General Information

Each Associate, including employees, directors, officers and contractors, is responsible for acting in accordance with all laws and regulations of local, state and federal agencies and the various accreditation and licensing organizations that apply to EMH and/or the individual’s profession.

Each Associate shall carry out his/her job responsibilities in an ethical, effective, and professional manner.

Each Associate is responsible for initiating/maintaining education regarding his/her role and responsibilities for complying with EMH’s Corporate Compliance program.

Each Associate is responsible for adhering to all organizational and departmental policies and procedures to ensure that corporate compliance is carried out as intended.

Each Associate is responsible for understanding EMH’s corporate culture, values and ethical code of conduct and how the Associate is empowered to use it.

Each Associate is responsible for reporting potential compliance violations to his or her direct supervisor, any Director, any member of the Senior Leadership Team, the Corporate Compliance Officer, the Compliance Hotline or other means that may be established for such reports.  No Associate will ever be penalized or suffer retaliation for raising a good faith issue or concern.

Click here to view the Ephraim McDowell Health Code of Conduct.

Our Corporate Compliance Officer is Tammy Meade Ensslin.  She can be contacted by calling (859) 239-2347 or emailing

Reporting of corporate compliance matters can be done 24 hours a day by visiting or calling the Complaint Hotline at 1.866.913.0280.

Joint Commission Public Notice

The Joint Commission may conduct an unannounced accreditation survey of Ephraim McDowell Regional Medical Center, Ephraim McDowell Fort Logan Hospital and Ephraim McDowell James B. Haggin Hospital at any time. The purpose of the survey is to evaluate the organization’s compliance with nationally established Joint Commission standards. The survey results will be used to determine whether, and the conditions under which, accreditation should be awarded the organization.

Joint Commission standards deal with organizational quality of care and safety of the environment in which care is provided. Anyone believing that he or she has pertinent and valid information about such matters may contact the hospital’s management. If the concerns cannot be resolved through the hospital, an individual may contact The Joint Commission by emailing

The Joint Commission will acknowledge comments in writing or by telephone and will inform the organization of any comments received.

Deficit Reduction Act of 2005

Ephraim McDowell Health shall ensure that all Associates are made aware of the federal and state false claims statutes enacted to prevent and detect fraud, waste and abuse in federally or state funded healthcare programs as required by the Deficit Reduction Act of 2005.

i.          False Claims Act (31 U.S.C. § 3729–3733):
Simply stated, the False Claims Act (“FCA”) imposes liability on any person or entity that submits or causes to be submitted a claim to the federal government for payment that he/she knows (or should know) is false or fraudulent.  The FCA, enacted during the Civil War to combat fraud in the provisioning of federal troops, has been greatly expanded since 1865 and is actively used to combat fraud and abuse in government funded programs, including healthcare.

The following are examples of false and/or fraudulent claims:

  • Billing for services or items that were not actually provided;
  • Upon obtaining money from the federal government to which the individual is not entitled, using false statements or records in order to retain the money (a so-called “reverse false claim”).
  • Making inaccurate, false or improper entries in medical records, cost reports and any other records used to support reimbursement;
  • Billing for services that were not medically necessary or for services that fail to meet professionally recognized standards for health care;
  • Billing for a non-covered service or characterizing a non-covered service, item or cost in a way that leads to reimbursement from a government program;
  • Using a code to bill for a higher level of service or procedure, causing an increase in the reimbursement rate, when the medical record reflects that a lower level of service or procedure was actually provided to the patient (known as “up-coding”);
  • Billing separately for each component of a group of procedures that are commonly used together and for which Medicare and/or Medicaid provide a special “bundled” reimbursement rate (“Unbundling”);
  • Billing more than once for the same service or item;
  • Charging rates in excess of established Medicare or Medicaid rates;
  • Failing to seek payment from beneficiaries who may have other primary payment sources;
  • Participating in kickbacks, bribes or rebates in exchange for referring goods, facilities, services or items that are reimbursed by government programs;
  • Repeatedly violating the terms of any applicable federal participation agreements.

Violating the FCA can result in civil fines equal to three times the government’s damages, penalties ranging from $5,500 to $11,000 per false claim, and reimbursement of the government’s costs to pursue the violator.  In addition, the FCA contains a qui tam relator (“Whistleblower”) provision that empowers private citizens to bring suit on behalf of the government against any person or business that has made a false claim or committed fraud.  Whistleblowers, usually current or former employees of the violator, are rewarded for exposing and reporting fraud by a bounty provided by the government in an amount of between 20% and 30% of any recovery.  Whistleblowers are protected under the FCA from retaliatory acts such as firing, demotion, or denial of benefits, for investigating, filing, or participating in a whistleblower action.

ii.         Kentucky Fraud and Abuse Control Laws:  The Commonwealth of Kentucky has enacted correlating statutes under its fraud and abuse control laws (“FAC”).  The FAC are generally applicable Medicaid anti-fraud statutes that make it unlawful for a person to submit or cause to be submitted false and fraudulent claims to the Kentucky Medicaid program.  Most, if not all, of those actions that would trigger liability under the FCA would trigger liability under the FAC.  Violations of the FAC are both civil and criminal offenses and are punishable by fines and imprisonment.  While the FAC does not contain a Whistleblower provision, Kentucky law nonetheless requires any person who knows or has reasonable cause to believe that a violation of the Kentucky false claims laws has been or is being committed by any person, corporation or entity, to report the information to the proper authorities.   As with the FCA, the FAC prohibits retaliation against any individual for investigating and reporting any suspected violations.

iii.         Reporting Concerns: Ephraim McDowell Health is committed to its mission of providing quality healthcare in compliance with all state and federal laws, including all applicable false claims law.  Ephraim McDowell Health encourages all Associates to be aware of the laws regarding false and fraudulent claims and to report concerns to their immediate supervisor when appropriate.  If the supervisor is not the appropriate contact or if the supervisor fails to respond quickly and appropriately to the concern, then the Associate should report the concern to the Corporate Compliance Officer, Administration or another Department Director or call Ephraim McDowell Health’s Corporate Compliance Hotline at 1-866-913-0280.

Clinical Laboratory Improvement Amendments (CLIA) Procedures for Complaint Reporting

Congress passed the Clinical Laboratory Improvement Amendments (CLIA) in 1988 establishing quality standards for all laboratory testing to ensure the accuracy, reliability and timeliness of patient test results regardless of where the test was performed. In this section you will find information regarding your right to express concerns you may have regarding a laboratory’s operations.

A complaint is any concern that you may have about a laboratory’s operation. Some of the most common complaints involve quality of testing, unlabeled specimens, unethical practices, e.g. record falsification, proficiency testing cheating, confidentiality of patient information, and laboratory personnel qualification or responsibility issue. Anyone can report a complaint. Complaints can be reported by patients, the relative of patient, the general public, physicians and any personnel working in a laboratory.

Should you have a complaint, please complete our Contact Form.

You may also contact:

Centers for Medicare & Medicaid Services
Atlanta Federal Center
61 Forsyth Street, SW, Suite 4T20
Atlanta, Georgia 30303


Cabinet for Health and Family Services
Office of the Secretary
275 E. Main Street
Frankfort, Kentucky 40621

When reporting a complaint, please provide as much and as detailed information as possible. Information that will facilitate the resolution of your complaint includes:

  • Name and address of laboratory
  • Who has been affected or involved
  • Complete description of your concern
  • Date(s) & time(s) of the incident(s)
  • Frequency and pervasiveness of issue
  • Name of other agencies you have contacted
  • Your name, address and telephone number

Anonymous complaints will also be accepted. Every complaint is documented and investigated. If you have provided contact information, you will receive a written acknowledgement that the complaint is being investigated. Once the investigation is complete, you will be notified of the outcome.