1.7 Internal Compliance Investigation Policy

  • PURPOSE:

    A detailed investigation of a report of non-compliance complaints or erroneous internal procedures will preserve the integrity of the Compliance Program and will assist in for the implementation of disciplinary actions.

    POLICY:

    LHCC is committed to full compliance with applicable state, federal and local laws. The Compliance Officer shall have the responsibility and authority to conduct and oversee independent compliance investigation to detect possible violations of the law, with legal guidance from our outside counsel as appropriate. The extent of the investigation will vary depending upon the matter investigated. The Compliance Officer will investigate every report of non-compliance to determine whether a violation of the Compliance Program or other state or federal healthcare law, statute or regulation has occurred. Investigations may include interviewing employees and/or reviewing documentation. Each employee must cooperate with such investigations.

    PROCEDURE:

    1. The Compliance Officer shall commence and/or oversee investigations on all compliance-related matters within seven (7) days following receipt of the report indicating a matter warranting investigation.
    2. The Compliance Officer may delegate the investigation responsibilities but will retain ultimate supervision and responsibility for all compliance investigations.
    3. The investigation may include, but is not limited to:
      1. reviewing and preserving documents related to the matter;
      2. interviewing appropriate individuals;
      3. reviewing policies and procedures applicable to the matter;
      4. collaborating with an internal LHCC facility authority, as needed; and
      5. engaging outside legal counsel to assist in the investigation, as needed.
    4. If a significant compliance violation is found, the Compliance Officer and/or an internal LHCC facility authority, shall develop and implement a corrective action plan.
    5. All investigation methods and findings pursuant to the investigation must be documented. Copies of supporting documentation should be attached to all reports.
      1. If the investigation findings do not substantiate the allegation or matter, the investigation will be closed by the Compliance Officer. Documentation regarding the investigation will be filed and maintained by the Compliance Officer for a minimum of seven (7) years after the investigation has closed.
      2. If a compliance violation is found, all documentation related to the investigation will be maintained as an “open” investigation until a corrective action plan has been completed and the matter has been resolved, at which time the investigation file will be filed and maintained for a minimum of seven (7) years after the investigation has been closed.
    6. For investigations implicating the CEO, President or Director of Operations, the Compliance Officer shall notify the CEO and will conduct and coordinate the investigation. For investigations implicating the Compliance Officer, the Director of Operations will conduct and coordinate the investigation.

    Revised 12/2013

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