Seashore Gardens Living Center’s 

SEASHORE GARDENS LIVING CENTER’S

CORPORATE COMPLIANCE PROGRAM

I.    STATEMENT OF POLICY: 

It is the intent of Seashore Gardens Living Center (hereinafter “SGLC”) to uphold the business integrity and ethical conduct of a participant in governmentally-funded healthcare programs and other contractual arrangements.  Delivery of care must be in compliance with all laws and regulations applicable to such programs as well as all Federal, State and local laws and regulations which govern its operations.  It is the responsibility of every SGLC employee, including affiliated providers and business associates operating at SGLC locations, to proactively identify issues relating to potential fraud and abuse and to comply with the policies and procedures designed to minimize such exposure.  Compliance in this area is challenging because the regulatory requirements governing reimbursement are complex and changing.  To underscore and enhance its continued pledge of compliance and to better assist all employees, including physicians and allied health professionals, in this area, SGLC is committed to this comprehensive Compliance Program.  SGLC has adopted the various directives set forth in the Office of Inspector General's Compliance Program Guidance for healthcare providers to prevent and detect potential violations of law.  The adoption and implementation of our voluntary Compliance Program will significantly advance the prevention of potential fraud, abuse and waste while, at the same time, ensuring the adherence to all governing State, Federal and local laws and regulations, which will only further the fundamental mission of SGLC.

II. CODE OF ETHICS: 

Basic Principles     

SGLC is committed to integrity, ethical behavior, and the highest professional conduct              from our employees and others who act on our behalf.  This Code of Ethics reaffirms our commitment to always doing what is professionally and ethically right, and is intended to guide us in upholding this commitment. 

This Code requires everyone to act with a level of integrity that is higher than what the government requires.  We clearly understand that the responsibility for ethical behavior rests with each of us through the judgments we make and our own responsibilities. 

SGLC also expects each employee to recognize and avoid activities and relationships that involve, or might appear to involve, conflicts of interest or behavior that may cause embarrassment to the organization or compromise its integrity. 

We expect outside colleagues, including physicians, vendors, consultants and others whose actions are directly connected to SGLC, to adhere to the same standards in their dealings with us and with others on our behalf.

III. CONDUCTING BUSINESS:

SGLC’s activities involve numerous business transactions each day.  Obviously, we must have strict rules to guard against fraud or dishonesty and guidelines for addressing possible problems that may arise. 

If you witness or suspect any questionable behavior from any individual, or any person with whom SGLC deals, especially in regards to the guidelines contained within this Compliance Program, you should report this behavior immediately so that it can be investigated. You may report concerns anonymously via our hotline (1-800-611-5406), and hotline operators will document and forward any such reports, as appropriate, to SGLC’s Corporate Compliance Officer for investigation. If evidence of a violation of this Code is established, any involved employee or agent is subject to disciplinary action, including termination.  Any such evidence will be reviewed by the Compliance Officer and/or the President/CEO. 

Laws Used in Fraud and Abuse Investigations

      •         Federal False Claims Act

•         Health Insurance Portability and Accountability Act (HIPAA)

•         Stark I and Stark II

•         Anti-Kickback Statute

•         Federal Sentencing Guidelines

•         Balanced Budget Act of 1997

False Claims Act    

Summary:  The False Claims Act 31 U.S.C. sec. 3729-3733, protects the federal government against fraud and abuse.  Under the False Claims Act (FCA), anyone who knowingly submit, or causes another person or entity to submit, or knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or approval of government funds are liable for three times the government's damages plus civil penalties of $5,500 to $11,000 per false claim.

The term "knowingly" means that a person:

1.  Has actual knowledge of the information;

2. Acts in deliberate ignorance of the truth or falsity of the information; or

3. Acts in reckless disregard of the truth or falsity of the information and no proof of specific intent   to defraud is required. 

The FCA contains qui tam, or whistleblower, provisions which allow anyone with evidence of fraud to sue on behalf of the government, in order to recover overpayments of federally funded health care programs.  The Department of Justice can investigate and decide whether to join the action.  If the government elects not to intervene, the qui tam relator may proceed with the action.  The whistleblower may be awarded a percentage of the recovered funds.

IV.   Medicare and Medicaid Requirements:

SGLC is a participant in the Medicare and Medicaid programs, both of which are governed by complicated laws and regulations.  We are obligated to comply with the terms and requirements of the Deficit Reduction Act of 2005 (the "DRA"). In accordance with the DRA, we have written policies and procedures for all employees that provide detailed information about the Federal False Claims Act, the Program Fraud Civil Remedies Act, relevant state laws, and the whistleblower protections under such laws, and SGLC’s policies for detecting and preventing waste, fraud, and abuse. These laws are strict and much more extensive than those of non-government commercial contracts.  For example, the Medicare and Medicaid payment guidelines identify not only under which, but also how much, they will reimburse healthcare providers for goods and services rendered to residents covered under those programs.  These guidelines are often times different than directives received from other third-party payers.  Violations of these laws and regulations can result in sanctions being imposed, not only on the employees actively involved, but also on the organization for which they work.  If SGLC were found to be involved, it could be banned from further participation in the Medicare and Medicaid programs.  It is essential, therefore, that there is strict compliance with all Medicare and Medicaid laws and regulations.

The DRA also requires that we provide this information to all contractors and agents for your review and that you agree to abide by the high ethical standards SGLC upholds in the work you do for us.
 

V.   VENDORS:

SGLC is committed to complying with Section 6032 of the Federal Deficit Reduction Act of 2005 as well as with all other federal and state and local laws and regulations and ensuring that its dealings with the Medicare and Medicaid programs, and any other federal and state sponsored programs is accurate and conforms to applicable law.

As one of our partners, we strongly encourage you to report any concerns about the work you do for us to our Compliance Department at 609-404-4848. You can also report concerns anonymously through the SGLC’s Compliance Hotline at 1-800-611-5406.

We would ask your cooperation in ensuring this information is reviewed by your Compliance Officer or appropriate senior manager to ensure your company's support in our work. If there is another person at your organization who should receive this important information, please contact us at 609-404-4848.

A background check of vendors will take place, which includes, at a minimum, screening the Government Services Administration (“GSA”) list of debarred or excluded vendors entitled, “List of Parties Excluded from Federal Procurement and Non-Procurement Programs, located at         www. Arnet.gov/epls.  Such a screening will continue on a periodic basis for all current vendors.

       VI.   PROCEDURES THAT ENSURE EFFECTIVE COMMUNICATION:

An open line of communication between SGLC’s Compliance Officer and all SGLC personnel and agents is imperative to the successful implementation and maintenance of our Compliance Program.  Furthermore, free flowing communication will reduce the potential for fraud, abuse and waste.  All information will be kept confidential, and employees will not be subject to retaliation, as described below.

VII.   REPORTING MECHANISMS:

Employees, physicians, contractors and vendors are required to report any non-compliance, potential non-compliance or suspected non-compliance on the part of any SGLC employee, physician, contractor or vendor, regardless of whether or not it occurs at SGLC, in accordance with the process set forth herein.  SGLC takes all reports of non-compliance seriously.  The purpose of disclosure is to provide a mechanism whereby employees, physicians, contractors and vendors of SGLC are able to report matters that may be unprofessional, unethical, illegal or potentially non-compliant without the fear of retribution.  Employees may be subject to discipline for failing to report any perceived or suspected non-compliance.  Reports may be made in the following manner:

  1.   In person, through a supervisor or the Compliance Officer; or

  2.   Orally, and anonymously if so desired, through SGLC’s toll-free hotline at                                1-800-611-5406.

SGLC’s toll-free hotline and in-person reporting processes are the responsibility of, and are monitored by, the Compliance Officer.  All reports will be assigned an identification code at the time of the call or date of contact that can be used when referring any new/additional information on the same matter.  The reporter is encouraged to provide as much information as possible to assist with the issue at hand.   

An individual reporting known or suspected improper conduct is not required to identify himself/herself.  Anonymous reports will be investigated and acted upon in the same manner as reports where the reporter reveals his/her identity.  No effort will be made to determine the identity of an individual making an anonymous report unless the individual admits to engaging in improper conduct.  This type of disclosure format should also be used by employees who are uncertain whether an action violates SGLC’s Code of Ethics or Compliance Program and would like to communicate with SGLC on a confidential basis.

VIII.   CONCLUSION: 

SGLC expects that its Compliance Program will ensure that all of its employees and affiliates will be better able to fulfill their commitment to ethical behavior, as well as meet the dynamic changes and challenges being imposed upon SGLC by Congress, the OIG, and private insurers.  Ultimately, it is SGLC’s desire that this voluntarily created Compliance Program will enable it to meet its goals, continually improve the quality of resident care, and substantially reduce potential fraud, waste, abuse and other noncompliance. In closing, through the appropriate implementation and continued maintenance of this Compliance Program, SGLC will be able to further the fundamental mission of SGLC.