I. POLICY
The Compliance & Ethics Program applies to all Aspen-affiliated entities.
II. DESCRIPTION
1. Compliance & Ethics Program. The Quality Assurance and Compliance Committee (“QA&C Committee”) of Aspen outlining the responsibilities of management, including the Chief Compliance Officer, for maintaining ethical business standards.
2. Administrative Responsibilities. Responsibility for managing the Compliance & Ethics Program is assigned to the Chief Compliance Officer. The Chief Compliance Officer reports on significant compliance efforts and identified compliance issues to the QA&C Committee. The Compliance Officer is responsible for the following:
a. Chairing the Compliance Committee and conducting regular meetings
b. Collaborating with operational and executive management in the review, revision, and formulation of policies, procedures, practices, and controls to guide activities and functions of the Company that involve issues of compliance
c. Regularly reviewing and updating of the Code of Conduct with the assistance of the HR Department
d. Assisting operations and resources in the development of educational and training programs and the tracking thereof
e. Ensuring that training occurs and is available so that employees and contractors are aware of the requirements in the Code of Conduct
f. Leading investigations of suspected noncompliance
g. Developing and monitoring corrective action plans and ensuring that any remedial action necessary occurs
h. Revising compliance program, monitoring activities or controls as necessary in response to incidents of noncompliance
i. Responding to compliance-related inquires of external auditors and reviewing bodies
j. Assisting with, implementing, overseeing, and documenting organizational compliance initiatives and efforts
The Compliance Officer is supported by a Compliance Team composed of professionals in the areas of Nursing, Therapy, MDS, Coding, and HIPAA.
3. Compliance Committee. The Compliance Committee members are representative of clinical and administrative service personnel. The Compliance Committee meets no less than quarterly and acts as a steering committee to the Chief Compliance Officer. The Compliance Committee shall
a. recommend, develop, and monitor policies, procedures, practices, and controls to carry out the organization’s standards and operations;
b. develop strategies to promote compliance and detect potential risk areas;
c. assist with the development of preventative and corrective action plans;
d. evaluate systems; and
e. monitor the findings of external and internal reviews for the purpose of identifying risk areas or deficient systems requiring preventative, corrective, or remedial action.
4. Policies & Procedures. Processes necessary to achieve compliance are contained in existing policies and procedures (e.g., Accounting, Clinical/Nursing, Therapy, MDS). Such policies and procedures are periodically reviewed. In addition, compliance-specific policies and procedures are maintained on the Aspen Portal by the Compliance Team to educate and guide operations in areas of regulatory and ethical compliance.
5. Education & Training. The Chief Compliance Officer, along with the HR Department, is responsible for creating a Code of Conduct and disseminating training on the standards set forth in the Code of Conduct.
6. Monitoring. High-risk areas are monitored by testing controls and reviewing claims. Regularly scheduled assessments performed by area resources of all subsidiaries’ billing, therapy, nursing, MDS, and medical records functions test whether compliance controls are effective. Area resources are responsible for performing assessments regularly and as needed. The results of resource monitoring are reviewed by the Compliance Team. Monitoring results are used to identify areas for additional training and also serve as a factor in the Compliance Team’s determination of which subsidiary locations should be subject to internal audit.
7. Auditing. An internal audit function referred to as a “Compliance Quality Audit” is performed by the Compliance Team at all Aspen-affiliated skilled nursing facility.
8. Reporting. Concerns may be reported to the Chief Compliance Officer, who is available at the Aspen Resource Center, or to any member of the Compliance Team. Online and toll-free telephone reporting methods are available 24 hours a day via the Aspen Compliance Hotline, which permits reporters to remain anonymous. Those who make reports in good faith are not subject to retaliation by any Aspen-affiliated entity.
Records of all compliance concerns received are maintained by the Chief Compliance Officer and include a description of the issue reported, the date reported, the method of reporting, the identity of the reporter (if known), the identity of the Aspen-affiliated entity involved, the assigned investigator, whether the concern was substantiated, the category of concern, and any corrective action taken.
Information collected will be used to improve quality of services, track and trend areas of risk and opportunities for training, develop the annual Compliance Work Plan, and identify locations to be subject to audit or investigation.
9. Investigations & Corrective Actions. Suspected issues of noncompliance shall be the subject of internal investigation under the direction of the Chief Compliance Officer. Appropriate and effective corrective actions shall be implemented if noncompliance is detected.