Suzanne Beldock, RN 315-713-5102 (office) 315-713-5600 (Internal
Anonymous Reporting Hotline) 1-866-493-9451 (External
Anonymous Reporting Hotline)
Corporate Compliance Program at CHMC is a mandatory, self-monitoring program to
assure our compliance with all federal, state and local laws applicable to
program is required to:
8 Elements of a Compliance Program
(1) The development and distribution of
written standards of conduct, as well as written policies and procedures, that reflect the
institution’s commitment to compliance.
(2) The designation of a compliance officer
and a compliance committee charged with the responsibility for developing,
operating, and monitoring the compliance program, and with authority to report
directly to the head of the organization.
(3) The development and implementation of
regular, effective education and training programs for all affected
(4) The creation and maintenance of an effective line of
communication between the compliance officer and all employees,
including a process (such as a hotline or other reporting system) to receive
complaints or questions that are addressed in a timely and meaningful way, and
the adoption of procedures to protect the anonymity of complainants and to
protect whistleblowers from retaliation
(5) The clear definition
of roles and responsibilities within the institution’s organization and ensuring the effective assignment of
(6) The use of audits and/or
other risk evaluation techniques to monitor compliance and identify problem areas.
(7) The enforcement of appropriate
disciplinary action against employees or contractors who have violated institutional policies,
procedures, and/or applicable Federal requirements for the use of Federal
research dollars, and
(8) The development of
policies and procedures for the investigation of identified instances of non-compliance or misconduct.
These should include directions regarding the prompt and proper response to
detected offenses, such as the initiation of appropriate corrective action and
Corporate Compliance PolicyIt is the policy of Claxton-Hepburn Medical Center (hereinafter referred to as “CHMC”) to comply with all applicable federal, state and local laws and regulations, both civil and criminal, as well as those pertaining to CHMC as a tax-exempt, charitable institution.
In addition to complying with the law, it is also the policy of CHMC to comply with the compliance code of conduct and applicable policies and procedures addressing standards of conduct, which are adopted from time to time by the Board or a committee thereof, the Chief Executive Officer or the CORE Compliance Committee.
No employee, agent or medical staff appointee of CHMC has any authority to act contrary to the provisions of the laws, the code of conduct or applicable policies addressing standards of conduct or to authorize, direct or condone violations by any other employee, agent or medical staff appointee.
Any employee, agent or medical staff appointee of CHMC who has knowledge of activities that he or she believes may violate the law or CHMC’s compliance code of conduct and/or applicable policies has an obligation, promptly after learning of such, to report the matter to his or her immediate supervisor, the Chief Executive Officer or to the Corporate Compliance Officer. Reports may be made anonymously and employees will not be penalized for truthful reports. Failure to report known violations, failure to detect violations due to negligence or reckless conduct and making false reports shall be grounds for disciplinary action, including termination. Any reports of retaliation, harassment or other workplace-related problems shall be referred to Human Resources.
CHMC communicates its standards and procedures to all employees and agents, through mandatory training programs by dissemination of information that explains, in a practical manner, what is required. This includes dissemination of the Compliance Code of Conduct as well as an Acknowledgment of Education by each employee via the HealthStream electronic education module. Compliance policies and procedures are also available on CHMC’s intranet.
CHMC achieves compliance with its standards by utilizing monitoring and auditing systems reasonably designed to detect errors or misconduct by its employees and agents and by having in place and publicizing a reporting system whereby employees, medical staff and other agents can report errors or misconduct by themselves or others within the organization without fear of retribution.
Employees, agents or medical staff appointees may report potential compliance issues to the Corporate Compliance Officer by phone, email, mail, or face-to-face. CHMC utilizes a hotline to report compliance issues for those who wish to remain anonymous.
The Corporate Compliance Officer has an obligation to act on all reported issues. Unresolved issues are taken to the highest authority in the organization for resolution.
After a violation has been detected, CHMC will take all reasonable steps to respond appropriately according to the Grievance/Complaint Management Policy (Admin. C-5). Modifications to systems and processes may be necessary to prevent and detect future violations.
This Corporate Compliance policy is intended to communicate current provisions regarding compliance. The Board reserves the right to change, modify, or waive all provisions herein. If any employee has a question concerning a particular provision contained herein or concerning any practice not addressed in this document, he or she should consult with the Corporate Compliance Officer.
RELATED POLICIES: Please contact our Corporate
Compliance Office for these related policies.
Standards for Privacy and Protected Health Information The Deficit Reduction Act (DRA) of 2005 became effective January 1, 2007, and mandates healthcare providers receiving $5 million in Medicaid reimbursement to have a Compliance Plan. The Compliance Plan must include policies regarding the False Claims Act, administrative remedies for false claims and statements; applicable state false claims provisions and whistleblower protections under these laws. Claxton-Hepburn Medical Center understands the importance of having a strong Compliance Plan to prevent fraud, waste, and abuse in our healthcare system. Claxton-Hepburn is proud to say we have had an effective compliance program in place since 1999. A specific requirement of the Deficit Reduction Act is that we communicate our fraud, waste and abuse policies to our employees, vendors and contractors. Additionally, the employees, agents, and contractors must, in performing work for Claxton-Hepburn Medical Center, adopt and abide by these policies.
Claxton-Hepburn Medical Center is
accredited by DNV Healthcare
Inc. DNV Healthcare is committed to improving the quality and safety of
care provided by health care organizations. Accreditation means that the
hospital has demonstrated compliance with organizational, patient care
and safety standards set forth by DNV Healthcare. In addition,
accreditation with DNV standards is the foundation of Claxton-Hepburn's quality management system. Click here to visit the DNV Healthcare Inc. website.
Safety or Quality Concerns? If you have a
concern or complaint about
patient care or safety, please share this directly with those providing
the care or services to you. If you do not feel that your concern has
been adequately addressed, you may contact the manager of that service
area. If you continue to feel that your concern has not been adequately
addressed, please contact Claxton-Hepburn Medical Center's Performance
Improvement Office, located at 214 King Street, Ogdensburg, NY 13669.
may contact them by phone at 315-713-5100 , or if you are still
not satisfied with the response, you may report your concern or
register a complaint with the following:DNV HealthcarePhone: 1-866-523-6842Email: email@example.comThe patient also has the right to file a complaint with the NY Department of Health at 1-800-804-5447.