Corporate Compliance Clinical Services Dept CTS Corporate Compliance

CTS Corporate Compliance Plan Completed upon initial hire for new staff Completed annually for

CTS Corporate Compliance Plan CTS is an equal opportunity employer No tolerance for harassment

Confidentiality CTS takes confidentiality very seriously. Confidentiality applies to: ◦ Patient info (HIPAA) ◦

HIPAA All patient information shall be maintained in confidence and made available only to

HIPAA cont. All staff will insure security of protected information (secured EHR passwords, access

Conflicts of Interest PRN work outside of CTS responsibilities is acceptable with prior approval.

Ethics CTS complies with ethical practices involving: ◦ Billing/Reimbursement regulations ◦ State licensure laws

Billing Individual, Group, Concurrent treatment must be billed appropriately. CPT and ICD 9 coding

Licensure Appropriate assistant supervision Timely/complete/accurate documentation Effective continuing education Insuring staff skills match requirements

Patient Abuse and Neglect Policy All patients of CTS have the right to be

Reporting Mechanisms If you have knowledge of activities in the department that are in

Reporting Mechanisms Reports can be anonymous or otherwise CTS will complete a full investigation

** IMPORTANT** Report any concerns you may have ASAP Follow Corporate Compliance plan –

$Summary Kim Schmidlin maintains an open-door policy Your duty to report infractions Willfull blindness$

Contacts Corporate Office: 910 -892 -0027 (Kim Schmidlin and Chastity Strickland) kims@carolinatherapy. net chastitys@carolinatherapy.

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Corporate Compliance Clinical Services Dept

CTS Corporate Compliance Plan Completed upon initial hire for new staff Completed annually for all staff Copy of complete Corporate Compliance Manual in each department Kim Schmidlin is CTS’s Corporate Compliance Officer

CTS Corporate Compliance Plan CTS is an equal opportunity employer No tolerance for harassment of any kind (verbal, physical, sexual, etc) in the workplace No tolerance for substance abuse in the workplace Referrals and kickbacks are strictly prohibited

Confidentiality CTS takes confidentiality very seriously. Confidentiality applies to: ◦ Patient info (HIPAA) ◦ CTS billing, advertising, promotional plans ◦ Staff info

HIPAA All patient information shall be maintained in confidence and made available only to those company personnel directly involved in patient consultations or in the preparation of a bill for supplies provided to the patient. No company employee, contractor, or agent shall discuss confidential information in any non-business setting, or use any such information for personal gain.

HIPAA cont. All staff will insure security of protected information (secured EHR passwords, access to computers, etc). It is against CTS’s electronic signature policy to share your password.

Conflicts of Interest PRN work outside of CTS responsibilities is acceptable with prior approval. Can not interfere with responsibilities to CTS

Ethics CTS complies with ethical practices involving: ◦ Billing/Reimbursement regulations ◦ State licensure laws

Billing Individual, Group, Concurrent treatment must be billed appropriately. CPT and ICD 9 coding should be accurate Patients will only be billed for services provided Billing will be submitted in a timely manner

Licensure Appropriate assistant supervision Timely/complete/accurate documentation Effective continuing education Insuring staff skills match requirements of the position

Patient Abuse and Neglect Policy All patients of CTS have the right to be treated and provided services with dignity and respect, free from any abusive treatment, neglect or exploitation, including the use of abusive language. CTS has zero tolerance for any type of patient abuse, neglect, exploitation, or mistreatment. Any employee found to have committed, conspired with another or fails to report an act of abuse, neglect, or exploitation, will be terminated and reported to the state regulatory agency, licensing officials, and/or local law enforcement, if appropriate. An employee failing to report confirmed or suspected abuse of a patient, by any other person, including another patient, a family member or facility staff member, will be held accountable and will share in the blame and consequences of the incident.

Reporting Mechanisms If you have knowledge of activities in the department that are in conflict with the CTS Corporate Compliance Plan or Patient’s Rights, it is your responsibility to report it to: ◦ ◦ ◦ Corporate Compliance Officer (Kim Schmidlin) HR Director (Chastity Strickland) Clinical Specialist (Brad Myers and Donna Overton) Area Director Program Manager

Reporting Mechanisms Reports can be anonymous or otherwise CTS will complete a full investigation and get a response to the staff member who reported the situation. If infraction is proven, appropriate action will be taken No repercussions if complaint is made in good faith Failure to report issues that you have knowledge of that are harmful to patients or staff: Willfull blindness

** IMPORTANT** Report any concerns you may have ASAP Follow Corporate Compliance plan – do not “Take matters into your own hands” (IE contacting licensure board, conducting your own investiation) Report contact by a government agency (State JCAHO surveys, etc) to AD ASAP Report receipt of subpoena to AD ASAP.

$Summary Kim Schmidlin maintains an open-door policy Your duty to report infractions Willfull blindness$

Summary Kim Schmidlin maintains an open-door policy Your duty to report infractions Willfull blindness prohibited Retaliation prohibited False allegations are prohibited

Contacts Corporate Office: 910 -892 -0027 (Kim Schmidlin and Chastity Strickland) kims@carolinatherapy. net chastitys@carolinatherapy. net Clinical Specialist: 252 -229 -5761 (Brad Myers) bradm@carolinatherapy. net 910 -835 -8066 (Donna Overton) donnao@carolinatherapy. net