Columbia, South Carolina


TO:             All Employees

SUBJECT: Compliance

I. Policy/Code of Conduct

  1. Generally

    The employees of the South Carolina Department of Mental Health ("SCDMH") shall embrace the spirit and the letter of the law governing SCDMH, exemplify the highest ethical standards in their conduct to contribute to the public good, and continuously strive to achieve the mission of SCDMH while being fully compliant with the numerous and complex laws regulating the provision of health care. SCDMH, as an entity, is committed to ensuring the promotion of full compliance and the prevention and detection of accidental and intentional noncompliance with all applicable legal and ethical responsibilities.

  2. Clients

    The employees of the SCDMH are committed to serving the people in our care with hope, dignity and respect while providing quality care that is delivered in a sensitive, compassionate and prompt manner.

  3. Employees

    We are committed to being a skilled, ethical work force which is culturally competent and dedicated to the highest standards of professionalism, integrity, and competence. As such, we are expected to conform to the professional code of ethics of our profession and/or facility in which we work.

  4. Volunteers, Contractors and Others

    Our working relationships with persons involved in accomplishing our mission will reflect our commitment to comply with applicable laws and we will conduct ourselves in the same manner as we do with our fellow employees.

II. Purpose

The purpose of this directive is to further our Policy by implementation of a Compliance program.

III. Scope

This program is developed consistent with the Office of Inspector General's Compliance Program Guidance and the Federal Sentencing Guidelines for Organizations and:

  1. Designates the Organizational Structure, assigns and coordinates the Responsibilities for compliance;

  2. Requires the development and provision of minimum Training and Education of employees in the area of compliance;

  3. Identifies Compliance Standards and Procedures;

  4. Incorporates the Auditing of identified Standards and Procedures into the organizational structure and requires that this capacity be supplemented as necessary;

  5. 1.Requires employees to immediately Report:

    (a) Non-compliance to their supervisor, or their Compliance Officer, or to the SCDMH Compliance Hotline, or

    (b)     Compliance related audits by an outside agency (e.g., DHHS, DHEC, OIG, CMS and others) to their facility Compliance Officer or their Supervisor.

    2. Compliance Officers shall establish means to Respond to such reports,  including corrective action, as needed.

  6. Ensures Enforcement of compliance matters by means of the employment policies and procedures, including the Employee Performance Management System (EPMS) and the Standards of Progressive Disciplinary Action.

IV. Appointment and Authority

The SCDMH Compliance Officer shall report directly to the State Director and must be a member of the highest level management team of SCDMH. The SCDMH General Counsel will designate an advisory attorney for Compliance issues. The SCDMH Compliance Officer will have direct access and provide semi-annual reports to the Mental Health Commission.

The SCDMH Compliance Officer shall have direct access to the SCDMH governing body and shall plan, organize and manage an agency wide program to ensure compliance with complex federal, state and local regulations governing health care providers, particularly those designated as Compliance Standards. The implementation of this program and its purposes shall be accomplished under the direction of the SCDMH Compliance Officer who is authorized to develop and maintain a Compliance Plan having the same force and effect as this Directive. Each Center and Facility shall develop and maintain a Compliance Plan following the terms of the SCDMH Compliance Plan. 

This Directive becomes effective 31 May 2006 and supersedes the previous Directive bearing this title and issued as Directive No. 823-01.

John Connery's signature

John J. Connery, M.A.
Interim State Director  

June 22, 2006