Reporting Violations

HELP US DO THE RIGHT THING

We at Scott Memorial Hospital are dedicated to operating within the bounds of any applicable law, regulation, or accreditation standard.  If you, as an employee or agent of the hospital, believe we have failed in that effort, please let us know.  You may inform your supervisor, director, or administrator.  You may also inform the compliance officer at this email address:  compliance.hotline@smh1.org  Your communications will be kept confidential.  If you wish to remain anonymous, you may do so by using an email account that doesn’t disclose your identity.

YOU WILL NOT BE PUNISHED IN ANY WAY FOR REPORTING A COMPLIANCE VIOLATION OR CONCERN.

Among the laws and regulations that apply to Scott Memorial Hospital are these[i]:

Medicare Conditions of Participation    42 Code of Federal Regulations §485.608 through §485.643

These are the conditions that a critical access hospital must meet to participate in the Medicare program.  Because

Scott Memorial Hospital participates in the Medicare program, all these conditions apply.  They can be found at this link:

 http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&tpl=%2Findex.tpl

Indiana Hospital Licensing Requirements    410 Indiana Administrative Code 15

Any hospital operating in Indiana must meet these requirements to be licensed.  They are enforced by the Indiana State Department of Health.  They can be found at this link:

http://www.in.gov/legislative/iac/

The Joint Commission   Comprehensive Accreditation Manual for Critical Access Hospitals

Joint Commission accreditation gives the hospital deemed status to participate in Medicare.  On years in which the hospital is surveyed by The Joint Commission, that accreditation is accepted by the Indiana State Department of Health as sufficient to support a hospital license.  Learn more about The Joint Commission at their website[ii]:

http://www.jointcommission.org

There are many other laws and regulations that apply:  HIPAA, Stark, Anti-Kickback, False Claims, PPACA, OSHA, etc.  Learn more about them on the hospital’s Z drive, accessible from any work computer in the hospital.  Once there, click on the COMPLIANCE folder.  Then click on the COMPLIANCE CORNER folder, then click on CLICK ON THIS FILE.  Once inside, follow the hyperlinks to the ‘Answer Page’ and you’ll find information on all these areas and more.  If you have any difficulties, please call the compliance officer at 812.752.8599 or email the hotline (address above).

If you wish to contact an outside agency, please follow this link.  You will remain within this website.

--Thank you for helping us do the right thing,

William Greene

Compliance Officer, Scott Memorial Hospital