February 15, 2019 NOTICE The Kaweah Delta Health Care District Board of Directors will meet in an Audit and Compliance Committee meeting at 2:30 PM on Wednesday, February 20, 2019 in the Kaweah Delta Medical Center Acequia Wing Executive Office Conference Room {400 W. Mineral King, Visalia}. The Board of Directors of the Kaweah Delta Health Care District will meet in a Closed Audit and Compliance Committee meeting immediately following the 2:30 PM meeting on Wednesday, February 20, 2019 in the Kaweah Delta Medical Center Executive Office - Acequia Wing Conference Room {400 W. Mineral King, Visalia} pursuant to Government Code 54956.9(d)(2). All Kaweah Delta Health Care District regular board meeting and committee meeting notices and agendas are posted 72 hours prior to meetings in the Kaweah Delta Medical Center, Mineral King Wing entry corridor between the Mineral King lobby and the Emergency Department waiting room. The disclosable public records related to agendas are available for public inspection at the Kaweah Delta Medical Center Acequia Wing, Executive Offices (Administration Department) {1st floor}, 400 West Mineral King Avenue, Visalia, CA and on the Kaweah Delta Health Care District web page http://www.kaweahdelta.org. KAWEAH DELTA HEALTH CARE DISTRICT Nevin House, Secretary/Treasurer Cindy Moccio Board Clerk Executive Assistant to CEO DISTRIBUTION: Governing Board Legal Counsel Executive Team Chief of Staff http://www.kaweahdelta.org/about/agenda.asp 400 West Mineral King Avenue Visalia, CA (559) 624 2000 www.kaweahdelta.org
KAWEAH DELTA HEALTH CARE DISTRICT BOARD OF DIRECTORS AUDIT AND COMPLIANCE COMMITTEE Wednesday, February 20, 2019 Kaweah Delta Medical Center Acequia Wing 400 West Mineral King Avenue, Visalia CA Executive Office Conference Room ATTENDING: Directors; Herb Hawkins (Chair) & Lynn Havard Mirviss; Gary Herbst, CEO; Tom Rayner, Senior VP Chief Operating Officer; Malinda Tupper, VP Chief Financial Officer; Regina Sawyer, VP Chief Nursing Officer; Dennis Lynch, Legal Counsel; Ben Cripps, Compliance and Privacy Officer; Suzy Plummer, Director of Internal Audit; Lisa Wass, Compliance Analyst OPEN MEETING 2:30 PM Call to order Herb Hawkins, Audit and Compliance Committee Chair Public / Medical Staff participation Members of the public wishing to address the Committee concerning items not on the agenda and within the subject matter jurisdiction of the Committee may step forward and are requested to identify themselves at this time. Members of the public or the medical staff may comment on agenda items after the item has been discussed by the Committee but before a Committee recommendation is decided. In either case, each speaker will be allowed five minutes. 1. Written Reports Committee review and discussion of written reports 1.1 Compliance Program Activity Report Ben Cripps 1.2 Compliance Annual Plan Ben Cripps 1.3 Annual Audit Plan Presentation Suzy Plummer 2. Verbal Reports 2.1 Compliance Program Provide an update on the status of Compliance Program activity Ben Cripps 2.2 Internal Audit Update Provide an update on the status of Internal Audit activity Suzy Plummer 3. Approval of Closed Meeting Agenda Kaweah Delta Medical Center Acequia Wing Acequia Wing Conference Room immediately following the open meeting o Conference with Legal Counsel Anticipated Litigation Significant exposure to litigation pursuant to Government Code 54956.9(d)(2) (8 cases) Ben Cripps and Dennis Lynch (Legal Counsel) February 20, 2019 - Audit and Compliance Committee Page 1 of 2 Herb Hawkins Zone I Lynn Havard Mirviss Zone II John Hipskind, MD Zone III David Francis Zone IV Nevin House Zone V Board Member Board President Vice President Board Member Secretary/Treasurer
Adjourn Open Meeting Herb Hawkins, Audit and Compliance Committee Chair CLOSED MEETING Immediately following the 2:30 PM open meeting Call to order Herb Hawkins, Audit and Compliance Committee Chair 1. Conference with Legal Counsel - Anticipated Litigation - Significant exposure to litigation pursuant to Government Code 54956.9(d)(2) (8 cases) Ben Cripps and Dennis Lynch (Legal Counsel) Adjourn Herb Hawkins, Audit and Compliance Committee Chair In compliance with the Americans with Disabilities Act, if you need special assistance to participate at this meeting, please contact the Board Clerk (559) 624-2330. Notification 48 hours prior to the meeting will enable the District to make reasonable arrangements to ensure accessibility to the Kaweah Delta Health Care District Board of Directors meeting. February 20, 2019 - Audit and Compliance Committee Page 2 of 2 Herb Hawkins Zone I Lynn Havard Mirviss Zone II John Hipskind, MD Zone III David Francis Zone IV Nevin House Zone V Board Member Board President Vice President Board Member Secretary/Treasurer
COMPLIANCE PROGRAM ACTIVITY REPORT Open Meeting Ben Cripps, Compliance and Privacy Officer November 2018 through January 2019 EDUCATION Live Presentations by Compliance Department Compliance and Patient Privacy New Hire Orientation Compliance and Patient Privacy Management Orientation Patient Privacy Nursing Potpourri Medical Identity Theft Health Information Management Privacy Breach Enforcement Update Hospice, Patient Access, 3 West/ICCU, KDMF Leadership Team, Radiation Oncology, Outpatient Therapy, Imaging Services, Mental Health, 4 North, 3 South, Institution Review Board, Respiratory, Chronic Disease Management Center, Chaplaincy Services, Urgent Care, 2 North, Information Systems Services, Exeter Clinic Written Communications sent from Compliance Department National Compliance and Ethics Week (Email) All Staff Compliance Matters Article Reporting Compliance Concerns Bulletin Board / All Staff Privacy Matters Article Guidelines for Releasing Patient Information to Law Enforcement Bulletin Board / All Staff Compliance Matters Article Fraud, Waste, and Abuse: The False Claims Act Bulletin Board / All Staff PREVENTION AND DETECTION California Department of Public Health (CDPH) All Facility Letters (AFL) Review and distribute AFL s to areas potentially affected by regulatory changes; department responses reviewed and tracked to address the regulatory change and identify potential current/future risk Medicare and Medi-Cal Monthly Bulletins Review and distribute bulletins to areas potentially affected by the regulatory change; department responses reviewed and tracked to address the regulatory change and identify potential current/future risk Office of Inspector General (OIG) Monthly Audit Plan Updates Review and distribute OIG Audit Plan issues to areas potentially affected by audit issue; department responses reviewed and tracked to identify potential current/future risk California State Senate and Assembly Bill Updates Review and distribute legislative updates to areas potentially affected by new or changed bill; department responses reviewed and tracked to address regulatory change and identify potential current/future risk Patient Privacy Walkthrough Monthly observations of privacy practices throughout Kaweah Delta; issues identified communicated to area Management for follow-up and education KD HUB (Cerner) Participation in system enhancements and optimization and risk mitigation strategies Prepared: February 2019
User Access Privacy Audits Daily monitoring of user access to identify potential privacy violations Office of Inspector General (OIG) Exclusion Attestations Quarterly monitoring of department OIG Exclusion List review and attestations Medicare PEPPER Report Analysis Quarterly review of Medicare Inpatient Rehabilitation, Hospice, Mental Health and Acute Inpatient PEPPER statistical reports to identify outlier and/or areas of risk; evaluate with Kaweah Delta leadership (as appropriate) OVERSIGHT, RESEARCH & CONSULTATION Fair Market Value (FMV) Oversight oversight and administration activities for physician payment rate setting/contracting activities including Physician Recruitment, Medical Directors, Call Contracts, and Exclusive and Non-Exclusive Provider Contracts Medicare Recovery Audit Contractor (RAC) and Medicare Probe Audit Activity Records preparation, tracking, appeal timelines, and reporting Licensing Applications Forms preparation and submission of licensing application to the California Department of Public Health; ongoing communication and follow-up regarding status of pending applications o o o Prepared: February 2019 Emergency Department Fast Track, Lab Draw Station Neonatal Intensive Care Unit (NICU) Acequia Wing 6 th Floor KD Hub Non Employee User Access Oversight and administration of non-employee user onboarding, privacy education, and user profile tracking; evaluate, document, and respond to requests for additional system access; on-going management of approximately 950 non-employee KD Hub users First Tier, Downstream, Related Entities (FDR) Fraud, Waste, and Abuse Training Research and consultation; evaluate Medicare Final Rule change to FDR Fraud, Waste, and Abuse training; provide recommendation to Kaweah Delta Medical Foundation (KDMF) on training and oversite requirements Hospice General Inpatient (GIP) Billing Research and consultation; investigate GIP licensing requirements for GIP services in an Inpatient Rehabilitation Facility; provided recommendation Patient Rights and Responsibilities Update Research and consultation; completed a review and update to the Patient Rights and Responsibilities postings throughout the facility to comply with regulatory requirements Site/Service Line-Specific Medi-Cal Contracting Research and consultation; provided clarification of Medi-Cal Contracting requirements for site and service-line specific contracting for the KDMF Skilled Nursing Facility (SNF) Required Forms Facilitate, coordinate, and monitor corrective efforts to ensure the appropriate and timely completion of mandatory admission forms for SNF patients Senate Bill (SB) 1152 Homeless Discharge Research and consultation; provided support to Kaweah Delta Leadership to clarify regulations and implement processes to comply with Senate Bill 1152; a bill requiring significant documentation and care management practices for Homeless Patients 340b Retail Pharmacy Dispute Research and Investigation; worked with Legal Counsel to pursue an unpaid payment obligation due to Kaweah Delta through the 340b Retail Pharmacy program; demand letter prepared by Legal Counsel; two (2) payments have been received to date totaling approximately 25% of the amount outstanding; the balance is expected over the course of the next twelve (12) months
Hospice Fraud Matter Research and Investigation; worked with Legal Counsel and Kaweah Delta Leadership to investigate and report a fraudulent Hospice scheme; detailed documentation provided to Legal Counsel, Assistant US Attorney and District Attorney to be notified Patient Family Services (PFS) LMFT Regulations Research and consultation; evaluated regulatory guidance concerning use of Licensed Marriage and Family Therapists (LMFT) as Social Workers in the inpatient setting; regulatory summary provided to PFS Leadership; re-education to leadership; employee name badges updated AUDITING AND MONITORING Quick Ultrasound Review The objective of the review was to assess Quick Ultrasound billing and documentation practices. The Compliance Department completed a review of thirty (30) claims for the period May July 2018 and noted a 100% compliance rate. The review concluded that all of the patient encounters contained the necessary and appropriate documentation for payment. At this time, the Compliance Department does not recommend a follow-up review. Home Health Home Bound Status Review The objective of the review was to assess the clinical findings and documentation supporting the need for skilled nursing and/or therapy services. The Compliance Department completed a review of thirty (30) Medicare Home Health encounters for the period May June 2018 and noted a 100% compliance rate. The review concluded that each of the encounters contained the necessary and appropriate documentation for payment. At this time, the Compliance Department does not recommend a follow-up review. Inpatient Rehab Probe Audit Noridian (Medicare Claims Administrator) completed a prepayment review of randomly selected Inpatient Rehabilitation Facility claims. Kaweah Delta was selected for the review based on data analysis indicating increased utilization compared to the previous utilization period. The review noted an 87% compliance rate. Management has reviewed the findings and will dispute the claim denials through the Medicare Appeals Process. Noridian has confirmed closure of the audit file and will not pursue further audit activities at this time. Prepared: February 2019
Kaweah Delta Health Care District Compliance Program Work Plan Calendar Year 2018 Compliance Oversight and Management Written Standards and Policies and Procedures comprehensive review and update to the Code of Conduct Distribute Code of Conduct to all employees, vendors, volunteers, medical staff comprehensive review of Compliance Program - Program Effectiveness Tool Compliance policy review and updates - All Policies: CP.01 - District Compliance Program Administration CP.02 - Review of Billing Practices CP.03 - Medical Director & Physician Provider Contracts CP.05 - Compliance and Privacy Issue Investigation and Resolution CP.06 - District Compliance Program Education CP.07 - Excluded Individuals-Entities CP.08 - Government Payer Regulatory Updates CP.10 - Compliance Reviews and Assessments CP.12 - Physician Relationships CP.13 - Federal and State False Claims Act and Employee Protection Provisions STARK and Anti-Kickback Oversight Medical Staff Non-Monetary Compensation Review Physician Payment Testing Review (semi-annual) Fair Market Value Oversight: Update and Distribute Medical Director Rates / Grid Review Contract Negotiations / FMV Analysis Licensing and Certification Annual Hospital License Renewal Hospice License Renewal New Licensures (As Necessary) Lindsay Annex Women's Health Clinic Urgent Care Clinic - Additional Location (Flagstaff) Sequoia MOB Cardiology Clinic Reporting Investigate and Respond to all Reports (Internally Reported and via Hotline) Status In Progress Pending In Progress In Progress Page 1 of 4
Kaweah Delta Health Care District Compliance Program Work Plan Calendar Year 2018 REVIEWS AND AUDITS: Internal: High Dollar Radiology Tests (OIG) Incorrect use of Modifier 50 (OIG Compliance Review) JW Modifier Audit - New Regulation 1/1/17 Medicare Important Message Therapy Cap Review MOON Observation Notice - New Regulation March 2017 Medicare Secondary Payer (Claims and Questionnaire) Patient Status (OIG WP 9) Medical Device Replacement payments (OIG WP 8) Medicare Part D Rebates Related to Drugs Dispensed - 340B (OIG WP 23) Home Bound Status and Skilled Need Home Health and Hospice Quick Ultrasound Condition Codes 49 or 50 Status In Progress External: PPS Coding Audit: 1 Radiation Oncology 2 Emergency Department Billing and Coding Review 3 Inpatient Rehab 4 To Be Determined based on Risk Assessment- DRG review off Pepper Report Maxim 1 To Be Determined based on Risk Assessment- FMC/CDMC 2 Cath Lab- Surgery-5 Rehab Audit Firm To Be Determined 1 Home Health Billing Review 2 Skilled Nursing Facility Billing PATIENT PRIVACY: Daily FairWarning Access Audits Phase 2 OCR Audit Gap Analysis Federal and State Breach Reporting/Plan of Correction Patient Privacy Walkthrough (All Campuses) Business Associate Agreement Review Notice of Privacy Practices Review and Update Develop ZixCorp Email Encryption Monitoring Process Redesign External User Access Process for MD Office Staff Review HIM Disclosure Process In Progress In Progress Pending Page 2 of 4
Affiliated Entity Privacy Assessment: Kaweah Delta Medical Foundation Kaweah Delta Health Care District Compliance Program Work Plan Calendar Year 2018 EDUCATION: All Employee Mandatory Annual Compliance, Privacy, and Code of Conduct Exam New Hire Employee Orientation - Day 1 New Manager Orientation GME Resident Orientation Nursing Education: Patient Privacy Potpourri Monthly Communi-K Articles & What's Up Doc Board Education - All Board and Audit and Compliance Committee Topics Area Specific Education: Health Information Management (HIM) Patient Accounting Security Patient Access Case Management Kaweah Delta Medical Foundation Billing Dept. SRCC Medical Oncology Compliance Education Surgery Sequoia Surgery Center Guild Institutional Review Board PREVENTION AND MONITORING: Coordination of RAC/Governmental Audits Review / Assign / Distribute Monthly Governmental payer bulletins OIG Exclusion List Attestations (Physician / Vendors) Quarterly Review and Summary of PEPPER Report Annual Sign Review Prepare 2019 Plan Year Risk Assessment Review OIG Work Plan Monthly Monitor Corrective Action Activities of Compliance Log Issues Cerner / Sorian Financials Implementation Oversight / Implementation Research and Consultation New & Existing Regulations Patient Privacy Mental Health Consent / EMTALA Committee Participation / Oversight Accreditation and Regulation Committee Case Management Committee Bioethics Committee Patient Safety Committee Pending Status Pending Page 3 of 4
Kaweah Delta Health Care District Compliance Program Work Plan Calendar Year 2018 Institutional Review Board 340b Leadership Committee Risk Monitoring Provider-based billing; Use of appropriate modifier (OIG 7) Medicare Costs Associated with Defective / Replacement Devices (OIG 10/11) Status Page 4 of 4
Compliance Oversight and Management Written Standards and Policies and Procedures comprehensive review and update to the Code of Conduct Distribute Code of Conduct to all employees, vendors, volunteers, medical staff comprehensive review of the Compliance Program - Program Effectiveness Tool Comprehensive review of all Privacy Policies / Create Privacy Policy Manual Compliance policy review and updates - Develop Attorney-Client Privilege Policy Develop Overpayment Policy Update Employee Conflict of Interest and Vendor Policy Update Solicitation Policy Affiliated Entity Policy Assessment: Kaweah Delta Medical Foundation STARK and Anti-Kickback Oversight Medical Staff Non-Monetary Compensation Review Physician Payment Testing Review (semi-annual) Physician Contracts Billing and Collection Audits Fair Market Value Oversight: Update and Distribute Medical Director Rates / Grid Contract Renewals and Amendments / FMV Analysis Licensing and Certification Annual Hospital License Renewal Hospice License Renewal New Licensures (As Necessary) Acequia Wing - NICU Acequia Wing 5th Floor ED Fast Track Lab Draw Station Kaweah Delta Health Care District Compliance Program Work Plan Calendar Year 2019 Reporting Investigate and Respond to all Reports (Internally Reported and via Hotline) Employee Reporting and Whistleblower Protection Education Page 1 of 4
Kaweah Delta Health Care District Compliance Program Work Plan Calendar Year 2019 REVIEWS AND AUDITS: Internal: High Dollar Radiology Tests (OIG) Medicare Important Message Qualified Medicare Beneficiary Program Billing Review (OA Indicator) MOON Observation Notice Medicare Secondary Payer (Claims and Questionnaire) Patient Status (OIG WP 9) Medical Device Replacement payments (OIG WP 8) Conditions of Admission / Skilled Nursing Facility SNF Required Documentation End Stage Renal Disease (ESRD) AKI Billing (Code 84) Permanent Cardiac Pacemakers (KX Modifier) End Stage Renal Disease (ESRD) Standing Orders Submitted beyond 12 Months Device Replacement Billing Condition Codes 49 or 50 Evaluation and Management Service Documentation Provided by Students Invoice Price Required for Skin Substitute Codes Payment for Outpatient Services Provided to Beneficiaries who are Inpatients of Other Facilities Cochlear Devices Replaced without Cost Application Code for Prefabricated Splints External: PPS Coding Audit: 1 TBD Based on Risk Priority 2 TBD Based on Risk Priority 3 TBD Based on Risk Priority 4 TBD Based on Risk Priority Maxim 1 TBD Based on Risk Priority 2 TBD Based on Risk Priority 3 TBD Based on Risk Priority 4 TBD Based on Risk Priority Page 2 of 4
Kaweah Delta Health Care District Compliance Program Work Plan Calendar Year 2019 PATIENT PRIVACY: Daily FairWarning Access Audits Finalize Phase 2 OCR Audit Gap Analysis Federal and State Breach Reporting/Plan of Correction Patient Privacy Walkthrough (All Campuses) Business Associate Agreement Review Develop ZixCorp Email Encryption Monitoring Process Review Health Information Management Release of Information and Disclosure Process Affiliated Entity Privacy Assessment: Kaweah Delta Medical Foundation EDUCATION: All Employee Mandatory Annual Compliance, Privacy, and Code of Conduct Exam New Hire Employee Orientation - Day 1 New Manager Orientation GME Resident Orientation Nursing Education: Patient Privacy Potpourri Monthly Communi-K Articles Board Education - Board and Compliance Committee Topics Area Specific Education: Health Information Management (HIM) Patient Accounting Patient Access Case Management Kaweah Delta Medical Foundation Sequoia Regional Cancer Center Medical Oncology Compliance Education Sequoia Surgery Center Hospital Guild PREVENTION AND MONITORING: Coordination of RAC/Governmental Audits Review / Assign / Distribute Monthly Governmental payer bulletins (Monthly) OIG Exclusion List Attestations (Physician / Vendors) (Quarterly) Quarterly Review and Summary of PEPPER Report (Quarterly) Annual Sign Review Prepare 2020 Plan Year Risk Assessment Review OIG Work Plan Monthly (Monthly) Monitor Corrective Action Activities of Compliance Log Issues Page 3 of 4
Kaweah Delta Health Care District Compliance Program Work Plan Calendar Year 2019 Research and Consultation New & Existing Regulations Patient Privacy Mental Health Consent / EMTALA New Service Lines Committee Participation / Oversight Strategic Planning - High Performing Outpatient Delivery Network Accreditation and Regulation Committee Case Management Committee Bioethics Committee Patient Safety Committee Institutional Review Board Research Oversight Committee 340b Leadership Committee Risk Monitoring Provider-based billing; Use of appropriate modifier (OIG 7) Nurse Practitioner Billing in Provider Based Departments Evaluation and Management Coding - KDMF Page 4 of 4
Proposed Annual Audit Plan January 2019-December 2019 Suzy Plummer, Director of Audit and Consulting Services
2019 Planned Audits and Reviews Tier 1 Denials Management and Underpayment Processes Payroll (HR and Finance Components) ISS-Presidio Report Follow Up 401k Tier 2 Construction Services Foundation Account Review Leave of Absence Processes and Compliance
2019 Audit Support and Cycled Audit Areas PRIME Project Support Resource Effectiveness Committee-Cost Savings Initiatives Data and Information Governance Employee Expense Reviews Cash Audits