WHAT’S NEW FY 2016-17 - SFDPH · Debra Solomon, Director 255-3471 [email protected] Reanna Albert 255-3697 [email protected] Marshia Herring 255-3752 [email protected]

WHAT’S NEW FY 2016-17

San Francisco Department of Public HealthContract Development & Technical Assistance (CDTA)

June 30, 2016

Utilizing sound business practices, CDTA facilitates the development of city health delivery system contracts, thus ensuring the availability of community services that protect and promote the health of all San Franciscans.

Today’s Overview2

Contract Development & Technical Assistance Michelle Long

Business Office Contract Compliance Debra Solomon

Controller’s Office Laura Marshall

Office of Compliance & Privacy Affairs Maria X. Martinez

Director of the Department of Public Health Barbara Garcia

Budget Office Shirley Giang

Office of Contract Management & Compliance Jacquie Hale

June 30, 2016What's New FY2016-17

Michelle Long, M.H.A.Director, Contract Development & Technical Assistance

1380 Howard Street

San Francisco Department of Public Health

Phone: (415) 255-3409

CDTA Website: www.sfdph.org/cdta

Contract Development & Technical Assistance3


Survey Says… #1 Lots of New Staff

Last year’s survey indicated that the majority of attendees had

never before attended an Annual “What’s New” Meeting.

Result:

“Contracts 101” – a suggestion from one of the attendees

“…it might be nice for newer management to be able

to have a smaller group training to understand the

process.”


4

Survey Says… #2 Handouts are important!

Last year’s survey indicated that the handouts and

the PowerPoint presentation from the meeting were

important to you and we needed to make things

easier for you to read and access.

Result:

One copy of afternoon presentation and handouts available in hard

copy to all attendees today;

Presentations from morning and afternoon and all handouts

available on CDTA website next week: www.sfdph.org/cdta (look

under PRESENTATIONS)


5

On the Website you can also find:

Performance Objectives for FY 16-17 (end of July)

Contract document templates for FY 16-17 and instructions – Appendix A and B

Contractual Services Invoice Procedures Manual (updated version – end of July)

Contract Change Request Form and Instructions

Fringe Benefit Rate Increase Request Policy & Procedure

Fringe Benefit Rate Increase Request Form

Indirect Cost Rate Increase Request Policy & Procedure

Indirect Cost Rate Increase Request Form

Budget Revision Form (mid July)


6

Comparative Analysis

Contract Change Request

June 30, 2016

7

What's New FY2016-17

Contract Change Request Form Analysis

What we’re trying to achieve

Reduction in number of contract changes

Response to contractors in a timely manner

Minimal delays to contract certification and

payment


8

Contract Change Requests Received

60 47

FY2014-15 FY2015-16

June 30, 2016

9


Contract Change Request Comparison Analysis

Contract Change Requests by Section

FY2014-15 FY2015-16

BHS-CYF 37% 30%

BHS-AOA 43% 55%

MHSA 10% 4%

Non-BHS 10% 11%


10


Type of Contract Change Requests

FY2014-15 FY2015-16

Change to Deliverables 55% 53%

Programmatic Changes 25% 17%

Budget Changes 78% 85%

Additional Funds 52% 32%


11

Note: CCR may contain more than one type of requested change


Contract Change Requests Approval Rate

FY2014-15 FY2015-16

Approved 40 42

Declined 14 5

Undecided 6 0

Total 60 47


12

CDTA & Grants Administration

Michelle Long, Director 255-3409 [email protected]

Francine Austin 255-3933 [email protected]

April J. Crawford 255-3931 [email protected]

Elizabeth Davis 255-3934 [email protected]

Erik Dubon 255-3917 [email protected]

Margaret Elam 255-3410 [email protected]

Mario Hernandez 255-3503 [email protected]

Hilda Jones 255-3924 [email protected]

Richelle L. Mojica 255-3555 [email protected]

Jim Stroh 255-3445 [email protected]

Eric Whitney 255-3932 [email protected]

Valerie Wiggins 255-3514 [email protected]

Andrew Williams III 255-3928 [email protected]

13


Questions?14


Debra Solomon

[email protected]

415.255.3741

Business Office Contract Compliance (BOCC)

June 30, 2016

15


Declaration of Compliance

The Program Monitoring process starts with the Declaration of

Compliance (lists requirements for each program area)

The Declaration is sent electronically to programs at the start of

each review cycle/funding period

Programs sign and return

Programs prepare Administrative Binder

The Declaration of Compliance may include new items or

clarifications

Please contact our office if you have questions

16


Review Cycles

July – June

Behavioral Health Services (BHS) Programs

Mental Health Services Act (MHSA) Programs

Substance Abuse Prevention Programs (SAPP)

Early Childhood Mental Health (ECMH) Programs

Housing and Urban Health (HUH) – General Fund

HIV Health Services (HHS) – General Fund

Community Health Equity Promotion (CHEP) – General Fund

January – December

Community Health Equity and Promotion (CHEP) – CDC

March – February

Housing and Urban Health (HUH) – Ryan White

HIV Health Services (HHS) – Ryan White

17


Program Monitoring Visits and Reports

BOCC Compliance Managers conduct program monitoring at

the conclusion of the review cycle for each program area

BOCC may contact you for a monitoring visit or may conduct a

desk audit

BOCC prepares monitoring reports for each program, with

information on:

Compliance

Deliverables

Performance Objectives

Client Satisfaction

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Reminder: Compliance Program

The Affordable Care Act requires that any legal entity

providing healthcare services have a Compliance Program

approved by their Executive Director and Board of Directors

DPH requires that a copy be kept in the Administrative Binder

Each program must:

Designate a Compliance Officer

Ensure attendance at quarterly Compliance meetings

Be certified by the DPH Compliance Office

19


Reminder: Privacy and Data Security

Each agency must have a privacy official and this person must

be identified in your Administrative Binder

There must be proof that all staff have completed privacy

training upon hire and annually thereafter

There must be an annually signed data security/confidentiality

form

20


Reminder…Proposition I Requirements

21

Agencies proposing new locations or site expansion are required to adhere to the DPH Good Neighbor Policy, based on San Francisco’s “Citizen’s Right-to-Know Act of 1998” (also referred to as Prop. I)

Prop I requires notification about proposed new or expanded sites, followed by community meeting(s) and a Health Commission hearing

The Department has documents to assist agencies in understanding and meeting these requirements:

The Request for Program Service Change should be completed and submitted to DPH 60 days prior to the implementation of a new program, or a move or expansion of an existing program

Contact your CDTA Program Manager if you need the form or more information


Business Office Contract Compliance22

Debra Solomon, Director 255-3471 [email protected]

Reanna Albert 255-3697 [email protected]

Marshia Herring 255-3752 [email protected]

Tom Mesa 255-3949 [email protected]

Michelle Pollard 255-3661 [email protected]


Questions?23


Laura Marshall

[email protected] or (415) 554-7511

Controller’s website for nonprofit resources:

http://www.sfcontroller.org/nonprofits

Controller’s Office24


Nonprofit Monitoring & Capacity Building Program

• Purpose– Joint Citywide fiscal and compliance monitoring for

nonprofit organizations that have multiple City contracts (120+ orgs)

– Saves nonprofits time and City taxpayers resources– Training & technical assistance to nonprofits and City depts.– Corrective Action Policy– Reporting (no findings, most findings, repeated findings)

• Who is involved? 10 depts.– DPH; DCYF; First 5; Dept. on the Status of Women; Human

Services Agency; Mayor’s Office of Housing & Community Development; Office of Economic & Workforce Development; Arts Commission; Sheriff’s Dept.; Dept. of Homelessness and Supportive Housing

25June 30, 2016 What's New FY2016-17

Support to City-Funded Nonprofits

26

• Technical Assistance (TA)– Departments refer nonprofits for TA – Focus on budgeting, cost allocation procedures, financial

reports, board development, evaluation – Nonprofit resources website:

http://www.sfcontroller.org/nonprofits

• Training – Survey contractors in joint pool on training interests

annually– New offerings in 2016: Financial Reporting, Operational

Excellence, Logic Models, Board Governance– Low turnout in 2016 – what do you need?

• TA and Training Providers – Northern California Community Loan Fund– Fiscal Management Associates– Social Policy Research Associates

June 30, 2016 What's New FY2016-17

FY14-15 Annual Report

• FY14-15 Memo (released Sept. 2015)– 85 nonprofit contractors (70%) met all standards by the end

of the cycle• 23 had no initial findings (18%)• 21 corrected initial findings by the end of the cycle (17%)• 41 had only pilot or best practice findings (34%)

– 41 nonprofit contractors (32%) had 1 or more findings remaining at the end of the cycle

– 3 most common unresolved findings: 1. Agency-wide budget shows allocation of shared and indirect

costs2. Process for allocating shared costs is consistent and reasonable3. Fiscal policies and procedures are current and implemented

• How we Use the Report– Elevated Concern Designation– Targeted technical assistance and training

*Expect FY15-16 report in September 2016

27June 30, 2016 What's New FY2016-17

Corrective Action Policy

• “Elevated Concern” can occur when a nonprofit has not done any or all of the following by City department deadlines:– Responded to the City’s request for monitoring

documents– Responded to the City’s request for corrective action– Provided a mutually agreed upon corrective action

plan – Implemented corrective action plan

• “Red Flag” status is rare and can occur when a nonprofit is at imminent risk of losing their funding for mismanagement or for being unable to perform services per their agreement

28June 30, 2016 What's New FY2016-17

Accomplishments & Plans

FY15-16 Accomplishments

• Piloted use of a Financial Health Assessment to better view trends in nonprofit financial capacity

• Reviewed departmental audit requirements and develop a draft matrix

• Trained contractors on OMB Super Circular Guidelines

FY16-17 Plans

• 10-Year Anniversary! Time for a strategic review.

• Solicit nonprofit feedback via August survey and focus group(s) in winter

• Engage City departments in creating a strategic framework for the program

29June 30, 2016 What's New FY2016-17

Feedback: We Want to Hear from You!

• End of Fiscal Year Survey – July

• Departmental Monitors & Program Officers

• My contact: [email protected] (415) 554-7511

30June 30, 2016 What's New FY2016-17

mailto:[email protected]

Questions?31


Maria X Martinez, MPAffairsDirector, Office of Compliance and Privacy Affairs

Chief Integrity Officer

SF Department of Public Health

101 Grove St., Rm 330, SF, CA 94102

Phone: 415-554-2877

Fax: 415-554-2552

[email protected]

Office of Compliance and Privacy Affairs32


Questions?33


Barbara GarciaDirector of HealthSan Francisco Department of Public Health

101 Grove Street, Room 308

San Francisco, CA 94102

415.554.2526

[email protected]

Director’s Remarks34


Questions?35


Shirley Giang

Director, Business Office Budget Unit

1380 Howard Street, 4th Floor

San Francisco, CA 94103

415.255.3416

[email protected]

Budget Office36


Cost of Doing Business (CODB) Update

As you know, in FY16-17 the Department will provide the second half of the 5% CODB funding allocated for FY15-16 and FY16-17, or an additional 2.5% CODB increase in FY16-17.

Initially the FY15-16 and FY16-17 CODB allocations were the exact same amounts (with the FY14-15 funding level used as the baseline), representing half of a 5% CODB allocation split equally over each of the two fiscal years. However, the Mayor’s Office recently provided additional funding, so that the FY16-17 CODB allocation would be based on a higher FY15-16 funding baseline (higher because it includes the FY15-16 CODB allocation).

The impact of the Mayor’s additional funding is that the FY16-17 CODB must be recalculated on the higher base. If you received a Funding Notification letter prior to June, you may be receiving a new one to capture the increase.

Please Note:

For Fee for Service reimbursed Contracts, the CODB increase should result in a rate increase; there is no requirement to increase units of service.

37


Cost of Doing Business (CODB) Update

The calculation of individual agency CODB allocations is guided by the same criteria as last year. The baseline amount upon which the actual CODB allocation is determined, includes the following:

General Fund monies, (which for this calculation includes MediCal/EPSDT and Realignment), as well as continuing work-orders (money given to DPH by other City Departments) which are funded by General Fund monies.

Not Included in the Baseline for Calculating CODB allocations

Grant funding, as it is not eligible for CODB funding

Mental Health Services Act (MHSA) funding in FY16-17

As we warned last year at this same meeting, MHSA funding which has historically utilized its unspent carryforward funding to support CODB increases equal to the same percentage provided by the Mayor and/or Board of Supervisors, may not be able to continue self-funding. As of FY16-17, there is no additional funding available to support CODB increases. Prior year allocations, e.g. FY15-16 allocations, will continue.


38

Funding Notification Letters Update39

For the following sections, HIV Health Services, Housing and Urban Health, HIV Prevention Section and Health Education (under CHEP) a single Funding Notification (FN) letter is issued covering each year of the full contract term. Subsequent FN letters are only issued if there is an annual change in funding.

Due to the FY16-17 CODB adjustment (resulting from the higher baseline), modification letters are currently being prepared to reflect CODB increases, along with any other changes to the funding allocation since it was last established.

Some FY16-17 FN letters have already been sent; however, many of these will need to be reissued to reflect the slight change to the FY16-17 CODB allocation, based on the new baseline.


Funding Notification Letters Update

BHS is in the process of issuing Funding Notification letters. BHS letters are issued

annually, reflecting annual amounts only.

BHS Funding Notification letters will be going out in the following order (if they

haven’t been sent already):

“New” services (e.g. post RFP) effective July 1

Contracts with No Funding Changes

Contracts to add the FY16-17 Cost of Doing Business (CODB) funding

Contracts with funding changes, but no contract negotiation

Contracts with contract negotiations

It is strongly requested that all agencies adhere to the timeline and submit contract

documents per the deadline indicated on the FN letter.

Funding change requests following the initial contract document submission will be

added via a contract modification, once the original submission is certified.


40

Requesting Contract Funding Changes Reminder

To add funding, or to move funding around within a contract, the process for an

agency to initiate the request is summarized below:

CDTA Website: www.sfdph.org/cdta

Form Use Submit To Available

1 Contract Change

Request Form

To request

approval for

programmatic or

budget changes

CDTA Manager

(who will provide

to SOC Manager

for approval)

CDTA Website:

Procedures and

Guidelines

2 Contract Budget

Revision Request

Form and Written

Justification

For a budget

revision to move

funding within

the existing line

items

CDTA Manager

(who will provide

to SOC Manager

for approval)

CDTA Website:

Procedures and

Guidelines

(coming soon)


41

Contract Funding Revision Update

To complete initial contract certifications in a timely manner, i.e. without interrupting the process

to incorporate changes based on revised FY16-17 Funding Notifications (FN), the Budget Unit

is going to bundle funding change requests and issue revised Funding Notifications on a

quarterly basis, rather than each time a change is requested. The schedule for reissuing FY16-

17 Funding Notifications is the following:

Agency

Action

DPH System of Care (SOC) Manager

Action

Bundled Deadline Due

Dates for Funding

Notification Reissuance

Submit Contract

Change Request

Form(s) to CDTA

Manager, detailing

requested contract

revisions

Submit Request for Contract Funding Notification

Form (including the information completed by the

Contract Office) to Business Office Budget Unit,

detailing approved contract revisions for inclusion

in revised FN Letter

(Note: sometimes the SOC, and not the Agency

will initiate the change)

(1) 9/30/16 (for October

FN Reissuance)

(2) 12/31/16 (for January

FN Reissuance)

(3) 3/31/17 (for April FN

Reissuance)

Exceptions For new contracts, or contracts requiring a formal modification, (i.e. increases

beyond the Contingency), and therefore approval by the Office of Contract

Administration, funding notifications will be reissued upon receipt of the Request

for Contract Funding Notification form.


42

Fact Sheets

The Budget Unit is in the process of doing two activities: (1)

reviewing existing procedures impacting the Budget Unit’s review

and approval of Appendix B, with the goal of simplifying,

reducing or revising to address issues and/or confusion, and (2)

documenting via Fact Sheets, information to help clarify and

explain the most common areas of confusion or questions.

Fact Sheet Handouts

Indirect Costs

Rent, Mortgage, and Depreciation

Food


43

Training on Invoice Procedures and the Invoice Manual

Invoice Procedures Manual Training Date

Monday, July 25, 2016


44

Budget Office


45

Shirley Giang, Director 255-3416 [email protected]

Deanna Chan 255-3768 [email protected]

Winnie Chen 255-3921 [email protected]

John Fordham 255-3530 [email protected]

Mimi Fung 255-3416 [email protected]

Aida Galino 255-3909 [email protected]

Ethan George (HUH) 554-2561 [email protected]

Nick Hancock 255-3776 [email protected]

Jessica Huang 255-3702 [email protected]

Judy Ng (HUH) 554-2761 [email protected]

Joshua Nossiter (MCAH) 558-4037 [email protected]

Judy Perillo 255-3451 [email protected]

Annie Salcedo 255-3498 [email protected]

Sajid Shaikh 255-3512 [email protected]

Questions?46


Jacquie HaleDirector, Office of Contract Management & Compliance

Office of Contract Management & Compliance47


What’s New in FY16-17?

48


New Citywide Contract Boiler Plate

Version P-600 (replaces P-500)

As of January 1, 2016 all new Professional Service Contracts will use a new boilerplate template referred to as “P-600.”

“New contract” includes brand new services or the continuation of the same services following a new RFP.

Annual renewals within an approved term (e.g., Year 3 of a 5-year term) will continue under the current boilerplate template version

New requirements (clauses) from the P-600 will be added to an ongoing P-500 by the Contracts Office Analyst.

Key highlights:

The template uses 12 Articles covering topic areas rather than 64 Sections covering each specific topic

Subcontractors must be listed in the body of the boilerplate.

Grant terms may be required to be incorporated into the contract itself.

Non-friendly automatic numbering.


49

“New” Requests You May Receive from the

Contracts Office Staff

The City’s Office of Contract Administration (OCA) reviews DPH contracts for completeness,

including forms to prove that the Department has complied with various City requirements.

OCA approval is required to achieve contract certification and enable payments. These are

some items you may be asked to provide to the Contracts Office which have emerged as OCA

deal breakers:

CMD Form 10 and Form 2A: If your General Fund monies are increasing by more than

20% percent from your current total contract amount shown in the Compensation language

of your contract (total combined funding for all years of the contract term), then you will

be asked by your Contract Analyst to complete, sign and return these forms. There is a

10 day waiting period once these are submitted, so it is important to respond ASAP.

DUNS Number: Your agency’s DUNS (Data Universal Numbering System) number is

required by Federal funding agencies for all recipients of Federal awards. It is also

required for all sub-recipients receiving funds directly from those recipients. The DUNS

number must be renewed annually.

US SAM Printout: A printout of your DUNS number must be submitted to OCA. DPH will do

this for grants, but if your funding is “generically” Federal, you may be asked to provide

the SAM (System of Award Management) print-out. DPH getting this clarified, but in the

meantime, it is faster to comply…..


50

Don’t Forget

RENEW YOUR INSURANCE: It is very important that agencies submit proof

of all required insurance, with valid terms (i.e., not almost about to expire).

Your contract will not be processed outside of DPH without meeting these

two requirements.

If your insurance expires while your contract is under review at OCA during

the certification process, OCA will reject it and that will add at least a week

to the process and delay your payment.

FIDELITY BOND or EMPLOYEE DISHONESTY Coverage: If your agency

receives a 25% advance, you will not receive the full 25% value unless you

have fidelity bond coverage equal to or greater than the 25% value.

Use the Contract Checklist to assist you as you prepare your contract

documents – it is located in the CDTA Website.


51

FY16-17 RFP’s

We plan to issue a draft schedule for FY16-17

anticipated RFPs by the end of August.

Our goal is to complete scheduled RFPs in FY16-17,

since many contracts have been extended through

12/31/17.

RFP planning is underway so there will be more

information as plans progress.


52

DPH Office of Contract Management & Compliance (“Contracts Office”)

53

• Jacquie Hale, Director 554-2609 [email protected]

Stephanie Hon 554-2881 [email protected]

• Irene Carmona 554-2652 [email protected]

Kristine Ly 554-2778 [email protected]

William Gaitan 554-2843 [email protected]

• Yvonne Eckhoff 255-3492 [email protected]

David Folmar 255-3491 [email protected]

Luciana Garcia 255-3518 [email protected]

Mahlet Girma 255-3504 [email protected]

Ada Ling 255-3493 [email protected]

Carolyn McKenney (on leave until 12/31/16) 255-3508 [email protected]

Brenda Mendieta (retiring June 30, 2016) 255-3490 [email protected]

• Robert Longhitano 554-2659 [email protected]

Florence Kyaun 554-2694 [email protected]

Arlene Lee 554-2938 [email protected]

Jonathan Lyens 554-2886 [email protected]

Ron Rossi 554-2839 [email protected]


Questions?54


Remember…

Use the Contract Checklist to assist you as you

prepare your documents

Your comments on today’s presentation are

appreciated. Please take the survey:


55

Thank you…

For promptly completing and returning your

contract documents

For your valuable contributions to the health of the

San Francisco community

For attending today’s meeting!



Office of Compliance & Privacy Affairs

Presentation at CDTA Meeting

June 30, 20161

Breach & Fraudulent Activity Reporting

Immediately report:

Any incident that could be conceived as a privacy

breach

Any observation (by you or your employee)

perceived to be non-compliance with billing,

coding, and documentation regulations

Any observation (by you or your employee)

perceived to be a potential Fraud, Abuse and

Waste OR Misuse of DPH and/or City resources

Call the Privacy Hotline number (855) 729-60402

Taking PHI Off-Site

OBTAIN APPROVAL from your supervisor

ONLY SAVE PHI to an encrypted device (laptop,

thumb drive/USB, handheld, etc.).

KEEP the paper document and/or device on your

person and in your possession at all times

DELETE and DESTROY PHI from the encrypted

device as soon as the objective is accomplished

3

Other Contractual Requirements

Designate Officers for Privacy, Data

Security and Compliance

Attest agency is compliant with

regulations

Have subcontractor BAAs in place if

they handle PHI

4

Staff Transitions

Prompt Notification to DPH of Staff Changes

Before new staff see clients

As soon as staff leave (call the Help Desk

at 415-759-3577

On-boarding & ANNUALLY

Privacy and Compliance Training

Electronically sign User Agreement

Electronically Sign Code of Conduct5

What’s New for FY1617

Ransoms / Fines / Lawsuits

Preparation for HIPAA Audits

Desk audits

Breach handling

Business Associate Agreements

Live training for CBO Privacy/ Compliance/

Security Officers

Redesign of online training modules

60 day repayment rule6

SFDPH Office of Compliance and

Privacy Affairs

We’re here to help!

Call us at (855) 729-6040 or email at

[email protected]

Consultation on privacy issues and possible exceptions

on attestations

Confidential Whistleblower complaints

Assist with access to DPH on-line Privacy & Data

Security and Compliance Training7

SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTHCOMPLIANCE AND PRIVACY

ANONYMOUS AND CONFIDENTIAL HOTLINE

1-855-729-6040or

[email protected]

What should be reported: ■ Privacy breaches (report immediately) ■ Non-compliance with billing, coding, and documentation regulations ■ Issues regarding Code of Conduct or Compliance with DPH Policies ■ Suspected Health Care Fraud, Abuse and Waste ■ Theft or Misuse of DPH and/or City resources ■ Conflict of interest ■ Misconduct: Research/Scientific, Workplace Harassment ■ Retaliation against the informant

Reporting Options: ■ Your supervisor/manager ■ Your designated Compliance or Privacy Officer ■ DPH Office of Compliance & Privacy Affairs Toll-Free Hotline: 855-729-6040 OR

[email protected] ■ Controller’s Office Whistleblower Program, City and County of San Francisco:

415-701-2311 OR [email protected] OR you may file online at www.sfgov.org\whistleblower

SFDPH has a strict non-retaliation policy!Your Privacy/Compliance Officer & Contact Info:

Office of Compliance and Privacy Affairs, San Francisco Department of Public Health 101 Grove Street, Room 330, San Francisco, CA 94102

Office email: [email protected] – Office telephone: 415-554-2787 Confidential Compliance and Privacy Hotline: 1-855-729-6040 toll-free

City and County of San Francisco

Edwin M. Lee, Mayor


Office of Compliance and Privacy Affairs

DPH Business Ethics and Best Practices October 12, 2015

If you must take or create PHI offsite…please read this: According to a study in the Journal of the American Medical Association, there were nearly 1,000 large data breaches reported nationally between 2010 and 2013 that affected more than 29 million individual health records. Researchers noted that more than 50% of the breaches resulted from loss or theft of laptops, paper records and thumb drives/USBs. Since January of 2015 alone, SFDPH has had 5 reported incidents where PHI was left unattended and stolen from an employee’s vehicle. As a result, a total of 440 patients and clients had to be notified that their protected health information was exposed. Please note that downloading, creating or transferring Protected Health Information (PHI) off a DPH worksite should be the rare exception. However, if your work at DPH requires you to download, create, or transfer PHI offsite, you must ALWAYS: 1. OBTAIN APPROVAL from your supervisor. If supervisors are unsure about approving your staff’s need to

download, create, or transfer PHI offsite, please contact the Office of Compliance and Privacy Affairs at 855-729-6040 or [email protected]. (Contractor staff should contact your Privacy Officer.)

2. ONLY SAVE this PHI to an encrypted device (laptop, thumb drive/USB, handheld, etc.). If you are unsure whether or not your device is encrypted, please contact the DPH Help Desk at 415-759-3577 and request security assessment of device in question. (Contractor staff should contact your Data Security Officer.)

3. KEEP the paper document and/or device on your person and in your possession at all times. Do NOT leave the device unattended at any time while in transit…not even for one minute.

4. DELETE and DESTROY PHI from the encrypted device as soon as the objective is accomplished. Double-delete by first deleting, then emptying your trash bin.

Please hold your patients’ health information as precious as you hold your patients’ health. It’s important.



Office of Compliance and Privacy Affairs, San Francisco Department of Public Health 101 Grove Street, Room 330, San Francisco, CA 94102

Office email: [email protected] – Office telephone: 415-554-2787 Confidential Compliance and Privacy Hotline: 1-855-729-6040 toll-free

Calls may be made confidentially and anonymously – Always remember: SFDPH has a non-retaliation policy

City and County of San Francisco Edwin M. Lee, Mayor


Office of Compliance and Privacy Affairs

DPH Business Ethics and Best Practices April 6, 2016 Supervisor/Manager Responsibilities

Immediately Report These Concerns:

Supervisors/Managers are key members of the Department’s compliance program and through leadership helps the department achieve ethical business practices and a healthy workplace. Identify any privacy or compliance risks within your own area of responsibility. Be proactive, conduct

routine internal audits, and monitor coding/billing practice in your program. Do not ignore or dismiss

any allegation or concern reported to you.

The following scenarios should be reported immediately:

Compliance and Privacy Matters: Immediately report any incident that could be conceived as a privacy breach

Immediately report any observation (by you or your employee) perceived to be non-compliance

with billing, coding, and documentation regulations

Immediately report any observation (by you or your employee) perceived to be a potential

Fraud, Abuse and Waste OR Misuse of DPH and/or City resources

Immediately report allegations of any of the above to:

Your designated privacy officer,

Your designated compliance officer, or

The DPH Office of Compliance and Privacy Affairs at 855-729-6040 or

[email protected]

Remember: Calls to the hotline may be made confidentially and anonymously (available 24 hours, 7 days a week). And remember, SFDPH has a strict Non-Retaliation Policy.


Documents

WHAT’S NEW FY 2016-17 - SFDPH · Debra Solomon, Director 255-3471 [email protected] Reanna Albert 255-3697 [email protected] Marshia Herring 255-3752 [email protected]