BOARD GOVERNANCE AUDIT AND COMPLIANCE COMMITTEE MEETING · 8/7/2014 · Minutes Governance Audit...

BOARD GOVERNANCE AUDIT AND COMPLIANCE COMMITTEE MEETING * Thursday, August 7, 2014 5:30 p.m. (Buffet for Committee members & invited guests) Administration Office 6:00 p.m. 1st Floor Conference Room 456 E. Grand Avenue, Escondido, CA 92025

Time Form A

Page

Target

CALL TO ORDER ...................................................................................................................... …………. …….. 6:00

Public Comments ................................................................................................................. ............... 5 ............. 6:05

5 minutes allowed per speaker with a cumulative total of 15 minutes per group. For further details & policy, see Request for Public Comment notices available in meeting room.

Information Item(s) ………….2 …...... 6:07

1. *Approval: Minutes – Thursday, June 5, 2014 (ADD A-Pp 11-14) ...................................... ………….3 …....1 6:10 2. Review: Legislative Update (ADD B-Pp 15-16) ................................................................... ………...15 ……2 6:25 3. Review: Internal Audit Activities Summary (ADD C-Pp 17-27)………………………………

a) Internal Audit Activity Report……………………………………………………………

4. Review: Compliance and Ethics Summary (ADD D-Pp 28-51) ............................... ………. a) Compliance Program Assessment…………………………………………………….. b) Compliance Hotline 2nd Quarter………………………………………………………... c) Compliance and Ethics Summary for July 2014……………………………………... d) Compliance and Ethics Summary for August 2014…………………………………..

………...20 …………… ………...40……………………………………………………

……3…...... ........4........................................

6:45 ………..

7:25 ....................................................

5. Review/Approve: Governance Policies (ADD E-Pp 52-60) ................................................. a) *Review/Approve: Board Meetings Held in Closed Session Policy………………... b) *Review/Approve: Business Associate Agreement Policy………………………….. c) *Review/Approve: Performance Improvement Policy #11232……………………… d) *Review/Approve: Annual Adoption of Statement of Investment #27092………….

6. Discussion Items: …………….…………………………………………………………………..

a) Board Meeting Attendance by Conference Call………………………………………

7. Review: Pending Items (ADD F-Pp 61-67)…………………………………………………….. a) Online Communications Policy #39152……………………………………………….. b) Expense Reimbursement and Advancements Policy #21806………………………

………...15 …….……..……………………………………… ………...10…………… ………...10…………………………

…….. ……5……6……7……8 ……..…..… .……..…...9…..10

7:40 ………..………..………..……… 7:50

………..

8:00 ………..………..

ADJOURNMENT ....................................................................................................................... …………… ............. 8:00

Board Governance Audit and Compliance Committee Members Bruce Krider, Chair Michael Covert, Chief Executive Officer Richard Engel, M.D.

Linda Greer, R.N., Director Janine Sarti, Chief Legal Officer Lachlan Macleay, M.D.

Steve Yerxa, Director Bob Hemker, Chief Financial Officer Paul Neustein, M.D.

Jeff Griffith, 1st

Alternate Tom Boyle, District Audit Officer Elly Garner

Mark Neu, Corporate Compliance Officer

NOTE: If you have a disability, please notify us by calling 858-675-5465 72 hours prior to the event so that we may provide reasonable accommodations

Date/Time/Location of Next Meeting: Thursday September 4, 2014 – Grand Building 1st Floor Conference Room

Asterisks indicate anticipated action. Action is not limited to those designated items.

Minutes Governance Audit and Compliance Committee – Thursday

June 5, 2014

Governance, Audit and Compliance -

TO: Board Governance, Audit and Compliance Committee MEETING DATE: Thursday, August 7, 2014 FROM: Nicolette Borseth, Secretary Background: The minutes of the Board Finance Committee meeting held on Thursday, June 5, 2014 are respectfully submitted for approval.

Budget Impact: N/A

Staff Recommendation: Staff recommends approval of the Thursday, June 5, 2014 Governance Audit and Compliance minutes.

Committee Questions:

COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: Required Time:

1

Legislative Update


TO: Board Governance, Audit and Compliance Committee MEETING DATE: Thursday, August 7, 2014 FROM: Elly Garner Background: Presentation of Legislative update.

Budget Impact: N/A

Staff Recommendation:


COMMITTEE RECOMMENDATION: Motion: Individual Action: Information: X Required Time:

2

Internal Audit Activity Summary


TO: Board Governance, Audit and Compliance Committee MEETING DATE: Thursday, August 7, 2014 FROM: Tom Boyle Background: Presentation of Internal Audit activity report.

Budget Impact: N/A




3

Compliance and Ethics Summary


TO: Board Governance, Audit and Compliance Committee MEETING DATE: Thursday, August 7, 2014 FROM: Mark Neu Background: Presentation of the compliance program assessment, compliance hotline 2nd quarter, and the compliance and ethics summaries for July 2014 and August 2014.

Budget Impact: N/A




4

Board Meetings Held in Closed Session


TO: Board Governance, Audit and Compliance Committee MEETING DATE: Thursday, August 7, 2014 FROM: Janine Sarti Background: New policy created that outlines when closed session board meetings are permissible under the law.

Budget Impact: N/A

Staff Recommendation: Once reviewed and approved staff recommends forwarding the Policy to the Board of Directors Committee for approval.



5

Business Associate Agreement Policy


TO: Board Governance, Audit and Compliance Committee MEETING DATE: Thursday, August 7, 2014 FROM: Janine Sarti Background: Governance has submitted a new policy to the Board Governance Audit and Compliance Committee for review and approval. The Business Associate Agreement Policy incorporates the requirements under the HIPAA Omnibus Rule and outlines how Business Associates Agreements are executed and managed by Palomar Health.

Budget Impact: N/A




6

Board Quality Review Committee Lucidoc Policy 11232 – Performance Improvement

Form A - Lucidoc Policy 11232 Performance Improvement

TO: Board Governance and Audit Committee MEETING DATE: Thursday, August 7, 2014 FROM: Opal Reinbold, Chief Quality Officer

Budget Impact: None

Staff Recommendation: Approval

The Board Quality Review Committee met on May 19, 2014 and reviewed Lucidoc Board Policy 11232 “Performance Improvement”. All areas which referenced PPH or Palomar Pomerado Health were changed to state PH and Palomar Health, respectively. The pending was approved with those changes and is being forwarded to the Board of Directors for final approval.



7

Board Policy

Annual Adoption of Statement of Investment

Annual Adoption of Statement of Investment Form A.doc

TO: Board Governance, Audit & Compliance Committee

MEETING DATE: Thursday, August 7, 2014

FROM: Bob Hemker, CFO

BY: Board Finance Committee

Wednesday, July 23, 2014

Background: In concert with the Legal Office, the Board Policy for Annual Adoption of

Statement of Investment has been reviewed, and no changes are being recommended.

Budget Impact: N/A

Staff Recommendations: Staff recommended adoption of the Policy as currently written, with a

recommendation for approval by the Board Governance Committee.


COMMITTEE RECOMMENDATION: The Board Finance Committee recommends to the

Board Governance and Audit Committee the adoption of the Board Policy for Annual Adoption

of Statement of Investment as currently written.

Motion: X

Individual Action:

Information:

Required Time:

8

Online Communications Policy #39152


TO: Board Governance, Audit and Compliance Committee MEETING DATE: Thursday, August 7, 2014 FROM: Janine Sarti Background: The Board Governance Audit and Compliance committee reviewed this policy at the June 5, 2014 meeting. At that meeting, the committee recommended replacing any use of PPH with PH, removing all uses of Pomerado, and removing the telephone number listed under (III)1 and updating the web address listed. It is now being recommended that references to the Online Communications Procedure and Computer Systems Usage at PH procedure be added.

Budget Impact: N/A




9

Expense Reimbursement and Advancements Policy #21806


TO: Board Governance, Audit and Compliance Committee MEETING DATE: Thursday, August 7, 2014 FROM: Janine Sarti Background: The Board Governance Audit and Compliance committee reviewed this policy at the May 5, 2014 meeting. At that meeting, the committee approved the changes noted in red. Additionally, it is being recommended that (III)(E) be changed to read as follows: “Expenditures paid to, or on behalf of, the President or CEO must first be approved by the Board Treasurer. After approval by the Board Treasurer, these documents will be submitted to the Board for ratification and signature.”

Budget Impact: N/A




10

ADDENDUM A

11

1

B O A R D G O V E R N A N C E A U D I T A N D C O M P L I A N C E C O M M I T T E E M E E T I N G A T T E N D A N C E R O S T E R & M E E T I N G M I N U T E S C A L E N D A R Y E A R 2 0 1 4

MEETING DATES:

MEMBERS

1/2/14 2/6/14 3/6/14 4/3/14 5/1/14 6/5/14 7/3/14 8/7/14 9/4/14 10/2/14 11/6/14

12/4/14

BRUCE KRIDER. – CHAIR C C P P P

LINDA GREER P P P P E

STEVE YERXA P E P P P JEFF GRIFFITHS – ALTERNATE E E E E E STAFF ATTENDEES

MICHAEL COVERT – CHIEF EXECUTIVE OFFICER E E E E P

ROBERT HEMKER – CHIEF FINANCIAL OFFICER E E E E E JANINE SARTI – CHIEF LEGAL OFFICER P P P P P

MARK NEU – CORPORATE COMPLIANCE OFFICER P P P P P

TOM BOYLE – DISTRICT AUDIT OFFICER P P P P P RICHARD ENGEL, M.D. E E E E E

LACHLAN MACLEAY, M.D. E E P P E

PAUL NEUSTEIN, M.D. E E E E E

ELLY GARNER – GOVERNMENT RELATIONS E E P P E

NICOLETTE BORSETH – BOARD COMMITTEE ASSISTANT S S S S S INVITED GUESTS SEE TEXT OF MINUTES FOR NAMES OF GUEST PRESENTERS

12

BOARD GOVERNANCE AUDIT AND COMPLIANCE COMMITTEE – MEETING MINUTES – THURSDAY, JUNE 5, 2014

CALL TO ORDER

The meeting – held in the Grand 1st Floor Conference Room, 456 E. Grand Avenue Escondido, CA 92025 – was called to order at 6:00 p.m. by Bruce Krider ESTABLISHMENT OF QUORUM

See roster PUBLIC COMMENTS

There were no public comments

MOTION: No motion taken. Y

INFORMATION ITEMS

1. MINUTES – THURSDAY, MAY 1, 2014 MOTION: By Director Krider, seconded by Director Yerxa and carried to recommend approval of the Minutes from the Thursday, May 1, 2014, meeting. All in favor, none opposed. Y

No discussion.

2. INTERNAL AUDIT ACTIVITIES SUMMARY a) DELOITTE & TOUCHE, LLP AUDIT PLAN FYE 2014 b) INTERNAL AUDIT ACTIVITY REPORT

MOTION: No Motion Taken. Y

Drew Sutter and Hiral Shah from Deloitte & Touche, LLP presented the Palomar Health Planned Scope and Timing of the Audit of the 2014 Financial Statements. o Deloitte presented and defined the scope of their audit. The audit will review the financial statements of Palomar Health District for the year ending June 30, 2014. o Deloitte will plan and perform the audit to obtain reasonable assurance about whether the financial statements are free of material misstatement caused by error of fraud. o Michael Covert explained that the Information Technology Department was outsourced to Cerner last year and would like Deloitte to analyze whether Cerner has

completed obligations under the agreement. District Audit Officer Tom Boyle discussed Audit activities including:

o On-going Internal audit projects for 2014, ongoing monitoring, and additional internal audit Projects for 2014

3. COMPLIANCE AND ETHICS SUMMARY a) COMPLIANCE AND ETHICS SUMMARY FOR JUNE 2014

MOTION: No Motion Taken

Y

Corporate Compliance Officer Mark Neu gave his Compliance and Ethics Committee summary for June 2014. The report included updates on the following: o Follow up items: Palomar Health’s large scale breach and the Security Integration Team (SIT) o Two Midnight Rule: Probe and Educate Update o Orders and Protocols o Team Palomar Update o Recent Enforcement Actions

4. REPORT OF DISTRICT AUDIT OFFICER’S AND COMPLIANCE OFFICER’S

INDEPENDENCE MOTION: No Motion Taken. Y

Bruce Krider, Chairman of the Governance Audit and Compliance Committee signed the report of District Audit Officer’s and Compliance Officer’s Independence.

5. ANNUAL EVALUATION OF COMPLIANCE PLAN MOTION: No Motion Taken. Y

Agenda item moved to August 7, 2014 Governance Audit and Compliance meeting.

6. ONLINE COMMUNICATIONS REPORT POLICY #39152 MOTION: No Motion Taken. Y

The Governance Audit and Compliance Committee reviewed the Online Communications Report Policy #39152 and recommended PPH be changed to PH throughout policy and the use of Pomerado be removed. Additionally, it was recommended the website be changed to palomarhealth.org and the phone number listed be removed. The policy will be sent to various Palomar Health departments to review. This policy will be added to the Governance Audit and Compliance agenda for August 7, 2014 for approval.

13

BOARD GOVERNANCE AUDIT AND COMPLIANCE COMMITTEE – MEETING MINUTES – THURSDAY, JUNE 5, 2014

ADJOURNMENT The meeting was adjourned at 7:14 p.m.

SIGNATURES:

COMMITTEE CHAIR

Bruce Krider

COMMITTEE SECRETARY

Nicolette V. Borseth

14

ADDENDUM B

15

*Placeholder*

Legislative Update to be

provided at time of

meeting

16

ADDENDUM C

17

Internal Audit Activity Report

Palomar Health District

Governance, Audit and Compliance Committee

August 7, 2014 18

2014 Audit Projects Percent Complete

25% 50% 75% 100% Status

1 Third Party Liens *FO Pending Action from others

2 Grants and Awards *CO No further Action Required

3 340 B Pharmacy Federal Drug Program *CF On Schedule

4 Dialysis *FO No further Action Required

5 Infection Control *FO No further Action Required

6 ARCH Health Partners *OA Pending Action from others

7 Leadership Education Pending

8 Implement ACL GRC cloud-based technology On Schedule

9 Cerner Roadmap validation *F Pending Action from others

10 Outpatient Pharmacy Inventory Validation *A Complete

11 Palomar Foundation Audit Firm Selection *A Complete 2

*F=Financial, O=Operational, C=Compliance, A=Added to Audit Plan

19

ACL Continuous Monitoring Tests

Percent Complete Description

25% 50% 75% 100%

12 Compliance – Risk Assessment/Dashboard*C

Assist Compliance Officer with developing an automated reporting tool with key metrics

13 Expense Reimbursement Analytic monitoring of credit card activities,

appropriate issuance and timely removal

14 Payroll – time & attendance analytics

Develop analytic tests to enhance routine review of time and attendance

15 General Ledger Analytic tests to provide Finance, External

Auditors and Internal Audit ability to monitor GL activities

16 Physician Order Profiles Report on trends regarding practice patterns

related to orders, costs and other preferences.

17 Accounts Payable Test for duplicate payments and related AP tests

run Ad Hoc by Finance Department

18 Excluded Provider Tests Monthly comparison of employees, physicians, vendors with providers excluded from Federal

programs (OIG, LEIE, etc)

19 Unclaimed Refunds Identify and report monthly unclaimed patient

refunds for Finance for disposition

20 Employee Vs. Vendor Compares vendor database to employee database

to identify suspicious accounts or activity 3 20

2014 Audit Project 25% 50% 75% 100% Comments

21 Expense Reduction Participation in Non-Labor Optimization Committee

22 Environmental Services – Food and Nutrition

23 Support Implementation of EDW Involvement Requested

24 Medical Staff Physician Credentialing (Annual) (Aug-Sept)

25 Added: ED Patient Through-put data report Removed: (Fiscal Year-End Testing) A

Coordinated with Deloitte

26 ED Level Charges

27 Charge Capture

28 Annual Audit Risk Assessment (Oct-Nov)

29 Independent Quality Review Budget Dependent

30 Coding review (coordinate with compliance) Budget Dependent 4 21

• Internal Audit Service (IAS) was asked to review the billing process for Express Care.

• IAS reviewed the scope of the project and established a plan for obtaining the billing

information with the Director of the Express Care Clinics.

• The Director has been cooperative but delayed in providing us with requested data

• IAS will review the documentation and billing practices as soon as the data becomes

available

Report Date: July 21, 2014

Project Lead: Kristy Larkin, Senior Internal Auditor

Objectives: To verify that the billing process of our Express Care clinics are appropriate.

22


Project Lead: Kristy Larkin, Senior Internal Auditor

Objectives: To verify the service measures that have been reported by Cerner.

• Internal Audit Service (IAS) has been asked by the Compliance Officer to review the Cerner

contract and verify that Cerner is meeting or exceeding the contracts obligations.

• IAS has been met with many delays on this project..

• The Information Security firm of CynergisTek will also review the contract for appropriate

content and suggest any improvements. Legal Department is developing a BAA in order

for this action to occur.

• The CIO is to facilitate our information requests with Cerner.

• Our testing and analysis will commence when the requested information is provided.

23

• Internal Audit Service (IAS) started the review for the 340B program on May 1, 2014

• IAS met with Pharmacy manager to go over the process and had requested documentation

• Pharmacy submitted the documentation on July 17,2014

• IAS will review the documentation contracts

• IAS will audit outside Pharmacy Vendors processes as to make sure they are in compliance

with the 340 B drug pricing program


Project Lead: Ruhina Livingstone

Collaborators: Kristy Larkin

Objectives: To verify that Palomar Health is in compliance with the 340B – Drug Pricing Program

24




Objectives: To Evaluate the effectiveness of third party recovery process and determine if opportunities

exist for process automation, expansion or scope or alternative processes

• Internal Audit Service (IAS) has been helping Lien Recovery Service (LRS) to streamline their process by

developing an automated report of relevant data from the patient accounting system since February 20, 2014.

• In July LRS has agreed with our recommendation that the report should be based on all potential E-Codes.

• The custom report will be automatically generated after the patient is discharged as opposed to earlier reports

which captured data based on original registration. (Information from original registration would be preferred

to initiate timely action on certain accounts, however information captured at time of admission is not always

complete and accurate for lien processing purposes.

• IAS suggested LRS schedule a meeting with IAS, coding and PFS staff to review and determine all the

appropriate E-Codes that should be used in order to expand the potential scope of lien prospects.

25




Objectives: To generate a report containing details for all patients that

required ED personnel and or oversight

• Internal Audit Service (IAS) has been assisting the Performance Excellence team with

the patient throughput initiative by accessing data regarding emergency department

activity at PMC.

• The first phase report has been delivered to Angie Germaine with the historical data for

ED census.

• The second phase report will be delivered by July 25,2014 with more details as

discussed in the meeting on July 10,2014 for Nick Metzger, nursing supervisor PMC

emergency department

26


Project Lead: Ruhina Livingstone, Internal Auditor and Kristy Larkin, Senior Internal Auditor

Objectives: 2014 GRC 20/20 Value Award

• IAS was nominated for The 2014 GRC Value award.

• The award recognizes GRC solutions that have returned significant and measurable value to an

organization.

• The GRC Value awards are to acknowledge specific quantifiable value in a specific instance.

27

ADDENDUM D

28

Compliance Program assessment Standard Met Comments

Designation of Corporate Compliance Officer (CCO):

X Dedicated FTE

Designation of Compliance and Ethics Committee (CEC): X Monthly Cross-disciplinary meeting

Written policies and procedures

X See next slide

Training and Education Programs

X NEO and annual

Employees

Board of Directors

Medical Directors

Contracted Staff Members

Volunteers

Effective lines of communication

X Global Compliance

Auditing and Monitoring

X PEPPER, LCDs, Annual risk assessment

Response to detected offenses

X Timely investigations per policy

29

Written policies and procedures Code of Conduct

Business Courtesies-Potential Referral Sources

Claim Development Billing and Cost Reporting

Compliance and Ethics Plan

Compliance Monitoring and Investigations

Conflicts of Interest, Commitment and Gifts

Contract Review Procedure

Contract Review Procedure For Physician Agreements

Federal Deficit Reduction Act of 2005 - Fraud and Retaliation

Government Investigations

Advanced Beneficiary Notice for Medicare Beneficiary – Outpt Medical Necessity

Inpatient Medical Necessity

Holiday Party Procedure

Palomar Health Compliance Hot Line

Personnel Excluded From Participation in Federal Healthcare

Physician Payments

Self-Reporting of Errors Related to Federal Healthcare Program Reimbursement

Privacy Policies

Security Policies

30

https://www.lucidoc.com/cgi/doc-gw.pl?ref=pphealth:17619





















Model Compliance plans

• Acute Care (billing, coding, cost report, physician recruitment)

• Home Health – no additional follow up

• Laboratory – Annual notice to physicians

• Skilled Nursing - no additional follow up

• Physician Practices – Policy updates only

31

Acute Care

• Billing (i.e. duplicate billing, unbundling)

• Coding (i.e. up-coding, DRG creep)

• Cost report (accuracy and integrity)

• Physician recruitment (Stark, AKS)

32

Laboratory

Annual Notice to physicians that includes:

• Local and national Medicare lab policies;

• Billing rules for organ or disease related panels;

• Lab fee schedule;

• Phone number of clinical consultant

33

COMPLIANCE HOTLINE LINE

Report to

Palomar Health

Governance Audit and Compliance Committee

Thursday August 7, 2014

34

Hotline Procedure Flowchart

35

Contd.

36

Standard Ethics and Compliance Allegations

Allegation Class Allegation Definition

Diversity, Equal Opportunity and Respect in the Workplace

Discrimination Statements or actions based on age, race, color, national origin, sexual orientation, gender, disability or religion that are the basis for employment, promotion or compensation decisions.


Harassment - Sexual Statements or actions expressing unwelcome sexual advances, requests for sexual favors, unsolicited physical contact or propositions, unwelcome flirtations, or offensive verbal or visual expressions or physical conduct of a sexual nature.


Harassment - Workplace

Persistent statements, conduct or actions that are uninvited, degrading, offensive, humiliating or intimidating and create an unpleasant or hostile environment.


Retaliation or Retribution

Statements or actions discharging, demoting, suspending, threatening, harassing or discriminating against an employee because of any lawful act taken by such employee in connection with reporting a violation of law or policy, filing a complaint, or assisting with an investigation or proceeding.

Employee Relations Conflict of Interest - Personal

Any personal interest, any business or professional activity or relationship, prior or current employment, or any obligation that may interfere with the ability to objectively perform job duties and responsibilities or impair independence and objectivity.

37


Employee Relations Inappropriate Behavior Statements or actions that are not harassing in nature, but are believed to be unsuitable for the workplace.

Employee Relations Unfair Employment Practices

Employment decisions, practices or disciplinary actions that are believed to be unfair regardless of whether they are the result of job performance, changes in business needs or other business related decisions.

Environmental, Health and Safety

Environment, Health and Safety

Conduct, actions, policies or practices that either violate local, provincial or federal environmental, health or safety laws or regulations or may cause or result in potentially hazardous conditions that impact the environment or the health or safety of employees, customers or others.


Threats and Physical Violence

Statements or actions that threaten acts of violence or the presence of weapons, firearms, ammunition, explosives or incendiary devices in the workplace, on work premises or in work vehicles.

Financial Concerns Accounting and Auditing Practices

Statements or actions that violate or conflict with either internal policies, procedures, or practices or government regulations related to the detailed reporting of the financial state or transactions of an organization or the examination, verification, or correction of its financial accounts.

Financial Concerns Conflict of Interest - Financial

Any financial interest, any business or professional activity, prior or current employment, or any obligation that may interfere with the ability to objectively perform job duties and responsibilities or impair independence and objectivity.


38


Financial Concerns Gifts, Bribes and Kickbacks

Payments, payments in kind, gifts, bribes, extensions of credit or benefits extended to or received by customers, employees, suppliers, vendors, competitors, directors, officers, auditors, government employees, government officials or agencies, or other parties that are unlawful, improper, or designed to influence business decisions or political processes.

Financial Concerns Trading on Inside Information

The purchase or sale of stock or other securities based on non-public and material information obtained during the course of employment or providing such information to another person who purchases or sells stock or other securities based upon that Information.

Misuse or Misappropriation of Assets or Information

Customer Relations Statements or actions that are negatively impacting or interfering with customers, customer relationships or customer agreements.


Disclosure of Confidential Information

The unauthorized or illegal disclosure, copying, duplication, misuse or release of confidential or personal data including but not limited to employment, financial, medical and health, customer lists, contracts, business plans, personnel records or other property marked or generally regarded as confidential or trade secrets


Misuse of Resources The improper, unauthorized or unlicensed use of property or resources for non business related reasons or purposes including improper use of systems and timekeeping.


39



Theft. The unauthorized removal or taking of supplies, equipment, furniture, fixtures, products, cash, merchandise or other tangible property.

Policy and Process Integrity

Trading on Inside Information

Discussions or agreements with competitors about prices or credit terms, submission of bids or offers, allocation of markets or customers, restrictions on production, distribution or boycotts of suppliers or customers that would result in monopolization or anticompetitive markets.


Espionage or Sabotage Actions that result in the gathering, receipt or acceptance of non-public confidential information or trade secrets about competitors to gain a competitive advantage or the deliberate destruction, disruption or damage to a competitor's equipment or property for competitive advantage or gain.


Falsification or Destruction of Information

Statements or actions that encourage or result in unlawful, untimely, false or intentional misrepresentation, concealment or destruction of information in order to deceive or mislead.

Other Request Request for guidance, interpretation, or other information regarding matters of law, regulations, or policies.

Other Other Statements actions or policies that concern the caller but are not currently resulting in harm, injury or corporate liability and cannot be included in any other category


40

Total Number of Reports – April 1, 2014 – July 31, 2014

20 18

29

23

48 48 48 48

0

10

20

30

40

50

60

Q3 - CY13 Q4 - CY14 Q1 - CY14 Q2 - CY14

Number of Reports

Annual Benchmark

41

Anonymous Reporting– April 1, 2014 – July 31, 2014

39.10% 60.90%

Anonymous

Identified Caller

Palomar Health Annual Benchmark

60.00% 40.00%

Anonymous

Identified Caller

42

Report by Priority - April 1, 2014 – July 31,2014

0

4

25

0

3

20

0

5

10

15

20

25

30

A B C

Q1-2014

Q2-2014

43

Report by Allegations Class – April 1, 2014 – July 31, 2014

26.10%

17.40%

26.10%

30.40%

73%

7% 6%

21%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

Diversity, EqualOpportunity and Respect

in the Workplace/Employee Relations

Environmental, Healthand Safety

Misuse orMisappropriation of

Assets

Other

Palomar Health

Annual Benchmark

44

Report by Allegation Type – April 1, 2014 – July 31, 2014

Employee Relations

Misuse or Misappropriation of Assets

Other



1

4

1

1

4

4

2

2

1

3

0

0 1 2 3 4 5

Other

Guidance Request

Misue of Resources

Disclosure of Information

Customer Relations

Environment, Health and Safety

Inappropriate Behavior

Retaliation or Retribution

Unfair Employment Practices

Harassment - Workplace

Conflict of Interest - Personal

45

1

CEC Summary

July 8, 2014

Standardized Procedures Update

An exception to the general rule for billing Medicare is contained in CFR § 482.24(c)(3) which sets

forth 4 requirements allowing a hospital to use pre-printed and electronic standing orders, order sets,

and protocols for patient orders

Review of process at Palomar Health

Approximately 30-40 procedures identified in Lucidoc

Will be standardized to be consistent with Medicare Conditions of Participation, including:

Prompt and timely review

Trace back to evidence based guidelines

Be sure to include “prompt” signing of orders

Work Plans through Q2 CY 2014

New Inpatient Admission Criteria (Two Midnight Rule) - Marcy Adelman

o CMS announced that all stays billed as inpatient need to cross two midnights as well as meet

set documentation criteria.

o Charts have been audited for probe and educate from both PMC and POM. CMS provided

results of PMC and POM probe and educate audits. PMC results were 5/10 correct, which

results in $62K denied of $129K in charges. POM results were 3/10 correct resulting in $48K

denied of $72K in charges.

o UR RNs reviewing all Medicare charts for signed electronic physician order.

o UR Committee reviews short stay charts that have been audited by the UR nurses.

o Educational letters mailed to physicians for each rebilled stay.

o Director of Patient Financial Services, Susan May sends letters to all patients that are going to

be rebilled as outpatient.

Part B payments for drugs purchased under the 340B Program - Cedric/Tom

o Cedric Terrell will share more regarding this work plan at next month’s CEC meeting.

Compounding Drugs

o Cedric Terrell will discuss this work plan at next month’s CEC meeting.

Controls over networked medical devices at hospitals – Prudence

o The objective of this work plan is to ensure that security controls over networked medical

devices are sufficient to effectively protect protected health information (ePHI).

o Prudence’s team will assess all network devices to determine which, if any, contain ePHI.

Additionally, they will run automated vulnerability scans on the network. Processes and

procedures will be implemented to ensure vulnerability scans are run on a regular basis and

that procedures are implemented to decommission equipment with ePHI.

o Robin Ford stated that they are currently getting a risk assessment ready that will identify

areas of risk.

o Prudence August will share more regarding this work plan at next month’s CEC meeting.

OIG Fraud Concerns Regarding Electronic Medical Records – Prudence

o Prudence August will discuss this work plan at next month’s CEC meeting.

EHR Risks

o Alan Conrad, M.D. stated that Ben Kanter, M.D. created a policy regarding copying and

pasting of medical records.

o Kim Jackson stated that her team has been reviewing every medical record to see if the

medical chart appears to have copied and pasted items within it. Kim is working on putting

together a report to present to medical staff leadership which would show which doctors have

continual issues related to copying and pasting in EHR.

46

2

Encryption – Robin

o 900 laptops have been encrypted to date. The only laptops left to encrypt are those with auto-

logon. Robin will be working with IT to ensure that these laptops are secure. Additionally,

Micah Rutkoff and other Information Security team members will be conducting a physical

inventory of Palomar Health buildings. All additional laptops will be encrypted.

Privacy – Kim

o The privacy and security assessment has been completed. Kim Jackson received the final

report on July 7, 2014.

o Overall, the report shows that Palomar Health is in compliance in most areas. Kim will create

a grid table showing areas of non-compliance a timeline as to when they need to be complete.

Compliance Program Assessment

Mark Neu reviewed the seven elements of an effective compliance program and explained that each

element had been met for FY2014.

Model Compliance Plans

o Acute Care (billing, coding, cost report, physician recruitment)

o Home Health – no additional follow up

o Laboratory – annual notice to physicians

o Skilled Nursing – no additional follow up

o Physician Practices – policy updates only

OIG Hospital Compliance Audits –IP

o For last few years, the OIG has been conducting audits wherein they are able to review any

items they want. There have been 40-50 around the country.

o Common Themes through all audits:

Short stays

Same day discharge & re-admission

Transfers/discharges

Mechanical ventilation

Claims paid in excess of charges

High severity level DRGs

Claims paid in excess of $150,000

Manufacturer credits for replacement devices

- Particularly challenging area because clinical people on the ground not

necessarily looking to see if a device failed prematurely which would prompt

need to go to manufacturer to receive a credit rather than purchasing a new

machine. Looking at how we manage device credits and whether we are

inappropriately billing Medicare for failed devices.

Psych Facility (IPF) Emergency Department

Adjustments

Claims for blood clotting factor

Hospital acquired conditions & POA indicator reporting

IP Psychiatric facility interrupted stays

OIG Hospital Compliance Audits –OP

o Claims paid in excess of charges

o Claims paid greater than $25,000

Susan May stated that this would not occur very often. Review of some centers of

excellence may a great place to start to map this.

o Claims for dental services

o Intensity modulated radiation therapy (IMRT)

o Claims billed during IP stays

47

3

o Claims with observation outliers

o Surgeries greater than one UOS

o Claims billed with E&M services

o Claims billed with modifiers (59,76, etc.)

o Manufacturer Credit for Replaced Devices

o Doxorubicin Hydrochloride

o Claims with injectable drugs

o Claims for Lupron injection

o Services billed during HHA episode

o Services billed during SNF stay

o Surgeries with units of service greater than one

o Outpatient prescription drugs

What Should We Do Now:

o The Risk Areas:

IP Claims Paid in Excess of $150K

IP Claims Paid in Excess of Charges

High Severity DRGs

OP Surgeries > 1 UOS

OP Services Billed During IP Admit

OP Claims Paid in Excess of $25K

o The Issues OIG is Targeting

Use of Modifier 59

Kyphoplasty

Manufacturer Credits, incl. device

Mechanical Vent Claims >96 hours

Same Day Discharge & Readmission

Incorrectly Billed Lupron Injections

Discharge Disposition

Hotline Benchmarking

The most basic question… “Are we getting too many or too few reports?”

Prior to 2009, the median report volume had remained at or near 0.9 reports per 100

employees (less than one percent) for many years.

Since 2011, 1.2 reports per 100 employees – 33% increase

o Has increased since then, possibly due to:

Growing employee confidence in the overall reporting process. Employees tend to

gain confidence in reporting if they see actual results.

Lower confidence in line management’s ability to respond appropriately.

Growing media coverage of whistleblower protections, lawsuits and awards.

Increasing sophistication of ethics and compliance programs’ communications and

training strategies.

Report Categories: Categories Remain Consistent

o Call category provides insight into the efficacy of a company’s training and policies by

reflecting employees’ understanding of what should be reported and when to call.

Accounting, Auditing and Financial Reporting – 3%

Business Integrity – 17%

HR, Diversity and Workplace Respect – 70%

Environment, Health and Safety – 7%

Misuse, Misappropriation of Corporate Assets: - 6%

First Time Versus Repeat Reporters

48

4

o The percentage of reports by self-identified Repeat Reporters has more than doubled in

the past five years.

Median Percentage of Repeat Reporters:

- 2009 – 14%

- 2010 – 24%

- 2011 – 27%

- 2012 – 27%

- 2013 – 31%

o Reports from Repeat Reporters were substantiated at a rate five percent higher than

those of first time reporters.

Follow-up Rate of Anonymous Reports

o The percentage of reports which were submitted anonymously that were subsequently

followed-up by the reporter using the PIN.

o Rate has remained flat at 31%

o Lack of follow-up could be a culture red-flag indicator if reporters do not seem to want

to know the outcome of the matter they raised.

Conclusion

o Questions to Ask:

Do we need more training?

Do we need to review or update our policies?

Are our communications with employees reaching the intended audiences and

having the desired effect?

Should we dig deeper into data of concern with employee surveys and focus

groups?

Do enough employees know about our reporting channels?

Are our investigations thorough and effective?

o It is paramount to respond effectively and expeditiously to employee reports. If

responses languish, if allegations are not reviewed, if those making allegations are not

communicated with effectively, employees may quickly lose faith in their employer and

turn to outsiders, including qui tam attorneys and the government, when they see

wrongdoing. Does our culture support employees who raise concerns?

Team Palomar Update

Next step is a meeting with the steering committee and “delegates” from the other groups in

order to establish the ongoing Team Palomar Committee.

o Wellness Committee

o Rewards & Recognition

o PEP

o Green Team

o Community Action Councils

o Community Benefit

Recent Enforcement

U.S. Files Lawsuit Against IPC The Hospitalist Company, Alleges Overbilling of

Federal Health Insurers for Physician Services (6/17/14)

o Systematic overbilling for E & M

o The lawsuit alleges that IPC encouraged its physicians to bill at the highest levels

regardless of the level of service provided and pressured physicians with lower billing

levels to “catch up” to their peers.

o IPC regularly monitored detailed reports of the codes billed by individual physicians

49

5

o Lawsuit alleges that IPC encouraged its physicians to bill at the highest levels regardless

of the level of service provided and pressured physicians with lower billing levels to

“catch up” to their peers.

o Stems from physician whistleblower’s lawsuit

False Claims Action (FCA) Statistics

o If the Government intervenes and obtains recovery, the Relator receives between 15%

and 25% of the proceeds

o Since 1986, of all of the qui tam actions filed, the average yearly intervention rate has

been about 20-25%

o Approximately $3 billion in health care FCA recoveries in FY 2010; a 25% increase

from 2009

o Recoveries have increased (higher penalties and greater publicity);

o $6.8 billion since 2009

o $27 billion ($18.5 billion in health care) overall since 1986

o Highest number of False Claims Act filings during 2011 (in excess of 600 new cases)

o Whistleblower protection is provided to those that take lawful actions in furtherance of

the qui tam suit, including investigation, initiation, testimony for, or assistance in the

action (Anti-Retaliation Provision and Cause of Action)

UCLA Medical Center (Olive View) - Sylmar, California - entered into a $40,750

settlement agreement with the OIG – 5/23/14

o Resolves EMTALA allegations of failing to provide an individual with an appropriate

MSE within the capability of the hospital's emergency department in order to determine

whether the patient had an emergency medical condition.

o Patient presented to the emergency department with signs of appendicitis and severe

abdominal pain that he rated at a 10 on a 10-point scale.

o Despite his severe pain and symptoms, he was forced to wait for several hours to receive

an MSE.

o After waiting for 6.5 hours, he left to seek medical screening and treatment at another

hospital, where he was diagnosed with acute appendicitis with a large peritoneal abscess

and had to undergo an immediate laparoscopic appendectomy.

Office for Civil Rights HIPAA Crackdown?

o The Office for Civil Rights (OCR) — the enforcement arm of the Department of Health

and Human Services — has been quite busy since June of 2013.

o Nine settlements have been announced for HIPAA violations, totaling more than $10

million in penalties assessed, including a whopping $4.8 million against New York-

Presbyterian Hospital and Columbia University.

o According to the OCR chief counsel for the Chicago region — that’s just the beginning.

Jerome Meites told a conference in Chicago, “(k)nowing what’s in the pipeline, I

suspect that number will be low compared to what’s coming up.”

o Risk assessments are certainly in order………pay now, or pay later.

50

*Placeholder*

August Compliance and

Ethics Committee

summary to be

provided at time of

meeting

51

ADDENDUM E

52

Board Meetings Held in Closed Session

I. PURPOSE:

To provide guidance to the Board of Directors as to when closed meetings may be held pursuant to the Brown Act.

II. DEFINITIONS:

For purposes of this policy, the following definitions will apply:

“Open Meeting” Requirement: The Brown Act imposes an “open meeting” requirement on local legislative bodies meaning that all of the deliberative processes, including discussion, debate and the acquisition of information, be open and available for public scrutiny.

Exceptions to “Open Meeting” Requirement: Governing boards are allowed to meet in closed sessions for specific, statutorily exempt subject areas that primarily involve personnel issues, pending litigation, labor negotiations, and real property acquisitions. There is a presumption in favor of access, with exceptions for confidentiality being narrowly construed.

III. TEXT / STANDARDS OF PRACTICE:

A. A closed meeting may only be held if one of the following exceptions to the Brown Act “open meeting” requirement are fulfilled:

1. The purpose of the meeting is to consider the appointment, employment, evaluation of performance, discipline, or dismissal of a public employee or to hear complaints or charges brought against the employee by another person or employee unless the employee requests a public session (Cal. Gov. Code § 54957 (b)).

2. The purpose of the meeting is to discuss litigation that has been initiated formally to which the District is a party formally (Cal. Gov. Code § 54956.9(d)(1)), that the Board expects to be sued based on the existing facts and circumstances (Cal. Gov. Code § 54956.9(d)(2), or that the Board wants to discuss potential litigation to be initiated by the District (Cal. Gov. Code § 54956.9(d)(4)).

3. The purpose of the meeting is to discuss, with the Board's designated representatives, the salaries, salary schedules, or compensation paid in the form of fringe benefits of its represented and unrepresented employees, and, for represented employees, any other matter within the statutorily provided scope of representation (Cal. Gov. Code § 54957.6).

4. The purpose of the meeting is to discuss the purchase, sale, exchange, or lease of real property with the Board’s negotiator, or to grant authority to the negotiator regarding the price and terms of payment for the purchase, sale, exchange, or lease (Cal. Gov. Code § 54956.8).

5. The purpose of the meeting is to discuss and determine whether an applicant for a license or license renewal, who has a criminal record, is sufficiently rehabilitated to obtain the license (Cal. Gov. Code § 54956.7).

6. The purpose of the meeting is to discuss, with the Governor, Attorney General, district attorney, agency counsel, sheriff, or chief of police, or their respective deputies, or a security consultant or a security operations manager, matters posing a threat to the security of public buildings, a threat to the security of essential public services, including water, drinking water, wastewater treatment, natural gas service, and electric service, or a threat to the public's right of access to public services or public facilities (Cal. Gov. Code § 54957).

7. The purpose of the meeting is to discuss insurance pooling (Cal. Gov. Code § 54956.95 (a)).

8. The purpose of the meeting is to discuss a claim for the payment of tort liability losses, public liability losses, or workers' compensation liability incurred by the North San Diego County Health Facilities Financing Authority or a local agency member of the North San Diego County Health Facilities Financing Authority (Cal. Gov. Code § 54956.95 (b)).

53

9. The purpose of the meeting is to discuss a response to a confidential final draft audit report from the Bureau of State Audits (Cal. Gov. Code § 54956.75 (a)).

10. The purpose of the meeting is to discuss an employee's application for early withdrawal of funds in a deferred compensation plan when the application is based on financial hardship arising from an unforeseeable emergency due to illness, accident, casualty, or other extraordinary event, as specified in the deferred compensation plan (Cal. Gov. Code § 54957.10).

11. The purpose of the meeting is the discussion or deliberation of reports involving health care facility trade secrets (Cal. Health & Safety Code § 32106(b)).

A. For the purposes of this exception, "health care facility trade secret" means information, including a formula, pattern, compilation, program, device, method, technique, or process, that: (1) derives independent economic value, actual or potential, from not being generally known to the public or to other persons who can obtain economic value from its disclosure or use; and (2) is the subject of efforts that are reasonable under the circumstances to maintain its secrecy (Cal. Civ. Code § 3426.1 (d)). Additionally, the trade secret must be necessary to initiate a new hospital service or program or add a hospital facility, and would, if prematurely disclosed, create a substantial probability of depriving the hospital of a substantial economic benefit (Cal. Health & Safety Code § 32106(c)).

12. The purpose of the meeting is to hold hearings on the reports of hospital medical audit or quality assurance committees provided that an applicant or medical staff member whose staff privileges are the direct subject of a hearing may request a public hearing (Cal. Health & Safety Code § 1461).

A. Deliberations of the board of directors in connection with matters pertaining to the hearings may be held in closed session (Cal. Health & Safety Code § 1461).

13. An emergency meeting has been called pursuant to Cal. Gov. Code § 54956.5, and the Board agrees to meet in closed session by a two-thirds vote of the members present, or, if less than two-thirds of the members are present, by a unanimous vote of the members present (Cal. Gov. Code § 54956.5(c)).

B. Additionally, neither the proceedings nor the records of organized committees of medical, medical-dental, podiatric, registered dietitian, psychological, marriage and family therapist, licensed clinical social worker, professional clinical counselor, or of a peer review body having the responsibility of evaluation and improvement of the quality of care rendered in the hospital, shall be subject to discovery (Cal. Evid. Code § 1157(a)).

1. No person in attendance at a meeting of any of those committees shall be required to testify as to what transpired at that meeting (Cal. Evid. Code § 1157(b)).

IV. ADDENDUM:

V. PUBLICATION HISTORY:

Revision Number

Effective Date

Document Owner at Publication Version Notes

VI. REFERENCES:

Reference Type Title Notes

54

*Placeholder*

Business Associate

Agreement Policy will

be provided at time of

meeting

55

Differences between version 1 and 2.

I. PURPOSE:

To provide directions to the employees of PPHPH from the Board of Directors relative to establishing and maintaining an organization that is committed to ongoing performance improvement culture, thereby meeting and striving to exceed regulatory and professional standards.

II. DEFINITIONS:


A. A Performance Improvement Plan will serve as a framework that describes how the following will be accomplished, including: 1. Designing Processes. 2. Monitoring through data collection. 3. Analyzing current performance. 4. Determining and prioritizing improvement opportunities. 5. Modifying processes. 6. Sustaining improvements. 7. Periodically assessing PPHPH performance in accordance with recent benchmark data.

B. The organization focuses on effectively reducing factors that contribute to unanticipated adverse events and/or outcomes. Poorly designed systems, system failures, or errors are identified through: 1. Investigating factors contributing to such events or "near misses" and sharing the acquired

knowledge across the system.2. Implementing processes to address high-risk situations common in healthcare, such as those

identified in the National Patient Safety Goals and Sentinel Event Alerts issued by Joint Commission.

3. Proactively applying techniques such as Failure Modes and Effects Analysis to reduce risks to patients.

C. Palomar Health is committed to providing the highest quality of clinical care. In order to achieve this: 1. Processes and outcomes of care, treatment and services for high volume and high risk diagnoses

are continuously monitored.2. Systems and processes are implemented to support reliable delivery of evidence-based practice.

D. This policy will be reviewed and updated as required or at least every year.

IV. ADDENDUM:

DOCUMENT / PUBLICATION HISTORY:CROSS-REFERENCE DOCUMENTS:


Performance Improvement11232 Official (Rev: 1)

Source:Administrative Board of Directors

Applies to Facilities: Applies to Departments:

Revision Number

Effective Date


1 (this version)

12/17/2001 Dr. Valentino Tesoro, SVP Quality and Clinical Effectiveness

Original Version

Authorized Signer(s): ( 12/17/2001 ) George G. Gigliotti, Chairman

Page 1 of 2Performance Improvement

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VI. REFERENCES:

Paper copies of this document may not be current and should not be relied on for official purposes. The current version is in Lucidoc at .

https://www.lucidoc.com/cgi/doc-gw.pl?ref=pphealth:11232$1&ref2=pphealth:11232$2


Source Documents 1

JCAHO CAMH Standard Improving Organization Performance

JCAHO CAMH Standard LeadershipJCAHO CAMH Standard Governance

Page 2 of 2Performance Improvement

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I. PURPOSE: A. This Statement of Investment Policy sets forth the investment guidelines for all Palomar Health ("PH ") investments purchased after March 1, 1996. The purpose of this policy is to ensure that PH's funds are prudently invested according to the Board of Director's objectives to preserve capital, provide necessary liquidity and to achieve a market-average rate of return through economic cycles.

B. PH may invest any portion of surplus funds of its Treasury that is not required for the immediate needs of PH ("Investable Funds"), subject to the requirements of the California Government Code and this policy. If the provisions of the Government Code are or become more restrictive than those contained herein, such provisions shall govern, and are deemed incorporated into this policy upon taking effect.

C. Government Code Section 53600 et seq., authorizes local agencies to make investments in specified vehicles with money in a sinking fund of, or surplus money in, its treasury not required for the immediate needs of the agency.

D. PH is a "local agency" subject to the provision of Government Code Section 53600 et seq., which recommends that the PH Board of Directors annually adopt a statement of its investment policy, and to consider any delegation of authority to make investments on its behalf of the Chief Financial Officer.

E. The Board of Directors of PH now desires to formally adopt this statement of investment policy, and to re-delegate to the Chief Financial Officer responsibility for all decisions regarding the sale or purchase of individual investments on behalf of PH.

II. DEFINITIONS: A. Safety of Principal. Safety of principal is the foremost objective of PH. The safety and risk associated with an investment refers to the potential loss of principal, interest or a combination of these amounts. Each investment transaction shall seek to ensure that capital losses are avoided, whether from institutional default, broker-dealer default, or erosion of market value of securities. To attain this objective, diversification is required in order that potential losses on individual securities do not exceed the income generated from the remainder of the portfolio.

B. Liquidity. Liquidity is the second most important objective of PH. Liquidity refers to the ability to "cash in" at any moment in time with a minimal chance of losing some portion of principal or interest. Liquidity is an important investment quality especially when the need for unexpected funds occasionally occurs. The investment portfolio shall remain sufficiently liquid to enable PH to meet all operating requirements that might be reasonably anticipated.

C. Yield. Yield is the potential dollar earnings an investment can provide; it is sometimes described as the rate of return. Within the limits of safety and liquidity, PH shall strive toward portfolio growth that exceeds the rate of inflation in order to preserve capital.


A. Delegation Of Authority To Chief Financial Officer; Procedures To Implement Investment Policy 1. Delegation of authority to Chief Financial Officer: The PH Chief Financial Officer is delegated

responsibility for all decisions regarding the sale or purchase of individual investments on behalf of PH. This delegation shall be reviewed annually by the Board through the Finance Committee. Any re-

Policy

ANNUAL ADOPTION OF STATEMENT OF INVESTMENT27092 Official (Rev: 5)

Source:Administrative Board of Directors

Applies to Facilities: Applies to Departments:

Page 1 of 3ANNUAL ADOPTION OF STATEMENT OF INVESTMENT

7/14/2014https://www.lucidoc.com/cgi/doc-gw.pl?ref=pphealth:27092$5/frame/DOCBODY58

delegation shall be recorded in the minutes of these meeting. No person may engage in an investment transaction except as provided under the terms of this policy and any other procedures established by the Chief Financial Officer. The Chief Financial Officer shall be responsible for all actions undertaken and shall establish a system of controls to regulate the activities of subordinate officials.

B. This policy will be reviewed and updated as required or at least every year. C. Document History:

1. Original Document Date: 7/14/95; Revision Number: 1 Dated: 6/06 2. Prior to 2006, this Policy was Board Policy 10-513

IV. ADDENDUM:


Revision Number

Effective Date


5 (this version)

05/07/2014 Bob Hemker, Chief Financial Officer Edited for consistency in use of term "PH" following first full "Palomar Health ("PH")" reference

Approved by Board Finance 07/13 Approved by GAC 01/14 Approved by Board 02/10/14

4(Changes)

09/10/2012 Bob Hemker, Chief Financial Officer Corrections based on name change for the District; approved at September 10, 2012, Board meeting

3(Changes)

09/12/2011 Bob Hemker, Chief Financial Officer Annual review for Board of Directors - deletion of Section F under Purpose - redundancy with Section E; Signatory changed to current Board Chair T.E. Kleiter; Effective date of Board Governance Committee approval for previous revision was actually October 19, 2010 -final signature in Lucidoc makes it appear to have been approved in 2011

2(Changes)

07/13/2011 Bob Hemker, Chief Financial Officer Clarification of language

1(Changes)

02/11/2008 Bob Hemker, Chief Financial Officer Effective date of Board approval of this revision (2/11/08) was incorrectly entered as 11/14/07.[Reviewed on 9/1/2009 by Bob Hemker: Extended review to 9/1/2010]

0(Changes)

11/14/2007 James Neal, Director of Corporate Integrity

Updated by the board review

Authorized Signer(s): ( 05/07/2014 ) Bob Hemker, Chief Financial Officer( 05/07/2014 ) Janine Sarti, Chief Legal Officer



VI. REFERENCES:


https://www.lucidoc.com/cgi/doc-gw.pl?ref=pphealth:27092$5

( 05/07/2014 ) Ted Kleiter, Chairman, Board of Directors




ADDENDUM F

61

Policy Online Communications Policy

39152 Official (Rev: 0)

Source:

Administrative

Legal

Applies to Facilities:

Applies to Departments:

I. PURPOSE:

The emergence of online platforms for communication is rapidly changing the way that information is shared and viewed. Individuals can freely post comments and electronically interact with others in real time over the Internet. Among these individuals are Palomar Pomerado Health (“PPH”) doctors, staff, and board members.

This PPH Online Communications Policy (“Policy”) will outline what is expected of PPH employees in their online activity. Any online usage directly related to PPH business must be approved by the PPH Marketing Department.

Discipline for violation of this Policy, confidentiality or privacy, is severe, and may lead to termination of employment.

Online activity includes, but is not limited to, the following:

-Social networks such as Facebook, Myspace and Twitter

-Professional networks such as LinkedIn and Spoke

-Blogs: both internal and external to PPH

-Online references and websites that allow posting such as Wikipedia and Digg

II. DEFINITIONS:

-Blog: a Web site that contains an online personal journal with reflections, comments, and hyperlinks.

-Social Networking: a way that Internet users build online networks of contacts and interact with these personal or

business friends in a secure environment.

-Wiki: a collaborative website that can be directly edited by anyone with access.

-PPH-Sponsored Blogs: Blogs explicitly sponsored by the PPH Marketing Department.

-Twitter: social networking and micro-blogging service that enables its users to send and read other users’ updates

known as tweets


If an employee is not sure about any of the Policy items, he/she may contact the Marketing Department. When in doubt, do not post.

1. If a member of the media, or Internet user, contacts an employee about a posting regarding PPH business, the employee should refer that person to PPH Public Relations either at 858.675.5018 or at PPH.orgpalomarhealth.org website’s Media Center.

2. For supplemental information, refer to Lucidoc and search under each of the following titles: Computer System Usage, Use of District Equipment and Supplies, Internet Access and Appropriate Usage Standards, Code of Conduct, and Online Communications Procedure.

3. PPH may suspend, modify, or withdraw this Policy at any time.

62

IV. ADDENDUM:

None.


Revision Number

Effective Date


0 (this version)

07/13/2011 Ofer Barlev, Legal Associate Updated the New Policy

VI.

Authorized Signer(s): ( 01/07/2011 ) Bruce G Krider, Board Chairman, PPH Board ( 07/13/2011 ) Janine Sarti, General Counsel

VI. REFERENCES:




Comment [FR1]: Recommend addeing references to the following procedures:

1.Online Communications 2.Computer Systems Usage at PH ...

63





Policy Expense Reimbursement and AdvancesPolicy

21806 Official (Rev: 4)

Source:

Board of Directors

Applies to Facilities:

Applies to Departments:

I. PURPOSE:

To establish a policy to ensure appropriate expenditure of District funds, advances and reimbursement of expenses for expenditures made on behalf of the District. Consistent with current regulations (Local Health Care Law, California Attorney General's Opinion), the expenses of board members, employees and contractors and employees only may be considered for travel reimbursement purposes; spousal expense is specifically excluded.

II. DEFINITIONS:


A. To be reimbursed for expenses, the individual must present an expense reimbursement voucher with proper support documentation. The expense reimbursement voucher must include: the purpose, nature, location, date and amount of each expenditure. In instances where the expenditure includes other persons, the names of the persons and the business purpose must be disclosed.

1. Supporting documentation and receipts must be submitted with the expense report for every expenditure of $25.00 or more;

2. Receipts for amounts less that $25.00 should be submitted if available; 3. In all cases, receipts for hotel bills, airline tickets, auto rentals and other travel documents

must be submitted. B. The expense reimbursement voucher must contain the following information.

1. Business purpose of expenditure; 2. Nature of the expenditure; 3. Location the expenditure took place; 4. Names of others besides the individual involved; 5. Amount and date of the expenditure.

C. When a charge account or charge card is used and the monthly statement has been submitted for payment by the District, an accounting must be attached indicating the purpose, nature, location, date and amount of each expenditure. In instances where the expenditure includes other persons, the names of the persons and the business purpose must be disclosed.

B. Before any voucher for expenditures to or on behalf of an employee is presented for payment, it must be signed by the employeeindividual and approved by an individual with at least one-up level of authority to the employee. The approver must have signing authority (Per the Signature Authorization Matrix (Lucidoc #11558)) and access to the cost center to which the transaction will be charged. the employee's supervisor.

C. Before any voucher for expenditures to or on behalf of a contractor is presented for payment, it must be reviewed and approved by the contract responsible party. The approver must have signing authority (Per the Signature Authorization Matrix (Lucidoc #11558)) and access to the cost center to which the transaction will be charged.

D.

Formatted: Indent: Left: 0.15"

Formatted: Font: Italic, Font color: Accent 1

Formatted: Font: Italic, Font color: Accent 1

64

E.D. Expenditures paid to, or on behalf of, any member of the Executive Management Team must be approved by the President & CEO before the voucher is presented for payment.

E. Expenditures paid to, or on behalf of, the President or CEO must befirst be approved by the BoardBoard Treasurer. After paymentapproval by the Board Treasurer, these documents will be submitted to the Board TreasurerBoard for ratification and signature.

F. Expenditures paid to, or on behalf of, Members of the Board must be approved by the approved expenses for the President & CEO. , and Members of the Board of Directors may be approved for payment by the President & CEO. After payment, these documents will be submitted to the Board Treasurer for ratification and signature.

G. Each employee will incur his or her own expenses and submit reimbursement forms and vouchers. In some cases, this is not practical and expenses of a group will be paid by one individual. The individual submitting the reimbursement request must: indicate the name of those in attendance.

1. Indicate the name of those in attendance;

2. Supply an analysis of expenses by entity and cost center;

3.G. Supply all of the required documentation for all applicable individuals H. If the spouse accompanies the Board Member or the employee, the expenses directly related to

the spouse are not reimbursed by the District. A separate accounting must be maintained and only those expenses directly related to the Board Member or employee are reimbursed.

I. Often it is necessary to make advances to an individual or to make advance payments on behalf of the individual, i.e. seminar registration, hotel registration and airline tickets. In such cases:

1. A properly approved form must be submitted along with the applicable documentation; 2. A full accounting for such expenses must be included in the final accounting submitted and

such advance must be deducted on the final expense claim. J.I. This policy will be reviewed and updated as required or at least every three years.

IV. ADDENDUM:

V. DOCUMENT / PUBLICATION HISTORY:

Original Document Date: 4/18/95 Reviewed: 11/95; 1/99; 6/05 Revision Number: 1 Dated: 6/05 Document Owner: Michael Covert Authorized Promulgating Officers: Marcelo R. Rivera, Chairman

Prior to 2005 this policy was Board Policy 10-504

V. CROSS REFERENCE DOCUMENTS:

Prior to 2005 this policy was Board Policy 10-504

Expense and Reimbursement Procedure (Lucidoc #10219)

Travel and Mileage Reimbursement Form (Located on Palomar Health Intranet

under Finance>Forms & Resources)

Non-Travel Business Expense Form (Located on Palomar Health Intranet under

Finance>Forms & Resources)


Formatted: No bullets or numbering


Formatted: Font: (Default) Times New Roman

Formatted: Indent: Left: 0"

Formatted: No bullets or numbering, Tabstops: Not at 2"


Formatted: No bullets or numbering

65

Signature Authorization Matrix (Lucidoc #11558)


Revision Number

Effective Date


4 (this version)

09/01/2010 Janine Sarti, Chief Legal Officer Incorporating January 2010 Governance Committee changes. Added at review: Reviewed and approved 01.2010 [This document revision was generated to track review signatures and does not contain any changes from the previous revision.] [Reviewed on 1/9/2012 by Nicole Adelberg: Set next review date to 9/1/2013]

3

(Changes)

09/01/2010 Ofer Barlev, Legal Associate Incorporating January 2010 Governance Committee changes.

2

(Changes)

06/01/2005 Ofer Barlev, Legal Associate Original Document Date: 4/18/95 Reviewed: 11/95; 1/99; 6/05 Revision Number: 1 Dated: 6/05 Document Owner: Michael Covert Authorized Promulgating Officers: Marcelo R. Rivera, Chairman [Reviewed on 6/14/2006 by James Neal: Extended review to 6/13/2009] Added at review: No material change made to text of document. Updated signatures to current signers.

1

(Changes)

06/01/2005 James Neal, Director of Corporate Integrity

Original Document Date: 4/18/95 Reviewed: 11/95; 1/99; 6/05 Revision Number: 1 Dated: 6/05 Document Owner: Michael Covert Authorized Promulgating Officers: Marcelo R. Rivera, Chairman [Reviewed on 6/14/2006 by

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https://www.lucidoc.com/cgi/doc-gw.pl?ref=pphealth:21806$3&ref2=pphealth:21806







James Neal: Extended review to 6/13/2009]

VI.

Authorized Signer(s): ( 01/09/2012 ) Janine Sarti, General Counsel VI. REFERENCES:


Source Documents Prior to 2005 this policy was Board Policy

10-504



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BOARD GOVERNANCE AUDIT AND COMPLIANCE COMMITTEE MEETING · 8/7/2014 · Minutes Governance Audit...

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Transcript of BOARD GOVERNANCE AUDIT AND COMPLIANCE COMMITTEE MEETING · 8/7/2014 · Minutes Governance Audit...