Com­pli­ance

All forms of communications with the Compliance Office are held in the highest regard and strictly confidential.

Anyone may raise issues, concerns, and complaints anonymously when contacting the Compliance Office or reporting through the Hotline. Onslow Memorial Hospital utilizes this hotline to provide an avenue for employees or interested parties to report suspected inappropriate activity involving OMH or its employees or agents.

To assist in investigating any compliance concerns, providing sufficient information and some contact information allows the Compliance Office to follow up in a thorough manner. The Compliance Office will keep the reporting employee's identity confidential, to the fullest extent practicable and or allowed by law.

Retaliation is not permitted against anyone who seeks advice, raises a concern, or reports misconduct to the Compliance Office in good faith. Suspected retaliation should be reported immediately to the Compliance Office.

Please feel free to raise any Compliance-related questions and concerns by:

1. Contacting the OMH Compliance Office
   Compliance Officer: Erin Tallman (910) 577-4731
   Compliance Specialist: Amber Royer (910) 577-4817
   Emailing the Compliance Office at ComplicanceOffice@onslow.org
   
   Contacting the Privacy Office
   Phone: (984) 974-1069
   Email: privacy@unchealth.unc.edu
   
2. Voicing an anonymous concern through the Compliance Hotline
   Phone: 1-800-362-2921
   Online: hotline.unchealthcare.org
   
   
3. Mail questions or concerns to:
   Compliance Office, Onslow Memorial Hospital, 241 New River Drive, Jacksonville, NC 28545

As a reminder, the Hotline is open to callers 24 hours a day, 7 days a week.

The Code of Conduct is the foundation of our corporate culture and a key element of our Compliance Program. The purpose of the Code of Conduct is to reinforce Onslow Memorial Hospital's institutional values and serve as a guide for moral, ethical, and legal behavior throughout our entire organization. Adherence to the Code of Conduct promotes Onslow Memorial Hospital's reputation for integrity and honesty in our community, and also ensures that we are compliant with applicable laws, rules, and regulations. It is the responsibility of our workforce to read, understand, and abide by the Code of Conduct.

Any questions or concerns of potential violations of the Code of Conduct or applicable policies, laws, or regulations, must be reported to the supervisor, Compliance Office, or Compliance Hotline.

1. Demonstrate Honesty, Integrity, and Professionalism at all Times
2. Abide by the Code of Conduct and Applicable Laws, Regulations, Policies, and Procedures
3. Honor Patient's Rights
4. Provide Quality Care
5. Provide Medically Necessary Care
6. Preserve Confidentiality and Information Security
7. Use Social Media and Technology Responsibly
8. Support Diversity and Inclusion
9. Work Safely
10. Compete Fairly
11. Record and Report Information Appropriately
12. Document, Code, Bill, and Collect Appropriately
13. Do Not Do Business with Excluded Individuals or Entities
14. Cooperate with Inquires, Audits, and Investigations
15. Use Resources Responsibly
16. Conduct Political Activity and Fundraising Appropriately
17. Disclose and Appropriately Manage Conflicts of Interest
18. Prohibit Bribes, Kickbacks, or Payment for Referrals
19. Prohibit Certain Inducements Affecting Patient Choice
20. Report Compliance Concerns without Fear of Retaliation

The OMH Compliance Office authors, or assists other departments in authoring policies and procedures to address regulatory requirements, identified areas of risk, and ethical business practices.

Employees may access Compliance policies by visiting the Compliance Policies page of the OMH Intranet Site.

If you have any questions or are in need of further assistance, please do not hesitate to contact the Compliance Department for clarification.

OMH requires all new employees to attend mandatory compliance education presented during initial orientation and to complete the required education through our computer based learning management system. The Compliance Training and Education policy (available to employees through our Intranet page) outlines the timely completion of required Compliance training by all new workforce members.

As outline in the Compliance Training and Education policy (available to employees through our Intranet page), OMH requires all existing employees to complete mandatory annual compliance education and training as part of their condition of continued employment to allow staff to be aware of laws and regulations relating to corporate/professional ethics, and good business practices. No employee is exempt from this training.

Core compliance components covered during education and training:

• OMH Code of Conduct
• Conflict of Interest
• Review of OMH Compliance Program
• Fraud, Waste, and Abuse Precention
• Duty to Comply with Laws and Regulations
• Duty to Report Misconduct

Onslow Memorial Hospital would like to thank you for your partnership in helping us to provide excellent service to our community. As Non-Employees of OMH, you are required annually to complete our mandatory education outlining our Code of Conduct and additional compliance policies and procedures currently in place, and in the time-frame indicated below.

• Non-Employed Workforce Members:

This includes applicable volunteers, shadows, interns, students, and other UNC Health workforce members will be required to complete the annual mandatory compliance training through the online module below. This training must be completed before starting your role at OMH.

After submitting the attestation at the end of the module, learners (except for OMH volunteers) will receive an email confirmation that they should save for their records and also provide to their applicable supervisor, coordinator, head of their sponsoring department, or other individual responsible for tracking their training.

• Downstream Entities:

The Centers for Medicare and Medicaid Services (CMS), in its regulatory guidance, refers to our contracted partners as first-tier, downstream, and related entities (FDRs). OMH is required to effectively manage and oversee our FDRs that assist us in providing administrative and/or health care services to our Medicare beneficiaries.

As an FDR contracted to provide administrative or health care services for our Medicare patients, you are required, within 90 days of hire and annually, to complete the mandatory compliance education outlining our Code of Conduct and additional compliance policies and procedures currently in place.

Both Non-Employed Workforce Members and Downstream Entities (FDR), please complete the following steps to ensure a compliant and effective onboarding process:

1. Complete the mandatory compliance education by clicking here: https://ncstoragemlunchealthcare.blob.core.windows.net/public/2023_Web_Annual_Training_for_Non_Employees/story.html
2. Once you’ve completed the education, you will be prompted to complete an attestation. Please ensure that you’re selecting “ONSLOW MEMORIAL HOSPTIAL” as your entity.
3. Upon completion of the attestation, you will be prompted to enter an email address in order to receive a copy of your attestation. You are responsible for providing a copy of the attestation to your employer/contractor. We advise that you also retain a copy for your personal records.
4. Education for Non-Employees must be completed before beginning any role with OMH and education for Downstream Entities must be completed within 90 days of hire, and annually thereafter.

QUESTIONS?

For any compliance related questions or concerns, please contact the Compliance Office at (910) 577-4731, (910) 577-4817 or via email at ComplianceOffice@onslow.org.

The OMH Compliance Program is oversen by the Finance and Compliance Committee of the Board of Directors.

The Compliance Program is administered by the Compliance Office, and led by OMH Compliance Officer, who is responsible for administering the program with the support of the Compliance Coordinator. Together, they are responsible for the day-to-day implementation of the Compliance Program.

The Compliance Program received support from the Executive Leadership, the Compliance Committee, and applicable UNC Roundtables.

The Compliance Office does not make operational decisions, but is available to advise and assist with applicable policies, rules, and regulations. Do not hesitate to reach out to the Compliance Office with questions or concerns.

The OMH Compliance Office creates an annual audit work plan, based upon a risk assessment, to guide Compliance monitoring and auditing activities throughout the organization.

A risk assessment is conducted prior to each topic being added to the work plan and helps determine overall risk or vulnerability areas to the organizations. Factors considered in our risk assessment include financial, regulatory, operational, likelihood, inherent complexity, and exiting environment of controls.

The annual work plan is reviewed and approved by the Compliance Officer as well as the Finance and Compliance Committee of the Board of Directors.

The Compliance audit process is a collaboration with operational key stakeholders across the organization. Throughout the process we conduct internal and external fact finding missions, review patient medical records, discuss any identified opportunities for improvement with key stakeholders, and make recommendations for improvement which is aimed at reducing the level of risk in a certain area or service. We wrap up the process with a thorough findings report which is communicated to key stakeholders as well as key senior leaders. The goals of our audit work plan efforts are communication, transparency, and action.

The Compliance Office will make appropriate inquiries, investigations, and reports when it becomes aware of potential violations of the Code of Conduct, laws, regulations, or Onslow Memorial Hospital policies and procedures.

As appropriate, the Compliance Office will report potential and actual violations to relevant parties, such as an employee's supervisor or department head, the Chief Medical Officer, Patient Advocacy, Human Resources, the Privacy Office, or government regulators.

Where appropriate, corrective action may be taken to address violations, in accordance with applicable policies or bylaws.

The Compliance Office will retain a summary of the event, the Compliance Office's investigation, the final action taken, and other appropriate documentation.

Deficiencies may be detected through auditing and monitoring, Hotline calls, and other processes. Potential deficiencies reported to the Compliance Office will be promptly investigated and referred to other parties, as appropriate.

The Compliance Office reports to the appropriate manager or executive any concerns to be addressed or errors to be corrected, with recommended actions, as applicable. Recommended actions may include: revising policies and procedures, developing and implementing training, undertaking discipline/corrective action, and disclosing and returning over payments to government or private payers.

All activities and actions taken to correct deficiencies will be documented.