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Compliance

Complying with, and exceeding, standards for operations, ethics and integrity

Ellenville Regional Hospital (ERH) is proud of its reputation for consistently practicing the principles of service, honesty, respect and performance. Our Corporate Compliance Program is designed to enhance our understanding of acceptable behavior and appropriate decision-making. All employees must act in compliance with all applicable legal rules and regulations, and avoid the appearance of impropriety. The Corporate Compliance Program is based upon the US Department Health & Human Services-Office of the Inspector General Guidance, as well as Section 363-D of the NYS Social Services Law, both of which detail the elements of an effective compliance program.

Compliance program and training policy

In order to achieve full compliance, it is the policy of ERH to offer ongoing and regular educational and training programs to ensure that all Board members, Medical Staff and Staff are familiar with the Hospital’s Compliance Program and understand fraud and abuse laws as well as the requirements imposed by Medicare, Medicaid, and other applicable Government and commercial third party payors.

A full copy of the ERH Corporate Compliance Program can be downloaded by clicking here.

Key elements of the Corporate Compliance Program include:

Complaint and Resolution Policy
It is the policy of Ellenville Regional Hospital to provide a mechanism for addressing patient concerns and complaints as well as a means for patients to ask questions, make suggestions, and give compliments. The objectives are:

  1. To have an effective mechanism for patients and their families to identify concerns or problems which need investigation and resolution;
  2. To comply with statutory requirements for allowing patients and their families to file grievances and make suggestions;
  3. To provide a forum for reduction in errors and for quality improvements through learning from patient viewpoints, concerns or needs;
  4. To maintain adequate documentation of complaints, resolutions and compliments;
  5. To avoid litigation and regulatory investigation by ensuring effective internal redress.

A full copy of the ERH Complaint and Resolution Policy can be downloaded by clicking here

Code of Conduct Policy
It is the policy of Ellenville Regional Hospital’s Board of Trustees, Medical Staff, employees and any contractors providing services, to conduct business and work together in a professional, courteous, cooperative, ethical and legal manner in order to provide quality and safe care to our patients.

A full copy of the ERH Code of Conduct Policy can be downloaded by clicking here.

Conflict of Interest Policy
Ellenville Regional Hospital’s Board of Trustees, Medical Staff and employees shall not enter into any transaction or utilize any position with the facility to make a decision when a conflict of interest exists with respect to the transaction or decision that might not be in the best interest of the hospital.

A conflict of interest exists when an individual to whom this policy applies, or any friend, relative, or business associates of such individual might directly or indirectly profit or reduce some detriment through the application of the position or knowledge of the individual.

A full copy of the ERH Conflict of Interest Policy can be downloaded by clicking here.

Whistleblower Policy
The purpose of this policy is to provide an avenue for ERH employees to raise concerns and reassurance that they will be protected from reprisals or victimization for whistle-blowing.

Whistleblower definition
A whistleblower as defined by this policy is an employee of Ellenville Regional Hospital who reports an activity that they consider to be illegal or dishonest to one or more of the parties specified in this Policy. The whistleblower is not responsible for investigating the activity or for determining fault or corrective measures; appropriate management officials are charged with these responsibilities.

Examples of illegal or dishonest activities are violations of federal, state or local laws; billing for services not performed or for goods not delivered; and other fraudulent financial reporting.

A full copy of the ERH Whistleblower Policy can be downloaded by clicking here.

Notice of Privacy Practices
ERH is required by law to protect the privacy of health information that may reveal your identity and to provide you with a copy of the notice that describes the health information privacy practices of our hospital, its medical staff and affiliated health care providers that jointly provide health care services with our hospital. A copy of our current notice will be posted in public areas throughout the hospital. You will also be able to obtain additional copies by downloading it by clicking here or by asking for one at the time of your next visit. The Patient Bill of Rights is posted in various locations through the hospital.

Information on our Corporate Compliance Program

For further information on Ellenville Regional Hospital Corporate Compliance Program or HIPAA issues, please contact the Corporate Compliance Officer at 845-647-6400, ext. 400 or email a compliance@ellenvilleregional.org (Confidential) or by mail at:

Corporate Compliance Officer
Ellenville Regional Hospital
10 Healthy Way
Ellenville, NY 12428