Record Retention Cape Cod Healthcare (CCHC) has established a Record Retention Policy to ensure compliance with legal requirements, maintain accessibility of critical records and minimize the costs of record keeping and handling. The policy defines which records must be maintained, the length of time they are retained and the proce- dures for storing and controlling them. For purposes of this policy, the term “records” is broadly defined. It includes all forms of documentation and data, such as correspon- dence, memoranda, notes, drafts, publications, invoices, ledgers, journals, notebooks, diaries, accounts, reports, surveys, statistical compilations, work papers, calendars, appointment records, voice recordings, computer servers and backup tapes, disks, flash drives, portable media, printouts and any other written or recorded information. A copy of the Record Retention Policy is maintained within the CCHC APPS under the “Record Retention” section of policies and procedures. Reporting Requirements Cape Cod Healthcare (CCHC) requires all employees and medical staff to promptly report any suspected criminal, fraudulent or illegal activity, or any conduct that violates the Code of Conduct. Concerns involving senior leadership—including the President/ CEO, CFO, Chief Legal Officer or Chief Compliance Officer—must be reported directly to the Chairperson of the Board of Trustees. Ignoring or concealing a possible violation is never acceptable, as silence may allow misconduct to continue or worsen.
How to Report?
Compliance Reviews and Audits The Chief Compliance Officer is responsible for coordinating periodic internal compliance reviews and audits, including those identified through CCHC’s Risk Assessment Policy. These reviews examine CCHC’s adherence to legal require- ments, internal policies and procedures designed to detect areas of concern, as well as business practices that may pose legal risks. CCHC personnel are expected to fully participate and cooperate in these reviews under the direction of legal counsel, the Chief Compliance Officer or external consultants engaged by CCHC. At the conclusion of each review, findings are reported to the Chief Compliance Officer shared with senior management as appropriate and presented to the Compliance Committee for further review and action.
Reporting Options • Chief Compliance Officer: Call 508-862-5621, email complianceoffice@capecodhealth.org, or written report (anonymous or named) via internal mail or U.S. mail. • Third-Party Vendor (Navex): Confidential, anony- mous reports by phone (1-800-892-9205), online at capecodhealthcare.ethicspoint.com or via mobile intake at capecodhealthcaremobile.ethicspoint.com. • Internal Channels: Speak with your supervisor, any CCHC Officer or a member of the Chief Compliance Officer (oral or written, anonymous or named). • All reports are reviewed promptly, shared with the Chief Compliance Officer, and addressed by the Compliance Committee. The Chief Compliance Officer provides updates to the Board of Trustees at each meeting. Non-Retaliation Cape Cod Healthcare (CCHC) is committed to ensur- ing that all individuals feel safe and comfortable raising concerns or asking questions about the Code of Conduct, CCHC policies or applicable laws. Retaliation of any kind against someone who makes a good faith compliance report will not be tolerated. A good faith report means that, to the best of the reporter’s knowledge, the information provided is accurate, truthful and complete. Any individual who retaliates—or attempts to retaliate— against someone who has reported a compliance issue in good faith will be subject to disciplinary action, up to and including termination, in accordance with CCHC policies and applicable law. Similarly, knowingly making a false accusation, or being uncooperative or untruthful during an investigation, will also result in disciplinary action, which may include termination.
Enforcement and Discipline
Cape Cod Healthcare (CCHC) enforces the compliance standards outlined in this Code, related policies, procedures and training materials. When violations occur, CCHC will take timely and appropriate corrective action to prevent recurrence. Responses may include: • Individual discipline or termination • Additional or remedial training and communications • Policy or billing changes • Disclosure to payers, including government programs • Return of inappropriate payments Discipline may also be imposed for failing to detect or report an offense. The type and level of discipline will reflect the seriousness of the circumstances, investigation findings and will remain consistent with applicable laws and CCHC policies.
15 | Cape Cod Healthcare
Code of Conduct | 16
Made with FlippingBook - Online catalogs