Catholic Health

1. 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.

2. Catholic Health Corporate Compliance Anne Mason Compliance & Privacy Officer

3. Principles of Corporate Compliance Promotes Ethical, Professional, and Legal conduct “Doing what is right” Defines Responsibility/Accountability Supports CHS Standards Assurance of Quality Care

4. Catholic Health SystemStandards 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

5. Important Keys to CHS Corporate Compliance 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

6. Catholic Health SystemStandards of Conduct 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.

7. Catholic Health SystemStandards of Conduct All associates are expected to follow standards for: Legal and Regulatory Compliance Business Ethics Conflict of Interest Appropriate Use of Resources Confidentiality Professional Conduct Responsibility And follow the Code of Ethics

8. Gifts and other Free items • Associates may NOT accept any cash gifts or cash equivalent gifts (gift cards) from any person or business conducting or seeking to conduct business with CHS • Prior to receiving work related gifts, social or entertainment events, or free meals associates must consult with their supervisor. See CHS Policy for further information

9. Conflict of Interest 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 Consultant Speakers’ bureau Advisory Panel Administrative positions with Pharm or DME Third party payor Other entities doing business with CHS All potential Conflicts of Interest must be reported

10. Insufficient or InaccurateDocumentation 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

11. False Claims ActGoverns Fraud, Waste & Abuse 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 (Whistleblower provision)

12. Medicare Conditions of Participation Government Sanctions 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.

13. Providing High Quality Services and Upholding Patient’s Rights Follow CHS Policies and Procedures Offer Language Assistance Services to those in need Ensure patient privacy and confidentiality is maintained (HIPAA and HITECH regulations)

14. Catholic Health Compliance Policies 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: Home Care Clinical Laboratory Physician Practices Nursing Facilities Coding & Billing Home Health Agency PACE Program

15. Language Assistance Program • Ensures that limited English proficiency, or hearing impaired persons utilizing CHS services are able to understand and communicate with CHS associates and physicians • Provided FREE of charge to the patient Language Assistance Program Policy is found in Compliance 360

16. Language Assistance Program 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

17. HIPAA/ HITECH HEALTH INSURANCE PORTABILITY ACCOUNTABILITY ACT and HITECH Health Information Technology for Economic and Clinical Health Act Privacy and Security Policies are in Compliance 360

18. What is Protected by HIPAA? Individually identifiable health information Also known as Protected Health Information (PHI) Transmitted or maintained in any form or medium

19. Protected Health Information (PHI) • Names • Full face photos • Medical Record Number • Health plan Number • Account Numbers • Certificate/License Numbers • Vehicle identifiers • E-mail and webaddresses • Biometric Identifiers • Geographic subdivisions smaller than a state • All elements of dates related to birth date, admission, discharge, or date of death, ages over 89 • Telephone and fax numbers • Social Security Number • Any other unique identifying data

20. What Information Can Providers Share? for: 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

21. HIPAA Safeguards • Be aware of surroundings • Be conscious of who is in the immediate area when discussing sensitive patient information or at your computer terminal • Secure area when not attended • Close out of computer screens containing PHI before leaving the area • Close medical records/chart when not in use • Do not allow other associates to utilize your ID and password • Don’t leave papers with PHI in plain view • Report theft or loss of computer devices immediately

22. Additional HIPAA Safeguards • Telephones - Be careful with phone call pertaining to patient information • Fax machines and Scanners -Pick up faxed or printed PHI immediately - Use fax cover sheet, verify # & receipt - Scan PHI only to CHS e-mail accounts • E-mail - Make sure to encrypt if being sent outside CHS - Careful forwarding and replying • Mail - Double check name/address and material prior to sending

23. Sending e-mail with Sensitive Information 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.

24. UNAUTHORIZED ACCESSING AND DISCLOSURE OF PATIENT INFORMATION Curiosity can be a normal human trait • However accessing health information on yourself, family members, friends, co-workers, persons of public interest or any others that you are not involved in the care of or … • Disclosing PHI inappropriately are...VIOLATIONS of HIPAA Individuals do NOT have the right to look up their own health records Your computer use can be monitored

25. Other Catholic HealthCompliance Concerns Lack of integrity Ethical concerns 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.

26. 3 Steps for ReportingCHCompliance Concerns Immediate supervisor or appropriate department Higher level manager Compliance Officer 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

27. Catholic Health Non-Retaliation Policy 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 HIPAA/Compliance concerns

28. Catholic HealthAssociate’s Responsibility 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 be truthful preserve documentation or records relevant to ongoing investigations

29. Possible Consequences for Non-Compliance For the Associate and CHS Managers/Supervisors/Administrators • Fines and Prisonsentences • Corrective Action includes termination of employment for violations or failure to report concerns For Catholic Health System • Exclusionfrom government funded insurance programs(Medicare/Medicaid) • Fines

30. Things to Remember • Adhere to CHS code of conduct, policies & procedures, and other standards • Duty to report Compliance/HIPAA concerns as soon as aware of situation • Do the right thing apply ethical decision making • If uncertain… Always Seek Knowledge (A.S.K.) Use Associate Booklet as reference on CHS website

31. CHS Contacts Compliance/HIPAA Privacy Officer Anne Mason 821-4469 CHS HIPAA Hotline 862-1790 HIPAA Security Analyst Sally O’Brien 862-1938 Corporate Compliance Hotline 1-888-200-5380 (available 24/7) All reports are confidential

32. 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 New York State Patient Bill Of Rights

33. Catholic Health RISK MANAGEMENT

34. 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.

35. FOUR ELEMENTS OF RISK MANAGEMENT Risk Identification Review Occurrence Reports Review Patient/Visitor Complaints Participate in Root Cause Analysis Review concerns expressed by CHS staff

36. FOUR ELEMENTS OF RISK MANAGEMENT Loss Prevention Educational Programs through CHS University Department specific inservices

37. FOUR ELEMENTS OF RISK MANAGEMENT Claims Management Investigating & reporting occurrences and claims made to insurance carriers Assist with discovery requests for lawsuits

38. Claims Management Assist with Summons & Complaints and Subpoenas **NOTIFY RISK MANAGEMENT IMMEDIATELY UPON RECEIPT OF A SUMMONS OR SUBPOENA

39. Claims Management 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

40. FOUR ELEMENTS OF RISK MANAGEMENT Risk Financing Obtaining & maintaining appropriate insurance coverage: HPL (Healthcare Professional Liability) GL (General Liability) D&O (Directors & Officers) Property & Casualty Auto Crime Fiduciary (Finance)

41. OCCURRENCE REPORTING 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.

42. What are sources of an Occurrence? Patient harm/potential for harm like falls, med errors Visitor injury Patient related equipment “failure”

43. What are sources of an Occurrence? Security issues like elopement, crime, altercations Lost or damaged property

44. What is the purpose of an Occurrence Report? • Enhance the quality of patient care • Assist in providing a safe environment • Quick notice of potential liability

45. 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

46. 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

47. 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

48. Documenting an Occurrencein the medical record • Date (MM/DD/YY) and time (military) • State facts, be clear and concise • Your own observations • If event described to writer, use quotes or “according to…” • Do not place blame in the record • DO NOT REFER TO • OCCURRENCE REPORT IN • THE MEDICAL RECORD

49. EMTALA REGULATIONS EMTALA is the Emergency Medical Treatment and Active Labor Act (aka COBRA) EMTALA provides a Guideline for safely and appropriately transferring patients in accordance with Federal regulations.

50. EMTALA REGULATIONS 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 TREATMENT