Mountain Land Compliance

Since 1986, Mountain Land Rehabilitation has provided evidence-based therapy while being true to our Core Values of Integrity, Clinical Excellence, and Operational & Fiscal Efficiency.

"As Mountain Land Rehabilitation celebrates more than 30 years I am very proud of the integrity of the members of our team. Our success and longevity is based on a culture of doing the right things for the right reasons. We understand it is our responsibility to know the rules and regulations in healthcare. It is our daily commitment to be compliant in all aspects of our care and business practices. Our core values guide us. Every employee is responsible for maintaining the highest standards of ethical conduct. As a company we are committed to doing what is right, having integrity, and being compliant."

- Mark Anderson, President

Healthcare 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 the 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 as “a leading healthcare provider committed to living our core values and inspiring life’s most meaningful endeavors.” which began in 1986, will continue on into the future.


Our Compliance & Business Integrity Elements

Policies

1. Standards of Conduct/Policies & Procedures

The first element of an effective Compliance Program is Standards of Conduct, Policies & Procedures. The Mountain Land Rehabilitation (MLR) Code of Conduct and Ethics (Code) states the overarching principles and values by which MLR 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 are addressed and corrected. Policies & procedures should be detailed and specific to describe the operation of the Compliance Program. MLR Compliance Policies & Procedures should incorporate the elements of an effective Compliance Program and should guide the actions of the Compliance Officer, the Compliance Panel, MLR leadership, and employees in their responsibilities to the Compliance Program.

Officer

2. Compliance Officer & Oversight

The second element of an effective Compliance Program is designation of a Compliance Officer (CCO) and, at MLR, the Compliance Panel. The CCO oversees the day-to-day operations of the MLR Compliance Program, the annual Compliance Work Plan, and is the Chairperson for the Compliance Panel. The MLR Compliance Panel provides compliance review and oversight as a mechanism to advise department leadership of regulations and obligations. The Compliance Panel includes mandatory members, such as the CCO, the Privacy Officer, the Security Officer, at least one member of the Board of Directors, and a senior MLR Officer. The MLR Compliance Panel meets on a regular basis and uses a formal agenda based on the Seven Elements of an effective compliance program.

Education

3. Education & Training

The third element of an effective Compliance Program is Education & Training. Education, training, and access to Compliance Policies & Procedures, as well as the MLR Code of Conduct & Ethics, should be provided to all MLR employees. Specifically, MLR provides ongoing education to ensure that employees are aware of the regulatory and legal requirements related to their job function.

Monitoring

4. Monitoring & Auditing

The fourth element of an effective Compliance Program is Auditing & Monitoring. Ongoing evaluation is critical to a successful compliance program. The key is to demonstrate a process of continuous improvement in compliance activities. The MLR process for auditing and monitoring measures the effectiveness of the Compliance Program, ensures compliance with payer contract requirements, and identifies compliance risks. The MLR process includes internal and external monitors, reviews, and audits. Additionally the process includes employee screening & due diligence. The purpose of screening is to actively monitor all staff that are providing services on behalf of MLR to verify that they are not identified as an “Excluded Provider” (OIG), or are engaged in illegal or unethical activities that would impact their status. Due Diligence contributes significantly to informed decision making by enhancing the amount and quality of information available to decision makers in the employment of personnel and all other areas of business operation.

Reporting

5. Reporting & Investigation

The fifth element of an effective Compliance Program is Reporting & Investigation. There are multiple methods for MLR employees to report potential problems or to raise concerns. Open lines of communication must be established ensuring confidentiality between the CCO, members of the Compliance Panel, MLR employees, managers, and the Board of Directors. Such lines of communication 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. The most important reporting system is an open door, and the best reporting system is one where employees feel comfortable approaching a supervisor and openly discussing any potential concern. The concepts of confidentiality and non-retaliation are fundamental to the MLR Compliance Program. Concerns or questions raised must be investigated, logged, tracked, and followed through to resolution.

Enforcement

6. Enforcement & Discipline

The sixth element of an effective compliance Program is Enforcement & 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, and describe expectations and consequences for non-compliant behaviors.

Prevention

7. Response & Prevention

The seventh element of an effective Compliance Program is Response & Prevention. When vulnerabilities or non-conformances are identified or reported, 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. MLR conducts reviews to verify that corrective action is implemented successfully eliminating the non-conformance or vulnerability. Measures are developed and implemented to prevent future recurrences. Monitoring is ongoing to assure that preventative measures are operating effectively.


Resource Acknowledgment: Compliance 101: Third Edition By Debbie Troklus, CHC-F, CCEP-F, CHRC, CHPC and Greg Warner

The Compliance materials and resources found on this website are the exclusive property of Mountain Land Rehabilitation. Do not distribute or reproduce without the express written consent of Mountain Land Rehabilitation.