COMMUNCATING COMPLIANCE CONCERNS

Non-Retaliation and Confidentiality

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

Anyone may raise issues, concerns, and ocmplaints 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.

Reporting Concerns

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 Coordinator: Michelle Benitez (910) 577-4817
   Emailing the Compliance Office at ComplicanceOffice@onslow.org
    
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.

CODE OF CONDUCT

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.

Standards of the Code of Conduct

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

Compliance Policies

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.

TRAINING & EDUCATION

Onslow Memorial Hospital recognizes that education and training is criticla to an effective Compliance Program

New Employees

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.

Existing Employees

As outline in the Compliance Training and Education policy (available to employees through our Intranet page), OMH requires all existing exmployees 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 ecempt from this training.

Education & 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

OVERSIGHT

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.

AUDITING & MONITORING

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.