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Corporate Compliance

VCU Health Community Memorial Hospital CORPORATE COMPLIANCE PROGRAM
 
I.  CORPORATE COMPLIANCE PROGRAM INTRODUCTION: 
In keeping with the mission of VCU Health Community Memorial Hospital, (hereafter sometimes referred as "CMH"), which is “striving for excellence in the delivery of healthcare”  and upon the direction of the Board of Trustees of CMH, this Corporate Compliance Program (the “Program”) has been developed.  It is CMH’s goal to strengthen the reputation of conducting itself in accordance with appropriate business ethics in compliance with applicable laws.  Because the healthcare regulatory environment is evolving at a rapid pace, CMH is committed to maintaining this reputation by enforcing facility-wide standards of ethics, efficiency, and conduct.  The Program is meant to consolidate the ethical and professional standards already required by CMH.   At CMH, compliance efforts are designed to strengthen a culture that promotes prevention, detection and resolution of instances of conduct that do not conform to federal and state law and federal, state and private payor healthcare program requirements, or other regulations,  as well as, CMH's code of conduct and policies.  This Program will provide a clear mandate for all employees to follow.  

II.   OVERVIEW AND PURPOSE OF THE COMPLIANCE  
 
CMH has long been committed to full compliance with the letter and spirit of all applicable federal, state, and local laws.  CMH has been committed to implementing regulations, which are essential to the advancement of its healthcare mission.  Because of these commitments, CMH strives to prevent non-compliance.  Pursuant to these commitments, CMH shall establish and maintain an effective Program.  CMH demands that any and all compliance issues or concerns be raised and promptly resolved.  The Program as described in this plan and as practiced by CMH enforces this demand.  The Program shall focus on prevention and detection of violations of federal, state, and local laws or regulations.

CMH’s Program shall be maintained under the authority of the VCU Health Community Memorial Hospital Board of Trustees.   The daily oversight of operations of the program will be performed by the Corporate Compliance Officer (the “Compliance Officer”), with guidance from the Corporate Compliance Committee (the “Committee”).

III.   COMPONENTS OF THE CORPORATE COMPLIANCE
 
CMH has adopted a policy of corporate responsibility and will require board members, officers, employees, volunteers, agents and contractors of CMH to comply with business and professional standards of conduct; federal, state and local laws and regulations; standards of accrediting bodies; and tenets of good corporate citizenship.

CMH will operate the Program with overall responsibility for the development, implementation and operation of the Program assigned to a Compliance Officer as appointed by the Chief Executive Officer of CMH and approved by the CMH Board of Trustees.  The Compliance Officer will have direct access to the Chief Executive Officer of CMH and its Board of Trustees. 
CMH’s Program contains the following key elements:  
  1. Adoption of a policy of compliance with business and professional standards of conduct, federal, state and local laws and regulations, standards of accrediting bodies and tenets of good corporate citizenship.
  2. Development of written compliance objectives to be followed by board members, officers, employees, volunteers, agents and contractors of CMH which incorporate business and professional standards of conduct, federal, state and local laws and regulations and standards of accrediting bodies and which outline tenets of good corporate citizenship and which specifically include policies regarding CMH’s commitment to accurate billing consistent with published Medicare and Medicaid regulations and procedures and applicable guidelines.
  3. Appointment  by the President/CEO of VCU Health Community Memorial Hospital a Compliance Officer and establishment of a Corporate Compliance Committee for approval by the Board of Trustees of CMH.
  4. Development of communication and education procedures including the posting and distribution of information concerning the Program to all board members, officers, employees, agents and contractors and providing at least one hour of training regarding CMH’s Program to each board member, officer, volunteer and employee of CMH.
  5. Development of a specialized education program for all employees involved in preparing and submitting Medicare and Medicaid bills which includes annual training in billing standards and procedures and an overview of the consequences of failing to comply with such standards and procedures.
  6. Implementation of a system of monitoring, auditing and reviewing of the Program procedures and the information and statistics compiled through the Program which will include an assessment of potential exposure to various business and operational practices and recommendations of the Corporate Compliance Committee with respect to action to be taken.
  7. Development of procedures for disclosure, reporting and corrective action.
  8. A requirement that quarterly reports regarding the operation of the Program is made to the Board of Trustees of CMH.
  9. Engagement of independent contractor(s) to perform an annual review of CMH’s Program and CMH’s compliance with the Program objectives which includes a review of the billing policies, procedures and practices of CMH.
  10. As part of its compliance policy, CMH will not knowingly employ, with or without pay, an individual or entity that is listed by a federal agency as debarred, suspended or otherwise ineligible for federal programs and will remove an individual or entity who has been debarred, suspended or is otherwise ineligible for federal programs from responsibility for or involvement with any Medicare or Medicaid billing function.
IV. CORPORATE COMPLIANCE COMMITTEE:

The Corporate Compliance Committee is designated to provide overall direction, implementation, and supervision of the requirements of the Program.  The Corporate Compliance Committee is composed of the following members: Corporate Compliance Officer, Vice President Finance, HIPPA Privacy Officer, HIPPA Security Officer and CMH Board Members.  Additional Healthcenter personnel will participate in the committee’s work.

The Corporate Compliance Committee will be chaired by a CMH Board member.  The Corporate Compliance Officer is responsible for designing policies and procedures to assure ethical and legal compliance.  All polices developed by the Compliance Committee are subject to CMH Board of Trustees approval.  The Corporate Compliance Committee meets, at a minimum, on a quarterly basis. Minutes are maintained for each meeting.  The Corporate Compliance Committee has the responsibility to periodically update the Program and distribute memorandums and/or policy statements updating provisions of the Program.

The Corporate Compliance Committee may delegate duties to other subcommittees of the Corporate Compliance Committee, which may include other staff of CMH.
 
The Corporate Compliance Committee shall be responsible for the following:
  1. Oversight in the development and implementation of CMH’s Program.
  2. Providing continuing guidance with regard to the operation of CMH’s Program.
  3. Evaluating the results of CMH’s annual Program Audit.
  4. Determining annual Focus Areas for utilization in CMH’s Program.
  5. Reviewing reports of disclosures, reports and other communications obtained   through CMH’s Programs.
  6. Review and selection of compliance objectives
  7. Review of Program Policies
  8. Review recommendations for corrective action  
V.   CORPORATE COMPLIANCE OFFICER  
 
The CMH Program will be maintained and operated by the Compliance Officer. The Compliance Officer will be appointed by the Chief Executive Officer of VCU Health Community Memorial Hospital and approved by the Board of Trustees of VCU Health Community Memorial Hospital . If the Compliance Officer is on vacation or otherwise unavailable, the duties of the Compliance Officer will be performed by the Chief Executive Officer of CMH  or another individual as may be designated by the Chief Executive Officer of CMH.

The Compliance Officer shall be responsible for the following:
  1. The development, implementation and maintenance of the program.
  2. Operational review of the program and related audits and reports.
  3. Preparation of reports to CMH Board of Directors, the Corporate Compliance Committee, other Hospital committees and CMH administration.
  4. The development of educational requirements of the Program.
  5. The monitoring of new laws, regulations and trends with regard to corporate compliance activities.
  6. Investigation of disclosures, reports or other communications made by employees, agents or contractors and investigation of issues discovered through the annual Program monitoring activities.
  7. Reviewing audits and reports prepared by independent contractor(s).
  8. Organization and maintenance of all documentation regarding Program activities.
  9. Other duties as assigned by the CMH Board of Trustees.
VI.   RESPONSIBILITIES OF MANAGEMENT:
 
All levels of management have the primary responsibility to set CMH’s standard for compliance.  Directors/managers serve as the primary example for, and an important source of information to, CMH’s employees.  Directors/managers must communicate the importance of compliance to every employee and actively promote adherence to the compliance program.  Informally, directors/managers must foster open communications about compliance and must direct all questions raised by employees to the Corporate Compliance Committee.  Certain directors/managers will be called upon to give formal presentations to employees explaining the compliance program and instructing employees how to deal with various compliance related issues.

Directors/managers have an affirmative duty to fully understand the compliance program and to ask any and all questions to clarify their obligations and the obligation of those employees they manage.  No director/manager will be excused based on a claim of ignorance or good intentions.  Directors/managers who fail to comply with these obligations may be terminated or otherwise disciplined.

All directors/managers must ensure that all actual or potential compliance issues are reported to the Corporate Compliance Committee.  In addition, all directors/managers must be accessible to employees who wish to report compliance issues.  Directors/managers also have the responsibility to ensure that no employee is retaliated against, in any way, for reporting a compliance issue.  
 
Directors/managers are equally accountable for their own actions as well as the action of the employees that they supervise.  Each director/manager will annually certify that the director/manager has reviewed the compliance program and that the director/manager fully understands it. 
Additionally, each director/manager's efforts toward implementing the compliance program will be evaluated annually as part of their annual performance evaluation.  The director/manager's performance rating will reflect, in part, the success of these efforts. Each director/manager must create an atmosphere that encourages compliance and fosters reporting of non-compliance as well as seeking the assistance of the Corporate Compliance Committee whenever necessary.

RESPONSIBILITY OF EMPLOYEES WITH ADHERENCE TO CORPORATE COMPLIANCE MISSION    
      
CMH continually strives to provide a high level of care and service in a professional and ethical manner.  The Program is integral to the achievement of these goals.  It is critical that all employees of CMH understand the Program and their individual responsibility to personally adhere to the guidelines set forth in this plan and to actively participate in and promote the Program as representatives of CMH.  An evaluation of each employee's performance in these areas will be conducted annually as part of that employee's performance evaluation. CMH is committed to creating an atmosphere to encourage all employees to actively participate in accomplishing system-wide compliance.  The standards of conduct described in this plan cannot, nor were they intended to, cover every situation which CMH employees encounter.  When the best course of action is unclear, or if a CMH employee observes a violation of these standards, employees are required to seek the guidance of or report the violations to any member of the Corporate Compliance Committee.  Adherence to the Program is of the utmost importance. If a CMH employee has suggestions for improvements to the Program outlined in this Plan, the employee may phone any member of the Corporate Compliance Committee or put a note in the Corporate Compliance Suggestion Box located in the hall near Medical Records or by phoning the Healthcare Ethicsline at 1-800-340-5877 or send an e-mail to: complianceofficer@cmh-sh.org.

CREATING THE CORPORATE CULTURE
  
Creating and reinforcing a corporate culture that embraces compliance is of utmost importance for the CMH Board of Trustees.  This culture will thrive only if employees learn about the compliance program and have access to it.  Therefore, in addition to providing ample compliance training, CMH guarantees access to the compliance program.  Employees will have multiple access points, including the Corporate Compliance Committee, the suggestion box, hotline, e-mail and several different management-level employees to whom they may make reports.  The employees will regularly be reminded of these numerous access points and urged to raise any and all compliance concerns. 

CMH’s COMMITMENT
 
CMH is committed to ensuring that the Program is fully implemented.  A comprehensive educational program will be provided upon orientation and annually thereafter to all employees, volunteers, board members, and medical staff. Each employee must know what is expected by the Program, abide by these expectations, and be sensitive to situations that could lead employees or others to violate these expectations.  CMH will do everything reasonable to convey clearly each employee's responsibilities.  If any employee is unclear as to the employee's obligation under the compliance program, the employee must seek out clarification from Corporate Compliance Officer or by the use of the suggestion box, e-mail or Hotline.
  
The effectiveness of the Program depends on each employee's willingness to bring all compliance issues to the attention of the employee' director or manager.  If an employee is unsure as to whether or not a particular situation raises a compliance issue, they are instructed to err on the side of caution by reporting it.  In other words, when in doubt, point it out!
 
VII.   IDENTIFYING OF FOCUS AREAS:

The Corporate Compliance Committee shall develop a process to identify those areas where there is a substantial risk that certain types of unauthorized unintended conduct might occur in violation of applicable state or federal law and prioritize areas for the purpose of establishing standards for ethical and legal compliance.  Certain areas of business (physician practices, laboratory, home health, hospice, nursing home, medical records, and human resources) have specific published guidance materials that identify areas where significant risk may occur.  Guidance for these areas include, but are not limited to, Medicare and Medicaid, fraud and abuse, antitrust, STARK, OSHA, HCQIA, HIPPA, ADA, COBRA, licensure, wage and hour laws,sexual harassment, medical staff credentialing, environmental issues, conflicts of interest, corporate record maintenance, and tax exempt status.  

As part of the Program, the Compliance Officer and the Compliance Committee will develop annual Focus Areas to give direction to the Program and to provide the foundation for the development of Program Compliance Objectives. These Focus Areas will reflect the results of the annual assessment of the Program monitoring and audit activities.

VIII.   DEVELOPMENT OF COMPLIANCE OBJECTIVES

CMH will develop Compliance Objectives for each Focus Area. “Compliance Objectives” are those departmental policies and procedures which reference business and professional standards of conduct, federal, state and local laws and regulations, standards of accrediting bodies and which provide guidance to board members, officers, employees, agents and contractors with regard to standards of conduct. The Compliance Officer and representatives of the department or areas whose activities relate to the Focus Areas will develop compliance objectives for CMH Focus Areas.  The Compliance Committee will review reports from the Focus Areas regarding their objectives on a quarterly basis.  In addition, the Compliance Committee will review and up-date the Focus Areas and corresponding compliance objectives on an annual basis.

IX.   DEVELOPMENT OF EDUCATION AND TRAINING:  

CMH will develop, implement and maintain a comprehensive Education Program to ensure communication and understanding of the purpose of CMH’s Program and the standards and procedures to be followed. The Education Program is designed to heighten the awareness of the benefits and the operation of the Program as well as to promote the understanding by board members, officers, employees, volunteers, agents and contractors of the responsibilities, process and underlying policies addressed by the Program.

The following procedures will be followed with regard to the Education Program:
  1. CMH will require at least one hour of training of all new and current employees and the members of the Board of Directors of CMH with regard to the purpose and operation of CMH’s Program, a review of the Program and Program Compliance Objectives and an overview of the consequences which may result from a violation of such compliance objectives.
  2. All new employees will receive Program training during orientation.
  3. All current employees will receive Program training on an annual basis on a schedule to be developed by the Educational Services Department.
  4. Members of the  Board of Directors of CMH will be trained annually by the Compliance Officer.  
  5. Agents and contractors will be informed of CMH’s Program through contract provisions and written statements distributed at the time the agent or contractor provides services to CMH.
  6. Employees who are involved in preparing or submitting bills through CMH will receive comprehensive training regarding their area of responsibility. The training program will provide for sufficient and adequate training in billing standards and procedures, an overview of the personal obligation of each employee for the accuracy of billing, examples of improper billing practices and the legal sanctions which could be imposed for improper billing practices. CMH will require contractors who prepare or submit bills to provide their employees with comprehensive training regarding their area of responsibility.
  7. CMH will produce and distribute Program training materials.
  8. CMH will publicize CMH’s Program through announcements, postings, publications and other communication outlets.     
  9. CMH will update the Education Program as necessary but will review the Education Program at least once per year and amend as necessary.  
X.  DISCLOSURE PROCEDURES

CMH will develop a mechanism for employees, agents and contractors of CMH to disclose to CMH information relating to the Program, including potential violations of policies, procedures and compliance objectives. These disclosure procedures include a reporting system by which any employee, agent or contractor may seek guidance or disclose information regarding potential violations without any threat of retribution from CMH. This policy also provides employees and agents with a clear process and guidelines for reporting potential violations or issues through the Program.  
 
Each employee will be required to sign a statement certifying that they have received, read and understand the standards of conduct upon employment and annually.

Each employee is responsible for ensuring that the standards contained in the Code of Conduct are met.  This Code of Conduct is a statement of standards of conduct for all affected employees and clearly delineates the commitment to compliance by senior management and directors.  This includes the responsibility to report violations or suspected violations of the Code of Conduct.  Compliance issues are to be raised first with the Compliance Officer or a member of CMH’s Management.  Alternatively, suspected compliance violations may be reported by writing the Compliance Officer,   and placing in suggestion box or by calling the Healthcare Ethicsline at 1-800-340-5877 or email to complianceofficer@cmh-sh.org.  There shall be NO retaliation or retribution of any kind following the good faith reporting of a violation or suspected violation.  Any CMH supervisor, manager, or employee who conducts or condones retaliation or retribution will be subject to discipline, up to and including discharge.   
  1. Methods of Disclosure
    • Each employee, agent and contractor of CMH has the right and the responsibility to discuss and report violations or potential future violations of the policies, procedures and Compliance Objectives of the Hospital or the Program.
    • Employees are encouraged to contact their supervisors with any questions or concerns regarding compliance with CMH policies, procedures, Compliance Objectives or the Program.
    • Employees who have discussed their questions or concerns with their supervisor and who are not satisfied that their question or concern has been adequately addressed or answered should contact the next management level and inform such individual of their questions and concerns. 
    • Employees who are unable to resolve their questions or concerns at the next management level or who are uncomfortable speaking with their supervisors or other members of management should contact the Compliance Officer directly or a member of the Committee.  
    • Agents or contractors of CMH should contact an individual in management who is associated with the agents’ duties.  If agents or contractors are unable to resolve their questions with a representative of the management or who are unable to identify the appropriate individual to address their concern, should contact the Compliance Officer directly or a member of the Committee.
    • Employees, agents and contractors with questions or concerns should be prepared to provide as much information as possible to their supervisor, manager or the Compliance Officer regarding the issue. Employees and agents should also be specific in their questions and concerns and note details such as dates, times and situations when relating questions and concerns.  
    • All board members, officers, employees, volunteers, agents and contractors are encouraged to use resources within the hospital, such as the Human Resources Department, Administration, Materials Management Department to address questions or obtain additional information regarding issues of concern to the employees, volunteers, agents or contractors.
    • Board members, officers, employees, agents and contractors may contact the Compliance Officer by one of the following methods:  
      • Healthcare Ethicsline - The Healthcare Ethicsline (1-800-340-5877) will be a phone line dedicated to questions, issues and concerns relating to the Program and compliance with CMH policies, procedures and compliance objectives. The phone line will be staffed twenty-four hours per day. Callers will be instructed on how to leave a message for the Compliance Officer, how the Compliance Officer will contact them with regard to their call and additional information.
      • E-Mail - E-mail address complianceofficer@cmh-sh.org will be established for the Compliance Officer and employees, agents and contractors may leave e-mail messages regarding questions, issues and concerns relating to the Program and compliance with CMH policies, procedures and compliance objectives.  
      • In-Person Meeting - Any board members, officers, employee, agent or contractor may request a confidential meeting with the Compliance Officer for the purpose of communicating questions, issues and concerns relating to the Program and compliance with CMH policies, procedures and compliance objectives. Employees, agents and contractors should contact the Compliance Officer directly to schedule an appointment.  
    • CMH will ensure that board members, officers, employees, volunteers, agents and contractors have methods of disclosure, which allow the appropriate protection of the identity of the employee, agent or contractor. CMH will make every attempt to keep the identity of the employee, volunteer agent and contractor confidential but reserves the right to disclose the identity of the employee, agent or contractor or information if required in the course of the investigation of the disclosure or communication.
    • Methods of disclosure will be communicated to board members, officers, employees, volunteers agents and contractors through educational sessions in the orientation process, continuing education relating to the Program, newsletters and other written information and posting throughout CMH.  
  2. Follow-up on Disclosures  
    • All information received through any disclosure method will be recorded in a compliance log. Where the board member, officer, employee, volunteer, agent or contractor making the disclosure has been identified, the Compliance Officer will acknowledge the receipt of the disclosure either verbally or in writing at the discretion of the Compliance Officer.
    • In order to ensure confidentiality and to protect the rights of board members, officers, employees, agents and contractors, actions taken by the Compliance Officer will not be disclosed or publicized. Employees and agents who make disclosures will be informed of the investigation process and assured that the information will be acted on appropriately, but will not be informed of the actions taken by the Compliance Officer or Compliance Committee.  
XI.  INVESTIGATION PROCEDURES

The Corporate Compliance Committee will provide oversight for investigations and employee interviews to ensure that CMH’s compliance polices practices and procedures are evaluated and to ensure the implementation of appropriate corrective action.

The Corporate Compliance Committee will ensure that reasonable steps are taken to respond appropriately to business ethics and compliance violations, to discipline violators and to put corrective action plans in place that will prevent future similar violations.

The Compliance Officer and the Corporate Compliance Committee will ensure that processes are maintained to provide guidance for adherence to CMH’s business ethics and legal compliance policies and procedures, and for reporting and investigating business practices.  A reporting system shall be in place whereby employees may report suspected violations.  A detailed report, follow-up, and outcome will be recorded and maintained by the Compliance Officer.  The Compliance Officer and the Committee will be responsible for coordinating and overseeing appropriate internal audits and surveys to verify adherence to, and awareness of the Program.  
             
The Corporate Compliance Committee will oversee appropriate investigations of business ethics and compliance policy violations to ensure consistency in the enforcement of CMH’s policies and procedures.  The Compliance Officer will provide follow-up of the investigation brought before the Compliance Committee.  Employees and physicians who may wish advice on certain policies and procedures are encouraged to utilize the appropriate reporting structure or consult with the Compliance Officer or any Compliance Committee member.

Each employee must report all actual or suspected Program violations or compliance concerns.  These reports are to be made to the Compliance Officer or Committee by contacting a member of the committee directly or by use of the Corporate Compliance Suggestion Box, e-mail complianceofficer@cmh-sh.org or by phoning the Healthcare Ethicsline at 1-800-340-5877.

CMH absolutely prohibits retaliation against any employee who makes a good faith report of a compliance issue.  If deemed necessary, an employee may make an anonymous corporate compliance report.  Intentionally false reports or reports made with malice intent that are subsequently determined to be unfound, may be dealt with through CMH’s disciplinary action policies.
 
CMH has established procedures for the investigation of disclosures made through the Program Disclosure Procedures.  Such disclosures will be logged, tracked and investigated by the Compliance Officer according to the procedures outlined in this policy.  

XII.  CORRECTIVE ACTION UPON DETERMINATION OF VIOLATION
CMH will respond to any violation or potential violations of policies, procedures and protocols, federal, state or local laws or regulations, standards or guidelines of any accrediting body or the policies or procedures of the Program detected or reported through the Program and institute corrective action to prevent similar violations and to appropriately evaluate and correct the violation.

The following procedures will be followed with regard to corrective action:  
  1. Board Member, Employee, Agent and Contractor Discipline
    • In the event that it is determined that a Board member has violated the Program, a report will be made to the Board of Trustees of CMH or any entity to which the Board Member belongs.  The Board of Trustees of the entity to which the Board member belongs will take such action as is appropriate under the circumstances.
    • Employees who are determined to have violated any Compliance Objective, violated the Program or who have failed to detect a violation or potential violation will be subject to discipline in accordance with the appropriate policy.
    • Each employee disciplinary action will be documented in accordance with Human Resource Department policy and will be documented in the Compliance Officer’s files. All disciplinary actions will remain confidential.      
    • Agents or contractors who are determined to have violated any Compliance Objective or  the Program will be disciplined in accordance to the parameters of the agent’s or contractor’s duties and relationship to CMH or in accordance with any contract provisions.
  2. Corrective Action
    • After an offense or violation has been detected, the Compliance Officer will institute steps to prevent the reoccurrence of the violation and make necessary modifications to the Compliance Objectives or the Program.
  3. Reporting of Discipline and Corrective Action
    • All disciplinary actions and corrective action made under the Program will be reported to the Corporate Compliance Committee.
    • A summary of all disciplinary actions and corrective action will be included in the quarterly reports of the Program to the Board of Trustees of VCU Health Community Memorial Hospital.
XIII.   MONITORING, AUDITING AND REVIEW PROCEDURES 

The Program will provide for the development of monitoring and reviewing systems designed to detect any ethical violations or any unauthorized unintended conduct that might occur in violation of state or federal law.  The Corporate Compliance officer, with the assistance of the Compliance Committee, will develop and implement systems for identification of risk (Focus Areas). The Committee will develop monitoring procedures to assist in ensuring that appropriate compliance procedures are followed.  These will include an initial review with periodic use of reviews and/or other evaluation techniques to monitor compliance and assist in the reduction of identified problem areas.  All identified areas of non-compliance will be investigated and action plans will be implemented to correct the areas of non-compliance.  The Compliance Committee will be responsible for overseeing appropriate internal audits and surveys to verify adherence to, and awareness of the compliance plan.  The committee will oversee appropriate investigations of business ethics and compliance policy violations to ensure consistency in the enforcement of CMH’s policies and procedures.    
         
XIV.   COMPLIANCE IN ACTION: 
 
While the foregoing sections of this plan set forth the Program's "big picture" they are not intended to be exhaustive in their content but rather provide an overview of those provisions of the Program that are universally applicable.  As individual policies and protocols are developed for each particularized area of CMH and will be disseminated to the appropriate personnel to whom they apply and incorporated into CMH’s Program. 
Employees must use the Program policies, along with their independent judgment; to ensure that any and all compliance issues are properly submitted to the Program for resolution.  
 
XV.   DOCUMENT RETENTION

CMH will institute a comprehensive document retention policy as part of the Program. All documents, including contracts, medical records, financial information and computer tapes and electronic information will be included in the policy.  The policy will define that information, which will be considered “records” and will establish schedules for the maintenance and destruction of documents The policy shall also address retention for the Program’s related documents.

The following procedures will be followed with regard to document retention:
  1. All records will be maintained for the minimum retention periods required by applicable federal, state or local laws or regulations, standards of any accrediting body or good record-keeping practice.  
  2. If federal, state or local law does not mandate retention requirements; records will be maintained for retention periods that will ensure the availability of the records when required or in accordance with the standards of an accrediting body or good record-keeping practice.  
  3. Specific guidelines will be developed in connection with the creation,
    distribution, storage, retrieval and security of each record.
  4. All records relating to the operation of the Program will be retained for five years.  
  
Updated 2/13/06