Southern Illinois Healthcare (SIH) is committed to providing quality health care and services in compliance with our mission and corporate values. This Corporate Compliance Program is a reaffirmation of SIH’s commitment to be a quality organization with high moral and ethical standards. Consistent with these high moral and ethical standards, SIH intends to comply with all laws, regulations, third party payor agreements, and internal procedures. Southern Illinois Healthcare’s Corporate Compliance Program has an emphasis on mitigating fraud and abuse in the Medicare and Medicaid program; however, the program is designed to address all laws and regulations that are applicable to SIH and its operations.

The Board of Trustees is responsible for making the Corporate Compliance Program’s objectives consistent with SIH’s Mission and Values and to see that the objectives of the Program are reflected in all governance, risk management, information management, financial, and operational activities. The effectiveness of the Program is monitored by the Board of Trustees through the receipt of reports from the Corporate Compliance Officer and the Corporate Compliance Committee.

The Board of Trustees has the authority and responsibility to make final decisions concerning compliance issues and must approve any change to the Corporate Compliance Program. The Corporate Compliance Officer and the Corporate Compliance Committee may suggest revisions of the Corporate Compliance Program to the Board of Trustees, but the Board has final authority to revise, amend, modify, replace, or terminate the Corporate Compliance Program.

The Corporate Compliance Department, under the direction of the Corporate Compliance Officer, performs the day-to-day operations of the Corporate Compliance Program. The mission/vision of the Corporate Compliance Department is to prevent violations of law, regulation, and policy throughout SIH and to run an exemplary compliance program that helps create an atmosphere of excellence and attention to legal and ethical standards. However, the ultimate responsibility for compliance rests with each individual within the organization.

The standards of the Corporate Compliance Program and the Code of Ethics can only be achieved and sustained through the actions and conduct of all members of the SIH workforce, which includes all levels of management, employees, students, and volunteers. While SIH cannot control actions of individuals other than its own workforce, it will decline business and other forms of association with businesses or individuals that do not operate in an ethical and compliant manner.

Each member of SIH’s workforce has an obligation to familiarize him or herself with all applicable laws and regulations, and to comply with those laws in performing his or her job responsibilities. Each member of the workforce should perform his/her duties in good faith, in a manner that he or she reasonably believes to be in the best interest of SIH and its patients, and with the same care that a reasonably prudent person in the same position would use under similar circumstances.

History

Southern Illinois Healthcare began its efforts to develop the Corporate Compliance Program in the fall of 1996. Since SIH is a values-driven organization, its Mission and Values Statement, approved by the Board of Trustees on January 25, 1996, formed the basis of the Corporate Compliance Program. The Board of Trustees approved a preliminary Corporate Compliance Program on December 11, 1997. Another key component of the Program, SIH’s Code of Ethics, was approved by the Board on March 26, 1998. The Code of Ethics outlines expected behaviors of all people and organizations associated with SIH consistent with the Mission and Values of the organization.

The Board of Trustees approved the first Corporate Compliance Program on January 28, 1999. The Corporate Compliance Program is a living document, subject to continuing modification and changes, to accommodate the continually changing regulatory environment. In order to keep the Corporate Compliance Program current, the Corporate Compliance Officer will review the Program no less often than annually and propose any changes that are necessary to the Board of Trustees.