Jeannine LeCompte, Publishing and Research Coordinator
Having established the legal necessity of possessing a hotline, and of the nature of the information it is meant to convey, it is now necessary to map out the practical steps which must be taken to ensure that the hotline works properly.
In order to make this happen, a facility should have policies and procedures in place to:
- Properly guide employees, contractors, residents, and resident families to whom and when they should be communicating compliance matters
- Ensure that everyone is confident that they can report compliance matters to management without fear of retaliation
- Ensure that everyone reports issues through the proper channels (to make sure they do not abuse the hotline for purely administrative issues)
- Ensure that everyone has the proper motives for reporting compliance matters on the hotline
These policies and procedures should help ensure that all employees, contractors, residents, and resident families are thoroughly educated on the purpose and use of the hotline.
Everyone who can use the hotline should have confidence that any genuine issue raised will be acted upon, and not ignored or covered up. This must include, for example, disciplinary action for corporate officers, managers, healthcare professionals, and other employees at all levels within the company who have failed to adhere to an organization’s standards of conduct, federal healthcare program requirements, or federal or state laws.
In addition, it is important that any call to a hotline and subsequent investigation be fully documented. This is vital to demonstrate the effectiveness of a company’s compliance program.
All audit results, logs of hotline calls and their resolution, corrective action plans, due diligence efforts regarding business transactions, disciplinary actions, modification and distribution of policies and procedures, and records of employee training, including the number of training hours, must be secured and maintained.
If a hotline service is outsourced, the compliance officer must ensure that incoming logs are provided directly and unchanged to company personnel, and that there is never any possibility of conflict of interest arising with regard to the outside service provider.
Finally, it should be kept in mind that there are methods of communication which are not anonymous, and which should be avoided when setting up a hotline. These methods can include telephone lines with caller ID or reverse lookup capabilities, and emails which can reveal sender address or location. In the case of “suggestion” or “drop boxes,” make sure that there is no camera surveillance of that area.
