The importance of a Compliance program is to ensure that our agency meets the highest possible standards for all relevant federal, state and local regulations, laws and guidelines. The compliance plan helps establish a culture within the organization that promotes prevention, detection, and resolution of any activities that do not conform to federal and state laws as well as our agency’s own business and ethical policies. A compliance program provides a framework for disseminating information and establishes mechanisms for investigation potential noncompliance. An effective compliance program sends an important message to employees. Having an Agency wide Compliance Program in place encourages an environment of quality and continuous improvement. As an agency we are continuing our efforts toward a solid compliance program. Value Behavioral Health provided Glade Run with an audit tool for Provider Compliance Program Checklist. This is just anther example of the attention that is continuing to be placed upon Agency’s to operationalize their compliance policies and procedures. The following will provide a brief overview of the compliance activities conducted during the past fiscal year. HIPAA: The HIPAA privacy and HIPAA security meetings have been combined. This committee is chaired by the Director of Information Systems and the Director of Quality and Compliance. The committee reviewed 6 reported HIPAA privacy violations. Two reported violations were not determined to be violations. However, there were 4 violations during the past year that resulted in retraining and progressive discipline for employees. The agency also provided Identify Theft Protection to three families as a result of the HIPAA violation. The HIPAA security officer with the assistance of the training director developed a new HIPAA security training to address potential risks and vulnerabilities related to the advances in the use of electronic devices and technology and the agency use of the Electronic Medical record. The HIPAA privacy officer will developing an updated course on HIPAA privacy. Fraud Waste and Abuse: Glade Run conducted a self audit of an allegation of potential fraud. After a thorough review of this allegation, it was determined that Glade Run did not believe that the allegation rose to the level of Medicaid Fraud, however Glade Run elected to self report to the Managed Care Organization’s Fraud, Waste and Abuse department. Glade Run did however, identified several performance improvement areas and other personnel issues that led to the termination of employment for one employee and a voluntary resignation of the other.

Glade Run was asked to participate in an Fraud, Waste and Abuse investigation with CCBHO regarding the questioning of the staffing credentials of an employee delivering BHRS services. After several months of investigation the MCO did rule that the employee did not meet the qualifications of the position and requested a payback of revenues generated during services rendered by this employee. Glade Run did not limit the scope of the investigation to just this one employee we conducted a full self audit of all employees providing master level services and made employment decisions accordingly. We also improved on several areas of the on-boarding process. Streamlining external audits/complaints/grievances: Significant efforts have been made to ensure that the Director of Quality and Compliance is notified of any external audits, grievances and complaints. This is a major culture shift as program personnel have relied on their own internal structure to coordinate these activities in the past. We believe that this will provide uniformity and greater systemic approaches to problem solving and opportunities for continued compliance with regulations and enhance quality service delivery. Internal Audits: The Quality and Compliance team with the collaboration of program personnel have developed program specific audit tools that incorporate both qualitative and quantitative reviews of medical records. The teams have developed an admission, quarterly and discharge audit. During fiscal year were 382 recorded medical record/chart audits. The first quarter of this fiscal year has already seen an increase as 408 audits have been recorded. Results of these audits are forwarded to program managers to use a supervision tool with employees but also for them to evaluate their processes and their compliance with standards. This continues to be an evolving system to ensure full effectiveness. The Joint Commission Accreditation: There continues to be a steady volume of audit activities related to the Joint Commission standards. Historically the results of Joint Commission surveys became the foundation of our quality improvement activities and focused very heavily on the RTF program.

As you can see, from the extensive work reported in this report, significant movement has been made to develop audit activities that go across all of Glade Run’s Continuum of services. With that being said, there is still a significant amount of audit activity associated with compliance with The Joint Commission Standards. Over 1000 audits have been conducted in several difference areas ranging from infection control to Utilization Reviews in response to previous Joint Commission findings. Communication: There is a clear culture shift occurring regarding the importance of compliance. The agency has always strived and provided quality of service delivery, however with the increased emphasis at a national level for increased enforcement of Fraud, Waste and Abuse initiatives, the seriousness of compliance has reached the awareness of providers. We have seen an increase in external audit activity and an increase in requests for paybacks. There is on-going meetings and consultation between Executive Program Team and the Quality and Compliance Department. Next Steps: The focus for will remain on imbedding a culture of compliance and quality service delivery. We need to develop a concrete compliance plan, educate staff and ensure implementation of that plan occurs.