Facility Compliance Officer

A Facility Compliance Officer (“FCO”) is designated at each CHS affiliated entity (“Affiliates”) to assist the Senior Vice President, Corporate Compliance and Privacy Officer (“CCO”) with the implementation, oversight, and ongoing operation of the Corporate Compliance Program. The FCO will ensure the Compliance Program responsibilities are met and the Program also adequately addresses concerns specific to the Affiliate.

A Facility Compliance Officer (“FCO”) is designated at each CHS affiliated entity (“Affiliates”)
to assist the Senior Vice President, Corporate Compliance and Privacy Officer (“CCO”) with the
implementation, oversight, and ongoing operation of the Corporate Compliance Program. The
FCO will ensure the Compliance Program responsibilities are met and the Program also adequately
addresses concerns specific to the Affiliate.

Implement the Corporate Compliance Program for the FCO’s Affiliate.
? Personally present compliance training at new hire orientation.
? Communicate immediately upon learning of a matter of potential
concern or upon receiving an allegation of non-compliance.
? Enter all reported incidents into the Compliance 360 incident module. Maintain
timely and thorough documentation and status updates in the system to ensure
complete documentation of all reported concerns.
?Assist in the development and implementation of corrective action plans when areas of
non-compliance are identified.
? Review and coordinate communication, distribution, and implementation of new Corporate
Compliance policies and procedures. Recommend additional policies and/or policy
language, as necessary.
? Chair the Facility Compliance Committee (“FCC”); ensure adherence to the standard
agendas for each FCC meeting, and prepare FCC minutes. Add agenda elements as needed
at the entity level to ensure adequate and appropriate coverage of facility-specific
compliance issues or concerns.
? Develop oral and written reports, including recommendations for improvement or
corrective actions based upon audit and investigative findings;
? Ensure adequate and complete follow through on potential risk areas to
demonstrate appropriate actions were taken to remediate risks;
? Work with appropriate business partners to implement and document all
corrective action plans identified during the course of auditing and monitoring
activities;
? Add FCC agenda elements, as needed, at the facility level to ensure adequate and
appropriate coverage of facility specific compliance issues or concerns;
? Collaborate with department directors to improve timely identification of
compliance variances.

? Facilitate the Compliance auditing and monitoring plans to determine compliance with
established laws, regulations, company policies, and managerial guidelines. Report all
results to the FCC and immediately notify the CCD of adverse outcomes.
? Implement and maintain the Document and Record Retention Policy including the
destruction guidelines for the Affiliate and its related entities.

?Collaborate with Human Resources and all Department Directors to ensure all relevant
staff complete new hire and annual compliance and privacy training, and all training is
appropriately documented in HealthStream.
? Ensure implementation of a process for conducting eligibility screening of all relevant
persons; coordinate with Human Resources, Medical Staff Development, Patient Financial
Services, and Contract Administration to ensure complete assessment of all required parties
through the use of the ExclusionCheck eligibility screening product.
? Promote an environment in which employees are free to confidentially report instances of
non-compliance without fear of retribution or retaliation.
? Maintain an awareness of current laws, statutes, regulations, etc. that impact healthcare
operations and physician relationships.
? Attend corporate-led educational events and regularly scheduled FCO Conference Calls
for compliance topics and vital updates.

Grandview Medical Center, a 434-bed regional referral center and tertiary-care facility, is located in Birmingham, AL., and is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Grandview Medical Center offers programs and services in all medical and surgical areas, including Cardiology, Oncology, Neurology, Women's Health, Mental Health, Digestive Diseases, Orthopedics, Physical Medicine and Rehab, Sports Medicine and Emergency Care. There are more than 600 physicians on the Grandview medical staff representing 30 specialties and subspecialties. The hospital has been named an accredited program for Metabolic and Bariatric surgery by ASMBS & ACS as well as an accredited chest pain center. Grandview Medical Center provides equal employment opportunity to all employees and applicants for employment regardless of any individual’s race, color, religion, sex, sexual orientation, gender identity, national origin, age, citizenship, military status, disability, genetic information or any other protected class status in accordance with applicable federal, state, and local laws.