KADLEC MEDICAL CENTER
HOUSE-WIDE
Section: 1500
POLICY AND PROCEDURES
TITLE: ROLES AND RESPONSIBILITIES OF
COMPLIANCE COMMITTEE
ADMINISTRATIVE
APPROVAL:
POLICY:
X
PROCEDURE:
GUIDELINE:
STANDARD:
NO. 1504
EFFECTIVE DATE:
PENDING
PAGE 1 OF 3
SUPERSEDES: 11/98
REVISION INITIATED:
COMMITTEE APPROVAL/REVIEW: Compliance Committee 06/02
DEVELOPMENT TEAM/AUTHOR(S):
AUDIT REVIEW: Randy Stanper ,Attny/04/02, Jennie Martin, Compliance Officer /05/02, Compliance Committee/06/02
The Board of Directors of the Hospital has established the Compliance Committee to oversee and administer the
Compliance Program. The Compliance Committee, acting through and with the assistance of the Compliance Officer,
has the following responsibilities:
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The Compliance Committee is established to advise the Compliance Officer, assist in identifying areas of risk, and
monitoring the ongoing effectiveness of the Compliance Program.
Regular review of Compliance Program policies to ensure they adequately address legal requirements and address
identified risk areas
Analyze the effectiveness of compliance education and training programs
Review compliance log for adequate and timely resolution of issues and/or inquiries
Assist in identifying areas of potential violations and establishing periodic monitoring /audit programs
Assist in development of policies addressing remediation of identified problems
Provide a forum for the discussion of ethical issues related to hospital business functions
The Compliance Committee will be chaired by the Compliance Officer and will consist of members appointed by
Hospital administration. The Compliance Committee will be composed of employees representing the following areas
or functions:
Patient Financial Services
Risk Management
Clinical Ancillary Area
Physician Recruiter
Emergency Department
Finance
Materials Management
Quality Care Management
Human Resources
Information Systems
Medical Records
The Compliance Committee shall meet periodically to review and consider any inquiries conducted or supervised by the
Compliance Officer. Prior to such meetings, the Compliance Officer shall submit to each Compliance Committee
member an agenda enumerating matters to be reviewed by the Compliance Committee. The President and CEO or the
Compliance Officer may call special meetings of the Compliance Committee. All submissions to the Compliance
Committee by the Compliance Officer shall be marked “Confidential.” Minutes will be recorded of all meetings and will
KADLEC MEDICAL CENTER
POLICIES & PROCEDURES
TITLE: ROLES AND RESPONSIBILITIES OF
DATE:
NO.
1504
Page 2 of 2
COMPLIANCE COMMITTEE
be maintained in the office of the Compliance Officer. The Compliance Officer shall communicate the Compliance
Committee’s actions and recommendations to appropriate Hospital officers, employees, and representatives.
The Compliance Committee, acting through the Compliance Officer, is empowered to investigate, evaluate, and report
facts, and make recommendations to the President and CEO and the Board of Directors of possible responses or
initiatives, including disciplinary or other adverse action for misconduct by Hospital employees. The Compliance
Committee shall review and evaluate the information developed and recommendations made by the Compliance
Officer and other members of the Compliance Committee. The Compliance Committee will report to and consult with
the President and CEO and the Ethics Committee and Governance Committee of the Board of Directors.
In conducting investigations (including Hotline complaints), the Compliance Committee shall respect the confidentiality
of privileged records and information and shall comply with applicable confidentiality laws and ethical standards. All
files of inquiries shall be marked “Confidential” and maintained by the Compliance Officer on a confidential basis. They
shall not be disclosed except: (i) to members of the Compliance Committee; (ii) to legal counsel retained by the
Compliance Officer and/or the Compliance Committee; (iii) to individuals or need to know and authorized by the
Compliance Committee to receive such information; or (iv) as may be required by law or order of a court of competent
jurisdiction.