Compliance Policy and Procedure Development

Effective compliance programs include having written standards of conduct. Southern Illinois Healthcare’s written standards of conduct are contained in the following documents:

• Corporate Compliance Program
• Policies (Compliance Department and other departments)
• Code of Ethics

This Corporate Compliance Program sets out the general principles governing the Program. However, an effective Corporate Compliance Program requires detailed standards, policies, and procedures designed to reduce unethical or noncompliant behavior. The Corporate Compliance Officer is responsible for developing and maintaining detailed policies and procedures that govern the operations of the Corporate Compliance Program. Appropriate managers within SIH are responsible for reviewing and revising current policies and creating new policies to address compliance issues that affect their respective departments.

Southern Illinois Healthcare’s Code of Ethics provides guidance to employees in carrying out their daily activities within appropriate ethical and legal standards. Following the Code of Ethics is one means by which compliance will be achieved.

Corporate Compliance Officer and Corporate Compliance Committee

Effective compliance programs include the designation of a Corporate Compliance Officer and a Corporate Compliance Committee to oversee the operations of the Corporate Compliance Program. Southern Illinois Healthcare has created the position of Corporate Compliance Officer and has also designated a Corporate Compliance Committee. The Corporate Compliance Officer is responsible for the development, implementation, and management of the Corporate Compliance Program for all SIH facilities. To increase the effectiveness and integrity of the Program, the Corporate Compliance Officer shall have the cooperation of and access to all members of the organization. The SIH Board of Trustees and senior management shall provide the Corporate Compliance Officer with appropriate resources to effectively manage and satisfy the elements of the Program. Also, the Corporate Compliance Officer shall have the authority to inquire into any matters arising or appearing to arise within the scope of the Corporate Compliance Program.

The Compliance Officer may appoint such staff as are necessary to assist in the performance of his/her responsibilities. Any members of the Corporate Compliance Department will be treated as the Corporate Compliance Officer for purposes of cooperation with his/her efforts to perform Corporate Compliance Program functions.

General Counsel directs the Corporate Compliance Officer in managing the Corporate Compliance Program and reports directly to the Board of Trustees on Corporate Compliance Program matters. In the event that fraudulent or abusive practices are discovered through compliance investigations or otherwise, General Counsel shall have the authority to terminate the operation of any department or function within SIH in order to prevent further harm or damage to government programs, commercial payors, other external entities, and/or SIH.

The Corporate Compliance Committee has been established to advise the Corporate Compliance Officer and assist in the implementation of the Compliance Program. The Committee reviews and evaluates compliance activities and reports to and consults with the Board of Trustees and its appropriate committees, as necessary. The Corporate Compliance Committee shall consist of at least two members of the Board of Trustees, the President/Chief Executive Officer, the Senior Vice President/Chief Financial Officer, the Vice President/General Counsel, the Corporate Compliance Officer, and such other members as the Board of Trustees deems appropriate. The Corporate Compliance Officer shall chair the Corporate Compliance Committee. The Corporate Compliance Committee shall meet at least quarterly, but any member of the Committee may call a special meeting.

Each facility within SIH shall have a designated facility compliance committee. The facility compliance committee is selected by the facility Administrator. The facility compliance committee advises the Corporate Compliance Officer, receives reports of compliance activities within the facility, and assists in the implementation and management of the Corporate Compliance Program at the respective facility. The facility compliance committees shall meet no less often than quarterly.

Compliance Training

Proper education and training is a significant element of the Corporate Compliance Program. It is important that all members of SIH’s workforce are knowledgeable about the Corporate Compliance Program. All new members of the organization’s workforce will receive orientation to the Corporate Compliance Program within the first 30 days of employment or assignment to SIH in order to understand his or her role in compliance. Annually thereafter, all employees will receive refresher training in compliance. The Corporate Compliance Officer retains documentation for all workforce members who complete compliance training. In addition, managers and employees working in areas at high-risk for compliance violations will receive additional education and training as necessary.

Open Lines of Communication

Open lines of communication are essential to an effective corporate compliance program. Southern Illinois Healthcare has established a Compliance Helpline that provides a venue for confidentially reporting compliance violations. The Compliance Helpline should be used as a means of reporting noncompliant activity. It is SIH’s policy that employees may use this Helpline without fear of retaliation. This non-retaliation policy applies to the reporting of any compliance violation, regardless of whether it is reported through the Helpline. In addition, all reports made to the Helpline will be held confidential to the extent practical. The following numbers are available to reach the Compliance Helpline:

Toll free: 1-800-965-4583 Local: 618-529-2540

These numbers are available for use at any time for employees and others to ask compliance related questions or report actual or potential noncompliant activities. The Helpline is staffed weekdays from 8:00 a.m. to 4:30 p.m. After 4:30 p.m., confidential voice mail is available. The Corporate Compliance Officer or other designated individual will investigate all reports made to the Compliance Helpline in a prompt and reasonable manner.

Enforcement of the Program

An effective compliance program requires enforcement. Willfully violating SIH’s Corporate Compliance Program will result in disciplinary action, which will be appropriate for the severity of the activity. Fraudulent and other illegal activities will not be tolerated and will result in immediate termination. Employees are expected to adhere to the Corporate Compliance Program as a condition of their employment at SIH. Failure to do so will result in disciplinary action. Sanctions could range from oral warnings to suspension, privilege revocation (subject to applicable peer review procedures), and termination.

Auditing and Monitoring

Periodic audits will be undertaken in order to identify deficiencies in SIH operations, particularly with regard to the claim development and submission process. The Corporate Compliance Officer shall establish appropriate procedures for conducting such audits and utilize a risk assessment process to identify and prioritize the areas that pose the greatest risks for compliance violations. The Corporate Compliance Officer shall develop an annual audit work plan that lists the risk areas to be audited and monitored for each fiscal year. The Corporate Compliance Officer and auditors or reviewers acting on behalf of the Corporate Compliance Officer shall have access to all documents necessary to perform corporate compliance functions, including those related to claim development and submission, business records, cost reports, patient records, pricing and cost data, employee records, schedules, e-mail, and the contents of computers.

Corrective Action

Not only does an effective compliance program include methods for identifying compliance violations such as the Helpline and auditing and monitoring, an effective program includes methods for responding to and correcting such violations. After a violation has been detected and confirmed, the Corporate Compliance Officer shall institute steps to prevent the reoccurrence of the violation and make any necessary modifications to SIH policy. Southern Illinois Healthcare will take appropriate corrective action, including prompt and proper restitution of any overpayment to the affected payor and the disposition of proper disciplinary action. When appropriate, corrective action may include reporting suspected violations to appropriate government agencies. Such reports shall only be made after consultation with SIH’s General Counsel and upon the approval of the President/Chief Executive Officer.