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 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 Code of 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, and 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 Written Standards of Conduct, and Policies & Procedures. The Company Code of Conduct and Ethics (Code) states the overarching principles and values by which the Company operates, and defines the underlying framework for compliance policies & procedures. The Code should describe the expectations that all employees conduct themselves in an ethical manner; that issues of noncompliance are reported appropriately; and that reported issues will be addressed and corrected. Policies & procedures should be detailed and specific to describe the operation of the Compliance Program. Company Compliance Policies & Procedures should incorporate the elements of an effective Compliance Program and should guide the actions of the Compliance Officer, the Compliance and Business Integrity (CBI) Panel, Company leadership, and Company employees in their responsibilities to the Compliance Work Plan and Company Compliance Program.
The second element of an effective Compliance Program is designation of a Compliance Officer (CCO) and a Compliance Panel. 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 regular basis and uses a formal agenda based on the seven elements of an effective compliance program plus the two additional elements per supplemental guidance from the Department of Health and Human Services (DHHS).
The third element of an effective Compliance Program is Screening and Due Diligence. The purpose of Screening is to exclude any employee that the company knows, or should have known, is engaged in illegal or unethical activities from a position of substantial authority. Due diligence contributes significantly to informed decision making by enhancing the amount and quality of information available to decision makers and by ensuring that this information is systematically used to deliberate on the decision at hand and all its costs, benefits, and risks.
The fourth element of an effective Compliance Program is Communication, Education, and Training. Open lines of communication must be established ensuring confidentiality between the CCO, members of the Compliance Panel, Company employees, managers, and the Governing Body. Such lines of communication must be must be accessible to all and allow compliance issues to be reported including a method for anonymous and confidential good faith reporting of potential compliance issues as they are identified. Education and training regarding compliance policies & procedures, as well as the Code of Conduct & Ethics should be apparent through Company compliance with Medicare program requirements. Company must provide education and training to ensure that employees are aware of the Medicare requirements related to their job function.
The fifth element of an effective Compliance Program is Auditing and Monitoring. A system for auditing and monitoring must be implemented to measure the effectiveness of the compliance program, ensure compliance with CMS requirements, and identify compliance risks. The system should include internal monitoring and audits as well as external audits, as appropriate. On a regular basis the CCO drafts the Company Auditing and Monitoring Plan, as part of the Compliance Work Plan.
The sixth element of an effective compliance Program is Enforcement and Discipline. When an investigation confirms a compliance offense, a plan must be in place to enforce consistent discipline. Written policies are required that apply appropriate disciplinary sanctions on those who fail to comply with the applicable requirements and standards of conduct. Disciplinary policies should include sanctions for non-compliance and failure to detect non-compliance when routine observation or due diligence should have provided adequate clues, or when there is a failure to report actual or suspected non-compliance. Discipline must be dealt with timely and enforced consistently. Disciplinary policies must be clearly written, describe expectations and consequences for non-compliant behaviors, and must be reviewed annually with employees.
The seventh element of an effective Compliance Program is Response and Prevention. When vulnerabilities or non-conformances are identified or reported (during risk assessment, auditing, or monitoring activities) a corrective action must be conducted in response to potential violations. The corrective action must include repayment of overpayments and disciplinary action against responsible employees. Company should conduct reviews to verify that the corrective action that was implemented successfully eliminated the non-conformance or vulnerability. Measures should be developed and implemented to prevent future recurrences. Appropriate monitoring should be ongoing to assure that preventative measures are operating effectively.
The Department of Health & Human Services recommends two additional elements for an effective Compliance Program. 1) Compliance Program Reports; and 2) Compliance Risk Assessments.
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.
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