" Tropical Texas Behavioral Health provides quality

“Tropical Texas Behavioral Health provides quality behavioral healthcare with respect, dignity and cultural sensitivity, through the efficient and effective delivery of services.”

QUALITY MANAGEMENT PLANFY 2008

TABLE OF CONTENTS

I. Purpose

II. Plan Development

III. Center Vision and Mission Statements

IV. Goals

V. Quality Assurance Structure and Design

VI. Collection and Measurement of Data

VII. Assessment of Data

VIII. Improvement

IX. Deficit Reduction Act/Corporate Compliance

TTBH QM PLAN Page 2 of 36

TROPICAL TEXAS BEHAVIORAL HEALTHQUALITY MANAGEMENT PLAN

I. PURPOSE

The goal of the quality management program is to improve outcomes for recipients of the mental health and mental retardation services authorized and managed by the Center. To accomplish this, the Center combines the use of information technologies with continuous quality improvement processes to provide quality assurance oversight of authority, administrative, fiscal and service delivery performance. The quality management program ensures that the Center’s Executive Management Team (EMT), Board of Trustees, Committees and Advisory Groups have the information needed to make management decisions that support the provision of the highest quality services.

The Center’s performance of important functions significantly effects outcomes for individuals, the cost to achieve successful outcomes and the perception of consumers and families of the quality and value of services. The Center has implemented system wide performance evaluation and improvement measures for its network of service providers as well as its business and administrative functions.

The quality management process is vital to demonstrating best value, balancing service cost and quality.

II. PLAN DEVELOPMENT

The Center’s Quality Management Plan is a functional and dynamic document, evolving over time. The Plan addresses the following quality management initiatives: oversight of the Center’s authority and provider functions; increased accountability; compliance with the requirements and objectives of the performance contract and Resiliency and Disease Management (RDM); and the integration of Local Planning and the consideration of public input in determining best value and standards for customer service and quality client care.

The quality oversight responsibilities built-in to the Center’s role as the local authority include the management and maximization of resources within the local communities to serve as many individuals as possible while obtaining the best results; monitoring client satisfaction as it pertains to provider choice and service quality, and objective evaluation of service providers.

As the Center prepares for a fee-for-service environment, it must be increasingly efficient in its use of available funds to obtain the highest quality of services. Quality oversight in this area ensures objective monitoring and evaluation of service delivery, provider performance, and the correction or improvement of deficient practices and non-compliance.


To ensure compliance, the Center will continue to utilize the Performance Improvement and Compliance Committee (PICC) to analyze performance, especially as it pertains to the evaluation of high impact areas including Crisis Redesign, RDM Fidelity Reviews and Texas Implementation of Medication Algorithm (TIMA) Studies. Areas requiring evaluation and oversight are identified in statute and in the requirements of the performance contract, by the contract accountability data stored in the state’s Mental Retardation and Behavioral Health Outpatient Warehouse (MBOW), and in any plans of corrective action resulting from external review by the various agencies regulating Center services and functions.

The QM Plan supports the Center’s Local Plan, developed with the input of clients, families, stakeholders and other members of the community. Quality oversight includes reviewing and monitoring progress made toward achieving goals and objectives, and recommending improvement activities. The effectiveness of The Plan is monitored through reports made to the PICC, EMT, Board of Trustees, and other oversight committees and advisory groups.

III. VISION AND MISSION STATEMENT

The QM Plan is driven by and supports the vision and mission of the Center, stated below.

VISION STATEMENT: Tropical Texas Behavioral Health continues its commitment to excellence and will be an innovative provider of comprehensive and compassionate behavioral health services. We will treat all stakeholders with honesty, fairness and respect.

MISSION STATEMENT: Tropical Texas Behavioral Health provides quality behavioral healthcare with respect, dignity and cultural sensitivity, through the efficient and effective delivery of services.

IV. GOALS

The Quality Management Plan is consistent with the organization’s mission, goals and objectives and has been developed to reflect the coordination between the activities of the Quality Assurance Division and other management functions such as governance and leadership, financial planning and management, human resources, service delivery, provider network management and information management. The schedule below reflects the goals included in the Center’s Local Plan, and those of the Board and EMT as reflected in the FY 2008 Strategic Plan. Progress toward the stated goals are reported quarterly to the Board of Trustees and the PNAC, respectively. The goals and objectives for the operational strategies fall under the following categories: Program Development; Internal Performance; Financial Performance, Stability & Growth; and Image & Building Enhancement. These initiatives and goals of the local authority are measured and assessed on at least a quarterly basis and if further improvement is needed a Performance Improvement Team is formed. Each of these goals will be continuously reassessed in accordance with changes throughout the state behavioral healthcare system and healthcare systems across the nation.


TROPICAL TEXAS BEHAVIORAL HEALTHSchedule for Initiating Significant Actions

PROGRAM DEVELOPMENT TASK Measure

Develop and implement crisis redesign.

1. Hold a minimum of two forums in each Cameron and Hidalgo County for input and prioritization of CR Plan AND Submit a CR Plan prior to November 1st, 2007-Meets

2. Number 1 plus Hotline Services meet requirements by January 15, 2008 AND Crisis Mobilization Teams will be in place by February 1, 2008-ExceedsNumber 1 and 2 and Quarterly reviews by the PNAC-Commendable

In House Pharmacy1. Have a pharmacy manager in place by April

15, 2008-Meets2. Begin in house pharmacy services by June

1, 2008-Exceeds3. Begin receiving pharmacy reports by August

31, 2008-Commendable

Clinical OutcomesMH Services

1. 35% of all adults served during the FY have acceptable or improving functioning.

2. 41% of all adults served during the FY have acceptable or improving criminal justice involvement.

3. 83% of all adults served during the FY have acceptable or improving employment.

4. 69% of all adults served during the FY have acceptable or improving housing.

5. 84% of all adults served during the FY have acceptable or improving co-occurring substance use.

6. Percent of all adults with time in crisis will not exceed 2.3% for those authorized for a LOC during the FY.

7. 77% of all adults served during the FY receive their first (not screening/ assessment) service encounter within 14 days of their intake assessment.

8. The average number of re-admissions per adult shall not exceed 0.24 during the FY.

MR Services

1. 60% or more clients surveyed agree with


PROGRAM DEVELOPMENT TASK Measure

statement: “I have choices about my life.”2. 60% or more clients surveyed agree with

statement: “I get to do the things I enjoy doing in the community.”

3. 60% or more clients surveyed agree with statement: “I get the support I need to make my life better.”

4. 60% or more clients surveyed agree with statement: “I have opportunities to develop and maintain friendships.”

5. 60% or more clients surveyed agree with statement: “I have opportunities to work in a job that I like.”

6. 60% or more clients surveyed agree with statement: “I feel respected as a valued member of my community.”

INTERNAL PERFORMANCE Status

Develop and implement strategies for recruitment and retention of a professional workforce.

1. Hold strategy meetings with Direct Care staff by February 29, 2008-Meets

2. Number 1 and Hold strategy meetings with Supervisors by February 29, 2008-Exceeds

3. Number 1 and 2 and Hold strategy meetings with Managers and EMT Members by February 29, 2008-Commendable

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1. Develop and implement a “One Month Post Hire” survey for feedback from New Employees by May 1, 2008-Meets

2. Develop and implement a “One Month Post Hire” survey for feedback from New Employees by April 1, 2008-Exceeds

3. Develop and implement a “One Month Post Hire” survey for feedback from New Employees by March1, 2008-Commendable

Continue to develop a succession plan for Executive and other mission critical positions.

1. Identify mission critical tasks by 3-31-2008-Meets.

2. Identify mission critical tasks by 2-29-2008-Exceeds.

3. Identify mission critical tasks by 1-31-2008-Commendable.

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1. Complete succession plans for all EMT members by 8-31-2008-Meets

2. Complete succession plans for all EMT


INTERNAL PERFORMANCE Status

members by 7-31-2008-Exceeds3. Complete succession plans for all EMT

members by 6-30-2008-Commendable

FINANCIAL PERFORMANCESTABILITY AND GROWTH Status

Maintain a strong financial position in preparation for fee for service environment.

1. 60-80 days operating funds available-Meets 2. 81-100 days of operating funds available-

Exceeds3. Over 101 days of operating funds available-

Commendable

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1. MH general revenue earned 65% by 8/31/08-Meets

2. MH general revenue earned 70% by 8/31/08-Exceeds

3. MH general revenue earned 75% by 8/31/08-Commendable

Improve utilization of information technology.

1. Implement electronic prescribing by 5/31/08-Meets

2. By 4/31/08-Exceeds3. By 3/31/08-Commendable

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1. Implement authorization system on client data By 5/08-Meets

2. By 4/08-Exceeds3. By 3/08-Commendable

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1. Utilize ATP for Mobile Crisis Screening By 5/31/08-Meets

2. By 4/31/08-Exceeds3. By 3/31/08-Commendable

Enhance Network Development

1. Meet all DSHS deadlines-Meets2. Submit all requirements prior to deadlines-

Exceeds3. DSHS approval on all requirements

submitted prior to deadlines-Commendable


FINANCIAL PERFORMANCESTABILITY AND GROWTH Status

Increase the efficiency (% of claims billed and claims collected) of the 3rd Party reimbursement process.

1. Bill 60% of Medicaid claims within 30 days of service-Meets

2. Bill 70%-Exceeds3. Bill 80%-Commendable

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1. Bill 75% of other 3rd party claims within 45 days of service-Meets

2. Bill 85%-Exceeds3. Bill 90%-Commendable

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1. Collect 80% of FMAP for Medicaid within 60 days of service-Meets

2. Collect 85%-Exceeds3. Collect 90%-Commendable

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1. Collect 75% of 3rd Party claims within 90 days of service-Meets

2. Collect 80%-Exceeds3. Collect 85%-Commendable

IMAGE BUILDING/ ENHANCEMENT Status

Obtain CARF Accreditation

1. Complete a Mock Survey by CARF surveyors by January 30, 2008-Meets

2. Complete a Mock Survey by CARF surveyors by December 31, 2007-Exceeds

3. Complete a Mock Survey by CARF surveyors by November 30, 2007-Commendable

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1. Declare our Intent for Survey by December 31, 2007-Meets

2. By December 15-Exceeds3. By December 3-Commendable

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1. Receive one year accreditation-Meets2. Receive three year accreditation-

Commendable


IMAGE BUILDING/ ENHANCEMENT Status

Continue to seek input from stakeholders and increase opportunities to advocate for clients, and as a result, promote Tropical awareness.

1. Participation in stakeholder activities two times per month-Meets

2. Participation in stakeholder activities three times per month-Exceeds

3. Participation in stakeholder activities four times per month-Commendable

Improve Customer Service

1. Develop a customer service program focusing on telephone etiquette and communication by June 30, 2008-Meets

2. Implement new Customer Service Training by April 30, 2008-Exceeds

3. Implement a new customer service initiative by February 29, 2008-Commendable

V. QUALITY ASSURANCE STRUCTURE AND DESIGN

This plan supports the implementation of performance improvement measures identified in the Center’s previous Quality Improvement Plan and includes such quality oversight activities as: developing performance measures based on identified weaknesses; monitoring performance measures to determine effectiveness; and recommending additional and/or alternative improvement activities. Quality Management activities are intended to be proactive, flexible, objective and responsive to the unique characteristics of programs and services. In order to accomplish this, it is necessary to consider the service types, applicable standards and the needs and wishes of specific service areas and programs. Toward this end, a variety of groups, technical assistance and support, and reporting systems are established to focus on the essential issues facing each individual service area and/or program. The Center as a whole has been restructured to better serve the needs of the consumers and to meet the state goals and objectives (see Attachment A: TTBH Organization Chart). A complete inventory of Center-wide contracts has been prepared and the role of contract monitors has been defined. Assignments will be made for the review of external providers. This structure will provide continuity across the Center and its providers. The Center has adopted approaches and methodologies that are utilized to implement specific quality management activities and include the following:

The Center has designated the EMT, the membership of which includes the Chief Executive Officer, Chief Operating Officer, Chief Administrative Officer, Chief Medical Officer and the Chief Financial Officer, to oversee internal quality assurance activities. The role of the EMT is long-term in nature and places a heavy emphasis on leadership and motivation. The Management and Information Systems Department participates in quality management functions through the provision of customized data reports that are utilized by management to make decisions pertaining to service delivery. Standing items on the EMT agenda include ongoing areas that need continual updates. Other agenda items are added by EMT members.

The Center utilizes standing Committees to review and monitor client service activities and functions. Committees carry out a major portion of quality assurance activities and impact


processes, procedures and practices. Committees include representation from all involved service areas in order to utilize the varied expertise and experience of Center staff, providers and other stakeholders. Current Center committees include, but are not limited to, the Performance Improvement and Compliance Committee (PICC), Clinical Records, Rights and Ethics, Death Review, Medical Staff, Professional Staff Organization (PSO) and Utilization Management (UM).

The role of the Performance Improvement and Compliance Committee (PICC) is to analyze results of ongoing measurement processes, address performance trends, and monitor plans of improvement. Through these activities the PICC is usually the group that completes the first steps of the Center’s improvement process. The steps include: identifying a process to improve; organizing a team that knows the process; and clarifying current knowledge of the process. After these steps are completed the performance improvement team that is organized completes the remaining steps. The PICC is comprised of management staff and staff representing the disciplines and types of services the Center provides. Areas assessed and overseen by the PICC for performance improvement include monthly supervisor documentation reviews, client satisfaction, data verification, timeliness of data entry, results of external reviews and corrective action plans, Health Information Management form completion (e.g. privacy, financials, consents, authorizations, treatment plans, etc.); client rights report (i.e. allegations, rights violations, technical assistance, appeals, complaints-monthly report); and contract performance measures.

If any of the above measures are determined to need improvement, the PICC will set up a Performance Improvement Team with a team charge and reporting deadline.

Performance Improvement Teams (PITs) are established for the purpose of reviewing specific areas and completing four steps of the improvement process referred to as PDCA: Planning the improvement action; Doing (test the action); Checking to determine the effect of the action; and Acting to implement the action on a wide scale. PITs may be made up of a single program or multiple programs based on similarity of functions. PITs provide a means for:

Ongoing self-assessment of processes, standards and outcomes; Proactive improvement, rather than reactive response; Identifying training needs; Service driven program improvements; Quality beyond standards compliance; and, Improved teamwork and trust.

The Rights and Ethics Committee meets at least quarterly. The mission of the Rights and Ethics Committee is to review, approve and monitor restrictions placed on clients’ rights on behalf of Tropical Texas Behavioral Health in compliance with all applicable rules and laws and other established criteria. The Rights and Ethics Committee’s efforts are aimed at continuous improvement of the quality and appropriateness of client care. Furthermore the Rights and Ethics Committee shall ensure that any restrictions are ethical, humane and in the best interest of the client.


The Rights and Ethics Committee is responsible for review activities including, but not limited to:

1. The use of emergency intervention and/or behavior management included in a Person Directed Plan;

2. The approval or disapproval of all experimental, nonstandard and research procedures;3. To review, approve and monitor, in conjunction with a person’s Service Coordinator,

programs designed to increase appropriate behavior(s) incorporating restrictions of rights;4. To review, approve and monitor other programs that, in the opinion of the committee,

involve risks to protection and rights of individuals being served.5. To review, approve and monitor the use of psychotropic medications for behavior

management.

The Rights and Ethics Committee oversight responsibilities include, but are not limited to, the review of behavior management plans, representative payee, restrictions of diets and guardianship of persons served and any other rights restrictions upon approval of the person and/or LAR. The Rights and Ethics Committee reports to the PICC on a quarterly basis.

The Center’s Utilization Management component that authorizes and/or denies services has been developed and is fully functional; this component authorizes/denies services based on protocols developed by the different providers under the auspices of the Center. UM protocols will be reflective of Performance Contract requirements and DSHS UM Guidelines related to RDM, as well as associated Fidelity Instruments. An outcome of the UM process will be tracking and trending the number of denials and number of authorizations. Based on the data collected, the UM department will be able to profile clients, staff and physicians. Depending on where the negative and positive outliers are, reports will go to appropriate disciplines or departments. This information will also become part of the Utilization Review process. The UM Committee meets monthly and currently measures and assesses the following data: Services Rendered Prior to Authorization; Clients Served prior to Authorization (Adult and Child); Service/Authorization Lag at Intake (Adult and Child); Waiting Lists (Adult and Child); UM Percentage of Services In-Vivo Summary of Hours; Clients Served But Not Assessed (Adult and Child); Population by Level of Care (LOC) Matrix (Adult and Child), Discharge Reason (Adult and Child); Appropriateness of Service Authorized-Contract Measure by Month (Adult and Child); LOC Deviation Reasons-Underserved (Adult and Child); LOC Deviation Reasons-Over served (Adult and Child); Rehabilitation Services; Pharmacy New Generation Medication Report and PAP Report; Facility Admissions; and Capacity Determination. The Center monitors access to services by monitoring appeals of termination, reduction and denial of services. All appeals are reported monthly to the UM Committee. Future changes will include adding Mental Retardation measures to the UM agenda. If any area is in need of improvement the UM Committee will set up a PIT with a team charge and deadline for reporting progress.

Included in the data reviewed by the PICC and UM Committee are the results of the Texas Implementation of Medication Algorithms (TIMA) Studies. Center medical staff have been trained to utilize the treatment guidelines set forth by TIMA to aggressively treat severe and persistent mental illness while also making appropriate efforts to reduce the need for crisis and/or inpatient hospital services. The QA Division will support medical staff performing quarterly internal reviews of physician and nursing service documentation to ensure compliance with


TIMA requirements and related performance contract guidelines, and use the findings to implement corrective actions as indicated.

Additionally, the Center utilizes several Councils in an oversight and advisory capacity. Councils serve to provide recommendations to the EMT and the Board of Trustees. Current Councils include, but are not limited to, adult and child/adolescent Community Resource Coordination Groups (CRCGs), the Planning and Network Advisory Council (PNAC), and the Staff Advisory Council (SAC).

VI. Collection and Measurement of Data

The Center is dedicated to the continuous improvement of the behavioral health services it provides, and will periodically evaluate the effectiveness and efficiency of, access to, and satisfaction with, services, and modify service delivery and administrative processes as appropriate based on evaluation findings.

Clinical outcomes and business performance will be evaluated based on benchmarks set forth in the Department of State Health Services and Department of Aging and Disability Services performance contracts, and the Center’s productivity standards.

Efficiency indicators for all services will be obtained using UM data available from MBOW and internal staff productivity reports.

Effectiveness, service access and satisfaction indicators will apply to all clients served. Efficiency indicators will apply to the Center, and measure the agency’s productivity and the extent to which available resources are used to achieve the greatest effect.

Client and family satisfaction is evaluated through bi-annual satisfaction surveys administered by the agency. Further, the Center’s mental health and mental retardation services Outcomes Management Questionnaires will collect and measure data for indicators pertaining to access to services and client satisfaction, and will be administered to clients periodically during, and in some cases after, their treatment.

Additionally, the data from the following areas are collected and reported to monitor performance:

Data Verification (MH and MR) ICF-MR Surveys HCS and TxHmL Surveys Interest Lists Internal and External Program Reviews CARE Anasazi Client Data System MBOW Management Reports Strategic Plan


Corporate Compliance Performance Contracts UM Provider Profiling Reports Staff Training Curriculum and Performance Evaluation Data Identified Quality Indicators, Processes, and Outcomes Stakeholder Satisfaction Surveys Organizational Performance Measures (self-assessment) Risk Indicators-Critical Incident Reporting System

VII. Assessment of Data

The processes described above will allow for comparative analyses of clinical outcomes and satisfaction for individual clients, specific clinic sites and overall business performance over time. The data will be used assess the Center’s performance and determine strengths, weaknesses, and opportunities for improvement. At least annually, the QA Division will provide a summary analysis of the outcomes management data to the Center’s Executive Team and Board of Trustees to recommend necessary administrative and/or clinical changes. The findings in the summary will also be included in the Center’s Strategic Plan.

MonitoringAll of the services provided by the Center will be monitored at least annually.

The following services are available to all clients: Education around eligibility for services Case Management Treatment Planning/Person Directed Planning Crisis Services Benefits Eligibility Assessment

The following services are available to adults with appropriate mental health diagnoses and children determined to have severe emotional problems:

Psychiatric Services Medication Related Services Behavioral Skills Training Inpatient Services Medication Training and Supports Patient Assistance Program Jail Diversion

The following services are available to adult mental health clients: Supported Employment Supported Housing Assertive Community Treatment (ACT) Consumer Peer Support Projects for Assistance in Transition from Homelessness (PATH)


Texas Correctional Office on Offenders with Medical or Mental Impairments (TCOOMMI)

The following services are available to Children and Adolescents: Wraparound Planning Transition Planning Juvenile Justice Family Psycho-education Flexible Community Supports Intensive Case Management Routine Case Management Family Support Groups Family Partner Services Counseling TCOOMMI

The following services are available to clients with a diagnosis of Mental Retardation: Service Coordination Supported Employment-Employment Assistance Supported Employment-Individualized Competitive Employment Skills Training-Day Habilitation Program ICF-MR Residential Services Home and Community Support (HCS) Waiver Texas Home Living Waiver In-Home Family Support Permanency Planning

The following services will be monitored quarterly due to critical importance: Continuity and Community Aftercare Medicaid Review Utilization Review New Generation Medications TIMA

Trending and Reporting FindingsThe results of the analyses including any identified trends will ultimately be sent to the PICC, EMT and Board of Trustees for recommended action. Reports will also be sent to service area managers, the Client Rights Officer, and other program managers and supervisors as indicated. Corrective measures and improvements are monitored through follow-up reviews tracked by the QA Division.

VIII. Improvement

Data collected will be analyzed monthly and/or quarterly to determine trends. The collected data will guide the development of plans of improvement. Data indicating negative outliers will be addressed through Performance Improvement Teams and/or brought to the attention of the EMT


for recommended action. While positive outliers will become best practices, serving as benchmarks for the Center’s continuous quality improvement processes, remedial action will be taken to address unacceptable levels of performance outcomes. Submission of plans of improvement to the QA Division will be required to address negative outliers. Follow-up activities and monitoring will be included in the plans to ensure maintenance of improvements. Identified program deficiencies will be prioritized for resolution by the PICC and EMT. Subsequent performance will be evaluated to determine the effectiveness of each plan of improvement.

IX. Deficit Reduction Act and Corporate Compliance

The Deficit Reduction Act (DRA) of 2005, Federal Anti-kickback Statute, Federal False Claims Act and Medicaid Fraud Prevention Act established a number of processes that healthcare organizations were required to put into practice to evidence corporate compliance. The Center has developed and implemented a fraud and abuse compliance program and policy (see Attachment B: Policy # SS1-05.04, Corporate Compliance Documentation and Claims Integrity Plan) specifying the responsibilities and obligations of its employees, volunteers and contracted providers regarding submission of reimbursement claims to Medicare, Medicaid and other government payers for services rendered. The policy also applies to all business arrangements with physicians, vendors and other person who may be impacted by federal or state laws relating to claims fraud and abuse. The Center’s policy, Corporate Compliance training curriculum and employee handbook contain detailed information concerning the False Claims Act, administrative remedies, civil and criminal penalties for false claims and information regarding whistleblower protections under the law.

As stated in the policy, a report reflecting the Center’s corporate compliance activities for the preceding fiscal year and planned activities for the upcoming year is provided annually to the EMT and Board of Trustees. The most recent report was delivered August 28, 2007.


Attachment A


Chief Executive Officer

Chief Medical OfficerChief Financial Officer Chief AdministrativeOfficerChief Operations Officer

Rights &CommunityRelations

HIM CoordCorp Compl

Privacy

D O N

HumanResources

Safety Officer /Environ. Svcs

Manager

Accounting

Contracts

RevenueEnhancement

MIS

Purchasing

Board of Trustees

ConsumerBenefits /Eligibility

Crisis Respite /After Hrs Crisis

Oversight

Special Projects

012208

UM / Continuityof Care

Physician Svcs

PharmacyServices

Brownsville Svc Center Edinburg Svc CenterHarlingen Svc Center

CaseManagement

Intake / Crisis /Mobil Crisis

Outreach Team

Jail Diversion

TCOOMMI

SubstanceAbuse

CaseManagement


Outreach Team

CaseManagement


Outreach Team

Rehabilitation

Supportive Emp& Housing

Youth & FamilyServices



PATH

Rehabilitation



CounselingCounselingCounseling

H I M H I M H I M

Nursing

QualityAssurance &

Planning

Cameron CountyACT

Hidalgo CountyACT

Nursing

Rehabilitation

Nursing

MR Services

HCS Programs

RGV ProviderSvcs

MR Eligibility &Svc Access

Tx Hm LvgWaiver Svcs

ICF-MRPrograms

ServiceCoordination

Nursing

AuthorityServices

ProviderServices

Training &Volunteer Svcs

San Benito ISDGrant Donna ISD Grant

CulturalAdaptation Grant

CulturalAdaptation Grant

Attachment B

Operating Policies: Effective Date:SS1-05.04 January 1, 2007

Revised:November 2007

CORPORATE COMPLIANCE DOCUMENTATION AND CLAIMS INTEGRITY PLAN

I. PURPOSE:

A. It is the practice of Tropical Texas Behavioral Health (TTBH) to obey the law and to follow ethical business and service practices especially as it pertain to quantitative and qualitative documentation requirements of professional services and fee and claims billing. TTBH requires its employees, volunteers and contract providers to be fully informed about and in compliance with all applicable laws and regulations and regulatory requirements.

B. TTBH has developed a fraud and abuse compliance program which sets out the responsibilities and obligations of all employees, volunteers and contract providers regarding submissions for reimbursement to Medicare, Medicaid and other government payers for services rendered by TTBH and any of its employees, volunteers and contract providers, subsidiaries, divisions and contractors. In addition, this Plan is intended to apply to all business arrangements with physicians, vendors and other persons which may be impacted by federal or state laws relating to claims fraud and abuse.

C. In order to support this commitment, TTBH has established the following:1. Designation of a TTBH official (Corporate Compliance Officer)

responsible for directing the effort to enhance compliance, including implementation of the Plan.

Odilia GarciaEmail: [email protected]

Phone: 956-289-7087 / 1-877-289-5880


Fax: 956-289-71282. Incorporation of standards and procedures which guide TTBH employees,

volunteers and contract providers and others involved with operational practices and administrative guidelines;

3. Identification of legal issues that may apply to business relationships;4. Development of compliance initiatives/requirements at the unit level;5. Coordinated training of clinical and administrative staff, volunteers, and

contract providers concerning applicable compliance requirements and TTBH procedures;

6. A uniform mechanism for employees, volunteers and contract providers, to raise questions and receive appropriate guidance concerning operational compliance issues;

7. Regular review and audit to assess compliance to identify issues requiring further education and to identify potential problems;

8. A process for employees, volunteers and contract providers, to report possible compliance issues and for such report to be fully and independently reviewed by the Corporate Compliance Officer;

9. Enforcement of standards through well publicized disciplinary guidelines.10. Formulation of corrective action plans to address any compliance

problems which are identified;11. Regular review of the overall compliance effort to ensure that operational

practices reflect current requirements that other adjustments are made to improve TTBH operations;

12. Coordination between TTBH departments and divisions and contract providers to ensure effective compliance in areas where activities might overlap.

II. SCOPE

A. This Plan applies to all TTBH staff, volunteers, contractors, and service activities and administrative actions governed by federal and state regulations related to health care providers.

B. It is the intent of TTBH that the scope of all documentation and claims compliance polices and procedures should promote integrity, support objectivity and foster trust between providers and clients and payors.

III. Compliance Officer

A. The primary responsibility for implementing and managing TTBH’s compliance plan shall be assigned to the TTBH Compliance Officer. The Compliance Officer will report documentation and claims issues directly to the Chief Executive Officer (CEO) and to the Chief Administrative Officer (CAO) and as required, to the governing body of TTBH. The TTBH Board of Trustees endorses this activity and requires that all TTBH staff, volunteers, contract providers and affiliates to


comply with state and federal guidelines related to billing and claims as well as federal and state laws related to fraud, waste and abuse.

B. The Compliance Officer will, with oversight of the CEO and the CAO and the assistance of the TTBH legal counsel where appropriate, perform the following activities:1. Review and amend as necessary, the Code of Conduct for all TTBH

employees, volunteers and contract providers.2. Assist in the review, revision, and formulation of appropriate guidelines for all

activities and functions of TTBH, which involve issues of compliance.3. Develop methods to ensure TTBH employees, volunteers and contract

providers and vendors are aware of the TTBH Code of Conduct and Corporate Compliance Policy and understand the importance of compliance.

4. Developing and delivering educational and training programs.5. Coordinate compliance reviews and audits in accordance with TTBH

procedures.6. Receive and investigate instances of suspected compliance issues, as set forth

in Sections IX, X and XI of this Plan.7. Assist in the development of appropriate corrective actions as set forth in

Section XI of this Plan.8. Prepare Annual Compliance Review, as set forth in Section XII of this Plan.9. Prepare Annual Corporate Compliance Work Plan, as set forth in Section XIII

of this Plan10. Prepare proposed revisions to the Compliance Plan, as set forth in Section

XIV of this Plan.11. Provide other assistance as directed by the CEO and CAO.

IV. COMPLIANCE COMMITTEE

A. A Compliance Committee is established to assist the Compliance Officer in the development, implementation and monitoring of compliance efforts. The Compliance Committee will consist of members appointed by TTBH’s CEO. Members of the committee will be representative of individuals involved in the billing and claims process of the TTBH and will serve two (2) year terms. The Compliance Officer will serve as the chair of the committee.

B. The committee’s responsibilities include’1. Analyzing the organization’s regulatory environment;2. Assessing existing and future policy and procedure needs to assure

compliance;3. Working with appropriate units, as well as affiliated providers to develop

standards of conduct and policies and procedures which promote adherence with TTBH Compliance Plan;

4. Recommending and monitoring the development of internal systems and controls to carry out TTBH’s standards, polices and procedures as part of daily operations;


5. Determining the appropriate strategy/approach to promote compliance with the program and detection of any potential violations, such as through hotlines and other fraud reporting mechanisms;

6. Developing a system to solicit, evaluate and respond to complaints and problems;

7. Monitoring internal and external audits and investigations for the purpose of identifying compliance issues by TTBH and its contracts and implementing corrective and preventive actions plans as necessary.

V. STAFF TRAINING

A. All staff, volunteers and contract providers providing services or involved in the billing and claims process must participate in billing and claims compliance training. This training shall be documented and all staff must demonstrate competency before they are allowed to submit bills and claims of services rendered. Individual staffs are responsible for maintaining compliance with TTBH billing and claims procedures and their managers are required to assure staff under their supervision is performing as required. TTBH has also adopted a Code of Conduct to guide all of its business activity.

B. All new hires receive Corporate Compliance training at new employee orientation. They demonstrate corporate competence and acknowledge the Code of Conduct as a condition of TTBH employment. All staff will attend Corporate Compliance training, demonstrate corporate citizenship and acknowledge the Code of Conduct annually thereafter. Management staff may request additional Corporate Compliance training at any time.

C. STAFF EDUCATION

1. Claims Development and SubmissionTTBH will provide no less than one (1) hour annually of training related to one or more of the following areas to direct service and billing and claims staff;

a. TTBH’s compliance program,b. An overview of the fraud and abuse laws as they relate to the

claim development and submission process,c. The consequences to both individuals and TTBH of failing to

comply with applicable laws.

2. Payments for Referrals and Related Fraud and Abuse Issues.

TTBH will provide the following education to employees, volunteers and contract providers involved in negotiating business relationships with physicians, providers, and vendors on behalf of TTBH. Such training will include, at a minimum, not less than one (1) hour annually of training relating to one or more of the following subjects:


a. TTBH’s compliance program;b. An overview of the fraud and abuse laws as they relate to

prohibitions against payments for referrals, kickbacks and rebates, and other illegal inducements; and

c. The consequences to both individuals and TTBH of failing to comply with applicable laws.

3. Documentation.

TTBH shall document the training provided to each employees, volunteers and contract providers. The documentation shall include the name and position of the employees, volunteers and contract providers, the date and duration of the educational activity or program; and a brief description of the subject matter of the education.

All training materials and curriculum directed to address regulatory compliance issues will be reviewed and updated as needed by the Compliance Officer.

D. STAFF CODE OF CONDUCT

A. This Code of Conduct has been adopted by the Board of Trustees of TTBH to provide guidance to TTBH employees, volunteers and contract providers as it relates to documentation, billing and other claims related issues. This Code adheres to and promotes TTBH’s Mission and Goals and is required of all staff at all times. TTBH’s Mission and Goals may be found in the Employee’s Handbook.

B. The Principles set forth in this Code of Conduct shall be distributed to all employees, volunteers and contract providers upon hire and periodically thereafter. All employees, volunteers and contract providers are responsible to ensure their behavior and activities are consistent with this Code and understand that failure to maintain this Code may result in termination of employment.

C. As used in this Code of Conduct, the terms “officer,” “director,” “employees, volunteers and contract providers,” include any persons who fill such roles or provide services on behalf of TTBH or any of its divisions, subsidiaries, or operating or business units.

Principle 1 – Service Delivery TTBH provides quality behavioral healthcare with respect, dignity and cultural sensitivity, through the efficient and effective delivery of services. TTBH continues its commitment to excellence and will be an innovative provider of comprehensive and compassionate


behavioral health services. We will treat all stakeholders with honesty, fairness and respect.

Principle 2 – Legal ComplianceAll employees, volunteers and contract providers of TTBH will strive to ensure all activity by or on behalf of the organization is in compliance with applicable federal and state laws and regulations.

Principle 3 – Business Ethics And RelationshipsTo fulfill TTBH’s commitment to the highest standards of business ethics and integrity, employees, volunteers and contract providers will accurately and honestly represent TTBH and will not engage in any activity or scheme intended to defraud anyone of money, property or honest services. Business transactions with vendors, contractors, and other third parties shall be transacted free from offers or solicitation of gifts and favors or other improper inducements in exchange for influence or assistance in a transaction.

Principle 4 – Human ResourceTTBH is an equal opportunity employer and does not discriminate in its hiring practices. Employee files are confidential, and access to them is limited to the individual and his/her supervisory personnel and any other persons who have obtained the employee’s consent. Other access is only permitted by applicable law and regulation.

Principle 5 – ConductAt time of orientation, all employees read and sign polices related to ethical conduct, conditions of employment, sexual harassment, and drugs and alcohol in the workplace. Failure to adhere to these standards of conduct will result in disciplinary action, which could include termination.

Principle 6 – ConfidentialityTTBH employees, volunteers and contract providers shall strive to maintain the confidentiality of clients and other confidential information in accordance with applicable legal and ethical standards and all federal and state laws.

Principle 7 – Conflicts of InterestDirectors, officers, committee members and key employees, volunteers and contract providers owe a duty of loyalty to the organization. Persons holding such positions may not use their positions to profit personally or to assist others in profiting in any way at the expense of the organization.


Principle 8 – Protection of AssetsAll employees, volunteers and contract providers will strive to preserve and protect TTBH’s assets by making prudent and effective use of TTBH’s resources and properly and accurately reporting all activities and costs.

Principle 9 – Marketing, Public Affairs & Outreach ProgramsTTBH’s marketing, public affairs and outreach programs are designed to inform interested parties about our programs and services we provide. These programs include but are not limited to advertising, direct mail, media relations, publications, public policy advocacy, speaking engagements, events and seminars. We are committed to promoting truthful and accurate information at all times to all audiences. Our marketing, public affairs and outreach programs comply with ethical standards of leading industry and professional associations.

VI. PHYSICIAN CONTRACTS

A. It is the policy of TTBH that all Federal and state anti-kickback and physician self-referral laws, which prohibit the offer or payment of any compensation to any party for the referral of clients, be followed. All physician contracts shall be reviewed and approved by legal counsel prior to the execution to avoid violation of federal anti-kickback or self-referral laws.

B. To comply with applicable laws regarding client referrals, TTBH:1. Shall comply with the polices governing gifts set forth in TTBH

Handbook;2. Shall not submit nor cause to be submitted a bill or claim for

reimbursement for services provided pursuant to a prohibited referral.

TTBH also shall ensure that any physician with whom an agreement is executed, and/or who serves as an attending physician in the facility, has current valid licenses as required by law and has not been excluded from participation in the Medicare and Medicaid programs.

VII. DOCUMENTATION AND CLAIMS AUDITS

A. Ongoing review and audit of all TTBH operations, including contracted services will occur under the supervision of the TTBH Compliance Officer. Such reviews and audits will be regular and ongoing, the results of which will be reported to TTBH’s CEO, the Compliance Committee and the Board of Trustees.

B. The TTBH Compliance Officer may, after consultation with the CEO and TTBH legal counsel, engage external experts to perform focused reviews as needed.


Monitoring shall occur at the provider level as well as with through third party review coordinated by the Compliance Officer. Billing and claims issues identified through reviews shall be reported by the TTBH Compliance Officer to the CEO and TTBH’s legal counsel and others as needed.

C. In order to assure compliance with Medicare/Medicaid and other government funded healthcare payment programs. TTBH has adopted a billing audit procedure to assist in its efforts to monitor the accuracy of claims. This procedure is adopted to ensure that representative claims from all of TTBH’s individual and institutional providers are periodically reviewed in a manner that will enable TTBH to promptly identify deficiencies in the claim development and submission process, which could result in inaccurate claims.

D. AUDIT PROCESS

1. TTBH will conduct audits in accordance with the schedule set forth below. The audits will be executed in accordance with the polices and procedures contained in the applicable auditing tool or protocol utilized by TTBH. TTBH will devote such resources as are reasonably necessary to ensure that the audits are initiated by persons with appropriate knowledge and experience to reflect changes in applicable laws and regulations.

E. AUDIT PLAN

1. Chart Audits. It is the policy of TTBH and the responsibility of each department manager to ensure that employees, volunteers and contract providers who have a direct impact on the claim development and submission to process are provided adequate and appropriate training. One mechanism for ensuring the accuracy of TTBH’s claims is to ensure that each new employee, volunteers and contract providers adequately understands the essential elements of his/her jobs functions. In furtherance of this objective, it is the policy of TTBH to review the work of employees, volunteers and contract providers in the manner set forth below:

2. Billers and Coders. Each employee, volunteer and contract provider whose principle function includes the billing or coding of claims to be submitted to the Medicare or Medicaid program shall have all of such employee’s, volunteer’s and contract provider’s claim related work reviewed by the employee’s, volunteer’s and contract provider’s supervisor for a period of not less than 15 days following the commencement date, or such later date as the manager is satisfied that the accuracy of the employees, volunteers and contract provider’s claims justify cessations of the reviews.


a. Registration. The work of every employee, volunteer and contract provider new to registration shall be reviewed for a period of not less than 30 days following the commencement date, or such later date as the manager is satisfied that the accuracy of employee’s, volunteer’s and contract providers’ claims justify cessation of the reviews.

b. Combine with Clinical Staff. Patient care providers shall be provided written guidelines with respect to documentation services rendered by such providers at least one (1) time during the first 60 days of employment of client care personnel, the providers (manager, supervisor, or other appropriate persons) shall review all of the provider’s documentation to ensure that the provider is accurately and completely documenting the services rendered by the provider. For the purpose of this policy, the term provider includes physicians, nurses, allied health professionals and other persons who may document the delivery of services in the TTBH’s records (including medical records).

c. Period Audits. TTBH will conduct periodic audits of claims submitted to the Medicare and Medicaid programs. At a minimum, TTBH’s audit activities shall consist of: (1) individual provider audits – the audit of not less than 100 claims annually of a sample randomly selected within an individual program site. Focus audits may also be conducted on individual staff.

d. Complaint Audits/Focused Reviews. Upon receipt of a credible allegation or complaint alleging improper or inaccurate billing practices at TTBH, TTBH shall undertake a review of the matter, including an extensive audit as dictated in the TTBH Corporate Compliance Policy.

VIII. COST REPORT SUBMISSIONS

A. TTBH is required to submit various cost reports to federal and state governments in connection with its operation and to receive payment. Such reports will be prepared as accurately as possible and in conformity with applicable law and regulations. If errors are discovered, billing personnel shall contact an immediate supervisor promptly for advice concerning how to correct the error(s) and notify the appropriate payor. In some instances errors shall also be reported to the TTBH Compliance Officer if it is suspected that the error has affected the TTBH wide billing process or jeopardized the TTBH’s on-going participation in federally funded programs.


B. In the preparation of cost reports, for Medicare or Medicaid or any other state or federal cost reporting documents, all employees, volunteers and contract providers involved in the preparation shall ensure that:

1. Information provided for or used in the cost report is adequately supported by documentation.

2. Non-allowable costs are properly identified and removed;3. Statistics are based on reliable information;4. Related parties are identified and their services treated in accordance with

program rules; and5. Costs claimed in non-conformity with program rules, as interpreted by the

Medicare or Medicaid program or the fiscal intermediary, either are disclosed in a letter accompanying the cost report or are in protested amounts.

IX. REPORTING COMPLIANCE ISSUES

A. Billing and claims shall be made only for services provided to clients, directly or under contract pursuant to all terms and conditions specified by the government or third-party payor and consist with industry practice. TTBH and its employees, volunteers and contract providers shall not make or submit any false or misleading entries on any bills or claim forms, and no employees, volunteers and contract providers shall engage in any arrangement or participate in such an arrangement at the direction of another employees, volunteers and contract providers (including any supervisor), that results in such prohibited acts. Any false statements on any bill or claim form shall subject the employees, volunteers and contract providers to disciplinary action by TTBH, including possible termination of employment.

B. False claims and billing fraud may take a variety of different forms, including but not limited to, false statements supporting claims for payment, misrepresentation of material facts, concealment of material facts or theft of benefits or payments from the part entitled to receive them. TTBH and employees, volunteers and contract providers shall specifically refrain from engaging in the following billing practices:

1. Making claims for items or services not rendered or not provided as claimed;

2. Submitting claims to any payor, including Medicare and Medicaid, for services or supplies that are not medically necessary;

3. Submitting claims for items or services that are not provided as claimed;4. Submitting claims to any payor, including Medicare and Medicaid, for

individual items or services when such items or services either are included in the TTBH’s per diem rate or are of the type that may be billed only as a unit and not unbundled;

5. Double billings (billing for the same item or service more than once);


6. Paying or receiving anything of financial benefit in exchange for Medicare or Medicaid referrals (such as receiving non-covered medical products at no charge in exchange for ordering Medicare-reimbursed products); or

7. Billing clients for services or supplies that are included in the per diem payment from Medicare, Medicaid, a managed care plan or other payor.

8. Submitting a false statement, false information, or misrepresentation or omitting pertinent facts to obtain a greater compensation than the provider is legally entitled.

9. Submitting false statement, false information, or misrepresentation, or omitting pertinent facts on any application or any document requested as a prerequisite for payment.

C. If an employee, volunteer or contract provider has any reason to believe that anyone (including themselves) is engaging in false billing practices, that employee, volunteer or contract provider shall immediately report the practice to TTBH’s Compliance Officer at 956-289-7087. All reports to the TTBH Compliance Officer remain confidential.

D. Failure to act when an employee, volunteer or contract provider has knowledge that someone is engaged in false billing practices shall be considered a breach of that employee’s, volunteer’s or contract provider’s responsibilities and shall subject him/her to disciplinary action by TTBH, including possible termination of employment and prosecution.

E. Questions about operational issues should be directed to person(s) having supervisory responsibility for a specific clinical provider, program or unit. Training materials will instruct TTBH employees, volunteers and contract providers that they need to report to the TTBH Compliance Officer any activity that they believe to be inconsistent with TTBH policies and or legal requirements. The materials will explain how the Compliance Officer can be contacted.

F. Employees, volunteers and contract providers must immediately report all known or suspected instances of documentation and claims fraud to the Compliance Officer. Employees, volunteers and contract providers who become aware of potential violations of professional licensing and certification requirements are to report them immediately to their immediate supervisor and to the Compliance Officer.

G. The Qui Tam Act- Whistleblowers Protection Act protects all employees, volunteers and contract providers who report in good faith of known or suspected compliance issues. No employees, volunteers or contract providers shall be subjected to retaliation or harassment of any kind. Concerns about possible retaliation or harassment should be reported to the Compliance Officer, who will immediately report to the CEO.


H. TTBH Compliance Officer will maintain a log of compliance concerns that are reported to the Compliance Office. All reports will be undertaken with a preliminary investigation, which will determine if a full investigation is warranted. In instances where a full inquiry is not warranted, the log should explain why no investigation was undertaken. This log will record the issue, the clinical providers, units, departments and/or organizations affected, the result of the any investigation and whether the issue has been addressed. Each month, a copy of this log will be provided to the CEO. The log reports should note any issues, which remain open. This log is to be treated as a confidential document and access should be limited to those people at TTBH who have responsibility for compliance matters.

X. COMPLIANCE HOTLINE

A. TTBH has established a telephone “Hotline” to permit compliance issues to be reported on a confidential basis. The Hotline 1-877-289-5880 is available 24 hours a day, seven days a week, and the Compliance Officer will ensure that training and educational materials include information on how the Hotline is accessed and all other reporting mechanisms.

XI. INVESTIGATING COMPLIANCE ISSUES

A. Whenever conduct is inconsistent with TTBH’s Corporate Compliance operating procedures and is reported, the TTBH Compliance Officer should determine whether there is reasonable cause to believe that a material compliance issue may exist. If a preliminary review indicates that a problem may exist, an inquiry into the matter will be undertaken. Responsibility for conducting the review will be decided on a case-by –case basis. The results of the inquiry will be made available to the CEO and CAO.

B. TTBH employees, volunteers and contract providers will be expected to cooperate fully with inquiries undertaken pursuant to this plan. To the extent practical and appropriate, efforts should be made to maintain the confidentiality of such inquiries and the information gathered.

C. Investigation of all calls and reports of potential fraud shall occur according to the following guidelines:

1. Purpose of the Investigation. The purpose of the investigation shall be to identify those situations in which the laws, rules and standards of the Medicare and Medicaid programs may not have been followed; to identify individuals who may have knowingly or inadvertently caused claims to be submitted or processed in a manner which violated Medicare or Medicaid laws, rules or standards; to identify individuals who may have knowingly or inadvertently violated the Codes of Conduct; to facilitate the correction of any practices not in compliance with the Medicare or Medicaid laws,


rules and standards; to implement those procedures necessary to insure future compliance; to protect TTBH in the event of civil or criminal enforcement actions, and to preserve and protect TTBH’s assets.

2. Control of Investigations. All reports received, whether by a manager of a TTBH program component or directly through an internal audit shall be forwarded to the Compliance Officer. The Compliance Officer will be responsible for directing the investigation of the alleged problem or incident or recommending that legal counsel conduct the investigation. Under the direction of the CEO, in undertaking this investigation, the Compliance Officer may solicit the support and assistance of legal counsel and internal or external auditors, and internal or external resources with knowledge of the applicable laws and regulations and required polices, procedures or standards that relate to the specific problem in question.

3. Investigative Process. Upon receipt of an employee’s, volunteer’s or contract provider’s complaint, report or other information (including audit results), which suggests that the existence of a serious pattern of conduct in violation of the compliance polices, or applicable laws or regulations, an investigation under the direction and control of the Compliance Officer shall be commenced. Steps to be followed in undertaking the investigation shall include at a minimum:

a. The Compliance Officer will notify the CEO and the CAO of the nature of the compliant and the Compliance Officer will conduct a preliminary investigation into the allegation to determine the level of investigation necessary based on the seriousness of the allegation. After the CEO and CAO review the preliminary investigation, they will determine and advice the Compliance Officer whether to proceed with a full formal investigation. In some instances a complaint may be resolved with a simple phone call while others will require a formal investigation. If the Compliance Officer has reasonable cause to believe that a risk issue exits, the Compliance Officer will report the issue to the CEO and CAO who will make a case by case decision as to whether an employee, volunteer or contract provider should be removed from his/her work area during the investigation.

b. The investigation shall be commenced as soon as possible but in

no more than five (5) business days following the receipt of the compliant or report. A full investigation will not exceed more than 30 business days. In instances where additional time is needed, a request by the Compliance Officer with an explanation as to the reason why may be sent to and approval may be granted by the CEO. The investigations shall include, as applicable, but need not be limited to:


1. An interview of the complainant, the person who is the focus of the complaint and other persons who may have knowledge of the alleged problem or process and a review of the applicable laws and regulations which might be relevant to or provide guidance with respect to the appropriateness or inappropriateness of the activity in question, to determine whether or not a problem actually exists.

a. If the preliminary review results in conclusions or findings that are permitted under applicable laws, regulations or policy or that the complained of act did not occur as alleged or that it does not otherwise appear to be a problem, the investigation shall be closed. The CEO, CAO, and the person who is the focus of the investigation will be notified that the case has been closed.

b. If the preliminary investigation concludes that there is the existence of a serious pattern of conduct in violation of the compliance plan, improper billing occurring, that practices are occurring which are contrary to applicable law, inaccurate claims are being submitted, or that additional evidence is necessary, the investigation shall proceed to the next step—a full formal investigation. If a full formal investigation is required, the CEO, CAO and the appropriate Program Director shall be notified a formal investigation will be required.

2. The identification and review of representative bills or claims submitted to the Medicare/Medicaid programs to determine the nature of the problem, the scope of the problem, the frequency of the problem, the duration of the problem, and the potential financial magnitude of the problem.

3. Identifying witnesses, taking written statements, and interviews of the person or persons in the departments and institutions who appeared to play a role in the process in which the problems exists. The purpose of the interview will be to determine the facts related to the complained of activity, and may include, but shall not be limited to:

a. Individual understanding of the Medicare and Medicaid laws, rules and regulations.


b. Collecting documentary and demonstrative evidence such as medical records, financial records, Human Resource files and records, copies of contracts or agreements with employees, agents, vendors an external contractors which describe business relationships;

c. The identification of persons with supervisory or managerial responsibility in the process;

d. The adequacy of the training of the individuals performing the functions within the process;

e. The extent to which any person knowingly or with reckless disregard or intentional indifference acted contrary to the Medicare or Medicaid laws, rules or regulations;

f. The nature and extent of potential civil or criminal liability of individuals or TTBH; and

g. Drawing conclusions and reporting investigative findings and preparation of a summary report which (1) defines the nature of the problem (2) summarizes the investigation process, (3) identifies any person whom the investigator believes to have either acted deliberately or with reckless disregard or intentional indifference toward the Medicare/Medicaid laws, rules and policies, (4) if possible, estimates the nature and extent of the resulting overpayment by the government, if any.

h. When an investigation is concluded, and a case has been confirmed, the Compliance Officer will notify the CEO, CAO, Human Resource Supervisor and the appropriate Program Director of the findings. The Federal False Claims Act requires that persons holding management positions be held responsible for awareness and practices of their staff. Persons in management positions may be held accountable for the foreseeable failure of staff to adhere to standards, policies, regulations and laws whether there is actual knowledge, deliberate ignorance or reckless disregard on the part of the management staff.

i. When an investigation is concluded and a case has been found to be unconfirmed, inconclusive or unfounded, the Compliance Officer will notify the CEO, CAO, and the appropriate Program Director of the findings. The person who is the focus of the


investigation will be notified that the case has been closed.

j. Investigation reports will have one of the four findings:

i. Confirmed—An allegation that is supported by evidence collected during an investigation.

ii. Unconfirmed—Evidence collected during the investigation proved that the allegation did not occur.

iii. Inconclusive—Evidence collected during the investigation led to no conclusion or definite result due to lack of witness or other relevant evidence.

iv. Unfounded—Allegation is determined not to be true prior to any investigation.

D. ORGANIZATIONAL RESPONSE

1. Criminal Activity. In the event TTBH uncovers what appears to be criminal activity on the part of any employees, volunteers and contract providers or program component, it shall undertake the following steps.

a. Immediately stop all billing related to the problem in the unit(s) where the problem exists until such time as the offending practices are corrected.

b. Initiate appropriate disciplinary action against the person or persons whose conduct appears to have been intentional, willfully indifferent or with reckless disregard for the Medicare and Medicaid laws. Appropriate disciplinary action shall include, at a minimum, the removal of the person from any position with oversight for or impact upon the claims submission or billing process and may include, in addition, suspension, demotion and discharge.

c. Make reports to governmental authorities and to law enforcement officials as appropriate.

2. Non-Criminal Activity. In the event the investigation reveals billing or other problems, which do not appear to be the result of conduct, which is intentional, willfully indifferent, or with reckless disregard for the Medicare and Medicaid laws, TTBH shall nevertheless undertake the following steps.

a. Improper Payments: In the event the problem results in duplicate payments by Medicare or Medicaid, or payments for services not rendered or provided other than as claimed, it shall:


1. Correct the defective practice or procedure as quickly as possible;

2. Calculate and repay to the appropriate governmental entity duplicate payments for improper payments resulting from the act or omission;

3. Initiate such disciplinary action, if any, as may be appropriate given the facts and circumstances. Appropriate disciplinary action may include, but is not limited to, reprimand, demotion, suspension and discharge.

4. Promptly undertake a program of education at the appropriate business unit to prevent future similar problems.

b. No improper Payment: In the event the problem has or does not result in an overpayment by the Medicare or Medicaid program, TTBH:

1. Correct the defective practice or procedure as quickly as possible.

2. Initiate such disciplinary action, if any, as may be appropriate given the facts and circumstances. Appropriate disciplinary action may include, but is not limited to, reprimand, demotion, suspension and discharge.

3. Promptly undertake a program of education at the appropriate business unit to prevent future similar problems.

E. STAFF DISCIPLINE

Employees, volunteers and contract providers may be subject to adverse personnel action for failing to participate in organizational compliance efforts, including but not limited to:1. The failure of an employee, volunteer or contract provider to comply with

TTBH policy and procedure and/or perform any obligation required of the employees, volunteers or contract providers relating to compliance with the program or applicable laws or regulations;

2. The failure to report suspected violations of compliance programs laws or applicable laws or regulations to an appropriate person; and

3. The failure on the part of a supervisory or managerial employee, volunteer and contract provider to implement and maintain policies and procedures reasonably necessary to ensure compliance with the terms of the program or applicable laws and regulations.

Adverse personnel action will follow TTBH’s existing employee, volunteer and contract provider’s Human Resources polices and procedures.

XII. CORRECTIVE ACTION PLANS


A. Whenever a compliance issue has been identified, the Compliance Officer has the responsibility and authority to take or direct appropriate action to address the issue. The corrective action will be set forth in writing. In developing the corrective action plan, the Compliance Officer should obtain advice and guidance from others as necessary, such as the CEO, CAO, the appropriate Program Director, the Human Resource Supervisor and TTBH’s legal counsel if needed. Information about corrective action plans shall be provided to the TTBH Compliance Committee and the CEO.

B. Corrective Action shall be pre-approved by, at a minimum, the CEO and CAO. Corrective action should be designed to ensure not only that the specific issue at hand is addressed, but also systems are placed in operation, which would prohibit the repeat of similar problems. Corrective actions may require certain functions be reassigned, training take place, restrictions on personnel take place, reassignment of duties, terminating contractual relationships, that repayment be made, or that the matter be disclosed externally. Corrective action may include recommendations that a sanction or disciplinary action be imposed. Moreover, if the Compliance Officer believes that any non-compliance has been willful, that belief and the basis for it, shall be reported to the CEO, CAO and to the Compliance Committee. TTBH employees, volunteers and contract providers who have engaged in willful billing and claims misconduct will be subject to the disciplinary action up to and including termination and criminal prosecution.

XIII. ANNUAL COMPLIANCE REVIEW

A. On or before the end of each fiscal year, the Compliance Officer will arrange for a review of TTBH’s current compliance and regulatory operations. The purpose of the review, which shall include probe samples, as the Compliance Officer considers advisable, is to ascertain whether the compliance operations of TTBH are within standards. A written report describing the results of the audit shall be prepared on or before September 1 of each year.

XIV. ANNUAL REPORT AND WORK PLAN

A. On or before September 1, the Compliance Officer shall prepare and distribute to the CEO and to TTBH’s governing board a report describing the compliance efforts during the preceding fiscal year and a proposed work plan for next fiscal year. The report shall include the following elements:1. A summary of the general compliance activities undertaken during the

preceding fiscal year, including any changes made to the Compliance Plan;

2. A summary of the Hotline log for the preceding fiscal year;3. A summary of the preceding fiscal year’s Compliance Review;4. A description of actions taken to ensure the effectiveness of the training

and education efforts;


5. A summary of actions to ensure compliance with TTBH’s policy on dealing with excluded persons;

6. Recommendations and result of recommendations for changes in the Plan that might improve the effectiveness of TTBH’s compliance effort; and

7. A copy of the proposed work plan for the next year.8. Any other information specifically requested by the CEO and the Board of

Trustees.

XV. REVISIONS TO THE INTEGRITY PLAN

A. This Compliance Plan is intended to be flexible and readily adaptable to changes in regulatory requirements and in the health care system as a whole. The Plan shall be regularly reviewed to assess whether it is working and effective. TTBH’s CEO shall have the authority to amend the plan at any time.

XVI. EXCLUDED PERSONS

A. TTBH complies with 42 U.S.C. 1320a-7a(a)(6), which imposes penalties for “arranging (by employment or otherwise) with an individual or entity that the person knows or should know is excluded from participation in a Federal health care program for the provision of items or services for which payment may be made under such a program”. Accordingly, prior to employing or contracting with any provider for whom TTBH intends to submit bills to a Federal health program, TTBH confirms the provider has not been excluded from participation in federally funded programs. Those steps will include checking the provider’s name against the HHS/OIG Cumulative Sanctions list and the GSA Debarred Bidders List. TTBH’s Compliance Officer will assure TTBH staff responsible for credentialing has addressed this with each new hire. TTBH will neither use nor hire a provider who is barred from participation in a federally funded program. If TTBH learns that any of its current providers (either as employees, volunteers or contract providers) has been proposed for exclusion or excluded, it will remove such persons from any involvement in or responsibility for Federal health insurance programs until such time that TTBH has confirmed the matter has been resolved.

XVII. REFERENCES:

A. The Deficit Reduction Act-2005B. The Federal Anti-Kickback StatuteC. The Stark LawD. The Texas Illegal Remuneration StatuteE. Civil Money Penalties StatuteF. The Federal False Claims ActG. The Medicaid Fraud Prevention ActH. Center for Medicare and Medicaid Services I. Office of the Attorney General


J. U.S. Department of Justice / Federal Bureau of Investigation


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