Elmcroft Associate Compliance Training Power Point Presentation

2014 Code of Ethical
Conduct/Compliance Program
Training Module
Our Mission Statement
Our Mission
Elmcroft Senior Living is dedicated to enriching the lives of the individuals
who live and work with us by responding to their unique needs and
universal desire for dignity and respect.
Our Values
The values that form the foundation of our mission are our commitment
enriching the lives of each resident, patient, and employee through teamwork;
respecting each individual;
promoting creative thinking and learning;
leading and serving with humility;
accepting and expecting accountability;
providing compassion and kindness to our residents, patients, and fellow
building trust by acting with integrity; and
the passionate pursuit of excellent care and service
A message from our Chief Compliance Officer…
Elmcroft’s mission statement and values state that we will enrich the lives of the
individuals who live and work with us, accept accountability, and build trust by
acting with integrity. Our Code of Ethical Conduct has been developed to ensure
that state and federal reimbursement, regulatory, and clinical guidelines are an
integral part of our day to day process for both associates and business associates.
It is within this framework of integrity and ethical behavior that our Code of Ethical
Conduct and Compliance Program were developed.
As the leader of the Compliance Team at Elmcroft, it is my goal to continually find
ways to enhance Elmcroft’s compliance program so that every Elmcroft associate is
consistently living up to our mission and values statement.
Tony Miranda, CHC, FHFMA
SVP, Chief Compliance Officer
Session Goals
Discuss and understand Elmcroft’s Code of Ethical
Clarify the role of associates for ensuring ethical and
legal business practices.
Clarify options for reporting suspected violations.
Review the seven elements of an effective Compliance
Session Goals
Understand the Compliance Program Plan (CPP) and its
relationship to Elmcroft’s Core Values.
Review ethical and legal issues using case examples.
Explore how our personal values reflect organizational
Why we need a Compliance Program?
Elmcroft must meet high ethical and legal standards in all our
Mandated by The Affordable Care Act 2010.
It’s just good business.
Elmcroft Senior
Source: Hospitals and Health Networks Magazine, April 2001
Code of Ethical Conduct
 Is a living document that guides each Elmcroft Associate in
how to live the Elmcroft Mission Statement and values.
 Guides us through the complex spider web of laws regulating
the Senior Housing Industry.
 Is an essential part of the relationship between Elmcroft and its
 We are all bound to adhere to the code as a condition of our
Violations of The Code are subject to disciplinary action up to and
including termination.
Being aware of potential violations and NOT reporting them is subject
to disciplinary action up to and including termination
Code of Ethical Conduct
If you see, or think you see, anything that may violate the
law, The Code or the requirements of quality resident care,
you have the responsibility to speak up.
Elmcroft will not tolerate retaliation, in any form, against
those who report, in good faith, potential violations.
Code of Ethical Conduct
Things are not always black and white.
When things are gray, consider the following:
 Evaluate your facts for accuracy;
 Think about the impact of your decision;
 Handle your decision as if it were going to be in the news;
 Identify the potential consequences of your decision before you take
 Consider if your decision is setting a precedent;
 Stop and reflect if you are in doubt.
Our Commitment to Ethical and Compliant Conduct
Elmcroft associates and vendors must make a commitment to
adhere to the principles set forth in the Code of Ethical
Respect one another
Foster a positive work environment
Treat our residents, families and vendors with respect
Protect our resident’s confidentiality
Ensure records are accurate and reflect the care given to our
Be good stewards of Elmcroft’s assets
Protect Elmcroft’s proprietary information
Report suspected violations in good faith
Our Commitment to Ethical and Compliant
We do not employ or contract with individuals or entities
that are excluded from participation in any federal or
state health care program.
We do not offer, give, accept, or receive improper or
illegal gifts, or inducements for referrals.
We NEVER accept gifts from residents or their families!
We safeguard resident Protected Health Information
Our Commitment to Ethical and Compliant
We ensure bills, claims, and requests for reimbursement are
true, correct, complete, and accurate and are supported by
appropriate documentation for medically necessary and
provided services.
Our Commitment to Ethical and Compliant
We maintain complete, accurate and proper documentation in
the medical and business records and we understand coding
must accurately describe the services we provided.
We are prohibited from making false or fraudulent statements in any
documentation or record.
Our Commitment to Ethical and Compliant
Anyone with knowledge of fraudulent or questionable practices
has a responsibility to report it.
Our Commitment to Each Other
We maintain a professional and safe work
We foster work environments in which concerns can
be raised and openly discussed without fear of
We do not tolerate conduct that disrupts our work
environment, including behavior that is
disrespectful, hostile, violent, intimidating,
threatening or harassing.
What actions would you take and why?
Mary, a single mother and your co-worker, confided in you over lunch that
she is quite upset. She had recently found out that she makes less money
than another nursing assistant who was hired at the same time, and she
feels she is being discriminated against.
When you asked her how she knew this, she replied that one of her friends
who works in payroll and has access to payroll records agreed to give her
the information. She told you she had promised her friend she would not
tell anyone, but felt she could trust you. Although she did not tell you her
friend’s name, you know it could only have been one of three people.
What would you do?
Care is at the heart of what we do.
You work hard every day to provide quality and compassionate care to our
patients and residents.
Elmcroft is committed to partnering with those who share our mission and
 Failure to follow The Code, the Compliance Plan, the Associate
Handbook, or Elmcroft policies and procedures and applicable laws and
regulations will not be tolerated.
 All violations will be taken seriously and may result in disciplinary action.
 Associates who commit unethical or illegal acts may face immediate
termination and possible legal action.
Your Duty to Report
Our commitment to ethical conduct and compliance
depends on you. If you find yourself in an ethical dilemma or
suspect an inappropriate or illegal situation, follow the
processes outlined in The Code.
 If you have a question or concern,
 Talk to your supervisor. He or she will be able to provide access to
the Compliance Program documents, if necessary.
 If you are not comfortable talking to your supervisor, you may
discuss concerns or report matters to the Local Compliance Officer,
the Ethics Line or the Chief Compliance Officer.
Your Duty to Report
All associates, contractors, and vendors have an obligation to report, in
good faith, concerns about possible instances of questionable conduct
or practices, wrongdoing, and/or non-compliance.
 This means you may be disciplined if you had an obligation to report and
did not do so.
The Ethics Line is available to provide associates and others with a
confidential method for raising compliance and ethics concerns and is
available 24 hours a day, seven days a week.
 Elmcroft will make every attempt to protect the callers’ anonymity
within the limits of the law and Elmcroft’s duty to investigate the
wrongdoing or alleged inappropriate conduct.
Your Duty to Report
Individuals who intentionally fabricate and maliciously report
conduct or practices, wrongdoing, and/or non-compliance in
bad faith may be subject to disciplinary action up to and
including termination.
Elmcroft prohibits retaliatory action against an associate
for making a good faith report.
 Associates and/or Supervisors will not attempt to prevent an
associate from reporting suspected violations.
 If an associate, supervisor or manager attempts such action,
he/she is subject to disciplinary action up to and including
 Any suspected retaliation should be reported to the Chief
Compliance Officer or Ethics Line immediately.
Our Compliance Program (CP)?
Our Compliance Program is a system designed to:
 Establish a culture of “doing the right thing” all the time
 Pro-actively detect and prevent violations of law
 Ensure ethical and legal business practices
 Ensure adherence to Federal guidelines governing our operations
 Provide for disclosure and monitoring of conflicts of interest
 Ensure resolution of instances of impropriety.
Seven Elements of an Effective Compliance Program
Written Compliance Policies
Designated Chief Compliance Officer
Training and Education
Effective lines of communication
Consistent Enforcement
Confidential Reporting and Response Methods
Monitoring and Auditing Systems
Element #1 – Written Compliance Policies
Our Compliance Program is comprised of written expectations,
standards, and procedures, which are contained in the following
Compliance Program Plan
Elmcroft’s Code of Ethical Conduct (The Code)
Elmcroft’s Associate Handbook
Elmcroft’s Policies and Procedures
Element #2 – Chief Compliance Officer and Compliance
Elmcroft’s Compliance Program is headed by Tony Miranda,
the Chief Compliance Officer and administered by the
Compliance Committee and the Compliance Department.
Element #3 – Effective Training and Education
The goal of education and training is to provide our associates,
contractors and vendors with the information and education
they need to fully understand and comply with applicable laws
and regulations, as well as Elmcroft’s Compliance Program.
Element #4 – Effective Lines of Communication
Ethics Line:
(866) 605-3804
Mailing Address:
Elmcroft Senior Living
9510 Ormsby Station Rd, Suite 101
Louisville, Kentucky 40223
Attention: Compliance Department
Email Addresses:
[email protected]
[email protected]
Chief Compliance
(502) 753-6034
Element #5 – Enforcement
The requirements of the Compliance Program must be taken
 Any associate, who engages in a deliberate or reckless
violation of standards, will be subject to disciplinary action,
up to and including termination.
Element #6 – Responding to offenses
When a report of a suspected violation or questionable
conduct is received by the Compliance Department, they will:
 Determine whether the report raises compliance issues;
 If not a compliance issue, the concern will be forwarded to the
appropriate department for review;
 Investigate the facts;
 Take corrective action and/or disciplinary action based on
the results of the investigation;
Element #7 – Auditing and Monitoring
A compliance risk assessment will be completed annually by the Chief
Compliance Officer and the Compliance Department as part of the annual
compliance work plan development.
The Compliance Department will conduct internal audit reviews on a
routine basis to ensure that applicable laws and regulations are being
followed, and that accurate information is being conveyed or submitted.
 Monitoring: systems and evaluations we do everyday in our daily work,
within our facilities such as:
Triple Check
Auditing: External or outside/independent activities such as what the
Compliance Auditors do when they come into your facility
Acceptance of Gifts including Meals and
 We do not solicit gifts or entertainment.
 We may not accept or solicit gifts from residents in any form.
 Perishable gifts; food, cakes, snacks; as long as shared with all staff
are acceptable.
 We may not accept cash or its equivalent (gift certificates,
stock, etc.).
 If a gift is accepted that exceeds our guidelines, it should be
returned with an explanation. If returning the gift would create
an awkward situation, check with your supervisor or call the
Ethics Line at (866) 605-3804 for guidance
Elmcroft’s Policy on Conflicts of Interest
 Associates have a duty to avoid interests, both real and
perceived, that may conflict with their employment or service
to Elmcroft.
 Associates should discuss outside employment options with their
supervisor before accepting any outside employment to ensure a
conflict is not caused or perceived to be caused by such
Fraud and Abuse Laws
False Claims Act
Anti-Kickback Statue
Physician Self-Referral Statute (Stark)
Exclusion Statute
Civil Monetary Penalties Law
What is the Deficit Reduction Act of 2005?
 Requirement for Medicaid in addition to Federal Fraud, Waste
and Abuse requirements.
 The Deficit Reduction Act of 2005 (DRA) is a law passed by
Congress to reconcile the 2006 federal budget. The DRA includes
specific provisions aimed at reducing Medicaid fraud and abuse.
While the DRA applies to all health care providers receiving at
least $5 million in annual Medicaid payments (By state), all
healthcare providers who accept Federal healthcare dollars must
adhere to the FCA and all other Fraud, Waste and Abuse
What does the DRA require Elmcroft to do?
 The DRA provisions aimed at reducing Medicaid fraud and abuse
require health care providers to do a number of things, including
 Establish written policies for all employees, contractors and agents
that provide detailed information about:
The federal False Claims Act (31 U.S.C. 3729-3733)
Applicable state false claims laws
Administrative remedies for false claims
Any comparable state laws pertaining to penalties for false claims and
 Whistleblower protections
What are False Claims Acts?
 Federal and State versions
 Protects government programs, including Medicare, Medicaid
and TRICARE from fraud and abuse.
 Knowingly presenting a false or fraudulent claim for payment;
 Knowingly making or using a false record or statement material
to a fraudulent claim;
 “Reverse False Claims” – false statements or records used to
avoid paying monies owed to the government.
 Government defines a “claim” as a line item on a bill.
 Penalty: monetary fines of $5,500 to $11,000 plus triple the amount of
the claim.
Fraud, Waste and Abuse
In order to prevent fraud and abuse, it essential to understand the
difference between fraud and abuse related to Medicare, Medicaid and
other government health programs.
 Fraud: making false statements or representations of fact to obtain
payment for which you are not entitled. This is an intentional act.
 Waste: the careless, inefficient, or unnecessary use of public resources.
This is usually an error.
 Abuse: Practices that result in unnecessary costs to the Medicare or
Medicaid programs such as billing for more expensive services than were
actually provided, inflating charges, billing for services that are not
medically necessary. Usually occurs related to an error.
Fraud and Abuse Risk Areas CMS is looking at
 Quality of Care
 Billing and Cost Reporting
Therapy and ADLs
 Resident Rights
Right to make decisions
Financial protections
Accurate claims
Credit balances
MDS accuracy
Billing for substandard care
Additional Risk Areas
 Employee screening
 Background
 Exclusions
 Licensure
 Kickbacks, inducements, and
 Financial waivers
 Physician payments
 Gifts
 Referral arrangements
 Joint ventures
Additions and specificities:
* Comprehensive resident care
* Medication management
* Use of psychotropic
* Resident safety
* Restorative and personal care
* Free goods and services
* Conflicts of interest
* Hospice relationships
* HIPAA compliance
Whistleblower (Qui Tam/Relator)
The FCA establishes the right of individuals, commonly
referred to as whistleblowers, with first- hand
knowledge of fraudulent activities to bring legal
action against people and companies engaged in the
illegal behavior.
 A whistleblower is a person who exposes misconduct or alleged
dishonest or illegal activity occurring in an organization.
Whistleblowers are protected by law.
 Individuals who bring a successful qui tam/whistleblower action
are entitled to receive a percentage of the monies recovered.
 Elmcroft strictly prohibits retaliation, in any form, against a
What actions would you take and why?
Clarice is the cook for a large skilled facility with a high volume of
skilled residents.
One day Clarice is sitting in the break room when she hears Pam, the
MDS Coordinator telling Adam, the Bookkeeper that “Mr. Hill did
not make his therapy minutes and is going to drop several RUG
levels.” Adam replies “That is going to cost us thousands of
dollars, the big wigs won’t be happy.” Pam states “Bill at the
higher RUG, I will fix the therapy minutes.”
Although Clarice has no idea what a RUG level is, she doesn’t think it
sounds right that Pam is “going to fix the therapy minutes.”
What should Clarice do?
Anti-Kickback Law
 Federal and State versions
 Prohibits providers from paying for referrals of
individuals or buying services for which payment may be
made by a federal or state health care program.
 Penalty: Criminal statute punishable by $25,000 fine per
violation, up to 5 years in federal prison and potential
exclusion from Medicare/Medicaid.
Elder Justice Act
This law requires a skilled care provider to report any
reasonable suspicion of a crime committed against any
individual who is a resident of, or receiving care from, the
 Report must be made within 2 hours of forming a reasonable
suspicion of a crime with serious bodily injury.
 Report must be made within 24 hours if there is no serious
bodily injury.
 Penalty: monetary fines up to $300,000 and potential
exclusion from Medicare/Medicaid.
Expectations of Associates
Read and understand Elmcroft’s Code of Ethical Conduct and commit to
living The Code.
Act responsibly.
Document according to legal and ethical standards.
Participate in associate education sessions for your job.
Assist in compliance auditing and monitoring activities that relate to your
Report suspected violations to your Supervisor, Administrator, Chief
Compliance Officer or call the Ethics Line (866-605-3804).
Your Compliance and Ethics Resources…
 Supervisor
 Administrator (Local Compliance Officer)
 Chief Compliance Officer
 Ethics Line 1-866-605-3804
 Code of Ethical Conduct
 Compliance Program Plan
 Compliance Policies and Procedures
 Elmcroft Associate Handbook
Questions about Compliance and
Contact Information
Tony Miranda, CHC, FHFMA
Senior Vice President
Chief Compliance Officer
Elmcroft Senior Living.
9510 Ormsby Station Rd, Suite 101
Louisville, KY 40223-4082
Tel. (502) 753-6034
Fax. (502) 753-6134
e-mail: [email protected]
Ethics Line:
[email protected]

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