Issued by: Executive Compliance Committee Prepared By: Chief Ethics & Compliance Officer Approved By: Board

Transcription

1 Compliance Officer Vendor-Promotional Training and Business Associate- BACKGROUND The Office of Inspector General (OIG) has issued guidance regarding the development and implementation of compliance programs for healthcare organizations. The guidance sets forth the OIG s suggestions as to how an organization can best establish internal controls and monitoring to both correct and prevent fraudulent activities. At a minimum, comprehensive compliance programs should include the following: the development and distribution of written standards of conduct, as well as written policies and procedures that promote the organization's commitment to compliance and that address specific areas of potential fraud; the designation of a chief compliance officer and other appropriate bodies, e.g., a corporate compliance committee, charged with the responsibility of operating and monitoring the compliance program, and who report directly to the CEO and the governing body; the development and implementation of regular, effective education and training programs for all affected employees; the maintenance of a process, such as a hotline, to receive complaints, and the adoption of procedures to protect the anonymity of complainants and to protect whistleblowers from retaliation; the development of a system to respond to allegations of improper/illegal activities and the enforcement of appropriate disciplinary action against employees who have violated internal compliance policies, applicable statutes, regulations or Federal healthcare program requirements; the use of audits and/or other evaluation techniques to monitor compliance and assist in the reduction of identified problem areas; and the investigation and remediation of identified systemic problems and the development of policies addressing the non-employment or retention of sanctioned individuals. SCOPE All Company-affiliated facilities and operations including, but not limited to, hospitals, ambulatory surgery centers and imaging centers, dialysis centers, cancer centers, sleep disorder centers, home health agencies, retirement living centers, skilled nursing facilities, psychiatric facilities, physician clinics, laboratories, retail pharmacies, medical office buildings and all Company corporate departments. Page 1 of 5

2 RESPONSIBLE PARTIES Facility Ethics and (ECO) Chief Ethics and (CECO) PURPOSE To establish the parameters surrounding acceptance of vendor-promotional training and business associate-sponsored seminars. POLICY 1. Vendor-Promotional Training is defined as training or education provided by any person or entity for the purpose of promoting its products or services. a. It includes travel paid by a vendor for employees to observe the vendor s product in a setting where the product is already installed or otherwise designed to showcase the product(s). b. It does not include training provided under a contract with the Company or by a contractor to facilitate use of products or services it furnishes under an existing contract with the Company. c. Vendor-promotional training, including travel and lodging, may be accepted free of charge when the business value to the Company outweighs any recreational or entertainment value of the training event, provided that the appropriate approvals are obtained in advance. 2. Business Associate- refers to seminars, conferences, user review group meetings or other educational sessions sponsored and hosted directly by a business associate (i.e., someone doing or seeking to do business with Company or a Page 2 of 5

3 Company-affiliated entity), providing that the appropriate approvals are obtained in advance, invitations to attend business associate-sponsored seminars, which may include free or reduced registration fees, travel, lodging and meals, may be accepted only when: a. the event is not limited to member participants (e.g., individuals from various companies and organizations have been invited to attend the event); b. no fee is charged to any invitee or, if a fee is charged for some portion of the event or a reduction given, the same fee is charged or same reduction is given to each invitee; and c. the value to the Company outweighs any recreational or entertainment value of the educational event. PROCEDURE An employee, other than a Corporate employee, who receives an invitation to attend Vendor- Promotional Training or a Business Associate-Sponsored Seminar, which may include travel, lodging or modest entertainment expenses must obtain the approval of his/her supervisor and the ECO before accepting the invitation. A Corporate employee must obtain the approval of the CECO prior to accepting such an invitation. 1. Prior to accepting an invitation to attend Vendor-Promotional Training or a Business Associate-Sponsored Seminar, the employee must submit the Form for Reporting Expenses Associated with Vendor-Promotional Training or a Business Associate- Sponsored Seminar, a copy of which is attached hereto. The employee must also provide any relevant supporting information (a course description and/or the letter of invitation, expenses to be paid, purpose of trip and all employees attending, including any employee s spouse). Upon completing the form, the employee, excluding Corporate employees, should submit the form and supporting documentation to his/her supervisor and the ECO. A Corporate Employee should submit the form and supporting documentation to the CECO. Page 3 of 5

4 2. The supervisor and ECO or CECO will assess the situation, including making a calculation as to the amount of time to be spent on substantive matters as compared to the amount of time spent in recreational or entertainment activities. The amount of time engaged in substantive matters must predominate in order for acceptance to be permitted. 3. If the supervisor and ECO determine that attendance does benefit the Company and is preferred despite the entertainment portion predominating over substantive, the ECO will request the advance written approval of the CECO. 4. If attendance at a Vendor-Promotional Training event or Business Associate-Sponsored Seminar involves travel outside the continental United States or lodging in excess of two nights, the employee must also receive approval from the CECO prior to accepting the invitation. REFERENCES Code of Conduct Page 4 of 5

5 Form for Reporting Expenses Associated with Vendor-Promotional Training or a Business Associate-Sponsored Seminar An employee, other than a Corporate employee, who receives an invitation to attend Vendor- Promotional Training or a Business Associate-Sponsored Seminar, which may include travel, lodging or modest entertainment expenses should complete and submit this form prior to accepting the invitation. A non-corporate employee should submit the completed form to his/her supervisor and the ECO. A Corporate employee should submit the completed form to the CECO. Please attach any additional supporting documentation along with an agenda, if applicable. Vendor/Business Associate Name: Event: Location: Date of Event: Business Purpose: How will the event benefit the Company or Facility? What percentage of the time will be spent on substantive matters (e.g. training, seminars)? Will a spouse or guest attend? Certification I hereby certify that this accurately and completely describes, to the best of my knowledge, all relevant details regarding the vendor-promotional training or business associate-sponsored seminar, which are required to be reported under the Vendor-Promotional Training and Business Associate-Sponsored Seminar Policy. Signature of Employee Typed/Printed Name of Employee Supervisor (if applicable) Reviewed by Title ECO/CECO Reviewed by Title Page 5 of 5