Luthercare’s Corporate Compliance & Ethics Program Overview
Compliance Program/Code of Conduct
Luthercare has an established Compliance & Ethics Program which aligns with our Mission Statement: Luthercare reflects Christ’s love through service to others and with our core values for your review on our “About Us” page on our website. Luthercare, its board, and its team members are committed to “doing the right thing” through diligence, communications, and training along with following our Code of Conduct as the cornerstone of our culture of compliance. Click on this link for our Code of Conduct.
Luthercare does a lot of important work each day, and we value our strong reputation as an organization in the Lebanon and Lancaster communities and our reputation as an employer. We provide care to our residents at our senior living communities through needed services for independent living, personal care, memory care, and skilled healthcare center short-term/longterm care. We nurture children at our child care and learning centers in Lebanon and Lancaster counties. And we support our team members doing all those wonderful things by providing additional corporate services such as technology, finance and accounting, human resources, marketing and philanthropy.
A compliance and ethics program may sound complicated. But it’s really just a way of making sure that we are clear about expectations and responsibilities, that we provide proper training for team members, that we are regularly looking at the quality of care and services, that we respond appropriately when we make a mistake, and that we have ways to communicate concerns and issues to leadership.
Compliance means living up to the trust that’s placed on Luthercare by the public, donors, payers, government agencies and all others within our sphere of connections. For a copy of Luthercare’s Corporate Compliance & Ethics Program, please email your request to our Compliance Officer at compliance@luthercare.org or call 717-626-1171 X1554.
Quality of Care & Honoring Resident’s Rights
Quality of Care covers a wide range of issues related to resident care and treatment in our health care and personal care centers. Each resident requires a comprehensive, accurate assessment and a fully implemented care plan and must be included in their plan of care to ensure person-centered care. Residents have the right to a dignified existence that promotes freedom of choice, self-determination, and reasonable accommodation of individual needs. This right ensures that care areas are addressed such as unnecessary medications, appropriate assistance with activities of daily living, fluid, and weight monitoring, appropriate therapy or supportive services to minimize residents’ decline in function. We must also maintain an adequate number of trained and supervised team members to care for our residents. Quality of Care is monitored through Quality Assurance Performance Improvement programs and Quality Management programs to improve outcomes.
Residents must be free from abuse and neglect. Luthercare has a zero tolerance for Abuse and Neglect. If a team member violates Luthercare’s Resident Abuse Prevention and Reporting standard, the team member will be subject to corrective action, up to and including, in appropriate cases, termination.
Elder Justice Act
Luthercare complies with the Elder Justice Act (EJA) ensuring that it provides annual notice to all Covered Individuals (including team members, contractors, and agents) of their reporting obligations under the EJA to report their reasonable suspicion of crimes committed against nursing home residents to the Pennsylvania Department of Health and local law enforcement. This reporting must happen in a timely manner.
All reportable incidents that:
- Result in serious bodily injury, the individual must report within two (2) hours after forming the reasonable suspicion to both agencies listed above.
- Do not result in serious bodily injury, the individual must report within 24 hours after forming the reasonable suspicion to both agencies listed above.
Open Admissions & Equal Opportunity Employer
In compliance with the Pennsylvania Human Relations Act and Title VI of the Federal Civil Rights Act, Luthercare, its board, and leadership has adopted the following Open Admissions Policy:
- It is the policy of Luthercare to admit and treat all residents without regard to age, gender, national origin, race, ethnicity, political affiliation or disability. There is no distinction in eligibility for, or in the manner of providing, any resident services provided by or through the facility. All persons and organizations that have occasion either to refer residents for admission or to recommend Luthercare are advised to refer residents without regard to the resident’s race, color, sex, national origin, religious creed, handicap or disability.
Luthercare is an Equal Opportunity Employer, and as such, it is policy to make decisions about hiring, promotion, and availability of benefits without regard to race, color, gender, age, ancestry, national origin, religious creed, handicap, or disability except to the extent that such factors are permissible occupational qualifications.
Employee Screening and the Anti-Kickback Law Regarding Vendor Relationships
Background checks are completed on all team members prior to hiring along with reference checks and verification of licenses or certifications.
The Anti-Kickback statute states that anyone who knowingly and willfully receives or pays anything of value to influence referral of federal healthcare business can be held accountable for a felony. Practices such as offering or receiving gifts to reward past or present potential new referrals are prohibited.
Creation and Retention of Records
Documentation and record-keeping are key areas in corporate compliance/ risk management. Luthercare is required to have a system in place to create, distribute, retain, and destroy medical records, billing and claims documentation. All documentation should be consistent and support the care and services provided to the resident.
HIPAA Privacy and Security
Luthercare has standards in place regarding the HIPAA Privacy rule which addresses the use and disclosure of protected health information (PHI) and the HIPAA Security rule which addresses the confidentiality of electronic PHI. Business Associate Agreements (BAA) are also utilized following HIPAA guidelines. Feel free to request a copy of Luthercare’s BAA from our Compliance Officer by email at compliance@luthercare.org or by calling 717-626-1171 X1554.
Privacy Notice
Luthercare is committed to a structured privacy program that provides for ongoing evaluation and effectiveness to ensure all residents’ privacy regarding protected health information (PHI). Click on this link for our Notice of Privacy Practices.
Excluded Provider Checks
Luthercare will not employ, or contract for services on its behalf, an individual or entity that it knows, or reasonably should know, has been convicted of a criminal offense related to a governmental plan or listed by a federal agency as debarred, excluded, sanctioned or otherwise ineligible for participation in a governmental plan. All team members, vendors, and contractors are required to immediately notify Luthercare if any of these actions are taken against them.
The False Claims Act/Deficit Reduction Act (DRA)/Billing,
We are required to comply with the DRA, and as such, Luthercare maintains a Compliance Program that is designed to detect fraud, waste, and abuse within our programs, as well as inadvertent billing and other compliance issues. For a copy of Luthercare’s False Claims Prevention Compliance, please email your request to our Compliance Officer at compliance@luthercare.org or call 717-626-1171 X1554.
Luthercare also maintains a non-retaliation policy. Team members and contractors may not be retaliated against because they made a good faith report to the Compliance Hotline or a supervisor, department manager, Director, or the Compliance Officer.
Questions/Concerns/Complaints
You are encouraged to communicate any compliance concerns to our Compliance Officer at compliance@luthercare.org. If you or one of your staff members prefers to report a compliance concern anonymously, please use the Compliance Hotlines available at 717-626-0668 or 1-800-401-8004.