Mountain Land Rehabilitation is committed to providing rehabilitation services in a quality and cost-efficient manner.
“As the President of Mountain Land Rehabilitation I am proud of the commitment and dedicated efforts of our leadership in actively seeking total compliance in all facets of the services which we provide. Our successes are in large part the product of talented and dedicated staff that understand the value of compliance in all that we do.”
- Mark Anderson, President
Health care is a complex, highly regulated, interdisciplinary, service-oriented industry, that continually faces changes in technology, delivery systems, standards of care and treatment protocols, rules and regulations, funding and reimbursement, and finally and most importantly the service needs of our patients and their families.
With that complexity in mind and at the direction of our Board of Directors, Mountain Land Rehabilitation has established a Plan of Compliance, Conduct and Ethics. The development and implementation of this guide and related compliance activities is fundamental to establishing a culture, within our organization, that promotes prevention, detection, and resolution of instances of conduct that do not conform with MLR policies and procedures, federal and state laws, as well as ethical business practices.
Our shared responsibility and commitment in this effort will ensure that “our vision is to be a vital and valued provider of health care and related services while helping our customers and our employees achieve their potential” which began in 1982 will continue on into the future.
The first element of an effective Compliance Program is designation of a Compliance Officer (CCO) and a Compliance Committee. The CCO runs the day-to-day operations of the Compliance Program and the Compliance and Business Integrity (CBI) Panel provides oversight and a mechanism to advise leadership of Compliance activities. The CBI Panel includes mandatory members, such as the CCO, the HIPAA Privacy Officer, and at least one member of the Board of Directors and a senior Company officer. The CBI Panel meets on a quarterly basis and uses a formal agenda based on the seven original elements of an effective compliance program plus the two additional elements per supplemental guidance from the Department of Health and Human Services (DHHS).
The second element of an effective Compliance Program is written standards of conduct (Company PCCE) and Policies and Procedures. We utilize Compliance Policies and Procedures that include policy specific to each element of an effective Compliance Program. This Policy guides the actions of the Compliance Officer, the CBI Panel, and various other individuals with their responsibilities to the Compliance Program. It also provides information to all employees regarding the Compliance Program.
The third element of an effective Compliance Program is Auditing and Monitoring. Auditing and Monitoring is used to mitigate risk. The process owner (Division or Department Quality & Compliance leaders) generally provides the Monitoring, while Auditing is conducted by an entity external to the process. On a yearly basis the CCO drafts the Auditing and Monitoring plan with substantial input from process owners and the CBI Panel. It is reviewed and approved by the CBI Panel and the Company Board of Directors.
The fourth element of an effective Compliance Program is Training and Education. On a yearly basis the CCO, and Company leadership draft the Training and Education plan with input from process owners and the CBI Panel. The plan includes training given by the CCO, process owners, and by others in the organization.
The fifth element of an effective Compliance Program is Response and Prevention. While compliance programs are intended to promote adherence to applicable substantive laws and regulations, situations may still arise where conduct inconsistent with legal requirements is reported, suspected or even confirmed. An effective compliance program will include a process by which the organization can respond to these actual or potential violations. The Company should respond immediately to detected deficiencies and develop effective corrective action plans. Company will conduct reviews to verify that the corrective action that was implemented successfully eliminated the deficiency or problem. After determining the cause of discovered non-compliance, measures should be developed and implemented to prevent future recurrences, and appropriate monitoring is instituted to assure that preventative measures are operating effectively.
The sixth element of an effective Compliance Program is Reporting and Investigation. All Employees should feel comfortable coming forward to discuss or report suspected wrongdoing. Employees must have the option to report concerns with an expectation of anonymity. Confidentiality requests related to the reported concern are honored to the extent possible. Company leadership, the CCO, and the Company Compliance Hotline are options for employees who want to report suspected wrongdoing. To help fulfill the duty of promoting the Compliance Program, CBI Panel members must ensure that the aforementioned communication resources are distributed to all employees. The CBI Panel and relevant senior executives are notified of all Compliance concerns. The CCO, and others, provide investigation of potential compliance concerns to determine the facts of each case and to provide an appropriate response that includes corrective action, as necessary. The CBI Panel is informed to the extent allowable and approves the results of all local investigations.
The seventh element of an effective compliance Program is Enforcement and Discipline. Non-compliant behavior should have consequence such that inappropriate conduct is discouraged. The type and degree of discipline should be consistent with the gravity of the inappropriate conduct.
Supplemental guidance (+2) from DHHS provides two additional elements of an effective Compliance Program. These are 1) creation of a Compliance Annual Report; and 2) Creation of a Risk Assessment document.
The Risk Assessment is a document that is central to the Compliance Program. The Auditing, Monitoring, and Training and Education plans previously discussed, represent the Company’s response to mitigate risks identified on the Risk Assessment. Process redesign is also an available option for risk mitigation. The CCO drafts the Risk Assessment document with input from the Panel and CEO. It is then reviewed and approved by the Panel and the Company Board of Directors.
Copyright © 2012 - Mountain Land Rehabilitation