The Board of Directors (the “Board”) shall establish a Compliance Committee of the Board (“Board Compliance Committee”) to oversee and evaluate Health Center’s Compliance Program and to make recommendations to assist the Board in approval and oversight of the development, maintenance, and implementation of Health Center’s Compliance Program policies and activities.
2. Duties and Responsibilities.
The Board Compliance Committee will work with Health Center’s Compliance Officer and CEO, as appropriate, in coordinating and overseeing the development, maintenance, and implementation of Health Center’s Compliance Program in a manner at least consistent with the recommendations of the Department of Health and Human Services, Office of Inspector General (“OIG”), as published in its Compliance Program Guidance for Individual and Small Group Physician Practices, 65 Fed. Reg. 59434 (Oct. 5, 2000).
- Identifying Areas of Risk. The Board Compliance Committee will be informed, through education and training, about the Federal and State statutory, regulatory, and policy requirements applicable to Health Center’s activities as a basis for reviewing the risk priorities identified by the Compliance Officer and making recommendations for actions to be taken by the full Board of Directors, as may be appropriate.
- Oversight of Compliance Program Activities. The Board Compliance Committee will receive information, as appropriate, from the Compliance Officer on activities of the Compliance Program, including but not limited to, education and training, employee reporting mechanisms, and disciplinary guidelines.
- Monitoring, Audits, and Investigations. The Board Compliance Committee will review significant findings of, and trends identified through, internal and external audits and investigations, as presented by the Compliance Officer, for the purpose of identifying and responding to potential risk areas and reports of non-compliance and will receive information regarding any corrective and preventive actions taken.
- Policies and Procedures. The Board Compliance Committee will work with the Compliance Officer to review and obtain Board approval of Standards of Conduct and policies and procedures that address areas of risk and that promote compliance with Health Center’s Compliance Program, laws, and regulations (including, as applicable, but not limited to, the laws authorizing and implementing Medicaid, Medicare, and other Federal and State health care programs, Section 6032 of the Deficit Reduction Act of 2005, the requirements under Section 330 of the Public Health Service Act, and the requirements set forth in the Health Resources and Services Administration’s Policy Information Notices and Program Assistance Letters) and contractual requirements imposed by third party payors.
- Evaluation of Effectiveness. The Board Compliance Committee will review the Compliance Officer’s evaluation of the Compliance Program. The review will evaluate the effectiveness of the Compliance Program as well as the extent to which the tasks in the Annual Compliance Program Work Plan have been completed.
- Developing Strategy. The Board Compliance Committee will analyze and, as needed, recommend to the full Board of Directors the development of new methods for promoting compliance and identifying potential violations and for soliciting, evaluating, and responding to complaints and reports of alleged non-compliance.
- Resources. The Board Compliance Committee will periodically review the resources assigned to Health Center’s Compliance Program to ensure that such resources are adequate for maintaining an effective Compliance Program and will make recommendations for changes in the budgeting of resources to the full Board of Directors.
3. Committee Structure.
- The Board Compliance Committee shall consist of the following members:
As Assigned at Annual Meeting
- The Board Compliance Committee shall be subject to same requirements regarding quorum, attendance, and voting as are other committees of the Board.
- Minutes reflecting Board Compliance Committee recommendations, action plans (with time frames and responsible person(s) noted), and evaluation or follow-up shall be maintained for each Board Compliance Committee meeting and will be approved by the Board Compliance Committee at the following meeting.
The Board Compliance Committee will report regularly (at least quarterly) to the full Board of Directors on the compliance activities undertaken as part of Health Center’s Compliance Program.