[Audio] In light of our enhanced collaboration with Inova, we are introducing a new supplemental compliance and ethics training module. This training is designed to ensure that all team members are equipped with the knowledge necessary to uphold the highest standards of compliance and privacy in our operations. Key Goals of the Training:
Introduce the Compliance Department: Familiarize yourself with our department, including key contacts who are available to support you with any compliance-related queries.
Share Contact Information: Learn how to easily reach out to our compliance team for assistance or to report any concerns.
High-Level Topics Covered:
Code of Conduct and importance of reviewing standards and expectations. Business Courtesies
Conflict of Interest
Fraud Waste and Abuse
Government Exclusions Sanctions Social Media and P-H-I
Use of Personal Devices Your participation in this training is crucial to our ongoing commitment to maintaining a culture of integrity and compliance.. 

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[Audio] Inova has been providing compliance and privacy support to P-S-V since 2016. They are staffed with experts in the field of regulatory compliance and provide valuable help to everyone at PSV. You may be asking yourself, what or who is the Compliance Department? The compliance team is like a friendly guide, helping everyone in the organization understand and follow the rules, ensuring that the company stays on the right side of the law and operates with integrity. They're here to support, educate, and protect patients and our organization from potential risks. The department is currently led by Inova's Acting Chief Compliance Officer and Chief Privacy Officer Eric Lyda. It is staffed with compliance professionals who together have 20 plus years in regulatory compliance as well as 20 plus years with Inova. P-S-V also has resources that can support you if any questions related to compliance or privacy arise.. 

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Acting Chief Compliance Officer  & Chief Privacy Officer – Eric Lyda

Assist Chief Privacy Officer – Walter Johnson

Staffed with professionals who together have several years of experience in Regulatory Compliance.
 PSV Resources PSVQualityTeam@psvcare.org Chief of Quality- Ronak Patel, MD Director of Quality & Clinical Services- Jennifer Taylor, RN  Director of Human Resources- Denise Baerga

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[Audio] Team members and managers must understand that the Code of Conduct prohibits punishment, intimidation or other retaliation against someone who in good faith, raises questions or reports potential compliance issues. This element to the Code aligns with P-S-V and Inova's culture of psychological safety that empowers each team member to fully engage. You do not have to notify management prior to contacting the hotline and your call will not be traced. You may choose to be anonymous or may provide your name and contact information. All calls are confidential. The hotline number is 888-800-4030 and the website link can be found on the PSV *Regulatory Compliance (sharepoint.com) page. No disciplinary actions will be taken against staff reporting compliance or privacy concerns. If you are concerned about the safety and quality of care here at P-S-V--, please address these concerns with your Supervisor, Manager, or the Director of Quality and Clinical Services.. 

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How to Report Concerns or Suspected Violations

888-800-4030 www.mycompliancereport.com **Inova’s Access Code is INO

compliancedepartment@inova.org Phone: (571) 472-8187 Fax: (571) 665-6796

PSV prohibits retaliation against any caller who in good faith reports information to the Compliance department and/or Hotline.*

If you are unsure of whether something is a compliance related issue, please  feel free to contact the compliance department using the hotline or department’s direct line. You have the choice to remain anonymous and all calls are confidential.

[Audio] The Code of Conduct is the cornerstone of the Compliance and Ethics Program and outlines our commitment to P-S-V--, to our patients and to each other. It works with other policies and procedures to guide our behavior as part of PSV's workforce Violations of the Code are considered serious and can be reason for discipline, up to and including termination. You may always find the latest version of this Code on P-S-V Code of Conduct.pdf or request a current copy of it from the P-S-V Human Resources Department. At the end of this training, you will be asked to attest your understanding of the Code of Conduct.. 

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PSV Code of Conduct and Regulatory Compliance Policies

Works with other PSV and Inova policies and procedures to guide your actions in the workplace.

Should be reviewed upon hire and annually  while employed by or working at PSV.

The Code of Conduct is available on HR - HR Policies and Procedures - All Documents (sharepoint.com) or from the PSV Human Resources Department.

All regulatory compliance policies and procedures can be found on * Policies and Procedures - Ethics and Compliance - All Documents (sharepoint.com)

[Audio] What is a conflict of interest? It is something that influences you to do your job in a way that may not be in the best interest of P-S-V or our patients. An actual conflict would occur if you used your position for personal gain OR dealing with contractors, suppliers or competitors for personal gain. A potential conflict could exist if you are doing business, on behalf of P-S-V--, with a company in which you or a relative have an interest OR if you have outside employment that may conflict with your job responsibilities at PSV. Relationships between P-S-V and our vendors must be free of conflicts of interest. Gifts to physicians from vendors may create conditions that carry a risk of perceived bias in the provision of care to our patients. To preserve the trust of the patient-physician relationship, physicians should decline cash gifts of any kind, and decline any gifts where reciprocity is implied or expected. When accepting promotional items, discounts, rebates or awards from vendors, the gift must be directly beneficial to the patients (including patient education) and of minimal value.. If you have questions surrounding whether a possible conflict of interest exists, please reach out to the Compliance department for further information and assistance.. 

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A conflict of interest occurs when any personal interest exists that might affect, or might reasonably appear to affect, your objective or impartial judgment or conduct on behalf of PSV.

A conflict can occur when a person has a vested interest—such as money, status, knowledge, relationships, or reputation—which puts into question whether their actions, judgment, or decision-making is unbiased.

[Audio] Business courtesies, like giving or receiving gifts, meals, or entertainment, are gestures meant to build relationships in business. However, in healthcare, they can pose risks because they might influence—or appear to influence—decisions about patient care or contracts. This could lead to conflicts of interest, where decisions are made based on these courtesies instead of what's best for patients or the organization, which can violate laws and ethical standards. It is your duty to be fair and unbiased and not driven by personal agenda. Offers of travel, lodging, gift cards, entertainment, gifts or free conferences are considered "business courtesies" and should never be solicited and may only be accepted if P-S-V or the team member pays the value of the event or service. More information can be found in the Code of Conduct and Employee Handbook located on HR HR and Administration Policies All Documents (sharepoint.com) Approval should be sought from your supervisor and/or the Chief Compliance Officer.. 

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Business Courtesy: Offers of meals, travel, lodging, gift cards, entertainment, gifts or free conferences

Acceptance may create a perceived or actual conflict of interest.

Seek approval from your supervisor and/or Chief Compliance Officer

Please note: Gift cards may not be accepted from vendors or patients as they are cash equivalents and prohibited in all cases.

If you have questions, the Compliance team is here to help, so please reach out to us!

[Audio] We are committed as a high reliability organization to refrain from conduct that may violate the fraud and abuse laws or applicable false claims laws. Fraud, waste and abuse are targets of government audits and have been identified as a source of overpayments to federal health plans. Law enforcement agencies take this matter seriously and will prosecute violations. Fraud is knowingly and willfully attempting to get paid for something we are not entitled to such as billing for a service that was not provided. Waste is the overutilization of services resulting in unnecessary costs incurred by Medicare and Medicaid such as providing a service that is not deemed medically necessary. Abuse is seeking payment when there is no legal entitlement to that payment such as charging in excess for a service. Billing rules are complex and even billing in error unintentionally can occur. If you discover or suspect errors in claims submission, immediately notify your supervisor, patient accounts or the Compliance Department so a review can be conducted. If we are aware of billing errors and fail to correct them, it may be considered reckless disregard for the rules and can result in serious violations and fines.. 

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If you discover an inaccurate claim, immediately notify your supervisor or the Compliance Department

As of September 30, 2022, the Medicare Fraud Strike Force reported 2,688 criminal actions, 3,483 indictments and $4.7 billion in fines/recoupments as a result of the combined efforts of the Office of Inspector General, the Department of Justice, Offices of the United States Attorneys, the Federal Bureau of Investigation, local law enforcement, and others.

Knowingly and willfully attempting to get paid for something we are not entitled to.  Example: Billing for a service that was not provided

Overutilization of services that result in unnecessary costs to the healthcare system, including Medicare and Medicaid. Example: Billing for medically unnecessary service

Seeking payment for items or services when there is no legal entitlement to that payment. Example: Charging in excess for services or supplies

[Audio] The government publishes lists of sanctioned individuals and organizations. P-S-V and Inova must not hire or do business with anyone who is on the sanction lists. Sanction testing of all team members, physicians and vendors is completed by P-S-V upon hire or initiation of a contract and monthly thereafter to ensure that no sanctioned individuals or entities are involved in PSV's services or business. If sanctioned individuals or entities are discovered, P-S-V must terminate that relationship and pay back any funds received based on that person's or the entities' activities. Some examples that would cause someone to become sanctioned or excluded include (but are not limited to): failure to pay back a government funded student loan, suspension of a clinical license or violation of government billing rules.. 

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The Government punishes individuals and organizations that have committed violations and publishes their names on the sanction lists.

PSV must not hire or do business with anyone on the sanction lists. Prior to entering into a contract, managers should ensure that there are no active federal exclusions.

Every PSV team member must successfully complete a background check before they can begin work at PSV.

PSV is required to check on a monthly basis, all team members, vendors and physicians against various sanction and excluded parties' lists.

[Audio] Social media is an ever-expanding reality of our society. Postings must never include patient information that might allow someone to identify a patient. Pictures or details about patients on social media sites even without naming them, may result in a H-I-P-A-A violation. You may not post pictures of patients or clinical areas within P-S-V--, unless it is for approved business purposes. Sharing patient information in this way may result in disciplinary action. If you identify yourself as working for P-S-V you should include a disclaimer stating, "The postings on this site are my own and do not necessarily reflect the views of PSV." Please refer to P-S-V Code of Conduct for additional guidance related to social media.. 

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You may NOT post pictures of patients, or clinical areas within PSV, except for 	official business purposes and with patient authorization.

Sharing patient information on social media may violate HIPAA rules and PSV policy and result in disciplinary action. ***If you have a newsworthy story, please consult with marketing leadership before sharing on Social Media.*** *If you

If you identify yourself as working at PSV, you will need to add the following disclaimer to 	your profile page:

"The postings on this site are my own and do not necessarily reflect the views of PSV.”

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[Audio] Personal devices are not authorized to store, photograph or transmit P-H-I unless through P-S-V approved applications or processes.
How may personal devices be used at P-S-V-? To connect to P-S-V Email via Internet browser or approved applications To access P-S-V applications via the internet using CITRIX and a secure token
To connect to approved Inova applications for example High Fives, Oracle
To perform clinical functions through E-P-I-C utilizing Canto and Haiku applications via Internet once the user and the devices are registered and approved by (I-T ) Security. Contact the P-S-V (I-T ) Helpdesk for more information.. 

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Personal devices are not authorized to store, photograph or transmit PHI unless through  PSV approved applications or processes.

Connect to PSV Email via Internet browser or applications

Access PSV applications via the Internet using CITRIX and secure token*

To connect to approved PSV applications e.g., High Fives, Oracle, via Canto or Haiku

*Non-Exempt team members will not have remote access, except for scheduling and time-keeping systems, HealthStream, or other PSV-approved applications.
 When working remotely, ALL team members must always protect PHI by working in a private location where PHI can not be seen or accessed by anyone other than the authorized PSV employee.  Never share your password with anyone.

[Audio] P-S-V recognizes the commitments its employees make to various outside organizations and events as volunteers, it cannot allow those relationships to interfere with the privacy of its patients, visitors and employees or the delivery of patient care and operations. As a result, P-S-V requires that its employees follow strict guidelines concerning solicitation. Employees or individuals not employed by P-S-V--, may not solicit individuals, including but not limited to patients, visitors and other employees, during working time (including the working time of either the employee making the solicitation or any employee being solicited). Employees may not distribute literature or other materials for any purpose during working time (including the working time of either the employee making the distribution or any employee to whom distribution is made). Solicitation may include the following actions. All are prohibited:
The offering of anything for sale. Asking for donations. Collecting funds. Promoting, encouraging or discouraging participation in or support for any organization, activity, event or membership in any organization. Distributing or delivering membership or applications for any organization Occasionally, P-S-V may authorize a special event and solicit support. Some examples include back to school or food drives or direct support to a cause that promotes the health and wellness of our patients such as Childhood Cancer Awareness Month. P-S-V will only permit these limited events to be open for solicitation.". 

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Employees may not solicit individuals, including but not limited to  patients, visitors and other employees during work time.

 Solicitation includes but is not limited to: Selling products or services Asking for donations Collecting funds Encouraging or discouraging participation or membership of an organization/event Distributing applications for advertising for an organization


 PSV may occasionally solicit support for certain causes such as  Back to School or Food drives.

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[Audio] One of PSV's most valuable assets is its body of confidential information. Confidential information includes PSV's methods, processes, techniques, computer software, equipment, service marks, copyrights, research data, clinical and pharmacological data, marketing and sales information, personnel data, patient lists, financial data, strategic plans and all other propriety information in the possession of P-S-V which is not published or disclosed to the general public. As an employee, you are responsible and accountable for the integrity and protection of PSV's business information and must take steps to protect the information that has been entrusted to you. Employees are expected to ensure protection of files, maintain a clean desk concept by not leaving confidential documents on your desk, printer or conference room/break room table. Reminder to never share your passwords with anyone!. 

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PSV employees are entrusted with many aspects of confidential information.  Confidential information includes but is not comprehensive   of processes/procedures, patient information, employee information,   financial data and other propriety information. Employees are responsible and accountable for the integrity and protection of the information. Actions to maintain confidentiality include: File retention Password integrity  ‘Clean desk concept’

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Compliance & 
Ethics Training 

In light of our enhanced collaboration with Inova, we are introducing a new supplemental compliance and ethics training module. This training is designed to ensure that all team members are equipped with the knowledge necessary to uphold the highest standards of compliance and privacy in our operations.

Key Goals of the Training:
Introduce the Compliance Department: Familiarize yourself with our department, including key contacts who are available to support you with any compliance-related queries.
Share Contact Information: Learn how to easily reach out to our compliance team for assistance or to report any concerns.
High-Level Topics Covered:
Code of Conduct and importance of reviewing standards and expectations. 
Business Courtesies
Conflict of Interest
Fraud Waste and Abuse
Government Exclusions Sanctions 
Social Media and P-H-I
Use of Personal Devices

Your participation in this training is crucial to our ongoing commitment to maintaining a culture of integrity and compliance.

avatar

Inova has been providing compliance and privacy support to P-S-V since 2016.  They are staffed with experts in the field of regulatory compliance and provide valuable help to everyone at PSV. 

You may be asking yourself, what or who is the Compliance Department? 

The compliance team is like a friendly guide, helping everyone in the organization understand and follow the rules, ensuring that the company stays on the right side of the law and operates with integrity. They're here to support, educate, and protect patients and our organization from potential risks.

The department is currently led by Inova's Acting Chief Compliance Officer and Chief Privacy Officer Eric Lyda. It is staffed with compliance professionals who together have 20 plus  years in regulatory compliance as well as 20 plus  years with Inova. 

P-S-V also has resources that can support you if any questions related to compliance or privacy arise.

Team members and managers must understand that the Code of Conduct prohibits punishment, intimidation or other retaliation against someone who in good faith, raises questions or reports potential compliance issues. This element to the Code aligns with P-S-V and Inova's culture of psychological safety that empowers each team member to fully engage.

You do not have to notify management prior to contacting the hotline and your call will not be traced. You may choose to be anonymous or may provide your name and contact information. All calls are confidential. 

The hotline number is 888-800-4030 and the website link can be found on the PSV *Regulatory Compliance (sharepoint.com) page.

No disciplinary actions will be taken against staff reporting compliance or privacy concerns. 

If you are concerned about the safety and quality of care here at P-S-V--, please address these concerns with your Supervisor, Manager, or the Director of Quality and Clinical Services.

 compliancedepartment@inova.org Phone: (571) 472-8187 Fax: (571) 665-6796

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The Code of Conduct is the cornerstone of the Compliance and Ethics Program and outlines our commitment to P-S-V--, to our patients and to each other.  It works with other policies and procedures to guide our behavior as part of PSV's workforce

Violations of the Code are considered serious and can be reason for discipline, up to and including termination. 

You may always find the latest version of this Code on P-S-V Code of Conduct.pdf  or request a current copy of it from the P-S-V Human Resources Department. 

At the end of this training, you will be asked to attest your understanding of the Code of Conduct.

 The Code of Conduct is available on HR - HR Policies and Procedures - All Documents (sharepoint.com) or from the PSV Human Resources Department.

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 All regulatory compliance policies and procedures can be found on * Policies and Procedures - Ethics and Compliance - All Documents (sharepoint.com)

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What is a conflict of interest? It is something that influences you to do your job in a way that may not be in the best interest of P-S-V or our patients. An actual conflict would occur if you used your position for personal gain OR dealing with contractors, suppliers or competitors for personal gain.

A potential conflict could exist if you are doing business, on behalf of P-S-V--, with a company in which you or a relative have an interest OR if you have outside employment that may conflict with your job responsibilities at PSV. 

Relationships between P-S-V and our vendors must be free of conflicts of interest. 

Gifts to physicians from vendors may create conditions that carry a risk of perceived bias in the provision of care to our patients. To preserve the trust of the patient-physician relationship, physicians should decline cash gifts of any kind, and decline any gifts where reciprocity is implied or expected. When accepting promotional items, discounts, rebates or awards from vendors, the gift must be directly beneficial to the patients (including patient education) and of minimal value..


If you have questions surrounding whether a possible conflict of interest exists, please reach out to the Compliance department for further information and assistance.

Business courtesies, like giving or receiving gifts, meals, or entertainment, are gestures meant to build relationships in business. However, in healthcare, they can pose risks because they might influence—or appear to influence—decisions about patient care or contracts. This could lead to conflicts of interest, where decisions are made based on these courtesies instead of what's best for patients or the organization, which can violate laws and ethical standards.

It is your duty to be fair and unbiased and not driven by personal agenda. Offers of travel, lodging, gift cards, entertainment, gifts or free conferences are considered "business courtesies" and should never be solicited and may only be accepted if P-S-V or the team member pays the value of the event or service. More information can be found in the Code of Conduct and Employee Handbook located on HR  HR and Administration Policies  All Documents (sharepoint.com)

Approval should be sought from your supervisor and/or the Chief Compliance Officer.

We are committed as a high reliability organization to refrain from conduct that may violate the fraud and abuse laws or applicable false claims laws.  Fraud, waste and abuse are targets of government audits and have been identified as a source of overpayments to federal health plans. Law enforcement agencies take this matter seriously and will prosecute violations.  

Fraud is knowingly and willfully attempting to get paid for something we are not entitled to such as billing for a service that was not provided. 

Waste is the overutilization of services resulting in unnecessary costs incurred by Medicare and Medicaid such as providing a service that is not deemed medically necessary. 

Abuse is seeking payment when there is no legal entitlement to that payment such as charging in excess for a service. 

Billing rules are complex and even billing in error unintentionally can occur. If you discover or suspect errors in claims submission, immediately notify your supervisor, patient accounts or the Compliance Department so a review can be conducted.  If we are aware of billing errors and fail to correct them, it may be considered reckless disregard for the rules and can result in serious violations and fines.

The government publishes lists of sanctioned individuals and organizations. P-S-V and Inova must not hire or do business with anyone who is on the sanction lists. 

Sanction testing of all team members, physicians and vendors is completed by P-S-V upon hire or initiation of a contract and monthly thereafter to ensure that no sanctioned individuals or entities are involved in PSV's services or business. 

If sanctioned individuals or entities are discovered, P-S-V must terminate that relationship and pay back any funds received based on that person's or the entities' activities.

Some examples that would cause someone to become sanctioned or excluded include (but are not limited to): failure to pay back a government funded student loan, suspension of a clinical license or violation of government billing rules.

Social media is an ever-expanding reality of our society. 

Postings must never include patient information that might allow someone to identify a patient. Pictures or details about patients on social media sites even without naming them, may result in a H-I-P-A-A violation. You may not post pictures of patients or clinical areas within P-S-V--, unless it is for approved business purposes. 

Sharing patient information in this way may result in disciplinary action. 

If you identify yourself as working for P-S-V you should include a disclaimer stating, "The postings on this site are my own and do not necessarily reflect the views of PSV."

Please refer to P-S-V Code of Conduct for additional guidance related to social media.

Personal devices are not authorized to store, photograph or transmit P-H-I unless through P-S-V approved applications or processes.
How may personal devices be used at P-S-V-?

To connect to P-S-V Email via Internet browser or approved applications 
To access P-S-V applications via the internet using CITRIX and a secure token
To connect to approved Inova applications for example High Fives, Oracle
To perform clinical functions through E-P-I-C utilizing Canto and Haiku applications via Internet once the user and the devices are registered and approved by (I-T ) Security.

Contact the P-S-V (I-T ) Helpdesk for more information.

P-S-V recognizes the commitments its employees make to various outside organizations and events as volunteers, it cannot allow those relationships to interfere with the privacy of its patients, visitors and employees or the delivery of patient care and operations. As a result, P-S-V requires that its employees follow strict guidelines concerning solicitation.


Employees or individuals not employed by P-S-V--, may not solicit individuals, including but not limited to patients, visitors and other employees, during working time (including the working time of either the employee making the solicitation or any employee being solicited). 
Employees may not distribute literature or other materials for any purpose during working time (including the working time of either the employee making the distribution or any employee to whom distribution is made). 

Solicitation may include the following actions.  All are  prohibited:
The offering of anything for sale. 
Asking for donations. 
Collecting funds. 
Promoting, encouraging or discouraging participation in or support for any organization, activity, event or membership in any organization. 
Distributing or delivering membership or applications for any organization

Occasionally, P-S-V may authorize a special event and solicit support.  Some examples include back to school or food drives or direct support to a cause that promotes the health and wellness of our patients such as Childhood Cancer Awareness Month.  P-S-V will only permit these limited events to be open for solicitation."

One of PSV's most valuable assets is its body of confidential information.

Confidential information includes PSV's methods, processes, techniques, computer software, equipment, service marks, copyrights, research data, clinical and pharmacological data, marketing and sales information, personnel data, patient lists, financial data, strategic plans and all other propriety information in the possession of P-S-V which is not published or disclosed to the general public.


As an employee, you are responsible and accountable for the integrity and protection of PSV's business information and must take steps to protect the information that has been entrusted to you. 

Employees are expected to ensure protection of files, maintain a clean desk concept by not leaving confidential documents on your desk, printer or conference room/break room table.  Reminder to never share your passwords with anyone!

Compliance & Ethics Training