Compliance Information

Jennie Flanagan, RN BT
315-713-5102 (office)
315-713-5600 (Internal Anonymous Reporting Hotline)
1-866-493-9451 (External Anonymous Reporting Hotline)

The Corporate Compliance Program at CHMC is a mandatory, self-monitoring program to assure our compliance with all federal, state and local laws applicable to healthcare.

Our program is required to:

  --Oversee the activities of CHMC and its employees with regard to compliance with laws, regulations, policies, & Code of Conduct

  --Heighten awareness of compliance and ethical issues through education

  --Provide mechanisms for detection, correction, and prevention of improper conduct

  --Provide employees with avenues for addressing compliance and ethical issues

 We deal with issues related to:

  --Fraud and abuse- (Deficit Reduction Act, Social Security Act, False Claims Act)

  --Regulatory standards and laws-Department of Health and DNV

  --Billing and coding requirements

  --HIPAA

  --Medical Necessity

  --Patient documentation

  --Information Requests

  --EMTALA - "patient anti-dumping law"

 

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 employees.

(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 oversight responsibilities.

(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 preventive measures.

Accreditation 

DNV (Det Norske Veritas) Healthcare Inc.

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. You 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 Healthcare
Phone: 1-866-523-6842
Email: hospitalcomplaint@dnv.com

The patient also has the right to file a complaint with the NY Department of Health at 1-800-804-5447.

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.