Rapid City Regional Hospital - Corporate Compliance

Corporate Compliance

Compliance & Ethics: A Guide to Regional Health's Code of Conduct Policy Crosswalk
Code of Conduct Section	Policy Number/Title
Statement of Integrity
Access to Care	FN-8211-13 / Community Benefit Policy GB-8311-02 / Patient Rights and Responsibilities GB-8311-18 / EMTALA Medical Screening Examination, Stabilization, Treatment, and Transfer
Accuracy of Records	AC-8212-06 / Accurate Record Keeping
Antitrust Laws	COC-8217-12 / Anti-Trust Law & Competitive Practices
Billing, Charging & Coding for Services	PA-8261-05 / Billing Practices PA-8261-06 / Three–Day Window Rule PA-8261-07 / Medicare / Medicaid Billing PA-8261-08 / Routine and Non-routine Overpayments PA-8261-09 / Refund Process CRB-8213-05 / Cost Reports COC-8217-19 / Medical Students, Nurse Practioner Students and Physician Assistant Students Medical Record Documentation
Compliance Program	COC-8217-01 / Corporate Compliance Program COC-8217-04 Excluded / Ineligible People & Entities PRS-8371-501 / Progressive Discipline
Compliance Communication Line	COC-8217-02 Corporate Compliance Communications Line / Whistleblowers / Nonretaliation
Confidentiality	COC-8217-12 / Anti-Trust Law & Competitive Practices COC-8217-17 / Protection of Property & Information Assets COC-8217-100 / Regional Health Privacy Program COC-8217-104 / Individual Patient Rights – Access to Medical Records COC-8217-105 / Individual Patient Rights – Accounting for Disclosure of Medical Record COC-8217-106 / Individual Patient Rights – Amending Medical Records COC-8217-107 / Individual Patient Rights – Request for Confidential Communications COC-8217-108 / Using, Disclosing, and Requesting only the Minimum Amount of Protected Health Information Necessary PRS-8371-507 / Access to Employee Health Information – Personnel Office COC-8217-110 / Authorization Requirements For Use or Disclosure of Protected Health Information (PHI) COC-8217-111 / Privacy Program Audits COC-8217-112 / Uses and Disclosures for Facility Directories COC-8217-113 / Disclosing Protected Health Information for Treatment, Payment, or Healthcare Operations (TPO) COC-8217-114 / Acceptable Disclosures – Other than Treatment, Payment or Healthcare Operations (TPO) COC-8217-115 / Disclosure of Protected of Protected Health Information to Family & Others COC-8217-116 / Disclosing Protected Health Information / Authorization Required COC-8217-117 / Release of Protected Health Information (PHI) to Law Enforcement or as Required by Law COC-8217-118 / Verification of Entities Requesting Disclosure of Protected Health Information COC-8217-119 / De-identification of Protected Health Information COC-8217-120 / Creation, Use & Disclosure of Limited Data Sets COC-8217-121 / Procedures for Validating Patient Authorizations COC-8217-122 / Procedures for Evaluation Subpoenas & Court Orders COC-8217-123 / Business Associate Contract Requirements COC-8217-124 / Alias Program for Patient Confidentiality COC-8217-125 / Camera Use in Rapid City Regional Hospital COC-8217-126 / Telefacsimile (FAX) Policy COC-8217-127 / Confidentiality of Information COC-8217-201 / Information Security Acceptable Use of Computer Resources COC-8217-202 / Appropriate Use of the T-Drive (Temporary Transfer) COC-8217-203 / Access to RCRH Information Systems COC-8217-204 / Appropriate Use of RCRH Based E-mail Systems COC-8217-205 / User Names and Passwords for Network and Computer Systems COC-8217-206 / Disposal of Confidential Information COC-8217-207 / Third Party Network Connections (In review) COC-8217-208 / Portable Computing Devices COC-8217-209 / Internet Blocking COC-8217-210 / Operating System Security & Hardening Requirements COC-8217-211 / Picture Archiving Computer System (PACS) Single-Use User Access Accounts/Passwords Procedure COC-8217-212 / Computer System Monitoring/Audit Requirements. COC-8217-213 / Computer Anti-Virus Program COC-8217-214 / Administrative Account Access COC-8217-215 / Administrative Account Password Escrow COC-8217-218 / Wireless Access Policy
Conflicts of Interest	PRS-8371-904 / Conflict of Interest PRS-8371-908 / Outside Employment (Moonlighting)
Doctors, Directors, Management	No specific policy developed at this time
Doctors Self-Referral “Stark”	COC-8217-10 / Self-Referral Prohibition (“Stark”)
Employee Relations & Equal Opportunity Employment	PRS-8371-101 / Equal Employment Opportunity PRS-8371-504 / Anti-Discrimination
Environmental Health & Safety	PO-8071-115 / Hazardous Material Handling PHA-7070-224 / Management of Controlled Substances for Inpatient and Housed Outpatient Use PRS-8371-512 / Drug Diversion Guidelines
Ethical Standards	GB-8311-B-16 / Corporate Ethics Statement
False Claims	COC-8217-22 / False Claims
Gifts	COC-8217-07 / Health Care Professional Courtesy Discounts COC-8217-15 / Gifts, Gratuities and Entertainment
Harassment	PRS-8371-511 / Workplace Violence Prevention Policy
Independent Contractors	LRM-8326-01 / Contracts
Inquiries to Government Payors	COC-8217-13 / Government Inspections & Investigations; Licensure and Accreditation Surveys COC-8217-16 / Government Relations – Dealing with Government Regulations & Employees
Marketing	No specific policy developed at this time
Non-retaliation	COC-8217-01 / Corporate Compliance Program COC-8217-02 / Corporate Compliance Communications Line / Whistle-Blowers / Non-Retaliation
Organizational Ethics	COC-8217-01 / Corporate Compliance Program MS-8030-14 / Health Care Ethics Committee Consultation
Patient Rights	GB-8311-02 / Patient Rights & Responsibilities
Performance Evaluations	PRS-8371-402 / Performance Appraisals and Pay for Performance
Political Activity & Contributions	COC-8217-11 / Tax-Exemption
Referrals for Business (Anti-kickback”)	COC-8217-08 / Anti-Kickback Prohibition COC-8217-09 / Anti-Kickback Safe Harbors COC-8217-18 / Ambulance Restocking
Research	IRB-8219-04 / Communication from the IRB IRB-8219-05 / Confidentiality / Anonymity of Human Subject Research Participation IRB-8219-08 / Criteria for Approval of Research IRB-8219-13 / Fee Policy for RCRH IRB IRB-8219-20 / IRB Training FilesIRB-8219-21 / Noncompliance IRB-8219-24 / IRB Requirements of the Submitting Investigator IRB-8219-29 / IRB Signatory Authority IRB-8219-37 / Quality Assurance MS-8030-8 / Scientific Misconduct And Reporting IRB-8219-06 / Conflict of Interest – Research IRB-8219-12 / IRB Expedited Review IRB-8219-19 / IRB Member and Staff Education IRB-8219-32 / Vulnerable Populations – Children IRB-8219-33 / Vulnerable Populations –Cognitively Impaired IRB-8219-36 / IRB Policies and Procedures Maintenance