It is Zandex’s policy to conduct all of its business and other practices in compliance with all applicable laws and regulations, and to act with Integrity, Respect andCompassion in all of our business dealings. Zandex, and its employees, volunteers, and Board of Directors have a reputation in the community of operating in an honest manner; and offering both respect and compassion to those we serve. Zandex will protect this reputation and integrity through the enforcement of its policies and procedures.
The purposes of the Zandex Corporate Compliance Program are to:
1. describe the policies of Zandex with respect to certain legal and ethical conduct;
2. establish a mechanism to detect, correct and prevent errors that result in violations of the laws and regulations governing health care and violations of Zandex policies;
3. encourage the members of Zandex (employees, volunteers, members of the Board of Directors and vendors who do business with Zandex) to report any incidents that they, in good faith, believe:
o could lead to fraud, waste and abuse against federal and state health care programs,
o could lead to Zandex being in violation of the conditions of participation for inclusion in health care programs funded by the state and federal government,
o could expose Zandex (or its members) to penalties for violation(s) of any federal or state health care programs, or
o are violations of Zandex company policies;
4. promote self-auditing and self-policing of our practices;
5. promote voluntary disclosure of violations of laws and regulations; and
6. establish, monitor and enforce the policies of Zandex.
The Corporate Compliance Program encompasses not only Zandex, Inc., and Zandex Health Care Corporation, of which Zandex, Inc. is the sole member or shareholder, but also each nursing facility owned by the company. Each facility shall have a designated compliance manager who shall utilize the Corporate Compliance Plan for guidance. Those facilities are:
Adams Lane Care Center; Beacon House; Beckett House; Cedar Hill Care Center; Forest Hill Care Center; Shadyside Care Center; Sterling Transitional Suites and Willow Haven Care Center.
This Program applies not only to the employees of Zandex, but also its Volunteers, Students, Board of Directors and Vendors doing business with Zandex, all referred to as members of Zandex. Any reference to “members of Zandex” should be considered to include each of these groups.
Corporate Compliance Program
The Zandex Board of Directors has directed the development and implementation of an effective Corporate Compliance Program which includes the following, many of which are recommended by the Office of Inspector General in its Compliance Program Guidance for Nursing Facilities issued in March 2000 and the Supplemental Compliance Program Guidance issued in September 2008.
1. The policies and procedures which encompass the Corporate Compliance Program at Zandex include:
o a. Corporate Compliance Program. The Corporate Compliance Program is available to all members of Zandex at zandex.com.
o b. Code of Conduct. The Code of Conduct is available to all members of Zandex at zandex.com.
o c. Prohibition of False Claims. The Prohibition of False Claims is available to all members of Zandex at zandex.com.
2. Designation of a Compliance Officer and Compliance Committee.
3. Education and Training Program Development and Implementation.
4. Creation of a Method of Reporting that is free from retaliation. The Human Resource Department will make every effort to ensure that those reporting concerns are protected from retaliation and that their comments are kept confidential. To further that commitment, an anonymous Hotline has been established.
5. Sanctions or Disciplinary Action Enforcement.
6. Ongoing Audit and Monitoring of Activities.
7. A program for Investigating, Resolving and Refunding, where appropriate.
Members of Zandex are not expected to have expert knowledge of all legal and regulatory requirements that may apply to their work. However, it is expected that members of Zandex will be sensitive to legal and ethical issues. The goal of this Plan is to give them the foundation to know enough to ask questions if they are uncertain about any given situation, and whom to ask. Each employee shall ask questions before engaging in any conduct which causes them concern.
Corporate Compliance Officer and Compliance Committees
The Corporate Compliance Officer for Zandex is designated as Peggy Morrison, Accounting Manager. The office of the corporate compliance officer is located at 1122 Taylor St., Zanesville, Ohio. The mailing address is: 1122 Taylor Street, Zanesville, OH 43701. The main phone number is: 740-454-1400. The Corporate Compliance Officer is responsible for the coordination of the Corporate Compliance Program of Zandex Inc., Zandex Health Care Corporation and its health care facilities.
There are designated Compliance Managers for each Zandex facility. To ascertain who these individuals are, pleasecall the corporate office at 740-454-1400.
The following have been designated to assist with the compliance efforts at Zandex; the prevention and detection of possible fraud and abuse; and the implementation of the Program:
Board of Directors. The Board of Directors has a designated Compliance Committee which meets as needed, to review the Compliance Program. The Corporate Compliance Officer has a responsibility to report activities and concerns to this committee. The Corporate Compliance Committee shall ensure that Zandex maintains a comprehensive program to (a) comply with all laws and regulations governing its business and activities, and (b) conduct its affairs in an ethical and responsible manner. The Committee shall receive a thorough report from the Auditor at least annually, together with such other information as theCommittee from time to time requires. The Committee shall inform the Board of the reports it receives from the Compliance Officer regarding the Compliance Program.
Zandex Compliance Committee. This Committee meets as needed and includes representatives from the following Zandex Departments: Accounting, the Compliance Officer, the President and CEO, the CFO, the Director of Clinical Services, and other individuals as deemed appropriate. Their responsibility is to evaluate and identify possible areas of concern or risk of inappropriate billing practices, review new regulations where applicable, monitor government audit activity and provide guidance to the Corporate Compliance Officer as appropriate.
The Committee also reviews compliance issues specific to the services which Zandex Health Care provides and evaluates changes in guidance and regulations governing the provision of these services.
Contract Compliance Committee. This committee includes the previous mentioned individuals and others who may be included on an as-needed basis. The Committee has the responsibility to review contracts with any actual or potential source of health care business or referrals and ensure services rendered by physicians are detailed in appropriate contracts.
HIPAA Compliance Committee. This committee includes representatives from a broad range of disciplines, including Information Technology, Health Information Management, Director of Clinical Services, and the Human Resource Director for Zandex. The purpose of the committee is to provide guidance to the Zandex Compliance Officer and others responsible for ensuring compliance with the HIPAA regulations and protecting PHI and personal information.
Financial Compliance. Financial Compliance is generally handled by the Auditor. Information is shared with the board of directors and corporate officers, as needed.
Compliance Officer's Responsibility and Authority: The Zandex Corporate Compliance Officer has the responsibility to:
· Provide overall leadership for the Corporate Compliance Program.
· Ensure the evaluation and investigation of each and every issue brought forward without prejudice and in a timely manner.
· Ensure that either appropriate action is taken or make appropriate recommendations to the Chief Executive Officer or the Board of Directors of Zandex.
· Review/revise/formulate policies and procedures as necessary.
· Remain current on federal, state and local regulations affecting the provision of health care and the services provided by Zandex and its affiliates.
· Monitor the development of education and training processes and their implementation.
· Initiate and supervise external audits to evaluate compliance.
· Ensure there are monitoring processes and practices to identify possible areas of concern regarding compliance.
· Periodically (at least quarterly) report on the status of the Compliance Program and its activities to the Board of Directors.
The Corporate Compliance Officer shall have ultimate administrative authority for implementing, monitoring and enforcing the Program. Additionally, the Corporate Compliance Officer shall have the authority to coordinate with legal counsel, and or outside contractors (i.e., auditors) as he/she deems necessary.
Education and Training
Members of Zandex will have access to a copy of this Program, the Code of Conduct and the Prohibition of False Claims policy. Members of Zandex will be educated as to their content and any substantive changes that may be made. The policies outlining the Corporate Compliance Program at Zandex are available through the Zandex web site. Orientation of all new employees, volunteers, medical staff members and Board members within Zandex will include an explanation about the Program.
Copies of the policies will be available to new medical staff members, board members, volunteers and vendors as appropriate. All employees will receive Fraud, Waste and Abuse compliance training upon hire and annually each year thereafter. Further, all employees will be provided with general information concerning compliance issues.
Some employees will receive additional specialized training appropriate to the areas in which they work, for example, secretarial and billing. Education will be provided in a variety of ways, including but not limited to orientation, written materials, newsletters, staff meetings and through formal education.
The Program will be reaffirmed at annual performance reviews. Additional/ongoing training will be provided periodically as appropriate. Failure to participate in compliance education and re-education will result in disciplinary action, up to and including termination. All compliance education will be documented.
Method of Reporting
Members of Zandex shall report any possible information regarding a known or suspected violation of any applicable laws, regulations, ethical standards or Zandex policy as soon as they become aware of such. If an employee has difficulty interpreting a policy, procedure or law, he or she should consult with his or her supervisor to determine whether consultation with the Corporate Compliance Officer is appropriate. The employee may report to any one of the following:
· Immediate Supervisor
· Vice President
· Facility Compliance Manager
· Zandex Corporate Compliance Officer
o Peggy Morrison, Accounting Manager
o Phone: 740-454-1400
o Email:
o Mailing Address: 1122 Taylor Street, Zanesville, OH 43701
o Office Address: 1122 Taylor Street, Zanesville, OH 43701
· Corporate Counsel
· Zandex's Chief Executive Officer
· Compliance Hotline (may be reported anonymously)
o Toll Free: 1-800-675-6345
Corporate Compliance Hotline. The Corporate Compliance Hotline is a key element of the Corporate Compliance Program. Calls coming into the Corporate Compliance Hotline will be held in the strictest of confidence. The Hotline is a completely confidential resource that can be called anonymously to allow all members of Zandex to voice concerns over any situation that may conflict with Zandex's commitment to ensuring the reputation and corporate integrity of the company. The Hotline calls are recorded in the same manner that voice mail messages are recorded. The incoming phone number, even if displayed is not recorded in the Corporate Compliance files or any database which may be generated.
Disciplinary Action Enforcement
Intentional actions by any member of Zandex which result in violations of the federal and state regulations governing health care, cause Zandex to submit a false claim for payment to any payer, or violate Zandex policies and procedures will result in disciplinary action according to the appropriate policies, (e.g., Corporate Policies, Board of Director Bylaws, etc.) Additionally, actions will be reported to the appropriate authorities as deemed necessary.
No member of Zandex who reports a compliance issue in good faith will be subject to disciplinary action or punished in any way for making a report. Any member of Zandex who attempts to retaliate against another who in good faith reported a compliance issue will be subject to disciplinary action, including termination if appropriate. Failure to report a known compliance issue is a violation of policy and may subject an employee to disciplinary action, including termination, where appropriate.
Monitoring and Auditing
One of the responsibilities of the Corporate Compliance Officer is to initiate and supervise internal and external audits to evaluate compliance. Another responsibility is to ensure the monitoring of processes and practices to identify possible areas of concern regarding compliance.
The Corporate Compliance Officer will work with the various committees to develop a risk assessment for Zandex and to then develop a plan to address those risks through audit and investigation of possible non-compliance. The risk assessment will be reviewed and updated annually and the Audit Plan will be monitored and activities reported to the Board of Directors, Compliance Committee, and other appropriate committees.
Periodic audits will be performed on those areas within Zandex that have been identified in the Risk Assessment and Audit Plan. Additionally audits to assess compliance with the standards and policies established at Zandex shall be conducted under the authority and direction of the CorporateCompliance Officer and reported annually to the Board of Directors.
Specifically, ongoing billing compliance monitoring will be conducted by the Accounting Department of Zandex and as requested by outside auditors. Periodic reviews will be made of available benchmarking data and directives and alerts, e.g., OIG Advisory Opinions, Fraud Alerts, Medicare Alerts and correspondence from Medicaid to ensure compliance with all areas of health care. Monitoring in those areas where issues were identified will be undertaken as deemed appropriate by the Corporate Compliance Officer.
Investigations/Resolutions
The Corporate Compliance Officer will review reports of possible violations to determine the appropriate action to be taken. The action taken shall be designed to ensure that the specific issue is addressed and, to the extentpossible, that similar problems do not occur in other departments or areas or re-occur in the original area.
If the report was received in a method other than personal communication directly with someone in corporate management or by anonymous call, then the person filing the concern shall be contacted as soon as feasible, usually within forty-eight (48) hours to let them know that the report was received.