CCHS Board Adopts New Compliance Plan

DAYTON-The Columbia County Health System Board of Commissioners formally adopted a new District Compliance Plan at their monthly meeting on Sept. 29.

CCHS Chief Executive Officer Shane McGuire publically thanked Chief Compliance Officer Cheryl Skiffington for all the work that went into the plan.

"This is a milestone moment. We are excited to get it out to our staff," McGuire told the commissioners.

In a separate interview Skiffington said, "We had been operating with a previous plan that needed a lot of work. It was not efficient, had outdated references, and it didn't read well."

Skiffington explained that the compliance plan is a written standard of conduct for all employees who provide direct patient care, and for ancillary service representatives as well. She said the plan requires an understanding and commitment to following all county, state and federal regulations regarding the standards outlined in the plan.

The 29-page document covers such ethical issues such as billing payers for incorrect amounts, changing claims to get higher reimbursements, and accepting gratuities from patients, Skiffington said.

Testing and monitoring are also a big part of the plan.

Skiffington said systematic checks are being performed in all departments, and that an audit was recently conducted of the Physical Therapy Department to determine whether there were any administrative deficiencies.

A recent risk audit of CCHS security systems uncovered several potential problems, pointing to the importance of staff education and training, which is also a requirement of the plan, Skiffington said.

Ensuring that all departments are in compliance with HIPAA, the federal patient privacy act, is a top priority as well, Skiffington said.

Some of the security issues brought to light by the risk audit underscore the importance of locking cabinets and maintaining secure shredding bins in the medical records department, developing business associate agreements with vendors to protect patient information, requiring company cell phones to use a PIN, and encrypting e-mail, Skiffington said.

"This was a good learning experience for us," Skiffington said.

In the meantime, Human Resources Manager Steve Stahl has implemented a digital training course for employees to take, and it covers such topics as customer protocol and security, with new modules added every year, Skiffington said.

Disciplinary action against those who violate the compliance policies is also addressed in the plan.

A 24-hour hotline for anonymous reporting of suspected misconduct has recently been implemented so that those who report can do so without fear of retaliation, she said.

Skiffington said she is required to meet with the nine-member compliance committee on a monthly basis to continue working on the plan's design and implementation, and ongoing review of it.

Prior to its adoption, the District Compliance Plan was "heavily reviewed" by the commissioners, and by attorney Kim Boggs, and it will be reviewed by the board annually, as required, Skiffington said.