FY 2013
Corporate
Compliance
& Rights Protection
Training
REASONS FOR A
COMPLIANCE PLAN
 To prevent unwanted events
from happening intentionally and
unintentionally.
 To help the organization
learn about these unwanted
events first.
 If they do occur and the
organization does not learn
about them first, an effective
plan can help mitigate or
reduce negative effects by
showing that they are
2
exceptions.
SEVEN ELEMENTS OF
EFFECTIVE COMPLIANCE
PLANS
1. Written standards of conduct
for all employees, contractors
and volunteers that promote a
clear commitment to
compliance.
2. The appointment of high level
individuals in the organization
to oversee the compliance
effort.
3. Due care taken by the
organization to not delegate
responsibility or authority to
those who may engage in
illegal activity.
4. Effective training and
3
SEVEN ELEMENTS
…CONTINUED
5. Monitoring and reporting
systems to uncover potential
problems and to encourage the
reporting of potential problems
by employees without fear of
retaliation.
6. Disciplinary systems for noncompliant employees - and their
managers- that are consistently
enforced at all levels of the
organization.
7. Reasonable steps taken to
respond appropriately to
detected offenses and to
4
prevent reoccurrence.
GAO: 3 PRIMARY
CATEGORIES OF FRAUD AND
ABUSE
 Improper billing practices:
upcoding, phantom treatment,
delivering more treatment
than necessary.
 Misrepresenting
qualifications: lapsed, expired
or false credentials;
performing outside the bounds
of one’s license.
 Improper business practices:
kickbacks for referrals to a
provider, cost report issues,
enhancement of profits by
limiting care.
5
LAWS TO BE
AWARE OF
 The Federal Antikickback Statute
 The Stark Law
 The Texas Illegal
Remuneration Statute
 Civil Money Penalties
Statute
 The Federal False Claims
Act
 The Medicaid Fraud
Prevention Act
6
THE ANTI-KICKBACK
STATUTE
 Applies to everyone not just
licensed staff
 “knowingly & willfully” - There
must be intent to engage in
wrongful act
 “solicits or receives/offers or
pays” – the prohibition applies
both to the offer and
acceptance of a kickback.
 “Remuneration, directly or
indirectly…” – does not require
exchanges of money just
anything of value.
7
THE STARK LAW- “SELF
REFERRALS”
 Physician must have a
financial relationship with an
entity
 Referrals to self or entity
owned or receiving
compensation
 No proof of intent to violate
the statute is required to
impose penalties
8
THE FEDERAL FALSE CLAIMS
ACT
 Submitting or causing to be
submitted a claim for payment
using a false record.
 Knowingly or with reckless
disregard or deliberate
ignorance of the falsity of the
claim.
 Fines can be enormous.
 Fraud Enforcement and
Recovery Act expanded FCA to
include claims to non
government payors. Creates
liability for knowingly
concealing the retention of an
overpayment.
9
MEDICAID FRAUD
PREVENTION ACT
 Applies to everyone not just
licensed staff
 Knowledge or acts with
conscious indifference or
reckless disregard
 Provides a multitude of actions
that constitute fraud, including
actions by managed care
organizations.
 Penalties: Revocation of
provider agreement, Medicaid
Exclusion list for no less than 10
yrs., state license discipline, and
10
monetary restitution.
PROVIDER EXCLUSIONS
DATABASE
 Any individual or entity that provides
or is involved in the provision of, or
billing for services or items
reimbursable by federal health care
programs may be excluded (MDs,
nurses, aides, PTs, billing companies,
non-licensed persons involved in some
aspect of health care industry).
 Most common exclusions include:
license revocation/suspension,
program-related convictions, patient
abuse and neglect and default on
health education loans.
 Exclusion does not expire or end on its
own terms; an individual or entity
must apply to the OIG for
reinstatement.
 Liability for using an excluded
individual or entity include:
o Civil money penalty of $10K for
each item or service claimed
11
o Assessment of up to three times the
amount claimed
o The violating entity could be added
QUI TAM ACT
A PROVISION UNDER THE FEDERAL
CIVIL FALSE CLAIMS ACT






Qui Tam is also known as
“Whistleblower Act”
Actions can be brought by
individuals even if government
declines prosecution
Suits are filed under seal with the
US Attorney.
Individual filing suit must be
“original source.”
Financial rewards for Qui Tam
plaintiffs can be significant – 25% 30% of proceeds from the action or
settlement.
Disgruntled employees and
competitors frequently Qui Tam
plaintiffs.
12
REPORTING COMPLIANCE
ISSUES
(CODE OF CONDUCT, # 14)
 As a general rule, report to your
supervisor
 As another option you may report
directly to the Compliance Officer,
Cindy Kegg
o In person at the League City office
o Phone / voice mail: 1-888-839-3229
o Interoffice mail (send to GCCLeague City)
o U.S. Mail: 4444 W. Main League
City 77573
o E-mail:
cindyk@gulfcoastcenter.org
o FAX: (281) 338-2460

DO NOT MAKE THE EASY
MISTAKE OF FAXING
TO 388-2460
(this is a CPA Office in Alvin!)
13
ACTION TAKEN IN DETECTED
COMPLIANCE OFFENSES AND OTHER
CONFIRMED CASES OF MISCONDUCT
(INCLUDING ABUSE NEGLECT AND
EXPLOITATION)
Considerations: Seriousness, Circumstances,
Work Record, Length between violations
Possible Actions: Required Training, Written
Reprimand, Probation, Demotion, Reassignment,
Termination, Disclosures as required by Law
 Confirmed Cases of Abuse, Neglect or Exploitation:
 Reported in CANRS
 May be reported to the Employee
Misconduct Registry, effective September 1,
2010. (Senate Bill 806, 81st Legislature)
 Compliance Detected Offenses: May Include a
Corrective Action Plan
 Reassignment may occur during an
investigation
14
RESPONSIBILITIES OF
SUPERVISORS/MANAGERS
(CODE OF CONDUCT, # 3)
Supervisory staff must:
 Promote, adhere to and participate in the
compliance program
 Ensure adherence to and participation in
the compliance program by employees
they are responsible for managing
 Instruct supervised personnel on the
strict adherence to the compliance
program, policies/procedures and legal
requirements as a condition of
employment
 Instruct supervised personnel that the
Center may take disciplinary action up to
and including termination for violations
of the compliance program, policies /
procedures or legal requirements

Supervisors/Managers should be
aware that: They will be held accountable
for failure to detect non-compliance with
applicable policies/procedures/legal
requirements where reasonable diligence
on the part of the supervisor or manager
would have led to the discovery of the
15
BUSINESS CODE OF
CONDUCT
(NOTE BOLDED & UNDERLINED REVISIONS)
1. Statement of Purpose
2. Ethical Standards
3. Leadership
Responsibilities
4. Conflict of
Interest/Outside
Business and Financial
Interests
5. Gifts and Favors
6. Compliance
7. Accounting and
Reporting
16
CONFLICTS OF INTEREST IN
GENERAL
(CODE OF CONDUCT, # 4)
 Staff are obligated to remain free of
conflicts of interest in the performance of
your responsibilities to the Center.
 A conflict of interest may exist if your
outside activities or personal interests
influence or appear to influence your
ability to make objective decisions in you
job responsibilities.
 A conflict may exist if the demands of any
outside activities hinder or distract you
from the performance of your job or cause
you to use Center resources for other than
Center purposes.
 Remember, policy 13.51 Outside
Employment specifically states that nonCenter employment may be granted at the
discretion of the ED and shall be
documented in the employee’s personnel
file prior to the acceptance of such
employment.
17
THE BOARD OF TRUSTEES AND
CENTER EMPLOYEES MAY NOT
HAVE A CONFLICT OF INTEREST
WITH CONTRACTS MANAGEMENT
(CODE OF CONDUCT # 4)
 Employed by Contractor
 Receiving paid consultation by
Contractor
 Received > 10% of your Gross
Income for the previous year
from Contractor
 Are a Member of Contractor’s
Board of Trustees/Directors
 Have Ownership > 10% of
voting stock of shares of the
Contractor
 Have Ownership of > 10% /
$5000 of the Fair Market
Value of the Contractor
18
BUSINESS CODE OF
CONDUCT…CONTINUED
8.
9.
10.
11.
12.
Corporate Resources
Political Activities
Confidentiality
Employee Relations
Customer Focus / Client
Relations
13. Controlled Substances
14. Reporting Misconduct
15. Risk Reporting
19
PROTECTING
CONFIDENTIALITY
(CODE OF CONDUCT, # 10)
You have breached confidentiality if you disclose
information to a third party who is not involved in
furthering care or does not have a legitimate need
to know.
 People included in furthering care are doctors,
nurses, social workers, service coordinators &
others directly involved in the care of the
individual.
 People not included in furthering care are those
in environmental services, personnel, patient
friend’s and family, your friends, and
colleagues not involved in the care of the
individual.
 The Mental Health Code (MHC) does allow the
release of information to law enforcement if
there is a threat of harm to self or others, or to
assist in medical evaluation or treatment.
 If your employment ends, you are still bound to
maintain confidentiality of all records and
information accessed during your employment.
 Information is not given to: family members or
friends without a release, law enforcement who
do not meet the MHC exceptions, legislature, or
20
Center personnel not involved in care.
THE HITECH ACT & BREACH
NOTIFICATION
 The act defines a breach as the “unauthorized acquisition,
access, use or disclosure of protected health information
which compromises the security or privacy of the protected
health info, except where an unauthorized person to whom
such information is disclosed would not reasonably have
been able to retain such information .
 Must notify the consumer/client within 60 days of discovery
of the breach
 Notification shall include: description of what happened,
what info was involved, steps they should take, and steps we
have taken, and contact procedures for if they have
questions.
 If more than 500 people involved …must notify the media
 Requires encryption of data [safetosend]
 Red Flags for Identity Theft:
Appointment scheduling and patient registration: info looks
forged, doesn’t know DOB, physical description does not match
identifying info.
o Delivery of services: records indicate treatment inconsistent
with exam, info in record contradicts what is already known of
client,
o Consumer/client billing and questions : address discrepancies,
consumer disputes bill claiming identity theft, consumer receives
21
a bill for services not received, address change that doesn’t seem
legitimate.
o Inquiries from Third Party: law enforcement, SSA notifies us
the consumer is dead, USPS informs us not an accurate
address, contact from an insurance fraud investigator
o
HIPAA...STAFF ACTIONS
Employees access PHI only to the
degree necessary to perform their
jobs.
 Staff should only have access to PHI
regarding the consumers that they
are working with, not other persons
receiving services
 Any staff persons outside the
interdisciplinary team working with
a consumer probably do not have a
need to know PHI about the
individual
 If you are unsure of who to release
information to, DON’T RELEASE
IT!!! Check with your Supervisor, or
Linda Bell, Director of Legal Affairs.
22
Staff Actions
Employees do not identify a
person directly or indirectly as
a recipient of services.
 When receiving a phone call, fax,
or e-mail, staff should not
confirm or deny that a person
receives services at Gulf Coast
Center.
 Confirming that a consumer is at
the facility would be violating
HIPAA Privacy Rules

23
Staff Actions
Employees have a duty to safeguard PHI
from intentional or unintentional use of
disclosure that is in violation of the
HIPAA Privacy Rule by…
 Keeping records locked up when not in use.
 Users should log off their computers while
away from their desks.
 Computer screens should not be in plain
sight
of public
 Written information in nurse stations, desks,
etc., should be covered from public view.
 Discussions about consumers should be
made
in private, away from public areas.
 Electronic records should be kept secure.
Facilities should monitor who accesses PHI.
 Paper records should be shredded and never
left in the garbage for disposal with
regular trash.
 Do not share your computer password
with anyone. Create a password that is
24
unique and difficult for someone else to
guess.
Do not write it down where someone else
can see it or find it.
Staff Actions
Employees refer requests for PHI,
requests from persons served to
amend records, and related
requests to the appropriate office.
 All requests made by consumers
should be made to Liz Bennett,
Technical Assistant Medical Records
Administration, located at Southern
Brazoria County CSC:
o
o
o
Direct line: (281) 585-7389 or;
SBCSC (979) 848-0933 x11313
Fax: (979) 848-0937 (call to
confirm receipt of fax)
 If you receive a subpoena, court
order, or a request for an affidavit,
notify Liz Bennett immediately.
25
Staff Actions
Employees report or assist others in
reporting suspected privacy rights /
HIPAA violations
 If an employee or consumer wishes to
make a complaint about The Gulf Coast
Center, call or refer them to:
o Cindy Kegg, The Gulf Coast Center’s
Rights Protection Officer/Corporate
Compliance Officer
o TDSHS or TDADS Office of Consumer
Services and Rights Protection
o U.S. Department of Health and
Human Services
o Texas Attorney General’s Office
26
NO HARASSMENT SEXUAL
OR OTHERWISE
(CODE OF CONDUCT , # 11)
 Any form of harassment violates federal, state and
local law
 Harassment could be related to race, creed, color,
sex, sexual orientation, national origin, ancestry,
citizenship status, marital status, pregnancy, age,
medical condition, handicap and/or disability
 Harassment does include offensive remarks or
jokes, other verbal, graphic, physical conduct
and/or threats of physical aggression (note: as part
of our commitment to safety, we have a No
Weapons Policy)
 If you feel a staff, consumer, vendor or supplier is
harassing you, report the harassment
immediately to a supervisor. If the supervisor is
involved or you feel they can not or will not
address the issue, contact the Chief Operations
Officer, HR Director, or Center Attorney.
Regardless of who you report to, the complaint
will be immediately forwarded to the Center
Attorney who will initiate an investigation within
5 business days.
 The Center can only resolve an issue of
harassment if we know about it. Therefore, it is
your responsibility to bring these kinds of
27
problems to our attention so that we can take the
necessary steps
to correct the problem or issue at hand
 If you have any questions as to what constitutes
HARASSMENT IN A
NUTSHELL
(CODE OF CONDUCT # 11)
Simple teasing, off-handed comments, and
isolated incidents of harassment, unless very
serious, will generally not constitute actionable
harassment in a court of law. However, it may
lead to disciplinary action, up to and including
termination depending upon the circumstances of
the situation.
Sexual harassment is actionable under Title VII
only if it is so “severe and persistent” as to alter
the conditions of the person’s employment and
create an abusive working environment
The four elements which will be used to make this
determination are:
 the frequency of the event or action;
 the severity;
 whether the event or action was physically
threatening or intimidating, and
 whether it unreasonably interferes with the job
performance, however this does not include a
28
“mere offensive utterance.”
INTERNAL INVESTIGATION
ETIQUETTE
 Investigations shall only be initiated by the Executive
Director, Legal Affairs Director, HR Manager, or the
Rights and Compliance Officer. EXCEPTION:
Investigations involving Connect Transit and its
services shall be investigated by Asset Management
and/or Facility and Transportation Services staff.
 Investigations shall be initiated due to harassment
allegations, employee misconduct, and/or consumerrelated complaints.
 Unless directed by one of the individuals listed above,
staff do not have the authority to initiate investigations
against fellow staff, contractors, or consumers.
Investigating does include and is not limited to
photographing, monitoring and documenting activity,
reading internal and external mail, and recording
conversations without the other persons knowledge
and consent. Staff involved in unauthorized
investigative tactics will be subject to disciplinary
action up to and including termination.
 During an investigation, staff must never conceal, destroy
or
alter documents; lie; or make misleading statements to
authorized Center staff conducting the investigation. Staff
who violate this requirement shall be terminated. Full 29
cooperation is required and includes providing
complete
timely and thorough information promptly.
CONSUMER / CLIENT
RELATIONS
(CODE OF CONDUCT # 12)
 All consumers/clients deserve to
be treated with respect and
dignity and have the right to be
involved in their care. Dignity
and respect include the
elimination of prejudicial
language
 It is the responsibility of each
employee to ensure that the
rights of clients are protected.
 Each employee must familiarize
themselves with rights set forth
in policy, procedures and in the
rights protection handbook.
30
FORBIDDEN CONSUMER EMPLOYEE RELATIONSHIPS
(CODE OF CONDUCT # 12)
Dating
Implied Sexual and Sexual in Nature
Contacts (i.e., physical act, telephonic and
electronic)
No Living Arrangement Agreements
No loans or storing/holding of Consumer
Funds/Money
Staff may accept no monetary gifts. Policy
does allow acceptance of gifts of <$50.00.
Recovery programs can not accepts gifts,
monetary or otherwise
Consumers can not do chores (i.e. picking up
trash or cleaning restrooms) for cigarettes or
other privileges; this is a violation of the
Department of Labor
Caution: Telephone communications should
be limited to Center Business due to
misinterpretations of others.
Caution: If a consumer/client has a business
and you would like to bid for his services or
have him do some work for you do realize that
there may be some ramifications for such
action. The relationship may appear to have 31
some form
of exploitation.
Caution: Avoid the appearance of
PREVENTING ABUSE,
NEGLECT AND
EXPLOITATION
Learn your Job
Understand expectations
and focus on doing your job well.
 Communication
Don’t take your anger or
frustration out on persons served or their
families. Do your part to help foster
positive relationships with co-workers and
keep morale high.
 Stress Management
Manage your stress
levels.
 Personal Problem Management
Leave
personal problems outside of the workplace.
If you are having difficulty with this, speak
to your supervisor. Seek help if you need
it!
32
RECOGNIZING SIGNS /
SYMPTOMS OF POSSIBLE
ABUSE
(CODE OF CONDUCT # 12)
 Multiple scratches, cuts, bruises,
burns
 Unusual patterns of injuries
 Inadequate or illogical explanation
of injury
 Serious injuries: sprains, breaks,
bedsores


Reports of confinement

Passive, withdrawn behavior with
certain people
Reluctance to participate in physical
exams
33
RECOGNIZING SIGNS /
SYMPTOMS OF
POSSIBLE NEGLECT
(CODE OF CONDUCT # 12)
 Lack of food or malnourishment
 Lack of water or dehydration
 Withholding
meds/overmedicating
 Inadequate shelter
 Unsanitary living conditions
 Untreated health problems
 Lack of personal
hygiene / clothes
34
EXAMPLES OF
EXPLOITATION
(CODE OF CONDUCT # 12)
 Taking, holding, borrowing
money
 Taking Social Security /SSI
checks
 Taking property
 Exchanging items of unequal
value
 Requesting items to be
purchased for staff
 Using consumers as free labor
35
REPORTING ALLEGATIONS
OF SUSPECTED ABUSE,
NEGLECT OR
EXPLOITATION
 ALL staff have the responsibility to
report.
 Immediately (within 1 hour) make a
report to DFPS via the reporting
website:
o www.txabusehotline.org or;
o call
1-800-647-7418
 Complete an Incident Report within 24
hours and fax to RPO if the alleged
perpetrator is a Center staff or
contract staff
 Employees and Consumers are
protected from retaliation when
reporting.
36
SUBSTANCE USE RECOVERY SERVICES
REPORTING ALLEGATIONS OF
SUSPECTED ABUSE, NEGLECT OR
EXPLOITATION
WHEN
THE
ALLEGED PERPETRATOR
IS A
CENTER STAFF OR CONTRACT STAFF
 All staff have responsibility to report.
 Immediately (within 1 hour) make a
report to: Rights Officer at 1-888-839-3229
 Complete an Incident Report within 24
hours and fax to Rights Protection Officer
 Employees and Consumers are protected
from retaliation when reporting.
 Department of State Health Service
notified within 24 hrs
 Investigative Report submitted to DSHS
upon completion
 DSHS may accept findings or reinvestigate


If the client also has a Mental Health ,
diagnosis follow guidelines for reporting to
37
DFPS on previous slide
If the AP is not a Center staff or contract
staff, report to proper authorities
REPORTING…CONTINUED
DO NOT notify the alleged
perpetrator of the impending
investigation.
DO NOT conduct a miniinvestigation.
DO NOT discuss incident with
others (with the possible
exception of your supervisor).
 DO preserve the safety of the
person and arrange for
emotional support or medical
care as appropriate
 DO protect any evidence (i.e..
ake pictures, secure the record,
etc.)
 DO cooperate with DFPS
investigators
38
WHEN YOU MAY NOT
RELEASE INFORMATION ON
A CENTER CLIENT
The “Interpretive Guidance on Laws
Pertaining to Privacy of Mental Health
and Mental Retardation Records for the
MHMR Service Delivery System” pursuant
to the TAC Protected Health Information,
Chapter 414, Subchapter A, states:
§When Authorization is not Required to
Use or Disclose Protected Health
Information that Relates to MHMR
Services
(b) When required or authorized by law
(3) A component may disclose PHI to
the Department of Family and Protective
Services) when necessary to report or
cooperate in the investigation of suspected
child abuse or neglect.
However, the PHI of a parent
or other person responsible for the
care of the child who is the subject 39
of the report or investigation may
only be disclosed pursuant to a
court order.
What Happens When a
DFPS Investigation
Occurs?
DFPS receives a report (website or
1-800 number)
Notifies RPO
RPO notifies
ED, Review
Committee,
Supervisor
Request
for Review
forwarded
to
Assistant
Commissioner of
APS
APS initiates an investigation
APS mails completed
investigative report to RPO upon
completion
Copy of report given to ED, Review
Committee and (if confirmed), to staff;
Case reviewed
Agree
with
finding
s
Disagree
with
findings
40
Case
Closed
REPORTING DEATHS
 Immediately report known information
to the RPO & treatment team
(email or phone)
 Complete an incident report within 24
hours and submit to the RPO via fax or
electronically
 If hand written, put original in Center mail
to
the RPO (in League City) after
notification
 In some cases, staff may be requested to
assist the RPO in obtaining information
regarding cause & manner of death (e.g. no
autopsy is conducted, family agrees to send
findings/death certificate to staff)
 Upon death, authorization for release of the
record can be legally given by the 1) personal
representative, 2) parent, 3) adult children or
4) spouse. This does not apply to other
relatives, including siblings. (Please follow
procedures for release of medical records).
41

The death of a former service recipient
should also be reported to the RPO upon discovery
INCIDENT
REPORTS…WHEN TO
REPORT
(CODE OF CONDUCT #15)
• Actual or suspected
abuse, neglect or
exploitation /other
rights violations
when a staff person
is the alleged
perpetrator
• Vehicle Accidents &
Injuries(client or
staff) Report
immediately to
• James Rollens III
• at 713-545-7595
• Violent behavior
• (client or staff)
• Threats or acts of
aggression (client
or staff)
• Destruction /loss
•
of property (client
or staff)
• Illegal behavior
(client or staff)
 Medical emergencies
 Psychiatric
emergencies
 Serious infraction of
program rules (client
or staff)
 Loss of consumer
record
 Use of personal
restraint
(if not part of
approved Behavior
Plan)
 Missing consumer
 Death of consumer
 Fire
 Violations of the
42
Business Code of
Conduct, as
appropriate.
 EMAILS W PHI
INCIDENT REPORTS
…PROCEDURES
 The following reports 
must be submitted to 
the RPO within 24

hours:
1) abuse/ neglect/
exploitation/ other
rights
issues (when staff is
the
alleged perpetrator)
2) deaths (active
clients)
3) incidents involving
workman’s comp (also
fax to Ricki at
Admin!)
All other reports must
be submitted to the
RPO within 48 hours
Write legibly
Fill in all appropriate
blanks
Include your
response /
follow-up to incident
then…

1) Fax to RPO in League
City: 281-338-2460 /
Send original to
RPO
immediately, or
2) Submit electronically

REMEMBER, 43
Do not keep a
copy or put a copy
In order to get credit
for this training you
must:
Sign In
&
Sign & Turn in the
Employee
Affirmation
44