Health And Palliative Services Of The Treasure Coast, Inc .
CORPORATE INTEGRITY AGREEMENTBETWEEN THEOFFICE OF INSPECTOR GENERALOF THEDEPARTMENT OF HEALTH AND HUMAN SERVICESANDHEALTH AND PALLIATIVE SERVICES OF THE TREASURE COAST, INC.,ANDTHE HOSPICE OF MARTIN AND ST. LUCIE, INC.,ANDHOSPICE OF THE TREASURE COAST, INC.I.PREAMBLEHealth and Palliative Services of the Treasure Coast, Inc., The Hospice of Martinand St. Lucie, Inc., Hospice of the Treasure Coast, Inc., collectively d/b/a The. TreasureCoast Hospice {TCH) hereby enters into this Corporate Integrity Agreement (CIA) withthe Office of Inspector General (OIG) of the United States Department of Health andHuman Services (HHS) to promote compliance with the statutes, regulations, and writtendirectives of Medicare, Medicaid, and all other Federal health care programs (as definedin 42 U.S.C. § 1320a-7b(f)) (Federal health care program requirements).Contemporaneously with this CIA, is entering into a Settlement Agreement with theUnited States.II.TERM AND SCOPE OF THE CIAA.The period ofthe compliance obligations assumed by TCH under this CIAshall be five years from the effective date of this CIA. The "Effective Date' shall be thedate on which the final signatory of this CIA executes this CIA. Each one-year period,beginning with the one-year period following the Effective Date, shall be referred to as a"Reporting Period."B.Sections VII, X, and XI shall expire no later than 120 days after OIG'sreceipt of: (1) TCH's final Annual Report or (2) any additional materials submitted byTCH pursuant to OIG's request, whichever is later.C.For purposes of this CIA, the term "Covered Persons" includes: (1) allowners, officers, directors, and employees of TCH; and (2) all contractors,subcontractors, agents, and other persons who furnish patient care items or services orwho perform billing or coding functions on behalf of TCH, excluding vendors whose soleTreasure Coast Hospice CIA1
connection with TCH is selling or otherwise providing medical supplies or equipment toTCH.III.CORPORATE INTEGRITY OBLIGATIONSTCH shall establish and maintain a Compliance Program that includes thefollowing elements:A.Compliance Officer and Committee, Board of Directors, and ManagementCompliance Obligations1.Compliance Officer. Within 90 days after the Effective Date, TCHshall appoint a Compliance Officer and shall maintain a Compliance Officer for the termof the CIA. The Compliance Officer shall be an employee and a member of seniormanagement of TCH, shall report directly to the Chief Executive Officer of TCH, andshall not be or be subordinate to the General Counsel or Chief Financial Officer or haveany responsibilities that involve acting in any capacity as legal counsel or supervisinglegal counsel functions for TCH. The Compliance Officer shall be responsible for,without limitation:a.developing and implementing policies, procedures, andpractices designed to ensure compliance with therequirements set forth in this CIA and with Federal healthcare program requirements;b.making periodic (at least quarterly) reports regardingcompliance matters directly to the Board of Directors of TCHand shall be authorized to report on such matters to the Boardof Directors at any time. Written documentation of theCompliance Officer's reports to the Board of Directors shallbe made available to OIG upon request; andc.monitoring the day-to-day compliance activities engaged inby TCH as well as any reporting obligations created underthis CIA.Any noncompliance job responsibilities of the Compliance Officer shall be limitedand must not interfere with the Compliance Officer's ability to perform the dutieso tlined in this CIA.Treasure Coast Hospice CIA2
TCH shall report to OIG, in writing, any changes in the identity of the ComplianceOfficer, or any actions or changes that would affect the Compliance Officer's ability toperform the duties necessary to meet the obligations in this CIA, within five days aftersuch a change.2.Compliance Committee. Within 90 days after the Effective Date,TCH shall appoint a Compliance Committee. The Compliance Committee shall, at aminimum, include the Compliance Officer and other members of senior managementnecessary to meet the requirements of this CIA ( , senior executives of relevantdepartments, such as billing, clinical, human resources, audit, and operations). TheCompliance Officer shall chair the Compliance Committee and the Committee shallsupport the Compliance Officer in fulfilling his/her responsibilities ( , shall assist inthe analysis of TCH' s risk areas and shall oversee monitoring of internal and externalaudits and investigations). The Compliance Committee shall meet at least quarterly. Theminutes of the Compliance Committee meetings shall be made available to OIG uponrequest.TCH shall report to OIG, in writing, any.actions or changes that would affect theCompliance Committee's ability to perform the duties necessary to meet the obligationsin this CIA, within 15 days after such a change.3.Board ofDirectors Compliance Obligations. The Board ofDirectors (or a committee of the Board) of TCH (Board) shall be responsible for thereview and oversight of matters related to compliance with Federal health care programrequirements and the obligations of this CIA. The Board must include independent (i.e.,non-executive) members.The Board shall, at a minimum, be responsible for the following:a.meeting at least quarterly to review and oversee TCH' scompliance program, including but not limited to theperformance of the Compliance Officer and ComplianceCommittee;b.submitting to OIG a description of the documents and othermaterials it reviewed, as well as any additional steps taken,such as the engagement of an independent advisor or otherthird party resources, in its oversight of the complianceprogram and in support of making the resolution belowduring each Reporting Period; andTreasure Coast Hospice CIA3
c.for each Reporting Period of the CIA, adopting a resolution,signed by each member of the Board summarizing its reviewand oversight ofTCH's compliance with Federal health careprogram requirements and the obligations of this CIA.At minimum, the resolution shall include the following language:"The Board of Directors has made a reasonable inquiry into the operationsof TCH' s Compliance Program, including the performance of theCompliance Officer and the Compliance Committee. Based on its inquiryand review, the Board has concluded that, to the best of its knowledge,TCH has implemented an effective Compliance Program to meet Federalhealth care program requirements and the obligations of the CIA."If the Board is unable to provide such a conclusion in the resolution, the Boardshall include in the resolution a written explanation of the reasons why it is unable toprovide the conclusion and the steps it is taking to implement an effective ComplianceProgram at TCH.TCH shall report to OIG, in writing, any changes in the composition of the Board,or any actions or changes that would affect the Board's ability to perform the dutiesnecessary to meet the obligations in this CIA, within 15 days after such a change.4.Management Certifications. In addition to the responsibilities setforth in this CIA for all Covered Persons, certain TCH employees (CertifyingEmployees) are expected to monitor and oversee activities within their areas of authorityand shall annually certify that the applicable TCH department is in compliance withapplicable Federal health care program requirements and the obligations of this CIA.These Certifying Employees shall include, at a minimum, the following: Chief ExecutiveOfficer (CEO), Chief Financial Officer (CFO), Compliance Officer (CO), Vice-Presidentof Medical Services, and all Clinical Directors. For each Reporting Period, eachCertifying Employee shall sign a certification that states:"I have been trained on and understand the compliance requirements andresponsibilities as they relate to [insert name of department], an area undermy supervision. My job responsibilities include ensuring compliance withregard to the [insert name of department] with all applicable Federal healthcare program requirements, obligations of the Corporate IntegrityAgreement, and TCH policies, and I have taken steps to promote suchcompliance. To the best of my knowledge, the [insert name of department]Treasure Coast Hospice CIA4
ofTCH is in compliance with all applicable Federal health care programrequirements and the obligations of the Corporate Integrity Agreement. Iunderstand that this certification is bei g provided to and relied upon by theUnited States."If any Certifying Employee is unable to provide such a certification, the CertifyingEmployee shall provide a written explanation of the reasons why he or she is unable toprovide the certification outlined above.B.Written StandardsWithin 90 days after the Effective Date, TCH shall develop and implement writtenpolicies and procedures regarding the operation of its compliance program, including thecompliance program requirements outlined in this CIA and TCH's compliance withFederal health care program requirements (Policies and Procedures). Throughout theterm of this CIA, TCH shall enforce its Policies and Procedures and shall makecompliance with its Policies and Procedures an element of evaluating the performance ofall employees. The Policies and Procedures shall be made available to all CoveredPersons.At least annually (and more frequently, if appropriate), TCH shall assess andupdate, as necessary, the Policies and Procedures. Any new or revised Policies andProcedures shall be made available to all Covered Persons.All Policies and Procedures shall be made available to OIG upon request.C.Training and Education1.Covered Persons Training. Within 90 days after the Effective Date,TCH shall develop a written plan (Training Plan) that outlines the steps TCH will take toensure that all Covered Persons receive at least annual training regarding TCH's CIArequirements and Compliance Program and the applicable Federal health care programrequirements, including the requirements of the Anti-Kickback Statute and the StarkLaw. The Training Plan shall include information regarding the following: trainingtopics, categories of Covered Persons required to attend each training session, length ofthe training session(s), schedule for training, and format of the training. TCH shallfurnish training to its Covered Persons pursuant to the Training Plan during eachReporting Period.Treasure Coast Hospice CIA5
2.Board Member Training. Within 120 days after the Effective Date,each member of the Board of Directors shall receive at least two hours of training. Thistraining shall address the corporate governance responsibilities of board members, andthe responsibilities of board members with respect to review and oversight of theCompliance Program. Specifically, the training shall address the unique responsibilitiesof health care Board members, including the risks, oversight areas, and strategicapproaches to conducting oversight of a health care entity. This training may beconducted by an outside compliance expert hired by the Board and should include adiscussion of the OIG's guidance on Board member responsibilities.New members of the Board of Directors shall receive the Board Member Trainingdescribed above within 3 0 days after becoming a member or within 90 days after theEffective Date, whichever is later.Training Records. TCH shall make available to OIG, upon request,3.training materials and records verifying that Covered Persons and Board members havetimely received the training required under this section.D.Review Procedures1.General Descriptiona.Engagement ofIndependent Review Organization. Within 90days after the Effective Date, TCH shall engage an entity (orentities), such as an accounting, ·auditing, or consulting firm(hereinafter "Independent Review Organization" or "IRO"),to perform the reviews listed in this Section 111.D. Theapplicable requirements relating to the IRO are outlined inAppendix A to this CIA, which is incorporated by reference.b.Retention ofRecords. The IRO and TCH shall retain andmake available to OIG, upon request, all work papers,supporting documentation, correspondence, and draft reports(those exchanged between the IRO and TCH) related to thereviews.2.Claims Review. The IRO shall review claims submitted by TCH andreimbursed by the Medicare and Medicaid programs, to determine whether the items andservices furnished were medically necessary and appropriately documented and whetherthe claims were correctly coded, submitted and reimbursed (Claims Review) and shallTreasure Coast Hospice CIA6
prepare a Claims Review Report, as outlined in Appendix B to this CIA, which isincorporated by reference.3.Independence and Objectivity Certification. The IRO shall includein its report(s) to TCH a certification that the IRO has (a) evaluated its professionalindependence and objectivity with respect to the reviews required under this Section 111.Dand (b) concluded that it is, in fact, independent and objective, in accordance with therequirements specified in Appendix A to this CIA. The IRO's certification shall includea summary of all current and prior engagements between TCH and the IRO.E.Risk Assessment and Internal Review ProcessWithin 90 days after the Effective Date, TCH shall develop and implement acentralized annual risk assessment and internal review process to identify and addressrisks associated with TCH's participation in the Federal health care programs, includingbut not limited to the risks associated with the submission of claims for items andservices furnished to Medicare and Medicaid program beneficiaries. The risk assessmentand internal review process shall require compliance, legal, and department leaders, atleast annually, to: (1) identify and prioritize risks, (2) develop internal audit work plansrelated to the identified risk areas, (3) implement the internal audit work plans, (4)develop corrective action plans in response to the results of any internal audits performed,and (5) track the implementation of the corrective action plans in order to assess theeffectiveness of such plans. TCH shall maintain the risk assessment and internal reviewprocess for the term of the CIA.F.Disclosure ProgramWithin 90 days after the Effective Date, TCH shall establish a Disclosure Programthat includes a mechanism ( , a toll-free compliance telephone line) to enableindividuals to disclose, to the Compliance Officer or some other person who is not in thedisclosing individual's chain of command, any identified issues or questions associatedwith TCH' s policies, conduct, practices, or procedures with respect to a F e.deral healthcare program believed by the individual to be a potential violation of criminal, civil, oradministrative law. TCH shall appropriately publicize the existence of the disclosure·mechanism ( , via periodic e-mails to employees or by posting the information inprominent common areas).The Disclosure Program shall emphasize a nonretribution, nonretaliation policyand shall include a reporting mechanism for anonymous communications for whichappropriate confidentiality shall be maintained. The Disclosure Program also shallTreasure Coast Hospice CIA7
include a requirement that all ofTCH's Covered Persons shall be expected to reportsuspected violations of any Federal health care program requirements to the ComplianceOfficer or other appropriate individual designated by TCH. Upon receipt of a disclosure,the Compliance Officer (or designee) shall gather all relevant information from thedisclosing individual. The Compliance Officer (or designee) shall make a preliminary,good faith inquiry into the allegations set forth in every disclosure to ensure that he or shehas obtained all of the information necessary to determine whether a further reviewshould be conducted. For any disclosure that is sufficiently specific so that it reasonably:(1) permits a determination of the appropriateness of the alleged improper practice; and(2) provides an opportunity for taking corrective action, TCH shall conduct an internalreview of the allegations set forth in the disclosure and ensure that proper follow-up isconducted.The Compliance Officer (or designee) shall maintain a disclosure log and shallrecord each disclosure in the disclosure log within two business days of receipt of thedisclosure. The disclosure log shall include a summary of each disclosure received(whether anonymous or not), the status of the respective internal reviews, and anycorrective action taken in response to the internal rev ews.G.Ineligible Persons1.Definitions. For purposes of this CIA:a.b.an "Ineligible Person" shall include an individual or entitywho:i.is currently excluded from participation in any Federalhealth care program; oru.has been convicted of a criminal offense that fallswithin the scope of 42 U.S.C. § 1320a-7(a), but has notyet been excluded."Exclusion List" means the HHS/OIG List of ExcludedIndividuals/Entities (LEIB) (available through the Internet athttp://www.oig.hhs.gov).2.Screening Requirements. TCH shall ensure that all prospective andcurrent Covered Persons are not Ineligible Persons, by implementing the followingscreening requirements.Treasure Coast Hospice CIA8
a.TCH shall screen all prospective Covered Persons against theExclusion List prior to engaging their services and, as part of. the hiring or contracting process, shall require such CoveredPersons to disclose whether they are Ineligible Persons.b.TCH shall screen all current Covered Persons against theExclusion List within 90 days after the Effective Date and ona monthly basis thereafter.c.TCH shall implement a policy requiring all Covered Personsto disclose immediately if they become an Ineligible Person.Nothing in this Section 111.G affects TCH's responsibility to refrain from (andliability for) billing Federal health care programs for items or services furnished, ordered,or prescribed by an excluded person. I:'CH understands that items or services furnished,ordered, or prescribed by excluded persons are not payable by Federal health careprograms and that TCH may be liable for overpayments and/or criminal, civil, andadministrative sanctions for employing or contracting with an excluded person regardlessof whether TCH meets the requirements of Section 111.G.3.Removal Requirement. If TCH has actual notice that a CoveredPerson has become an Ineligible Person, TCH shall remove such Covered Person fromresponsibility for, or involvement with, TCH's business operations related to the Federalhealth care program(s) from which such Covered Person has been excluded and shallremove such Covered Person from any position for which the Covered Person'scompensation or the items or services furnished, ordered, or prescribed by the CoveredPerson are paid in whole or part, directly or indirectly, by any Federal health careprogram(s) from which the Covered Person has been excluded at least until such time asthe Covered Person is reinstated into participation in such Federal health care program(s).Pending Charges and Proposed Exclusions. If TCH has actual4.notice that a Covered Person is charged with a criminal offense that falls within the scopeof 42 U.S.C. §§ 1320a-7(a), 1320a-7(b)(l)-(3), or is proposed for exclusion during theCovered Person's employment or contract term or during the term of a physician's orother practitioner's medical staff privileges, TCH shall take all appropriate actions toensure that t e responsibilities of that Covered Person have not and shall not adverselyaffect the quality of care rendered to any beneficiary or the accuracy of any claimssubmitted to any Federal health care program.Treasure Coast Hospice CIA9
H.Notification of Government Investigation or Legal ProceedingWithin 30 days after discovery, TCH shall notify OIG, in writing, of any ongoinginvestigation or legal proceeding known to TCH conducted or brought by a governmentalentity or its agent
Health and Palliative Services of the Treasure Coast, Inc., The Hospice ofMartin and St. Lucie, Inc., Hospice ofthe Treasure Coast, Inc., collectively d/b/a The. Treasure Coast Hospice {TCH) hereby enters i
DEPARTMENT DIVISION NAME Family Medicine Palliative Medicine Algu,Kavita Palliative Medicine Arvanitis,Jennifer Palliative Medicine Berman,Hershl (Hal) Palliative Medicine Buchman,Stephen (Sandy) Palliative Medicine Cellarius,Victor Palliative Medicine Goldman,Russell Palliative Medicine Hashemi,Narges Palliative Medicine Howe,Marnie
palliative care plan 2012-2016 Inpatient palliative care There are 300 specialist palliative care beds located in NSW public hospitals, affiliated hospitals and other facilities in the NSW health system. Care is also routinely provided in non-designated palliative care beds. In 2008-09, there were 19,800 palliative care
Palliative Care Services Operational Policy 15 NATIONAL ADVISOR FOR PALLIATIVE MEDICINE SERVICES It is a great honour and delight to produce this operational policy for palliative care services in the Ministry of Health. Over the past 10 years, the understanding of palliative
polices, pain policies, integrated palliative care services or hospices. Palliative care, public health and human rights . Three disciplines (palliative care, public health, and human rights) are now interacting with a growing resonance. The maturing of palliative care as a clinical specialty a
2014 Inducted as a Fellow in Palliative Care Nursing awarded by the Hospice and Palliative Nurses Association at the Annual Assembly of the American Academy of Hospice and Palliative Medicine and Hospice and Palliative Nurses Association, March 12 -15. San Diego, CA. 2012-2014 Awarded National Palliative Care Research Center . Junior Faculty
End of Life Nursing Education Consortium, Pediatric Palliative Care – ELNEC PPC ELNEC- Pediatric Palliative Care was designed and developed by 20 pediatric palliative care experts and piloted in 2003. Each year, at least three national train -the-trainer pediatric palliative care
Mar 11, 2015 · FOR QUALITY PALLIATIVE CARE To build a national consensus around the definition, philosophy and principles of palliative care To promote consistent and high quality care Clinical practice guidelines for quality palliative care released 2004, revised 2009 Established the eight domains of palliative care
Palliative Care Service Penetration Palliative care service penetration is the percentage of annual hospital admissions seen by the palliative care team. Penetration is used to determine how well palliative care programs are reaching patients in need. 100 initial consults / 3,50
