The Corporate Compliance department provides leadership to the System's compliance function via consultative services, program oversight and procurement of compliance related tools and resources. Services include:

• Administering CHE’s System-wide Corporate Compliance Program;
• Providing tools to enhance CHE’s Compliance Program infrastructure including a variety of templates, model policies, educational tools and best practices that can result in significant on-going savings for each member of our System;
• Providing (where applicable) and supporting consistent compliance standards to help identify and reduce instances of illegal and/or unethical behavior; and
• Providing access to a network of internal and external subject matter experts to assist the CHE’s Regional Health Corporations (RHC) in obtaining cost-effective, high quality compliance-related services.

CHE and each of its RHCs operate in a highly competitive environment and under complex and rapidly changing laws and regulations. The CHE Compliance Program provides guidance to System officers, colleagues, vendors and agents and RHCs. Each RHC has a local compliance officer and compliance program specific to their organizational structure and needs. Compliance efforts are designed to establish an organizational culture that promotes prevention, detection and resolution of matters that could violate laws, regulations, payor requirements and organizational policies.

Compliance & Audit Committee
The CHE Compliance and Audit Committee is responsible for overseeing CHE Compliance Program and directing the activities of the compliance and audit functions. Specifically, the Compliance and Audit Committee makes regular and thoughtful inquiry into CHE’s:

• Systems of internal controls regarding finance, accounting, legal/regulatory compliance;
• Auditing, accounting and financial reporting processes generally;
• Financial statements and other financial information provided by CHE to its external auditors;
• Compliance with legal and regulatory requirements; and
• Performance of internal audit function and independent auditors.

Consistent with these functions, the Committee encourages continuous improvement of, and adherence to, CHE’s policies, procedures and practices at all levels.

Education and Training
One of the cornerstones of an effective compliance program is education and training. Compliance does not exist solely within one department or team, but rather lives within the fabric of the organization. In an effort to promote active participation in, and awareness of the Compliance Program, all colleagues receive an orientation to the Compliance Program at their work location within ninety (90) days of hire. Additionally, colleagues are required to complete annual compliance training and additional specific training in risk areas as warranted. Education is also provided on a regular basis to CHE board members and officers and each RHC compliance officer is provided material to share with their local boards as well.

Code of Conduct
The CHE Code of Conduct serves as a resource guide for all colleagues in the System Office and from which local RHCs may derive a Code of Conduct specific to them. The Code of Conduct defines the expectation of behavior and practices which are both acceptable and unacceptable to the System Office. It outlines the organizational commitment to ethical business practices as well as government requirements.

Auditing and Monitoring
A fundamental aspect of preventing, detecting and resolving matters which may result in non-compliance with laws, regulations or policy is auditing and monitoring. Each RHC is expected to develop an annual work plan which outlines the areas scheduled for audit or review during the year. CHE supports the local compliance officers with their efforts to identify and remediate high risk areas for the varied organizations within the system.

Reporting Concerns
CHE seeks to promote an environment where colleague concerns regarding violations or potential violations of the Code of Conduct, policies and procedures, federal and state laws and regulations, or any activity that might be considered misconduct may be reported and addressed without fear of retaliation, retribution or harassment.

Multiple avenues exist for colleagues to report concerns. Colleagues are encouraged to report their concerns to their immediate supervisor, any member of management, human resources or the local compliance officer. Any colleague may also report their concern to the CHE Corporate Compliance department. In the event a colleague is not comfortable reporting a concern through these channels, they are encouraged to use the confidential reporting number for their local RHC or CHE.

Confidential reporting services are provided 24/7 by a third party. Callers may choose to remain anonymous and calls are not traced or recorded, or identified by caller ID. When colleagues make a report, they are greeted by a live operator. Callers may call back to the reporting service and receive response information regarding their concern. This allows for two-way communication, even when the caller chooses to remain anonymous.

Each local RHC has its own hotline number. In addition, the CHE System Office has a hotline number: 877-424-3001.

For additional information about CHE’s Corporate Compliance Program, please contact:

Kim Lansford
Vice President of Compliance & Internal Audit, 610-355-2177