1. Corporate Compliance Training

2. Purpose of P&S Corporate Compliance
To have an effective compliance and ethics program:
• To exercise due diligence to prevent and detect wrong-doing
• Promote an organizational culture that encourages ethical
conduct and a commitment to compliance with the law.
• Raise awareness
• Positive impact to corporate reputation/culture
• Provide a “safe” mechanism(s) for reporting and seeking help

3. Objectives of P&S Corporate Compliance
To meet the objectives of the 7 elements of a corporate
compliance program as out line by the (FSG) Federal
Sentencing Guidelines:
• Review Written Policies & Procedures
• Select Compliance Officer & Committee
• Training & Education
• Effective Lines of Communication
• Discipline & Background Checks
• Auditing and Monitoring
• Responding & Corrective Action

4. Written Policies & Procedures
• Develop and implement policies, procedures, and
practices designed to ensure compliance with state &
federal regulations and programs.
• P & S adheres to the requirements set forth in policy &
Code of Conduct by federal and state regulations
(e.g., licensure, Medicare/Medicaid requirements, HIPAA/HITECH requirements, etc.).

5. P & S Code of Conduct:
• Deter, Detect, Correct & Prevent Misconduct
• P&S Surgical Hospital strives to provide the
highest quality procedural care in a patient focused
environment. P & S Surgical Hospital is committed
to our core values of:
• Service
• Respect
• Compassionate Care
• Friendliness
• Stewardship

6. P & S Code of Conduct:
• The Code of Conduct provide standards by which all members of
the organization will conduct themselves.
• Individuals conduct must be in a manner that protects and promotes
organizational-wide integrity and enhances P & S Surgical Hospitals’
ability to achieve its objectives and mission.
• This applies to all employees, officers, administrators, board
members, medical staff, vendors, contracted employees,
consultants, students, and volunteers.
• Staff members must certify annually that they have received,
read, understand, and agree to abide by Code of Conduct.

7. Compliance Officer & Committee
• Continue to design, implement, oversee, and monitor the compliance
program
• Report on a regular basis to the CEO, compliance committee, and when
necessary to the governing body.
• Develop, coordinate, and participate in a multifaceted educational &
training program.
• Ensure that independent contractors and agents are aware of the
organization’s compliance program requirements.
• Assist with internal compliance review and monitoring activities.

8. Training & Education
• Communication process to report any compliance issues or concerns
• New Hire Initial Orientation
• Code of Conduct Training – Annually
• 7 Elements of an Effective Compliance Program – Annually
• Conflict of Interest Statements – Annually
• Safe guarding PHI/ePHI
• It is every employee’s responsibility to report suspected
violations of the laws, regulations and policies, or other
questionable conduct.

9. Effective Lines of Communication
Reporting Compliance Issues or Concerns:
1. Your manager
2. Executive Team Member
3. Director of Human Resource
Chenire Craig- 998-7307
4. Compliance Officer
Compliance “Anonymous” Hotline - 1-866-570-2523

10. Effective Lines of Communication
• Dirk Rhodes, Corporate Compliance Dept.
• Phone: (318) - 998-6135
• Contact via E-mail: DirkRhodes@pssurgery.com
• P&S Corporate “Hotline” ComplianceLine:
1-866-570-2523
• 100% anonymous; Available 24 hours a day/ 7 days a week
• There will be no retaliation for reporting concerns in good faith,
but appropriate disciplinary action will be taken against those
who commit misconduct.
• All reported allegations will have to be verified before any
actions are taken place.

11. Discipline / Background Checks
• All employees undergo a background check/ drug screening upon
initial hiring.
• A monthly SanctionCheck is preformed on all employees, medical
staff, and vendors to show that P&S is compliant with federal &
state regulations and programs that we participate in.
• Annually employee(s) should receive a copy of the Sanction Policy
that supports the Code of Conduct and outlines the disciplinary
actions chain in the event of misconduct.

12. Auditing & Monitoring
• Unethical or inappropriate care • MCR inpatient one day
of patients stays
• Lack of correct and sufficient • Conflict on Interest
documentation in admitting / /Inappropriate vendor
discharging patients relationships
• Medical Necessity • Inappropriate access
and/or release of (PHI)
• Billing for services or supplies
that were not provided • Bribes or kickbacks
• Altering claims for higher • Business Associate
payment Agreements (BAA)
• 2 Annual (External) • Physician Ownership
Billing/Coding Audits Disclosure

13. Responding & Corrective Action
• The Compliance Department reviews all allegations in a serious matter and take the
necessary steps to deter, detect, correct, & prevent any wrong-doing or misconduct.
• All reported allegations will have to be verified before any actions are taken place.
• All allegations, audits (internal & external), and monitoring is reported directly to
the CEO/ Compliance Committee/Board as necessary.
• All allegations, audits (internal & external), and monitoring tools are responded back
to in the allotted time frame per the institution.
• In regards to the P & S “Hotline” ComplianceLine
• ≤ 72 hours to respond to any issue or concern (Severity I to III)
• May take longer considering certain factors and seeking P&S Legal Counsel for
review
We want to provide a safe patient centered environment for
Patients & Employees!!

14. Quick Facts
• All employees are held responsible and accountable for compliance
and can be charged with fraud
• The corporate compliance committee investigates every complaint
of noncompliance
• There will be no retaliation for reporting concerns in good faith, but
appropriate disciplinary action will taken against those who commit
misconduct
• Prohibits asking for or receiving anything of value to induce or
reward referrals of Federal health care program business

15. Examples of Compliance Issues
• Never read another employee’s confidential records without permission
• Never use another person’s password to access confidential information
• Only discuss a patient’s condition with those involved in the patient’s
care
• Never treat or act differently to someone because they identified a
compliance or ethical issue
• Accepting gifts from vendors, providers, or third parties are prohibited
as outlined in the conflict of interest policy at P&S. All gifts (>$10.00 per
person per transaction) need prior administration approval before accepting.
• Only bill for visits, procedures and/or tests performed
• Always provide complete documentation for ALL services performed

16. Case Study
(Example)
I am a nursing assistant on one of the patient care floors. Recently,
while cleaning a bathroom, a housekeeper, Sam, was stuck by a
needle that had been mislaid in the bathroom. Sam was concerned
about whether the patient was HIV positive, so he called his friend,
Rose, a technician in the lab, and asked her to check and see whether
there had been an HIV test performed on the patient whose
bathroom he has been cleaning. Rose did check and told him that a
recent HIV test was negative.

17. Q&A
1. What's wrong with this picture?
 Patient Confidentiality
 Infection Control
2. Which Facility policies does this relate to?
 Guidelines for the Prevention of Transmission of Blood-borne Pathogens in the Workplace
 Employee Incident/Accident
 Code of Conduct
3. What are some choices for how you can handle this?
 Wash the site
 Report to a nurse supervisor about the needle stick
 Fill out an occurrence report to the nurse supervisor/infection control officer
 See the infection control officer for testing and further instuctions
4. Who can help if you are unsure about what to do?
 Infection Control Officer
 Director of Nursing/Supervisor
 Executive Team Member
 Compliance Officer/Hotline
 Human Resources

18. Remember!
DO THE RIGHT THING:
• When you become aware of or observe something you
believe to be improper, report it.
• Keep yourself trained and informed.
• No retaliation for reporting in good faith!
No Pointing Fingers!!