This program promotes a culture of integrity; supports compliance with applicable laws, regulations, and payer requirements; protects residents and patients; and prevents, detects, and corrects non-compliance, fraud, waste, and abuse.
All personnel must comply with our Code of Conduct, including requirements related to:
New-hire and annual training cover the Code of Conduct, HIPAA, fraud/waste/abuse (FWA), documentation and billing rules, resident rights, and reporting mechanisms. Attendance and completion are tracked.
We maintain multiple channels for good-faith reporting, available 24/7 and allowing anonymous reports where permitted:
Retaliation for raising a concern or participating in an investigation is prohibited.
All credible allegations are assessed promptly, confidentially, and impartially. Corrective actions may include education, process remediation, repayment, disclosure when appropriate, disciplinary measures, and monitoring to verify sustained improvement.
Risk-based audits are performed on clinical documentation, MDS/RAI, therapy services, medical necessity, billing and claims, cost reports, vendor arrangements, exclusion screening, and HIPAA safeguards. Findings are documented, trended, and reported to leadership.
We implement administrative, physical, and technical safeguards; minimum necessary standards; access controls; encryption where appropriate;
workforce training; business associate agreements; and breach response procedures, including individual and regulatory notifications when required.
All financial relationships with referring providers and vendors must be in written agreements reflecting fair market value and legitimate business needs. Arrangements are reviewed for compliance with applicable fraud and abuse laws, and parties are screened against exclusion lists.
We uphold resident autonomy, informed consent, grievance rights, visitation, freedom from abuse and neglect, and individualized plans of care. Quality metrics and incident reports are reviewed for trends and corrective action.
Subpoenas, audits, and requests from government or accreditation bodies must be immediately forwarded to the Compliance Officer and Legal Counsel. Records are preserved; staff cooperate fully and professionally.
Records are retained according to federal and state requirements and our retention schedule. Destruction holds are implemented promptly upon notice of an investigation or litigation.
At least annually, we evaluate the effectiveness of the compliance program, including risk assessments, policy updates, training content, audit scopes, and reporting statistics.
All workforce members must acknowledge receipt and understanding of this policy and the Code of Conduct as a condition of employment or engagement.
