Integrity & Compliance Officer Trinity Senior Living Communities Livonia, Michigan Position Specification July 2016 TradeCenter, Suite 5900, Woburn, MA 01801 781-938-1975 www.zurickdavis.com
Summary Trinity Senior Living Communities (TSLC) is seeking an Integrity and Compliance Officer. Reporting directly to the Chief Executive Officer of TSLC with dual accountability to the Trinity Health System Chief Integrity & Compliance Officer, the new Integrity and Compliance Officer will be responsible for the leadership and operations of the Integrity & Compliance Program across all TSLC which span Michigan, Illinois, Ohio, Indiana, Iowa and Maryland. The Opportunity The Integrity & Compliance Officer is the face of the Integrity & Compliance Program in the Ministry. S/he is widely recognized in the organization for high ethical standards, and for their understanding and embodiment of the Mission. The Integrity & Compliance Officer is a demonstrated problem solver and effective communicator, with an ability to address complex situations in collaboration with others. The Integrity & Compliance Officer acts with an appropriate sense of urgency, and builds essential relationships while tirelessly promoting the objectives of the Integrity & Compliance Program. The TSLC Integrity & Compliance Officer works with other members of the TSLC leadership team to ensure the Integrity & Compliance Program is effectively implemented and operating in the senior living communities owned and/or operated by TSLC in accordance with TSLC and Trinity Health policies and program standards. The TSLC Integrity & Compliance Officer is responsible for promoting the principles and objectives of the Integrity & Compliance Program to TSLC colleagues, management, governance and business partners. The Organization Trinity Senior Living Communities (TSLC) is a National Health Ministry of Trinity Health. TSLC owns and operates 46 senior living communities that includes independent and assisting living apartments, HUD apartments, memory care, skilled nursing, rehabilitation and wellness and continuing care retirement communities. TSLC employs approximately 6,000 colleagues and has communities in 10 states with 6,600 beds and total operating revenues of approximately $370 million. Trinity Health is one of the largest multi-institutional Catholic health care delivery systems in the nation. It serves people and communities in 21 states from coast to coast with 90 hospitals, and 120 continuing care locations - including home care, hospice, PACE and senior living facilities - that provide nearly 2.1 million visits annually. With annual operating revenues of about $15.9 billion and assets of about $20.4 billion, Trinity Health returns about $1 billion to its communities annually in the form of charity care and other community benefit programs. The Integrity & Compliance Program is Trinity Health's system-wide ethics and compliance program. The Integrity & Compliance Program demonstrates Trinity Health's commitment to ensuring its operations are conducted in a manner consistent with the Mission and Core Values, in accordance with the highest standards of ethical and professional behavior, and in compliance with all laws and regulations that apply to our health care ministry. This position oversees Integrity and Compliance for approximately 55 senior living sanctuaries across six states. For more information, please visit www.trinityseniorsanctuary.org. 2
The Position Scope of the Integrity and Compliance Officer Position: 1. Leads the Integrity & Compliance Program for TSLC's senior living communities providing long-term care, skilled nursing, rehabilitative and memory care, independent and assisted living, and other services in accordance with policies and program standards of TSLC and Trinity Health. 2. Chairs the TSLC Integrity & Compliance Committee established to support the operations of TSLC s Integrity & Compliance Program. Ensures the Integrity & Compliance Committee meets regularly with appropriate representation and participation of TSLC management. 3. Plans and implements the delivery of TSLC's Integrity & Compliance Program and supporting resources in a shared services model, aligned with resources and support provided through Trinity Health's system-wide Integrity and Compliance Program. 4. Responsible for Code of Conduct distribution and compliance training programs for TSLC colleagues, including annual and periodic training programs responsive to compliance/legal/regulatory risks impacting TSLC operations. 5. Works in partnership with TSLC leadership to ensure TSLC develops and maintains policies and procedures addressing key areas of legal, regulatory or other compliance risks impacting TSLC operations. 6. Promotes continuous awareness and understanding of the Integrity & Compliance Program, the Code of Conduct, and TSLC and Trinity Health's commitment to follow all laws and regulations through ongoing communication and awareness activities within TSLC operating locations. 7. Ensures the timely investigation and effective follow-up on issues reported through the Trinity Health Integrity & Compliance Line or through other means, including reports of potential violations of laws, regulations, TSLC/Trinity Health policies in coordination with TSLC leadership and Trinity Health resources, as appropriate. 8. Leads the performance of periodic risk assessments to identify and assess potential areas of legal, regulatory and business ethics risks impacting TSLC operations. 9. Works with TSLC leadership and Trinity Health's Integrity & Audit Services department to establish auditing and monitoring programs for TSLC operations designed to continuously assess compliance with applicable laws, regulations, and TSLC policies. 10. Establish processes to oversee and monitor corrective actions taken in response to compliance matters identified through internal and external audits, regulatory investigations and internal monitoring activities. 11. Ensures TSLC has established policies and systems for the performance of effective colleague and medical staff background checks, sanctions screening and screening for eligibility to participate in federal and state health care programs in coordination with Trinity Health. 12. Coordinates with TSLC human resources to ensure appropriate integration of the Integrity & Compliance Program with TSLC's performance management processes. 13. Ensures TSLC leaders are kept up-to-date concerning significant activities of the Integrity & Compliance Program, including the status of investigations, significant findings from auditing and monitoring activities, and other issues requiring senior management attention and support for corrective actions. 14. Ensures TSLC has established an effective privacy program as required by Health Insurance Portability and Accountability Act (HIPPA) regulations. Coordinates privacy 3
program activities with the designated Regional Security Official supporting TSLC. 15. Provide periodic reports to the Continuing Care Group Board of Directors (or delegated committee of the board) on the operations of TSLC Integrity & Compliance Program, including the status of any significant legal, regulatory or other compliance matters. 16. Promptly notify TSLC s general counsel and the Trinity Health System Integrity & Compliance Officer and General Counsel s Office of significant legal and regulatory matters impacting TSLC. 17. Works with TSLC legal counsel to ensure effective conflicts of interest policies and processes for governance and senior management have been established. 18. Serves as a member of the Trinity Health Integrity & Compliance Officer Council providing input and feedback on the design, operation and ongoing effectiveness or Trinity Health s Integrity & Compliance Program. The Candidate The candidate for this position will be a mission driven leader, committed to working within a values based, patient centric organization. Bringing 10 years of relevant experience to the role, working in a large multi-site organization, and with experience operating in a leadership role, the ideal candidate will be Masters Prepared. The background of the selected candidate is somewhat fluid and may include: clinical, finance, compliance, consulting or legal experience (JD). That said, the ideal candidate will be an RN/JD and have experience working within a regulatory environment within the senior care sector. From a skills and presentation perspective, the candidate must possess outstanding communication skills and be comfortable presenting at the senior leadership level. S/he will have experience addressing regulatory compliance issues involving long-term care, skilled nursing and rehabilitation services. This includes understanding all laws and regulations pertaining to participation in the Medicare and Medicaid programs. Other personal attributes include: The poise and sophistication to operate in a system-wide role and promote the important mission and activities of TSLC, especially in regard to all regulatory and compliance issues. Being part of a high performing, collaborative team whose shared mission is the provision of a higher level of care. The ability to support and partner with senior management, physician leadership, and peer groups to drive the continued development of an effective and robust integrity program. Possessing the personal charisma to motivate and inspire others into action and bringing a can do proactive approach to the arena of compliance. A comprehensive understanding of the changing landscape as it relates to healthcare delivery, including new payment models such as accountable care organizations and bundled payment programs and their impact, from a compliance perspective on the senior living sector within Trinity Health. A high level of Emotional Intelligence. Being highly skilled at building relationships and gaining buy in through engagement, listening, and possessing a transparent communication style. 4
The ability to foster an atmosphere of respect, trust, and aligned commitment to organizational goals consistent with the Mission and Core Values of Trinity Health. The ability to be persuasive, yet diplomatic with the skillset to work with disparate parties in reaching consensus. Being a skilled facilitator who understands the nuances of serving many masters in a system environment. Critical Success Factors The Integrity and Compliance Officer will: Demonstrate his or her abilities as a relationship person and have the ability to build sustainable relationships across the organization and at all levels. S/he will be comfortable working as part of a team and within a culture that is humble and respectful, but also possess the self-confidence to work alongside a diverse group of people and personalities to drive a successful compliance program. Demonstrate a strong working knowledge of the health care industry regulatory environment, particularly laws and regulations pertaining to participation in the Medicare and Medicaid programs, fraud and abuse laws, and regulatory compliance program operations. Build upon the existing Integrity and Compliance Program already in place and develop streamlined policies, procedures and reporting relationships across the individual ministries and leverage the system compliance program to meet the objectives of TSLC. Manage the day-to-day, nuts and bolts of Integrity and Compliance and ensure that all operations are running consistently, efficiently and effectively across all provider sites. Compensation A compensation package will be constructed commensurate with the background and experience of the selected candidate and includes a comprehensive benefits program. Most significant is the opportunity to assume a key leadership role within a highly reputable organization renowned for its delivery of high quality patient care and its compassionate approach to treating the patient in a holistic manner, one that is consistent with Trinity ministry philosophy and values. For More Information We appreciate all referrals. Interested parties please send resume and cover letter to TSLCICO2177@ZurickDavis.com. For additional questions, please contact Fernando Limbo or Annette Cooke at 781.938.1975. All contact with ZurickDavis will remain confidential. Trinity Health Senior Living Communities is an Equal Opportunity Employer 5