Appointment of Compliance Officer 

Compliance Policy #902

Boulder Community Hospital shall appoint a Compliance Officer and a Compliance Committee to develop and implement the Hospital's compliance program, subject to the authority and oversight of the Hospital's Board of Directors.

Responsibility: All Hospital Employees
 
PROCEDURE

Appointment of Compliance Officer
The Chief Executive Officer shall appoint a Compliance Officer, subject to approval of the Board of Directors.  The Compliance Officer shall be a Director, Vice President, Manager or other individual in charge of a major
functional unit of the Hospital and shall be knowledgeable about compliance issues.  The Compliance Officer shall report to the Chief Executive Officer and to the Board of Directors.
 
Authority of Compliance Officer
The Compliance Officer has authority to:
1. Consult outside counsel as legally necessary;
2. Conduct internal investigations and audits related to compliance issues, including contracting with consultants as appropriate to assist with such audits or investigations of suspected wrong doing;
3. Recommend and approve employee discipline related to compliance issues;
4. Interpret ambiguities in the Hospital's compliance policies;
5. Review all documents and other information relevant to compliance activities, including without limitation, patient records, billing records, marketing information and the Hospital's arrangements with other parties such as employees, physicians and other practitioners, suppliers, agents, payers and independent contractors; and
6. Maintain direct access to the Chief Executive Officer and when appropriate, the Executive Committee of the Board and the Board of Directors.
 
Responsibilities of Compliance Officer
The Compliance Officer shall be responsible for developing and implementing the Hospital's compliance program and monitoring, evaluating and revising the program as necessary to conform to changes in the Hospital's regulatory and business environment.  The responsibilities of the Compliance Officer shall include the following:
1. Reviewing the Hospital's code of ethics, policies, procedure manuals and business practices for compliance with the legal standards applicable to the Hospital's operations;
2. Developing and recommending compliance policies to the Board of Directors;
3. Approving, in conjunction with the Compliance Committee, standards of conduct;
4. Overseeing and monitoring the implementation of the Hospital's compliance program;
5. Reporting on a regular basis to the Chief Executive Officer, Compliance Committee, the Executive Committee and the Board, the Board of Directors, on the progress of implementation of the Hospital's compliance program and other matters required by Hospital policies or as the Compliance Officer deems appropriate;
6. Analyzing the Hospital's industry environment and legal requirements with which it must comply and identifying, periodically, specific risk areas;
7. Assessing existing policies and procedures for incorporation into the Hospital's compliance program;
8. Periodically reviewing and updating the Hospital's compliance standards and policies to respond to changes in the Hospital's operations, as well as applicable, the laws, the policies and procedures of governmental agencies,and as appropriate, the requirements of private payers;
8. Periodically reviewing and updating the Hospital's compliance standards and policies to respond to changes in the Hospital's operations, as well as applicable, the laws, the policies and procedures of governmental agencies, and as appropriate, the requirements of private payers;
9. Working with appropriate Hospital departments to develop standards of conduct, policies and procedures to promote compliance;
10. Recommending and monitoring, in conjunction with the relevant departments, the development of internal systems and controls to carry out the Hospital's compliance standards, policies and procedures;
11. Developing, coordinating, overseeing and participating in, as necessary, education and training programs to inform Hospital employees, management, independent contractors and agents of applicable state and federal laws and to promote compliance with such laws;
12. Coordinating personnel issues with the Hospital's Department of Human Resources with respect to verification of the qualifications and background of applicants and discipline of employees who violate the Hospital's compliance policies;
13. Developing mechanisms to detect potential compliance violations and promote adherence to the Hospital's compliance program; and
14. Developing policies and programs to solicit, evaluate and respond to complaints and problems related to compliance issues and encourage individualswithin the Hospital to report suspected misconduct or noncompliance with applicable standards without fear of retaliation;
15. Independently investigating and acting on compliance matters, directing internal investigations, and coordinating any resulting corrective action with the appropriate Hospital department, independent contractor or agent;
16. Designing and coordinating, in cooperation with the applicable Hospital departments, internal compliance reviews, monitoring activities and audits, including annual reviews of Hospital departments;
17. Coordinating the Hospital's response to any external investigation or voluntary disclosure to an applicable regulatory agency;
18. Other activities as assigned by the Board or the Chief Executive Officer or identified in the Hospital's compliance policies.
 
Compliance Committee

Composition of the Compliance Committee
 
The Chief Executive Officer, in consultation with the Compliance Officer, shall appoint a Compliance Committee to assist and advise the Compliance Officer, assist in the implementation of the Hospital's compliance program,and develop strategies for promoting compliance with the Hospital's program.
 
Members of the Compliance Committee shall include individuals within the Hospital who are knowledgeable about compliance issues and about the operations of the Hospital, such as billing, finance, human resources, physician employment and contracting, medical records, coding, laboratory services, emergency services, home health and other areas of the Hospital's operation.  The Compliance Officer, the Chief Executive Officer or his or her designee and the Chief Executive Officer of Community Medical Services Organization or his or her designee shall also serve on the Compliance Committee.  The Chief Executive Officer may appoint other individuals to the Committee.  The Compliance Committee shall meet as necessary to carry out its functions.
 
Responsibilities of the Compliance Committee
The Compliance Committee's functions include the following:
1. Analyzing the Hospital's industry environment, legal requirements with which the Hospital must comply and specific risk areas;
2. Assessing existing policies and procedures which address specific risk areas for possible incorporation into the Hospital's compliance program;
3. Coordinating with the Compliance Officer and appropriate Hospital departments to develop standards of conduct, procedures and protocols topromote compliance with the Hospital's compliance program;
4. Recommending and monitoring, in conjunction with the Compliance Officer and relevant departments, the development of internal systems and controls to carry off the Hospital's standards, policies and procedures;
5. Determining the appropriate strategies to promote compliance with the Hospital's program and detection of any potential violations;
6. Developing, in coordination with the Compliance Officer,  a system to solicit, evaluate and respond to complaints and problems; and
7. Other activities as assigned by the Chief Executive Officer or the Board of Directors or described in the Hospital's compliance policies.
 
Conflict of Interest

The Compliance Officer or any member of the Compliance Committee shall not participate in any activities assigned under the Hospital's compliance policies or otherwise, which involve the audit, investigation or review of that individual or of any activities under his or her direction or control.

Return to Top

Left mouse button enlarges type
Right mouse button decreases type
Eliminate graphics and print content