|Questions||St. Joseph’s Hospital||Piedmont- Columbus Hospital|
|How internal monitoring and auditing is conducted||“The Compliance Office, with input from Leadership, develops an annual work plan, also known as an internal audit plan, which outlines the areas of focus for the year. The work plan specifies the time for audits, the service areas, and functions to be audited. The
Corporate Compliance Committee reviews and approves the annual work plan, makes suggested changes, and is kept apprised of any changes made to the plan by the Compliance Office. In addition, the results of the work plan are shared with the Corporate
Compliance Committee and their feedback obtained on outcomes and recommended solutions as problems are identified” (“ St. Joseph’s Hospital Health Center Corporate Compliance Plan”, 2012).
|Monitoring and auditing is conducted under direction by the Chief Compliance Officer and Senior PCR staff. The Chief Compliance Officer and PCR staff will have access to documentation created for auditing purposes (“Policy Search”, 2019).|
|How compliance and practice standards are implemented||“Every new employee receives a copy of the Business Conduct & Code of Ethics and participates in an educational session conducted by the Compliance Office during their formal classroom
orientation. Board of Trustees receive a copy of the Business Conduct & Code of Ethics and receive educational sessions, as
appropriate, conducted by the Compliance Officer” (“ St. Joseph’s Hospital Health Center Corporate Compliance Plan”, 2012).
|The Chief Compliance Officer will focus compliance with federal, state and local laws, promotion of good corporate citizenship, Prevention and early detection of misconduct, and identification and prioritization of high risk areas. Communication and education are provided to all PCR staff regarding compliance and corporate responsibility. (“Policy Search”, 2019).|
|The designated compliance officer (or person designated to be the contact for compliance matters), who that person reports to, and their relationship to the organization’s governing board||“The President of St. Joseph’s has appointed a Compliance Officer. The Compliance Officer is a part of Senior
Leadership. Senior Leadership at St. Joseph’s Hospital Health Center encompasses the President, Vice Presidents, General Counsel and Directors. The Chief Financial Officer of Finance (CFO) shall not supervise the Compliance Officer. The Compliance Officer has direct access to the President and, as required, to the Board of Trustees” (“ St. Joseph’s Hospital Health Center Corporate Compliance Plan”, 2012).
|Chief Compliance Officer not directly related to Board of Directors but reports to the leadership team that reports to Board of Directors (“Policy Search”, 2019)|
|How employees are trained and educated to model compliant behaviors||“Mandatory new employee orientation and the Employee Handbook provide an overview of fraud and abuse laws with examples that give the new employee the ability to identify circumstances of fraud, waste and abuse, an explanation of the elements of the Compliance Program, including the complaint or reporting process and highlight St. Joseph’s commitment to integrity in its business operations and compliance with applicable laws and regulations”().||Code of Conduct is provided to all employees and leadership staff on a yearly basis and attestation of review and acknowledgement is required to be documented for every employee of the hospital (“ Policy Search”, 2019)|
|How violations or offenses are detected, reported, and corrected||“St. Joseph’s may impose sanctions on any member of the workforce who intentionally or unintentionally violates established policies or
procedures. This means that every confirmed act of non-compliance may result in corrective action or discipline. Sanctions, which are penalties imposed, can result in not only disciplinary action, but the removal of privileges, discharge of employment, contract penalties and in some cases civil and/or criminal prosecution” (“ St. Joseph’s Hospital Health Center Corporate Compliance Plan”, 2012).
|“Employees, medical staff, students, independent contractors, and other PCR agents who, upon
investigation, are found to have committed violations of applicable laws and regulations, the Corporate
Compliance Program, the Code of Conduct or the policies and procedures of PCR will be subject to
appropriate disciplinary action, up to and including termination of employment, medical staff privileges
or any contractual or affiliated relationship. PCR will adopt appropriate measures to reward behavior
which promotes compliance”(“Policy Search”, 2019)
|How lines of communication with employees is developed||“St. Joseph’s Compliance Office maintains a Hotline which allows callers to report concerns anonymously and without the fear or retaliation Individuals are encouraged to call the Hotline if they have any question about whether their concern should be reported. A written record of every report received will be kept for a period of seven years. Every effort will be made to preserve the confidentiality of reports of non-compliance (although calls made anonymously will almost always preserve the autonomy of the caller). Individuals must understand, however, that circumstances may arise in which it is necessary or appropriate to disclose information. In such cases disclosures will be on a “need to know” basis only and the Compliance Officer will work with the individual(s) in these cases if his or her identity is known” (“ St. Joseph’s Hospital Health Center Corporate Compliance Plan”, 2012)..||Employees have multiple outlets for communication and they include: email, flyers, Healthstream, newsletters and breakroom postings (“Policy Search”, 2019)|
|How disciplinary standards are enforced||“The Compliance Officer reports the results of each investigation considered significant in his/her sound judgment to the Compliance
Office Leadership, Corporate Compliance Committee, General Counsel, St. Josephs President, Board of Trustees and Senior Leadership as appropriate. He/she will recommend a course of discipline and/or other corrective action. Sanctions for non-compliance may be imposed. Corrective action recommended by the Compliance Officer will be reviewed with the Vice President for the service
area and Human Resources as appropriate” (“ St. Joseph’s Hospital Health Center Corporate Compliance Plan”, 2012).
|Failure for the employee to complete compliance training will lead to termination of the employee (“Policy Search”, 20|