Reporting Policy - Health Care Compliance Association ...



Reporting Policy

A. PURPOSE

To provide a mechanism to report anything that is suspected to violate law or company policy. To prevent retaliation, retribution, and harassment against any person who makes a report.

B. POLICY

Should any HOSPITAL personnel (including any employee, agent or other person performing services for or on behalf of the Corporation) have questions or concerns regarding violations of law or policy, such persons must request clarification or direction from the appropriate Supervisor, Manager, Department Head, Corporate Compliance Officer, or through placing a call to the Confidential Compliance Hotline. Likewise, all suspected violations of HOSPITAL’S Corporate Compliance Plan must be reported to the appropriate Department Head, Corporate Compliance Officer, or Corporate Compliance Hotline. Any patient or patient’s representative may also report suspected violations of law or company policy to a Supervisor, Manager, Department Head, Corporate Compliance Officer, or Corporate Compliance Hotline. There shall be no retaliation, retribution, or harassment against anyone who reports suspected violations.

C. PROCEDURE

1. To ask a compliance question or to report a suspected violation, an individual should contact the appropriate Supervisor or Manager. If that does not seem practicable, the question or report should be made to the next higher supervisory level. If the individual is uncomfortable with speaking with the Supervisor, Manager, or Department Head, the Corporate Compliance Officer should be contacted. If the individual is uncomfortable with speaking with any of the above representatives, the Confidential Compliance Hotline should be called. Resolution of issues at the departmental level is encouraged.

2. To assure anonymity an employee or agent should call the Hotline that has been set up to provide information and to receive reports. The telephone number is 1-800-###-####. This is a phone line that is operated by an outside agency. All calls are anonymous (unless the caller identifies himself) and confidential. The anonymous caller will be assigned a call back number and be asked to call in periodically in case additional information is needed and to be informed regarding investigation or follow-up results. HOSPITAL will preserve the anonymity of individuals who wish to remain anonymous, subject to limitations imposed by the law. Anonymity may not be preserved if a reporter identifies himself by name or provides other information that is identifying. HOSPITAL is legally required to report certain types of serious infractions to external agencies. If there is no way to respond to an inquiry or alleged compliance issue without knowing a reporter’s identity, the reporter will be notified and will have the option or revealing his identity or remaining anonymous, in which case the organization may not be able to act on the information.

3. Contacts made via the internal phone system, email, US mail, interoffice mail, or personal conversation cannot be guaranteed anonymity.

4. When a report is made to a Department Head, a response should be initiated within one business day of the report being received by the Department Head. This response may be a direct answer, it may be an action plan for obtaining the answer, or it may be that the report has been forwarded to the Corporate Compliance Department. Once the Corporate Compliance Department has been contacted, action will be initiated within one business day of the Corporate Compliance Officer’s receipt of the report or question. If the Compliance Officer or Department Head is not able to provide prompt answers, legal counsel or other experts will be consulted.

5. Individuals who make a report to the Compliance Hotline will receive a call back number from the Hotline operator. The Hotline operator will forward the information received by the caller to the Corporate Compliance Officer. The Corporate Compliance Officer will respond with an answer to the Hotline operator within either two (2) weeks or by the assigned call back date. If a final answer to the question is not available within two weeks, an initial response will be made, along with an estimate of when a final answer will be available. The Corporate Compliance Officer will make a report to the Hotline operator every two weeks until the answer is finalized. Calls concerning the Corporate Compliance Officer will be forwarded to Administration directly from the Hotline operator.

6. All suspected violations are to be investigated by Hospital management as appropriate.

7. Failure to report suspected violations in accordance with this Reporting Policy is, in and of itself, a violation of the Corporate Compliance Plan that will subject the person failing to make such a report to discipline in accordance with the Discipline Policy.

8. Twin County Regional Healthcare managers, supervisors, and employees are not permitted to engage in retaliation, retribution, or any form of harassment directed against any individual who reports a suspected violation. Anyone who engages in retaliation, retribution, or harassment is subject to discipline in accordance with the Discipline Policy.

D. ATTACHMENTS

Compliance Issues Report Form

COMPLIANCE ISSUES REPORT FORM

Date:_____________ Time:____________

Form of contact: ____Phone; ____email; ____US mail; ____interoffice mail; ____personal conversation

Person receiving information and completing this form:________________________________

Review anonymity/confidentiality conditions and limitations: ____yes; ____no

*It is the policy of TCRH to preserve the anonymity of individuals who wish to remain anonymous, subject to limitations imposed by the law. We may not be able to preserve your anonymity if you identify yourself by name or provide other information that identifies you. TCRH is legally required to report certain types of serious infractions to external agencies. If there is no way to respond to an inquiry or alleged compliance issue without knowing a reporter’s identity, you will be notified and will have the option of revealing your identity or remaining anonymous.

Reporter: ___________________________________________; ____not identified

Nature of report: ____informational; ____consultative; ____complaint/issue

Report:

Others with knowledge of problem: ________________________________________________

Action taken:

____reporter referred to following policy/procedure: ________________________

____reporter referred to following person/department: _______________________

____stated that the following steps would be taken:

Commitment: ____follow up with reporter on ___________

____it is not necessary to speak with reporter again

File closed as of___________________

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