What is MyComplianceReport?

MyComplianceReport is a web-based portal supported by the third-party vendor, ComplianceLine. It is a comprehensive and confidential reporting tool that enables all Lifespace Communities to address fraud, abuse, and other misconduct in our environment and to promote a healthy and safe experience for everyone.

May I report using either the Internet or the telephone?

Yes. The Compliance Hotline accepts reports via telephone (1-877-219-1121) or online at (http://lifespace.compliancelinemcr.com/).

Is MyComplianceReport and the Compliance Hotline the same thing?

The Compliance Hotline is an all-inclusive term and refers to the MyComplianceReport web-based portal as well as the toll-free telephone number.

Can I remain anonymous if reporting through the Compliance Hotline?

Yes. The Compliance Hotline does not attempt to identify reporters, whether submitting telephonically or electronically. Reporters have the option to remain anonymous or provide their name and other contact information. Reporters are provided a Report Key that allows for anonymous communication with a member of the Compliance and Ethics Department.

What types of situations should I report?

Any questions or concerns regarding actual or potential violations of applicable law, regulation, policy or procedure, or the Code of Conduct (Code) should be reported. Reporters are protected from retaliation for concerns raised in Good Faith (believed to be true).

Examples:

• HIPAA/privacy concerns, such as health information given to the wrong patient, wrong patient chart used, wrong armband, lost/stolen device containing hospital/patient information, accessing protected health information without professional need (self, family members, co-workers, celebrities, etc.)
• Specific incidents of unacceptable or disruptive colleague behaviors (physical or verbal)
• Employee relations matters (hiring practices, retaliation, discrimination, harassment, workplace conflicts)
• Unsafe work environment (safety rules not followed, broken equipment, etc.)
• Documenting or billing for services not provided
• Clinical scope of practice issues (nurse working without a valid certification, medical staff member practicing without the appropriate privileges)
• Using position or company resources for personal gain, non-work related reasons
• Ongoing, previously reported concerns that require an independent review
• Questions or seek guidance on matters when it is uncomfortable speaking with an internal business partner or member of management

What information do I need to provide about my complaint?

The Compliance and Ethics Department must receive specific details concerning the matter in order to facilitate a thorough review. Providing partial or incomplete information may result in case closure due to insufficient information. Information needed to complete a thorough review may include:

• First/last name of person(s) or organization(s) engaged in alleged wrongdoing
• Description of the event, location, and date/time of when event occurred
• Specific details or synopsis of the concern(s) being raised
• First/last names of witnesses to the event or others who may have knowledge of the concern(s) being raised
• How the event was discovered if the reporter was not a participant or directly involved
• Supporting documentation if available, including policies, memoranda, emails, text messages, etc.

Why should I report what I know? What’s in it for me?

Lifespace strives to provide compassionate, high-quality care and act with integrity. Lifespace team members have an obligation to report unsafe practices, unethical behavior or violations pertaining to the Code, policy or procedure, or applicable law or regulation. When someone’s actions violate our Code, our policies or procedures, or applicable laws or regulations, it can harm both Lifespace and our residents and patients. If a law is violated, the result could be civil or criminal action against Lifespace and the person(s) responsible.

We take any potential violation seriously. Reports of potential misconduct are reviewed carefully and steps are taken to correct the situation, including disciplinary action when appropriate.

Where do these reports go? Who can access them?

Reports made through the ComplianceLine are maintained on a secure server. A limited number of employees in the Human Resources and Compliance and Ethics Departments can access these reports. These team members are specially trained to handle complex and sensitive matters in a confidential manner.

How long will the investigation take?

Each allegation reported through the Integrity Line is unique, so the estimated time of completion depends on many factors, such as the complexity of the issue, the number of people involved, the nature and extent of documents or other evidence involved, and the urgency of the matter. Reporters may use the Report Key to check on the status of a review or communicate with the lead investigator.

How do I get updates from investigators? How do I share additional details? How do I know the outcome of my report?

Reporters are provided a Report Key that allows for anonymous communication with the lead investigator who is a member of the Human Resources or the Compliance and Ethics Department. The Report Key is a form of a report identification number that allows the reporter to check on the status of a case review or communicate with the lead investigator. On the ComplianceLine homepage, click ‘Follow-up’ to ask questions, provide updates or inquire about the status of the review.

What does “confidentiality” mean? Is it the same as “anonymity?”

Confidentiality means that members of the Human Resources and the Compliance and Ethics Departments will not disclose information to individuals outside of the reasonable “need to know” standard. This includes information received, used, maintained or accessed during the course of normal duties, such as case reviews.

Anonymity (or “anonymous”) means that Lifespace team members may report any concern through the Integrity Line without disclosing their identity. Reports made in Good Faith will be taken and reviewed without an attempt to identify the reporter.

Be advised that:

• There are circumstances in which confidentiality and anonymity may not be maintained, such as disclosures pursuant to a subpoena or court order, a lawful discovery request or a disclosure necessary to resolve a potential compliance matter.
• Anonymity applies to an individual’s identity.
• Confidentiality applies to information received, used, maintained or accessed.
• Reporters may choose to release their identity during or after a completed review.
• Information about a reporter’s identity, if provided, will be retained in the Compliance and Ethics Department’s records.
• Information shared outside of the Integrity Line case review process is not protected by the Compliance and Ethics Department.
• Information shared through the Integrity Line may lead to indirect identification of a reporter given the specific details provided.