Compliance Program

 

What is a Compliance Program?

A program promoting the prevention, detection and resolution of instances that do not conform to federal, state, and local laws.

 

Why do we need a Compliance Program?

To prevent fraud, waste, and abuse.

 

How do I report a Compliance Concern?

Notify your supervisor

Notify your compliance officer: - Traci Waugh 249-7832 or compliance@ponderamedical.com

 

Call the anonymous Compliance Hotline: 877-650-8048

 

PMC Policy & Procedures

00  Alphabetical Operating Policy Tracking List

00a Numerical Operating Policy Tracking List

00b Corporate Compliance Plan

00ba Board Resolution Adopting PMC’s Compliance Plan

00bb Compliance Code of Business Conduct

00bc Compliance Code of Business Conduct Summary

00c PMC Organizational Chart - Positions

00d PMC Mission Vision Values

01  Policy Dissemination

02  Licensure Certification or Registration
      of Personnel and Medical Staff

03  Responsibilities of Governance and Administration

04  Department Availability

05  Non-Exempt Employee Timesheet Policy

06  Retention of Revised or
      Outdated Policies and Procedures

07  Capitalization Policy

08  Communication and Communication Systems

09  Conditions of Admission
      Patient Bill of Rights Policy

09a PMC Conditions of Admission Form

10  Patient Grievance Policy

11  Employee Discount Policy

12  Expenditure Approval Policy

13  Reporting Changes of Ownership
14  On-Line Interpretation for
      Non-English Speaking Patrons


16  Quality Assurance Performance Improvement Plan

17  Voluntary Expense Reduction Hours Days

18  Exempt Employee Timesheet Policy-Retired

19  Emergency Housing

20  Employee Vehicle Use

21  Utilization of-Delegation of Unlicensed
      Assistive Personnel

22  Hire and Orientation Policy

23  Pay Periods and Pay Dates Policy

24  Defective Products Recall Notices and Safety Alerts

25  Chemical Safety Policy

26  Preventive Maintenance
27  Transfer of Patients and Medical Records
       to Other Facilities

28  BLS Training of Personnel

29  Handling & Review of all PMC Contracts Agreements

30  Products Evaluation Standardization

31  Tuition Assistance Program

32_Medical Staff Peer Review

33  Tuberculosis Exposure Control Plan & Respiratory            Protection Program

34  Code Blue Policy

35  DME Financial Management

36  DME Financial Management Review

39  Equal Employment Opportunity

40  Tobacco Free  Environment Policy

41  Employee Dress Code

42  Mass Fatality Casualty Policy

43  Pre-Registration Policy

44  Billing and Collection Policy

45  Bereavement Leave Policy

46  Employee Grievance Policy and Form

47  Break and Meal Periods

48  Time Clock Policy

49  Influenza Vaccination Program

50  Pneumococcal Vaccination Program

51  Wage Administration Policy

52  Drug and Alcohol Testing

53  Attendance Policy

54  Employee Referral Program

55  PMC Key Policy

56  HIPAA Breach Notification Policy

57  HIPAA Privacy Policy

58  Extended Illness Benefits Policy

59  Designated Record Set Policy

60  Employee Immunization Policy

61  Information Technology Policy

62  Information Technology Id and Authentication

63  Information Technology Disposal
     of External Media Hardware

64  Discipline Policy

65  Separation from Employment Policy

66  Reduction in Workforce Policy

68  PMC-Code Green-Security Threat-Restricted Access

69  PMC Code Orange (Fire Plan) Policy

70  Earned Time Off Policy

71  Code Dr. Armstrong (Behavioral Emergency) Policy

72  Customer Service Recovery

73  Code Brown Bomb Threat-
      Accident & Injury Prevention Program

74  Patient Financial Assistance

75  Annual Program Evaluation

76  Risk Management Policy and Procedure

77  Risk & Concern Reporting Program Management

78  Description of Hospital Services

79  IT CCTV Policy

80  Document Disposal-Shredding and Destruction

81  Hospital Construction, Renovation and Demolition

82  Emergency Water Plan

83  Compliance Investigation

84  Non-Retaliation

85  Over-Payment Reporting Policy

86 Political Activity and Lobbying on Behalf of PMC

87 Conflict of Interest

88 Electronic Health Records Audit Policy

89 Lab Specials

90 Non-Monetary Compensation and
    Incidental Benefits Exception

91 Ordering Outpatient Ancillary Services
     for Non-Medical Staff Providers

92 Gifts-Free Services to Patients or
     Potential Patients-Marketing Limits

93 Employee Illness

94 Visitors and Infection Prevention

95 Staff Development and Education

96 1135 Emergency Care Waiver

97 Administrative Encryption of Laptops and Portable Storage Devices

98 Encryption of PHI in Transit

99 Informed Consent or Refusal to Consent

100 Charge Description Master (CDM) Maintenance Policy

101 Self Reporting-Self Disclosure Policy

102 Exclusion Search Requirements Policy

103 Search Warrant Policy

104 Emails and Texts to Patients and Others

105 Agreements with Physicians Allied Health Professionals and Other Referral Sources

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 ©2018 Pondera Medical Center • 805 Sunset Blvd • Conrad, MT 59425 • (406) 271-3211  •  caseyr@ponderamedical.org