Louisiana State University School of Medicine at Shreveport

Louisiana State University School of Medicine at Shreveport Policy Date Updated Page Compliance Policy Summary -- 2 Vendor Solicitation Policy 4/1/2011 8 Drug Samples 7/1/2010 11 Continuing Medical Education -- 13 NB: The Institute on Medicine as a Profession has added the following to this document: 1. The page numbers in red for ease of navigation 2. The yellow highlighting to indicate the referenced policy language

LSUHSC-Shreveport http://www.compliance.lsuhscshreveport.edu/compliancepolici... LSUHSC-Shreveport E.A. Conway Medical Center Huey P. Long Medical Center COMPLIANCE POLICY SUMMARY A. Code of Conduct All new employees will receive a copy of the Code of Conduct, and shall sign an attestation stating that they have received, read, and agree to abide by the institution s Code of Conduct. New employees shall receive the Code of Conduct while completing hiring related materials. The Code of Conduct will be reviewed annually by employees during their annual required educational sessions. If there are any revisions to the LSUHSC-S/EACMC/HPLMC Code of Conduct a copy of the revised code will be distributed throughout the LSUHSC-S/EACMC to employees within 30 days of initiating such a change. B. Confidential Disclosure Employees are required, as a condition of their employment, to report suspected misconduct. Reports can be made confidentially and anonymously by calling one of the following. LSUHSC-S/EACMC/HPLMC Compliance Access Line at 800-465-1923 LSUHSC Hotline 318-675-7764 Records regarding reports made through the local and the system s Compliance Access Lines will be maintained in a logbook within the Compliance Office. C. Communicating with Governmental Entities All employees shall immediately forward a copy of all governmental contacts to the Compliance Office, via facsimile, (318) 675-8520, or hand delivery. The Compliance Office shall promptly assist with the response to any governmental requests. D. Compliance Auditing and Monitoring All compliance audits shall be conducted prior to billing, unless otherwise directed by the Compliance Office. Compliance audits or reviews shall be conducted internally by the Compliance Analysts. Detailed work papers and summary reports are maintained on all audits. Copies of the reports are provided ot the audited provider and their department chair. 1 of 6 1/26/11 6:06 PM Page 2 of 13

LSUHSC-Shreveport http://www.compliance.lsuhscshreveport.edu/compliancepolici... Summaries containing the results of the audits or reviews will be presented to the Compliance Officer for appropriate validation and action/recommendation, and will be maintained in the Compliance Office. E. Compliance Committee The Compliance Committee is composed of key members of executive management. The current committee the Compliance Officer as Chairperson, the Vice Chancellor for Clinical Affairs and Medical Director, who is responsible for clinical affairs, all medical staff issues, and hospital operations, the Vice Chancellor for Administration and Finance- is responsible for administration and finance, and has administrative responsibility for the departments of Human Resources, and Billing, the Hospital Administrator-is responsible for hospital operations, the Associate Hospital Administrator, and the Dean for Research. The Compliance Committee meets not less than monthly. F. Compliance Education Compliance training is required for employees and is a condition of employment. Employees are assigned to one of 3 categories (Relevant Covered Persons, Covered persons, Other) primarily based upon their job title and department. When needed, information concerning job duties is obtained from the department. Class assignments are made based on the role of the employee in patient care and billing. Daily downloads are made from the H.R. Employee database to identify new hires and departmental transfers. Assignments of classes are made in a Microsoft Access database based upon the categories above and the Department is notified of their employee(s) education requirement. Employees log in to the Compliance Education database via Active Server Pages in Internet Explorer, view the education material which is a PowerPoint presentation and certify that they have viewed the material. When the employee certifies they have viewed the material, the database is date stamped with the completion date and an email is sent to the Compliance Office indicating the completion and score if applicable. The Education Department will maintain attendance logs of the educational sessions Education is monitored by the Compliance Office and the respective Departments by Active Server pages as well. Employees who fail to comply with the compliance educational requirements will be subject to disciplinary action, up to and including termination 2 of 6 1/26/11 6:06 PM Page 3 of 13

LSUHSC-Shreveport http://www.compliance.lsuhscshreveport.edu/compliancepolici... G. Compliance Officer The Compliance Officer is responsible for developing, implementing and updating the compliance plan, compliance policies, as well as directing the day-to-day compliance activities. The Compliance Officer is an executive level member of management, who has access to all campus level administration, system level administration, the audit committee of the LSU Board of Supervisors, and the LSU Board of Supervisors. The Compliance Officer has the authority to investigate alleged or apparent t compliance violations and intervene as warranted. H. Compliance Reporting Responsibility of Employees It is every LSUHSC-S/EACMC employee s responsibility to report all suspected violation(s) of any of the following. Federal Laws and Regulations (i.e. Medicare, EMTALA, HIPAA) State Laws and Regulations (i.e. Medicaid) LSUHSC-S/EACMC Compliance Policies or Procedures. Questionable conduct. I. Contract Review for Compliance All contracts will be reviewed prior to approval for compliance with Federal, State, and University laws, regulations, and policies. Contractors will be screened for their eligibility status in the Federal healthcare programs. The approved contractor shall receive and execute a copy of the LSUHS-S s Code of Conduct. J. Coordination Between Campuses Each of the three campuses (LSUHSC-S, EAC, HPLMC) has a full time Compliance Officer. At the EAC and HPLMC campuses, the Compliance Officer also functions as the Privacy Officer. For all compliance program oversight and direction, as well as compliance issue management, the Compliance Officers report to the Compliance Officer at the LSUHSC-S campus. For day to day management, the campus Compliance Officers at EAC and HPLMC report to their respective hospital administrators. The LSUHSC-S Compliance Officer and the respective hospital administrators work closely and in concert in the management of the campus initiative. K. Employee Anonymity and Confidential Disclosure Employees may report suspected misconduct/non-compliant behavior in writing, in person, or through the anonymous hotline. Every person who reports, regardless of the mechanism used, is assured anonymity. All complaints, with the exception of HIPAA violations, are reported to 3 of 6 1/26/11 6:06 PM Page 4 of 13

LSUHSC-Shreveport http://www.compliance.lsuhscshreveport.edu/compliancepolici... the Compliance Officer and investigated by the Compliance Officer to assure confidentiality. L. Employee Sanction Screening All prospective employees shall be screened prior to employment to assure that they have not been declared ineligible to participate in the Federal healthcare programs. All prospective employees must sign an attestation stating that they are not currently ineligible to participate in any Federal healthcare program and that they have not been convicted or currently under investigation for a criminal offense relating to the provision of healthcare services. LSUHSC-S/EACMC/HPLMC will not knowingly employ or engage in business with anyone who is currently under sanction or exclusion from participation in the Federal Healthcare Programs. The employment process for all employees shall include an attestation by the applicant/candidate relating to whether they have charges pending or are currently under investigation for allegations of healthcare related wrongdoing, and that they will immediately notify LSUHSC-S/EACMC/HPLMC if they become sanctioned or charged with healthcare related misconduct. All employees shall be screened at least semiannually for exclusion from the Federal healthcare programs. Employees found to be on either of the exclusion lists or have become ineligible to participate in governmental programs shall be immediately terminated. M. Documentation LSUHSC-S/EACMC/HPLMC adopts and supports the CMS documentation guidelines for all Medicare billings. Medicaid documentation should be consistent with the Louisiana Medicaid guidelines. It is the provider s responsibility to properly document his/her services in the patient s medical record(s). The signature of the provider on the superbill or other documents that direct the billing for professional services serves as his/her certification that his professional documentation in the medical record supports the bill being submitted for reimbursement. N. Enforcement Employees who violate LSUHSC-S/EACMC Compliance Policies shall be disciplined, on a case by case basis, in proportion to the severity of the violation. Said discipline shall be up to and may include termination. All such disciplinary action shall be reviewed by the Administrative Compliance Committee and shall be a consideration in whether or not to grant annual merit/step increases or raises. O. Excluded/Ineligible Persons/Entities Vendors are screened quarterly using computer cross of the vendor file with the excluded entity databases EPLS and LEIE. 4 of 6 1/26/11 6:06 PM Page 5 of 13

LSUHSC-Shreveport http://www.compliance.lsuhscshreveport.edu/compliancepolici... Any individual or entity who is currently excluded, debarred, or otherwise ineligible to participate in Federal healthcare programs or has been convicted of a criminal offense related to the provision of healthcare items or services is considered as an ineligible person and LSUHSC-S/EACMC shall not do business with an ineligible person/entity. P. Governing Board Oversight The Compliance Officer meets with and reports to the Compliance Committee mets at least quarterly, and actively participates in the monthly meetings of the Hospital Clinical Board, which is composed of the Clinical Chairs of each department. A compliance update or report is given at each meeting. The Compliance Officer also provides quarterly status reports to the System s Office, which are reported through the audit committee of the Board of Supervisors to the Board. Q. Hotline A toll free hotline is established and housed in the Compliance Office, accessible only to the Compliance Officer. There is a recorder on the phone to be used in off-hours, should the caller so choose. Caller ID is disabled on this phone. All calls are answered or retrieved by the Compliance Officer and documented in the log. Non-compliance calls are referred to the appropriate department (usually HR or Administration) R. Internal Investigations All internal compliance investigations are conducted by the Compliance Officer. Investigation may and usually does include interviews, computer searches, surveillance and medical record and billing record reviews. The results of investigations are reported to the Compliance Committee and to the System s office when the scope and or risk/repayment level exceeds campus level remedial/education and remedy. S. Physician Signature on Superbill The faculty physician shall sign or initial the superbill as his direction to submit the claim for payment. The signature or initial of the teaching physician on the superbill is his certification that the documentation in the medical record supports the bill submitted. T. Retaliation-Whistleblower Protection Individuals will be free from any type of retribution as a result of reporting suspected misconduct. LSUHSC-S/EAC/HPLMC officials may not fire, threaten or otherwise harm any person on the basis of the employee s reporting or participating in resolving a compliance issue. U. Supervisory Accountability for Compliance All persons in supervisory positions are responsible for ensuring that each employee reporting to them has attended compliance training. Managers and supervisors are responsible for informing employees that strict adherence to the compliance laws, regulations, and policies are 5 of 6 1/26/11 6:06 PM Page 6 of 13

LSUHSC-Shreveport http://www.compliance.lsuhscshreveport.edu/compliancepolici... a condition of their employment. V. Vendor Policy LSUHSC-S/EACMC employees shall not accept anything of value from any provider of healthcare services or products, with the exception of promotional items of only nominal value, such as donuts, pens, note pads, etc. 6 of 6 1/26/11 6:06 PM Page 7 of 13

Purpose: Definition: Policy: LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER SHREVEPORT VENDOR SOLICITATION POLICY To assure vendors entering LSUHSC for the purpose of conducting business, do so in such a manner as to not interfere with the normal operations of the institution, and comply with institutional requirements regarding confidentiality of information. Vendor bonafide representatives of companies providing goods or services to the healthcare industry for the purpose of profit; for the purpose of this policy, vendors with contracts for services with LSUHSC, (i.e., elevator repair, construction or maintenance) are excluded. 1. All vendors conducting business within the medical center complex have a legal and ethical responsibility to safeguard the privacy of all patients and protect the confidentiality of their health information. By completion of the vendor registration process, the individual agrees to comply with all rules and regulations set forth in this and any other applicable institutional policy or directive. 2. All vendors, in order to be approved for sales or service access within the LSUHSC, must register and maintain a current data file in the Purchasing Department. Such registration data shall include but not be limited to the following: Vendor name Company, which the vendor is representing Vendor address Vendor telephone number Signed Confidentiality Statement Official business card The Purchasing Department shall maintain a database of all authorized vendors; information contained in the database shall be made accessible to Patient Information, University Police and Hospital Administration. Page 8 of 13

Procedure: 3. Under no circumstance shall a vendor proceed directly to a hospital department or physician office. Vendors are not allowed in patient care areas of the hospital or clinics without specific permission from Hospital Administration. While in a patient care area, the vendor must be accompanied by an employee of the institution at all times. 4. Supplies or equipment are never left for evaluation or sample purposes without specific permission from the appropriate Hospital Department. In the case of equipment to be used for evaluation purposes, written permission must be granted by the Biomedical Department. As per hospital safety requirements, no equipment is to be used without a safety inspection. 5. LSUHSC assumes no responsibility for supplies or equipment left by vendors for the purpose of evaluation. 6. Food shall not be brought into the hospital or patient care areas by vendors. All vendors seeking access to any LSUHSC department shall follow the following procedure: 1. Obtain approved vendor status from the Purchasing Department; process includes signing confidentiality statement. 2. Schedule appointment(s) with individual or groups with whom the vendor would like to meet. This shall be done directly with the individual(s) involved. Purchasing will not schedule vendor appointments. 3. Upon arrival, shall check in at the Patient Information desk located in the hospital lobby (King s Highway entrance). 4. Patient information shall verify by phone the vendor appointment with the office, department or Biomedical engineering, issue a vendor badge and direct the representative to the office/department. 5. Upon completion of the appointment, the representative shall return to the Patient Information desk, returning the vendor badge. 6. In the event that there is no one available at the Information desk, the vendor shall check in through the University Police station located adjacent to the lobby. Page 9 of 13

7. Vendors selling or performing maintenance service on medical equipment must proceed to the Biomedical Engineering Department to sign in and out. 8. Vendors performing maintenance service on medical equipment shall leave service reports; indicating services provided Biomedical Engineering, upon completion of work. After hours service reports are to be left in the appropriate box outside Biomedical Engineering. Failure to comply with this policy shall result in action taken against the vendor, including possible banning from the institution and reporting to parent company. Hospital Administrator 3/16/11 Date Approved by Clinical Board: 2/20/01, 5/18/04, 5/15/07, 3/15/11 Written: 1/1/90 Reviewed: 2/04, 4/07, 3/11 Revised: 12/00, 4/04 Page 10 of 13

LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - SHREVEPORT PURPOSE: POLICY: SCOPE: DRUG SAMPLES To regulate the handling of sample medications Sample medications are stored, controlled and distributed in accordance with federal and state guidelines and medical center policies and procedures. All drug samples kept in ambulatory care clinics, emergency rooms or other areas must be maintained in an automated dispensing machine and adhere to the procedure that follows: This policy applies to all employees permitted to prescribe and dispense under the hospital bylaws. The department Chairman, Section Chief, or Medical director will determine which drug samples are to be used in their respective areas. If drug samples are to be kept: 1. All drug samples that are received will be recorded on a sample medication receipt form. The Department Chairman/Section Chief/Medical Director will sign the form, indicating the medications are appropriate for dispensing in that clinic. The Department Chairman/Section Chief/Medical Director shall designate one or two persons responsible for stocking the sample medications in the automated dispensing machine (ADS), and verifying compliance with the sample drug policy. Those chosen to be responsible for stocking the sample medications must possess a professional license which enables them to handle prescription medications. 2. The sample medication receipt form will be FAXed to the pharmacy, (5181) so that the sample medications, and lot numbers can be added into the automated dispensing machine database. 3. The sample medications will be locked in a secure area until the medications have been entered into the automated dispensing machine. Sample medications may not be distributed from this area. 4. After the pharmacy has entered the sample drug information into the ADS database, the designated person will stock the samples in the appropriate cabinet of the automated dispensing machine. Page 11 of 13

5. Each employee permitted to distribute sample medications will be given access to dispense those medications from the automated dispensing machine by Pharmacy personnel. Employees will be granted access by the Department Chairman/Section Chief/Medical Director of the clinic. 6. Any expired drug samples will be removed by the Pharmacy Department for proper disposal. 7. Any drug samples that are not stored according to hospital policy will be removed by the Pharmacy Department for proper disposal. 8. Pharmacy will be responsible for removing any recalled sample medications in the automated dispensing machines. Pharmacy will also generate a list of patients who have been issued recalled sample medications. This list will be given to the Department Chairman/Section Chief/Medical Director who will decide on action to be taken. 9. Sample medications must be labeled prior to distribution. Sample boxes may be taped together with label attached or doses may be placed in plastic bags and the label attached to the bag. The sample labels may be obtained from the general service store (#1340) or the directions may be written on the label generated by the automated dispensing machine. 10. Controlled substance samples are not allowed. Any controlled substances discovered by Pharmacy will be confiscated and destroyed according to state and federal laws. Exception: Pregabalin (Lyrica ) samples may be stored in the ACC Pharmacy and signed out by the patient s physician or nurse for dispensing by the physician. A record of receipt and distribution will be kept by pharmacy in order to maintain chain of custody. Administrator 6/16/10 Date Approved by Clinical Board: 1/16/01, 2/18/03, 7/18/06, 6/15/10 Revised 2/98, 2/03, 6/06, 10/07 Reviewed: 1/01, 2/03, 4/10 Page 12 of 13

»» Home» Mission Statement» Conferences» Regularly Scheduled Conferences (Grand Rounds)» Maps/Directions» Registration Form» State Requirements» Contact US» Community Info» Related Links» Disclosure Statement Contact Information: C ontinuing Medical Education 1501 Kings Hwy. Shreveport, LA 7 1 1 3 0-3 9 3 2 P hone: 3 1 8.6 7 5.4 6 2 9 Fax: 3 1 8.6 7 5.4 6 3 0 E mail: s wils o@ls uhs c.edu A dmin login 1501 Kings Highway Shreveport, Louisiana 71130 (318) 675-4629 2nd Annual Trauma Symposium Ocotber 13-14, 2011 Radiology for the Non-Radiologist October 22, 2011 ACCREDITATION STATEMENT CME Accreditation Statement Louisiana State University Health Sciences Center- Shreveport, School of Medicine is accredited by the ACCME, to provide continuing medical education for physicians. Credit Designation Statement Louisiana State University Health Sciences Center- Shreveport, School of Medicine designates this educational activity for a maximum of 1.00 AMA PRA Category 1 Credit(s). Physicians should claim credit commensurate with the extent of their participation in this activity. CME Mailing List 1501 Kings Highway - Shreveport, Louisiana 71130 Copyright (c) 2011 Medical Communication. All Rights Reserved. Page 13 of 13