRCP home page on InComm. B. HIPAA Highlights 1. The Chief Risk and Compliance Officer or designated staff develop and distribute a monthly newsletter, HIPAA Highlights. 2. HIPAA Highlights contains articles that focus on important HIPAA Privacy compliance issues, including areas that cause confusion among employees and/or which expose the CHNw to potential risk of non-compliance. 3. HIPAA Highlights is distributed via to all CHNw employees and is posted on the NRCP home page on InComm. 6. Targeted In-Depth Training A. In-depth compliance and HIPAA Privacy training is developed by the Chief Risk and Compliance Officer or designated staff and tailored to the audience, as appropriate; i.e., issues pertinent to the roles of the individual employees. Such training may be provided in face-to-face training sessions, computer-based training, teleconferences, compliance alerts or written materials. B. Examples of targeted in-depth training are: 1. New Manager Orientation: Compliance and HIPAA Privacy 2. HIPAA Privacy Refresher 3. Fraud and Abuse for Managers

6 NETWORK POLICY & PROCEDURE Page 6 of 7 4. New CPN Physician Orientation (portion specific to compliance and HIPAA) C. Targeted in-depth training may also be developed by the Chief Risk and Compliance Officer, or designated staff, to educate appropriate employees on any revisions or the addition of new policies and procedures relating to compliance. Such training shall be made available within 30 days of the effective date of the revised or new policies and procedures. 7. Compliance Education Process The Compliance Liaisons at affiliate entities not participating in CHNw Human Resources/Talent Management processes (e.g. Community Hospital of Anderson) shall ensure that a process is established at his/her affiliate entity. Such process shall include: A. Providing a copy of the Code of Conduct and Business Ethics on or before the first day of orientation. B. Obtaining the employee s signed acknowledgment form. C. Providing the Compliance education for new employees, using materials provided or approved by the Chief Risk and Compliance Officer, within 30 calendar days of employment. D. Providing the annual Compliance education to all current employees subject to this policy, using training provided or approved by the Chief Risk and Compliance Officer. E. Reporting the name of the supervisor of any employee, who fails to receive Compliance education for new employees within 30 calendar days of an individual being hired and an action plan for resolution, to the appropriate Human Resources representative. F. Suspending without pay any employee who fails to receive the annual Compliance education by the established deadline.

7 NETWORK POLICY & PROCEDURE Page 7 of 7 8. Reports The Chief Risk and Compliance Officer will make periodic reports on Compliance education to the Committee; Network Finance and Audit Committee; and/or CHNw Board of Directors. RELATED FORMS: NRCP and HIPAA Privacy: A Guide for New Employees Code of Conduct and Business Ethics RELATED POLICIES: COMP-022 Code of Conduct and Business Ethics COMP-013 Compliance Liaison HR-003 Corrective Action APPROVED BY: _[~ORIGINAL SIGNATURE ON FILE IN ADMINISTRATION~ ]_ Bryan A. Mills, President and CEO, Community Health Network