It is the essential practice of Transcendent Healthcare to care for and improve the health of our residents with compassion and a special concern for the underserved, poor and elderly.
Transcendent Healthcare will be the provider of choice for residents, physicians and employees in this region. Our decisions and actions will be resident centered, compassionate, and of the highest quality. Our care will be supported by a highly trained and committed workforce, advanced technology, and strong teaching programs.
Justice: Respecting the dignity of all persons.
Service: Extending ourselves to heal and comfort our community.
Stewardship: Utilizing our resources to realize the maximum benefits to our residents, employees and the larger community we serve.
Dignity: Respecting the inherent value of each person.
Excellence: Pursuing only the highest standards of quality in all that we do.
Integrity: Demonstrating open, honest and sincere behavior in all interactions.
Transcendent Healthcare is committed to the highest standards of ethics, honesty and integrity in pursuit of its mission. The president/owner of Transcendent Healthcare, members of the senior management team, employees, members of the medical staff, volunteers, vendors, independent contractors, and others representing Transcendent Healthcare are expected to adhere to these standards of conduct in the discharge of their duties. Transcendent Healthcare Corporate Compliance and Ethics Program demonstrates the commitment to ethical conduct and compliance by setting forth guidelines for conduct designed to prevent and detect violations of law and encouraging compliance by providing support, training, and educational resources to assist Transcendent Healthcare in fulfilling its compliance responsibilities by creating a process to monitor compliance efforts and documenting the expectations for member of the Transcendent Healthcare community in the performance of their responsibilities at Transcendent Healthcare.
Transcendent Healthcare has a Corporate Compliance and Ethics committee, chaired by the Corporate Compliance Officer and composed of members of senior management necessary to support the CCO in fulfilling their responsibilities under the Program. The CCO reports on compliance activities to the President/Owner of Transcendent Healthcare. Each skilled nursing facility in the corporation has a Compliance and Ethics Committee, chaired by the Facility Compliance and Ethics Liaison. The Corporate Compliance Officer will oversee the Facility Compliance and Ethics Liaisons.
The committee is composed of members of the senior management team of Transcendent Healthcare.
The Corporate Compliance and Ethics Committee has oversight responsibilities for the compliance activities of Transcendent Healthcare and assists in fulfilling its legal compliance obligations, providing support for functions related to Transcendent Healthcare’s operations and activities. This committee provides a forum for discussion of compliance-related issues and the status of action plans developed to resolve those issues. The Corporate Compliance and Ethics Committee oversees the following areas of compliance activity:
- Informing, training and educating the Transcendent Healthcare community about the Transcendent Code of Conduct and ethical obligations under that code.
- Monitoring compliance activities, including policies, procedures, training and education programs at each of the organization’s skilled nursing facilities.
- Serving as a resource to Transcendent on matters of compliance and legal and regulatory changes, and assessing and identifying areas of risk.
- Maintaining the confidential reporting of compliance matters.
- Assisting operational units in developing corrective action plans.
- Recommending and reviewing the disciplinary action for violations of the code.
The Corporate Compliance and Ethics Committee advises the CCO and assists in the development and implementation of the Program. The duties and responsibilities of the Corporate Compliance and Ethics Committee include:
- Assisting in the development of a risk-based compliance and ethics plan that addresses regulatory compliance with all governing bodies and regulatory agencies, including but not limited to the Center for Medicare & Medicaid Services, Indiana Department of Social Services, Indiana Department of Public Health, and the Office of the Inspector General.
- Delegating primary responsibility for compliance with standards and regulations of the Department of Labor, Internal Revenue Service, Drug Enforcement Administration and Quality Improvement Organizations.
- Coordinating efforts, communication and reporting between the CCO, security officer and privacy officer; General Counsel; and compliance management in all the SNFs to ensure effective monitoring and reporting. Within the various facilities, departments of the organization, and the system and its entities, management will have day-to-day oversight and responsibility to ensure that internal controls over compliance are in place and working effectively.
- Maintaining a system to solicit, evaluate and respond to complaints and problems.
- Periodically reviewing the Code policies and procedures as well as other compliance-related policies as requested; approving appropriate additions, deletions and/or revisions as recommended by the CCO and General Counsel; and ensuring that all officers, directors, employees, contractors, and volunteers are familiar with the Code through training and education and fulfilling their duties for completing the annual disclosure statement.
- Monitoring compliance education activities and scope and provide input to the overall content of annual training. In addition, Transcendent Healthcare, long term care facilities and departments may consult with the CCO regarding general and specialized compliance training sessions based on unique requirements.
- Performance of compliance effectiveness performance assessment to identify inherent business risks and evaluate internal compliance controls necessary for an effective Program. The assessment may include an evaluation of policies and implementing procedures, the accuracy of medical coding and billing, and the level of employee awareness regarding Corporate Compliance and Ethics Programs. From the assessment, the Corporate Compliance and Ethics Committee will approve recommendations for improvement and support the implementation of those actions.
The Corporate Compliance and Ethic Committee consists of the following member of senior management:
- President/Owner of Transcendent Healthcare
- Senior Director of Financial Services
- Senior Director of Clinical Operations
- Senior Director of Sales and Marketing
- Senior Director of Rehabilitative Services
- Facility Executive Directors
- Facility Medical Directors
- General Counsel
- Chief Compliance Officer/Chair
Management staff will be invited to attend committee meetings when appropriate, including the Business Office Managers, Director of Social Services and the MDS Coordinators.
All documents will be maintained for a period of time, consistent with state or federal laws and Transcendent Healthcare policy.
All policies and procedures related to the Program or any federal healthcare rule or regulations shall be reviewed and revised on a yearly basis or as necessary.
The following areas are covered in the Transcendent Healthcare Code:
- Reporting violations of the standards
- Following all federal healthcare program rules and regulations
- Compliance with the law
- Providing excellent resident care
- Preparing and submitting accurate claims
- Protecting confidential information
- Adhering to antireferral and healthcare fraud and abuse legislation
- Not accepting inappropriate gifts or gratuities
- Not giving inappropriate gifts to residents, physicians and vendors
- Avoiding conflicts of interest
- Following antitrust regulations
- Keeping accurate and complete records
- Conducting political activities according to the law
- Protecting the environment
- Providing a safe workplace
- Not tolerating harassment or discrimination
- Appropriately using assets
- Protecting access to information systems
- Adhering to intellectual property laws
- Ensuring and maintaining the privacy and security of confidential resident, employee and business information collected and maintained by Transcendent Healthcare.
Transcendent Healthcare’s Code provides the guiding standards of conduct for all members of the Transcendent Healthcare community and sets forth Transcendent Healthcare’s commitment to good practices and compliance with applicable laws and regulations. Senior management is responsible for ensuring that the Code is observed by all member of the Transcendent Healthcare community under their direct and indirect supervision.
Transcendent Healthcare employees, volunteers and contracted individuals shall acknowledge receipt of the Transcendent Healthcare Code and accept individual responsibility for knowing and adhering to the Code annually. The Code shall be signed by all employees as part of the new employee orientation and annual employee training and during their annual performance review process. Volunteers and contracted individuals should also sign acknowledgments annually.
Transcendent Healthcare is committed with all applicable laws, rules and regulations. It is the responsibility of each member of the Transcendent Healthcare community to follow, in the course and scope of his or her employment at, or affiliation with, Transcendent Healthcare, all applicable laws, rules, regulations, and policies and to maintain an educational healthcare and business environment that is committed to integrity and ethical conduct.
Transcendent Healthcare does not participate in any scientific research projects on any level.
Transcendent Healthcare is committed to following federal and state anti-kickback laws and regulations. When someone who can influence Transcendent Healthcare purchasing decisions takes money or anything of value from a vendor, it may be considered a kickback and is illegal. Additionally, member of the Transcendent Healthcare community should be aware that if someone refers to a resident to another provider and receives something of value in exchange, it may be considered a kickback. Anti-kickback rules also apply to the recruitment of physicians and the acquisition of physician practices.
Transcendent Healthcare is committed to complying with state and federal antitrust (Monopolies) laws and regulations. Transcendent Healthcare’s policy and business practices prohibit setting charges in collusion with competitors, certain exclusive arrangement with vendors, and the sharing of confidential information with competitors. Additionally, members of the Transcendent Healthcare community are prohibited from sharing confidential information with competing providers, such as salaries or charges for services rendered.
All purchasing decisions shall be made without any conflicts of interest. Any concerns about the legality of a proposed transaction, such as inducements offered by a vendor or supplier, should be discussed with the supervisor, General Counsel of the CCO.
Transcendent Healthcare is committed to following and enforcing its conflict of interest policy. All members of the Transcendent Healthcare community should avoid potential or perceived conflict of interest. Any concerns about a proposed transaction that may involve inducements offered by a vendor or supplier or a business relationship with a company that is connected with you or a family member should be discussed with the CCO.
All employees, medical staff members, contractors and vendors providing served to Transcendent Healthcare shall comply with all applicable laws and Transcendent Healthcare policies. The organization reviews at least once per year all employees, medical staff members and contractors and vendors of the organization against Medical exclusion lists. A similar scan is run for all new employees and vendors of the organization prior to hiring these individuals to provide services for Transcendent Healthcare.
Transcendent Healthcare is committed to complying with all applicable environmental laws and maintaining all necessary environmental permits and approvals. Environmental compliance includes the proper handling, storage, use, shipment, and disposal of all materials that are regulated under any applicable environmental law. If any employee has knowledge that a spill, release, or discharge of any material regulated pursuant to an applicable environmental law has occurred, the employee shall immediately report such an event in accordance with the Transcendent Healthcare Safety Manual to ensure the necessary actions are taken. Necessary action may include evacuating employees; reporting such an event to a governmental authority, if required, pursuant to any environmental law, and containing and cleaning up any such spill, release, or discharge. Employees should also report any other violations of applicable environmental law of which they have knowledge that could endanger the health and safety of other individuals.
Transcendent Healthcare is committed to the appropriate protection of confidential information. The organization is required under Health Insurance Portability and Accountability Act of 1996 (HIPAA) rules and regulations to protect the confidentiality of resident protected health information. Many members of the Transcendent Healthcare community have access to various forms of sensitive, confidential and proprietary information. Transcendent Healthcare policy prohibits seeking, disclosing or giving of such information, including confidential information, except as allowed or required by law.
Transcendent Healthcare prohibits the unlawful possession, use, manufacture, or distribution of illegal drugs and alcohol. Transcendent Healthcare prohibits the unlawful possession, use, manufacture, or distribution of illegal drugs and alcohol on its property or as part of any Transcendent Healthcare sponsored activity. Additionally, members of the medical staff, including those who maintain DEA registration, shall comply with all federal and state laws regarding controlled substances.
Transcendent Healthcare is committed to the principles of equal employment and affirmative action. Transcendent Healthcare does not discriminate on the basis of race, color, religion, sex, national or ethnic origin, age, disability, sexual orientation or military service in administration of educational policies, programs, or activities; its admission policies; its other institutional administered programs; or employment. The Corporate Compliance and Ethics program has the responsibility for monitoring affirmative action and assisting with application and interpretation of laws that impose those obligations of Transcendent Healthcare.
Any member of the Transcendent Healthcare community who experiences harassment or discrimination on the basis of sex, race, color, religion, national origin, age, disability, or sexual orientation should immediately seek assistance from the CCO. The CCO either receives or is informed of, all complaints of unlawful discrimination raised within the Transcendent Healthcare community and assists in the resolution of those complaints. Transcendent Healthcare prohibits retaliation against members of the Transcendent Healthcare community who, in good faith, make complaints of harassing or discriminatory conduct.
Transcendent Healthcare is committed to cooperating with government investigators as required by law. If an employee receives a subpoena, search warrant, or other similar document, referring to any Transcendent Healthcare entity, before taking any action, the employee shall immediately contact the Office of General Counsel. The Office of General Counsel is responsible for authorizing the release or copying of documents. If a government investigator, agent or auditor comes to Transcendent Healthcare, the CCO, the Office of General Counsel, or the Executive Director may be contacted prior to an employee cooperating with such investigation, agent or auditor.
Transcendent Healthcare is committed to providing compliance training and education with applicable laws, rules and regulations. All employees, contracted individuals and members of the organization will receive compliance training each year, specifically related to the Code and Transcendent Healthcare’s Program. Employees in specific departments or job functions, such as billing, coding, nursing and physicians may receive, as needed, additional specific ours of training each year related to compliance and their job function.
Medical staff that do not participate in general compliance training will receive a compliance training package that includes Transcendent Healthcare Cod and policies, procedures, and training materials, as applicable.
Transcendent Healthcare is charging, billing, documenting and submitting claims for reimbursement for Transcendent Healthcare services in the manner required by applicable laws, rules and regulations. All employees should know and carefully follow the applicable rules for submission of bills and claims for reimbursement on behalf of Transcendent Healthcare entities. If you know or suspect that a bill or claim for reimbursement is incorrect, you are required to report it immediately to your supervisor or the CCO. If the organization becomes aware of any overpayments, these shall be repaid to the fiscal intermediary or other payer in accordance with federal and state law and applicable rules and regulations. Remedial action shall be completed as required.
Transcendent Healthcare is committed to the lawful referral of Transcendent Healthcare residents to services outside Transcendent Healthcare for the delivery of the appropriate resident care. If a referring physician, or his/her immediate family member, has an ownership or investment interest in or compensation arrangement with the entity to which a resident is referred, and payment for the referred services will be made from a federal or state healthcare program, such as Medicare or Medicaid, a federal law, commonly referred to as the Stark Law, may prohibit the referral. No Transcendent Healthcare physician shall refer a resident for services in violation of the law. If a physician has questions about referrals, he or she should consult with the CCO or Office of General Counsel.
If the organization becomes aware of any reportable event, such as reimbursement overpayment, or criminal activity, it shall be reported as required under federal or state law.
Transcendent Healthcare files a cost report with the Medicare program each fiscal year that includes fiscal, statistical, and operational information about the facility. Transcendent Healthcare has taken steps to ensure the completeness and accuracy of the information that is submitted in these filings.
All members of the Transcendent Healthcare workforce community carry out their duties pursuant to Transcendent Healthcare policies and as required by law. Transcendent Healthcare workforce members may report violations of local, state or federal laws, rules or regulations to the CCO, a supervisor, General Counsel. Failure to report violations may result in disciplinary actions up to and including termination. Disciplinary actions shall abide by all substantive and procedural protections applicable to the Discipline and Termination Policy or other applicable Transcendent Healthcare policies and procedures.
The CCO has no disciplinary enforcement authority; the CCO may investigate, evaluate, and make recommendations consistent with Transcendent Healthcare policies and procedures as they apply to employees and the medical staff. Any disciplinary action shall be determined in conjunction with the President/Owner of the organization and enforced by the appropriate supervisor.
Transcendent Healthcare is committed to following local, state and federal laws, rules and regulations. The CCO shall ensure that the organization maintains a means to report potential violations. Transcendent Healthcare workforce members are required to report to the CCO, a supervisor any potential Transcendent Healthcare job-related criminal conduct or other situation that may endanger the health and safety of any individual. All persons making reports are assured that such reports will be treated confidentially ad shared with others only on a bona fide, need-to-know basis. Transcendent Healthcare will take no adverse action against persons making reports in good faith and prohibits retaliation against persons who make such reports. False accusations made with the intent of harming or retaliating against another person may subject the accuser to disciplinary action up to and including termination. Members of the Transcendent Healthcare community wanting to report a violation or a potential problem may contact the CCO.