Morrow Memorial Home has developed a Corporate Compliance Program.  The intent was to affirm the commitment of our organization to abide by high legal and ethical standards with the delivery of health care services and the operation of residential facilities for the elderly.

 

Under the direction of our Board of Directors, Morrow Memorial Home developed a Corporate Compliance Program in January of 1999.  The intent was to affirm the commitment of our organization to abide by high legal and ethical standards with the delivery of health care services and the operation of residential facilities for the elderly.

 

We have developed the following policies and procedures for the implementation of the program as it relates to Morrow Home employees, vendors and providers (contractors).  Specifically, these policies and procedures provide guidance to all employees, vendors and providers regarding the operation of the Corporate Compliance Program and the available mechanisms through which compliance issues can and should be reported.

 

This is the abbreviated version we distribute to our employees.  The formal version is distributed to our vendors and providers, placed in the employee break rooms, at the employee work stations and in the brochure stands throughout our facility, for anyone to review.

 

Each employee and contractor is responsible for adhering to the standards of this program.  This web page version is given to our employees during their employment orientation and every January at our mandatory all-staff compliance meeting.  The entire program is also kept in the Administrative Policies Book and in the office of the Compliance Officer.

 

For any questions regarding our Corporate Compliance Program, e-mail or call our Compliance Officer or the Executive Director of Morrow Memorial Home.  To report any compliance concerns regarding our employees or vendors and providers we do business with, call our Corporate Compliance Officer at (608) 269-3168 or e-mail us at mbonello@morrowhome.org.

 

 

This committee consists of three members and the Compliance Officer.  The committee and the officer are appointed by the Executive Director and approved by the Morrow Home Board of Directors.  Once appointed, the officer serves in that position until the Executive Director and the board determine that a replacement is necessary in order to maintain the effectiveness of the program.

 

 

The committee has overall responsibility for managing and overseeing the compliance program.  Under the direction of the Compliance Officer, the committee is responsible for operating the program on a daily basis and has the appropriate resources to perform its responsibilities within the program.  The committee assumes responsibility for investigating any compliance violation, in accordance with the procedures outlined in the program manual.

 

 

The Compliance Officer serves as an ombudsman to whom employees and contractors should report suspected violations of standards of conduct described in the program.

 

Morrow Home instructs its employees and contractors to report to the Compliance Officer any suspected compliance violation.  To facilitate such disclosure, we prominently display throughout our campus the announcement of the Compliance Officer appointment and the necessity of promptly reporting suspected misconduct or questionable practices. The Compliance Officer makes all reasonable efforts to maintain the anonymity of the reporting individual and the confidentiality of the report.

 

The Compliance Officer and the Executive Director are responsible for training efforts of the program.  In this capacity, they may be assisted by outside experts and/or legal counsel.

 

 

If a Morrow Home employee or contractor has a concern regarding any ethics or compliance issue, including the standards of conduct or policies and procedures described in program, that person should immediately contact his/her supervisor and/or the Compliance Officer.  The Compliance Officer immediately investigates all reports in a confidential manner.

 

 

Employees and contractors are expected to report suspected violations of the following:  1) Applicable legal requirements, 2) Morrow Home standards of conduct, policies and procedures, 3) Other compliance policies and procedures which are currently included in the Morrow Home policies and procedures manual or which may be adopted from time-to-time, 4) Violations of privacy and confidentiality of medical records.

 

Anyone who acquires information that gives him/her reason to believe that another employee, contractor or any other person or entity associated with Morrow Home, is engaged in or plans to operate in a manner prohibited by the compliance program or Morrow Home policies and procedures, should promptly report such information to the Compliance Officer.

 

Anyone who is directed to engage in conduct prohibited by the compliance program should immediately report such information to the Compliance Officer.

Morrow Home does not tolerate any supervisor or another employee retaliating against an employee or contractor for reporting compliance issues.  If such a situation were to occur, disciplinary action may be taken.

 

 

Morrow Memorial Home maintains all licenses, certifications, approvals and accreditations necessary for the operation of each health care facility, service, agency or department within Morrow Home's system of operations.

 

 

 

Employees of Morrow Home cannot provide or accept business entertainment and gifts above ordinary and reasonable items deemed to be of nominal value, provided those items do not violate local, state or federal law.  Any questions in this section should be directed to the Compliance Officer for interpretation.

 

Cash or other gifts to physicians and other referral sources are absolutely prohibited.  The Executive Director of Morrow Memorial Home must approve non-cash items given to physicians or other referral sources greater than nominal value.  Such approval must be confirmed prior to giving the item, along with the stated reason for the gift documented in writing.

 

 

Morrow Home and its employees do not make payments or provide anything of value to anyone to induce the use of our health care services. The only exception is in full compliance with laws authorizing such payments in specific circumstances.

 

Employees of Morrow Home may not make or offer to make any payment or provide anything of value to another person with the understanding or intention that payment or items of value will influence any government official, resident/tenant/client/patient, physician or other source of referrals.  Such payment cannot be used for improper or unlawful purposes.  If it were publicly disclosed, this type of action would embarrass the employee and Morrow Home and may result in legal action.

 

 

 

When employees and non-employees associated with Morrow Home are in a position to make referrals, they must make such referrals based on the preferences of the individual seeking care, or if the individual does not express a preference, what is best for the individual.

 

In any case, referrals must be made without regard to the number of referrals any physician or other health care provider has made to Morrow Home.

 

 

Morrow Home presents itself to the communities it serves through its marketing activities in a manner consistent with its mission and capabilities.  We will not tolerate and do not practice engaging in unethical, abusive or illegal marketing or advertising practices in connection with offering or providing services.

 

 

We do not pay incentives to employees or contractors based on the number of persons they refer to us for services.  The decision to provide services referred to Morrow Home is a medical decision that is made by qualified health care professionals.

 

 

Our organization maintains the right to privacy and confidentiality of all medical information in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

 

 

The Compliance Officer and Executive Director are responsible for the program's implementation and for ensuring that all employees and contractors are fully informed about and comply with the compliance program and any changes made to it. 

 

 

Training and implementation of the Corporate Compliance Program was initially conducted in January of 1999 and is reconfirmed every January with our employees and contractors.  New employees are oriented to the program expectations within 90 days of their hiring.

 

On an annual basis, all employees are required to sign an agreement that they have received the employee version of our compliance program, that it was reviewed with them, they understand it, and agree to follow it.  These agreements are kept in the employee's personnel file in the human resources department.

 

 

All service agreements between Morrow Memorial Home and vendors and providers that furnish resident/ tenant/client/patient/child care services to the people we serve through our organization must sign a statement that they agree to follow the compliance program.  These individuals/entities must receive a copy of the compliance program, review it and sign the agreement that they will comply with the expected standards, policies and procedures.  Any individual/entity conducting business on behalf of contractors is expected to follow the standards of this program.

 

 

To insure that employees are familiar with the compliance program, we conduct on going communication with them in regard to reinforcement and updates with the program.  The Compliance Officer is responsible for these communication efforts.

 

Whenever it occurs, the initial exposure an employee has to the compliance program shall include a review of applicable state and federal regulatory requirements relating to the provision of health care services by Morrow Home.

 

The compliance committee may require that a contractor who has a service agreement with Morrow Home, or anyone who provides services on behalf of the contractor, participate in training programs relating to the compliance program.

 

 

The Compliance Officer distributes in writing and/or posting in obvious places within our organization any modifications to the compliance program or manual.  Written explanations of changes may be provided.  If it is determined that written or posted changes are not sufficient, then an interim training will be conducted.

 

Employees are provided with periodic notification and information about the compliance program through Morrow Home’s staff newsletter, compliance manuals located in employee break rooms and compliance manuals placed at staff work stations.

 

 

Upon receiving a report of a known or suspected violation of the Corporate Compliance Program, the procedure for investigation is for the Compliance Officer to notify the Executive Director, then call a meeting of the compliance committee.  The committee will investigate the matter to determine whether a violation of the program standards or other misconduct has occurred.

 

If the Executive Director is the subject of the report, the Compliance Officer will notify the President of the Morrow Memorial Home Board of Directors, who will convene a committee of the board to investigate the matter.  Such an investigation will be conducted in the same manner as outlined for the compliance committee, except that all communication regarding the matter will be made to the President of the board instead of the Executive Director.  Any corrective action taken will be the responsibility of the President of the board.

 

 

 

It is the intention of Morrow Memorial Home to comply with the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) as they pertain to privacy and confidentiality.  All medical records and other individually identifiable health information held or disclosed by Morrow Home, whether communicated electronically, in writing or verbally fall within the protection of this regulation.

 

All residents/tenants/clients/patients are given a clear written explanation of how they can access, use, keep and disclose their health information.  Such information includes a complaint mechanism.

 

Morrow Home does not knowingly release health-related information without the voluntary consent of the care recipient or as allowed or required by other statutes.  Any release of health information for non-health purposes requires the explicit authorization of the individual.  All disclosures are limited to the least amount necessary for the purpose of disclosure unless, as allowed, when the full record is needed to provide the best quality care to the recipient.

 

Our organization has developed and implemented written policies and procedures defining who has access to care recipient information, how that information is used within our organization, and when information can or cannot be disclosed.  Employees of Morrow Memorial Home receive sufficient training as to the significance of privacy protection procedures.

 

The Morrow Home Administrator serves as our Privacy Officer to monitor the effectiveness of our privacy standards and facility/organization compliance.  Our Computer Coordinator is our Security Officer who monitors and makes recommendations necessary to maintain the integrity of medical records under our care.

 

We instruct and expect contractors or anyone who does business with us to protect the privacy of health information.  This requirement is met by providing those individuals/entities with a copy of our Corporate Compliance Program manual.

Morrow Home has a grievance process to provide a means for our care recipients to make an inquiry or complaint regarding any concern about the privacy and use of their medical records.

 

To report any privacy concerns, call our Administrator at (608) 269-3168 or e-mail us at mbonello@morrowhome.org.