I. Overview of Compliance Plan
Adult Resources Center, Inc. has adopted this Compliance Plan in order to serve its Individuals as well as any and all third parties in accordance with the law as well as with the highest of ethical standards. The effectiveness of this Compliance Plan hinges on the active participation of all Board members, personnel, and independent contractors in preventing, detecting, and appropriately responding to fraud, abuse or other misconduct.
This Compliance Program is designed to promote Adult Resources Center, Inc.'s compliance with all applicable federal, State and local laws and regulations as well as government contracts and conditions of public support programs.
This plan is a long term commitment to conduct business in ways that promote "doing the right thing". The plan will be continually monitored to make sure that the "right thing" is being done and responding to changes and problems that are identified along the way.
There are many benefits to Adult Resources Center, Inc.'s Compliance Plan including but not limited to:
- Finding "weaknesses" before audit-Early Detection
- Promoting ethical conduct
- Communicating the Adult Resources Center, Inc.'s commitment to regulatory compliance
- Educating Staff (Whistleblower lawsuit protection)
- Drives for more efficient and effective operations
- Improves the financial health of the agency
- Defends the organization; may mitigate fines and paybacks
All Adult Resources Center, Inc. personnel and contractors have the obligation to assist in making the Compliance Plan successful. Personnel are expected to:
- Read and familiarize themselves with Adult Resources Center, Inc.'s Code of Conduct and compliance procedures
- Review and understand the key policies governing their particular job functions
- Report any fraud, abuse or other improper activity through mechanisms established under the Compliance Plan
- Cooperate in all Adult Resources Center, Inc. audits and investigations
- Carry out their jobs in a manner that demonstrates a commitment to honesty, integrity and compliance with the law.
II. Elements of the Compliance Program
The Adult Resources Center, Inc. Compliance Program is based on compliance guidelines provided by the United States Department of Health and Human Services Office of the Inspector General and the requirements imposed on health care providers under Section 363-d of the New York Social Services Law.
The key elements of the Compliance Program, which are discussed in greater detail within the Compliance Plan are:
- Written Policies and Procedures (Entire Compliance Plan)
- Compliance Program Oversight (Section VI)
- Education and Training (Section VII)
- Effective, Confidential Communications (Section VIII)
- Enforcement of Compliance Standards (Section IX)
- Auditing and Monitoring (Section X)
- Responding to Offenses & Developing a Corrective Action Plan (Section XI)
- Whistleblower Protections & Non-Intimidation/Non-Retaliation (Section XII)
The following are the definitions for the terms as used in the Compliance Plan:
Actions that do not involve intentional misrepresentations of fact, but nevertheless are inconsistent with sound financial, business, or healthcare practices and create significant risk to the integrity of the organization such as 1) unnecessary cost to the programs,
2) reimbursement for services that are not medically necessary, or 3) reimbursement for services that fail to meet professionally recognized standards of care.
Any person or business that acts as a representative of or has the authority to act for or on behalf of Adult Resources Center, Inc..
The federal statute, as it relates to healthcare, which prohibits anyone from knowingly and willfully soliciting, receiving, offering, or paying any remuneration directly or indirectly, in cash or in kind, in exchange for services or purchases for which payment may be made by Medicare and/or Medicaid.
The process of utilizing a medical classification system to assign a numeric code to diagnostic and procedural data.
A group of people designated and chaired by the Compliance Officer to oversee and help administer this Compliance Plan.
The person within the organization who is assigned the responsibility of maintaining and overseeing an effective Compliance Plan.
Compliance Plan ("Plan"):
This plan which establishes the standards of conduct for ARC designed to promote honest and ethical behavior, which also provides a structure for educating and communicating those standards to employees, management, and Board members with the overall objective to prevent, detect, and report significant noncompliance to the best of anyone's abilities.
Federal False Claims Act:
A federal law that imposes liability on any person who submits a claim to the federal government that he or she knows (or should know) is false. The False Claims Act also imposes liability on an individual who may knowingly submit a false record in order to obtain payment from the government. The third area of liability includes those instances in which someone may obtain money from the federal government to which he may not be entitled, and then uses false statements or records in order to retain the money. The Act provides that private parties may bring an action on behalf of the United States. These private parties are known as "qui tam relators."
Medicare, Medicaid and any other programs funded by the federal government.
Intentional misrepresentation designed to induce reliance by another person to obtain unauthorized benefit.
Agencies involved in health care investigations include, but are not limited to, the United States Department of Health and Human Services' Office of Inspector General, United States Department of Justice, Federal Bureau of Investigation, Centers for Medicaid and Medicare Services, New York State Department of Health, Office of the Medicaid Inspector General, New York State Medicaid Fraud Control Units, and New York State Office of Mental Retardation and Developmental Disabilities.
A federal law titled "Health Insurance Portability and Accountability Act". Regulations issued under HIPAA protect the privacy of health information and identifying information for all Americans. HIPAA went into effect on April 14, 2003.
Any vendor, physician, dentist, therapist, psychologist, social worker, nursing staff member, dietician, volunteer, agent or other person who is empowered by contract or otherwise to provide health-related services on behalf of ARC.
To act "knowingly" is to act with actual knowledge, deliberate ignorance, or a reckless disregard for the truth or the falsity of information.
Any action, behavior or failure to act that is not in conformity with Adult Resources Center, Inc. standards, guidelines, or procedures or that is a violation of any federal, state or local law or regulation.
Exhibiting lack of due care or concern.
New York State False Claims Act:
Closely tracts the federal False Claims Act. It imposes penalties and fines on individuals and entities that file false or fraudulent claims for payment from any state or local government, including healthcare programs such as Medicaid.
Failure or refusal to act in accordance with this Compliance Plan, or other standards or procedures, or with federal, state or local laws or regulations.
Private Payor Programs:
Any payor of healthcare services other than Medicare or Medicaid, including but not limited to private individuals and insurance plans.
Qui Tam Relator:
Individuals who bring an action on behalf of the United States under the federal False Claims Act or on behalf of New York State under the New York State False Claims Act. Qui Tam Relators may share in a percentage of the proceeds from the False Claims Act action or settlement. These individuals are also known as "whistleblowers".
Any action that constitutes any of the definitions of fraud or abuse or are a violation of a federal, state or local law or regulation.
Medicaid or any other program funded in whole or part by New York State.
Unnecessary expenditures or to use carelessly.
Same definition as above for Qui Tam Relator
Protection provided under the federal law and the State False Claims Act to whistleblowers or qui tam relators who are discharged, demoted, suspended, threatened, harassed, or in any manner discriminated against in the terms and conditions of their employment as a result of their furtherance of an action under the federal law or the State False Claims Act.
IV. Healthcare Laws and Statement of Policy
The following are descriptions of some of the major federal statutes specifically applicable to healthcare providers. This listing is not intended to identify all of the applicable laws. Employees, independent contractors, agents and vendors should promptly consult the Compliance Officer with specific questions.
The federal Anti-Kickback statute prohibits any person from knowingly and willfully soliciting, receiving, offering or paying anything of value to another person in return for the referral of a patient, or in return for the purchasing, leasing, ordering, or arranging for any item or service, reimbursed by a federal health care program such as Medicare or Medicaid (42 U.S.C. 1310a-7b). Penalties for violating the statute include imprisonment, criminal fines, exclusion from government health care programs and civil monetary penalties. A similar New York state law prohibits the exchange of remuneration for referrals for items or services covered by the state's Medicaid program (N.Y. Social Services Law 366-d)
Statement of Policy:
Prohibition on Exchange of Remuneration for Client Referrals:
Personnel are prohibited from 1) offering or paying anything of value, whether in cash or in kind, to another party in return for the referral of a client to Adult Resources Center, Inc. Likewise, personnel are prohibited from 2) soliciting or receiving anything of value, whether in case or in kind, from another party in return for the referral of a person served by Adult Resources Center, Inc. to another health care provider.
The following are examples of conduct that violates this policy, but violations are not limited to, the following:
- An employee accepts free meals or tickets to an event from a doctor in which Adult Resources Center, Inc. refers persons served for medical care.
- Adult Resources Center, Inc. leases space to a medical clinic that receives client referrals from Adult Resources Center, Inc. at a rent greater than fair market value.
- Adult Resources Center, Inc. receives free equipment or services from a laboratory in which Adult Resources Center, Inc. orders laboratory tests.
Personnel should refer clients for medical care to other providers based solely on the medical needs of the client and in accordance with Adult Resources Center, Inc. policies and procedures.
Acceptance of Gifts from Vendors:
The acceptance of gifts from vendors or prospective vendors of Adult Resources Center, Inc. may constitute an improper kickback under state and federal law. Accordingly, personnel may not solicit or receive any such gifts except what is permitted under Adult Resources Center, Inc. policies and procedures.
Structuring Business Agreements to Comply with Safe Harbors:
Certain common business arrangements between parties exchanging referrals may be structured to fit within "safe harbors" to the anti-kickback statute. Complying with a safe harbor ensures that no portion of the compensation flowing under the arrangement may be characterized as an improper inducement for referrals.
The Anti-kickback statute is complex and Adult Resources Center, Inc. expects that there may be questions that arise for a particular activity or arrangement. Personnel are encouraged to ask their supervisors for any guidance and if necessary may contact the Compliance Officer for assistance.
Enforcement of Policy:
Personnel who do not comply with this policy will be subject to disciplinary action by Adult Resources Center, Inc. Depending upon the facts and the circumstances of each case, Adult Resources Center, Inc. may reprimand, suspend or dismiss any employee who fails to comply with this policy.
False Claims Act:
The False Claims Act is violated if a person knowingly makes, uses or causes to be made or used, a false record statement to get a false or fraudulent claim paid or approved by the federal government. (31 U.S.C. 3729) The potential penalties for violating the False Claims Act include treble damages (damages equal to three times the amount of the false claims), civil penalties of up to $11,000 per claim and exclusion from federal health care programs. In addition, the federal government may impose administrative sanctions of up to $5,500 plus twice the amount of the false claim under the Federal Program Civil Remedies Act of 1986 (31 U.S.C. 3801)
Several New York State laws also prohibit the making of false claims and statements. Criminal penalties may be imposed for knowingly making a false entry into a business record or filing a false document with a government agency (Article 175 of the Penal Law), committing a fraudulent insurance act (Article 176 of the Penal Law) or engaging in health care fraud (Article 177 of the Penal Law).
Statement of Policy:
Types of Conduct Implicating the False Claims Act:
- Submitting claims to the Medicaid program for services not actually rendered or for which Adult Resources Center, Inc. is not otherwise entitled to reimbursement.
- Submitting cost reports to Medicaid that are inaccurate or incomplete
- Assisting another healthcare provider in improperly billing Medicaid for health services for which Adult Resources Center, Inc. is obligated to pay
- Failing to bill Medicare or a private insurer as the primary payor to submitting a claim to the Medicaid program.
The list above is a sample of some items and is not all - inclusive. All personnel and independent contractors are strictly prohibited from engaging in any conduct that violates the False Claims Act. There can be criminal as well as civil and administrative penalties for violations of this Act.
Reporting of False Claims Violations by Employees:
Personnel are expected to report to Medicaid or any other federal healthcare program any claim or report that appears to be fraudulent or false as well as any conduct that appears to violate the False Claims Act. Any of the mechanisms that have been described are acceptable. All reports received from employees will be evaluated and investigated as necessary pursuant to this policy.
Personnel have the legal right to file qui tam lawsuits if they become aware that Adult Resources Center, Inc. has submitted claims for reimbursement to Medicaid or other government programs in violation of the False Claims Act. In a qui tam lawsuit, the employee "relator," files the cause under seal and requests that the federal government intervene and take over the prosecution of the matter. The "relator" may receive a portion of the funds if there is a government recovery. Adult Resources Center, Inc. will not impede any employee from filing a qui tam lawsuit by threats of retaliation or otherwise.
However, all employees are encouraged to report and attempt to resolve any False Claims violations through the internal procedures established by Adult Resources Center, Inc. prior to filing such case.
Personnel and Contractor Education:
Adult Resources Center, Inc. provides training to employees under the Personnel training guidelines. This training will include a component addressing the False Claims Act as well as State laws punishing the making of false claims or statements. Human Resources will work with the Compliance Officer to ensure that the Personnel Policies Handbook contains information on the False Claims Act and the State laws.
The Compliance Officer will ensure that there are periodic compliance audits conducted to cover the submission of accurate claims and cost reports to the Medicaid program, as well as any other activities deemed by the Compliance Officer to raise potential risks under the False Claims Act. The Compliance Officer will oversee the development and implementation of a corrective action plan to address any compliance identified through such audits.
Disclosure of False Claims:
Under the False Claims Act, Adult Resources Center, Inc. may avoid treble damages and civil penalties if it discloses to the relevant federal healthcare program any false or fraudulent claims, and makes appropriate restitution of any overpayments, within 30 days of discovery of the false claim. Accordingly, the Compliance Officer will promptly investigate all reports of potential False Claims Act violations to provide Adult Resources Center, Inc. with an opportunity to make disclosure and restitution within the 30-day period.
The False Claims Act is complex and Adult Resources Center, Inc. expects that there may be questions that arise for a particular activity or arrangement. Personnel are encouraged to ask their supervisors for any guidance and if necessary may contact the Compliance Officer for assistance.
Enforcement of Policy:
Personnel who do not comply with this policy will be subject to disciplinary action by Adult Resources Center, Inc. Depending upon the facts and the circumstances of each case, Adult Resources Center, Inc. may reprimand, suspend or dismiss any employee who fails to comply with this policy.
V. Corporate Compliance Policy
- Employees Code of Conduct
- Conflict of Interest Policy Statement
- Employee Conflict of Interest Policy (Amended)
- Exclusion Screening
Employees Code of Conduct
It is the expectation of Adult Resources Center, Inc. that all employees shall conduct themselves in a mature, professional manner at all times, whether in the program, on the facility or out in the community. The conduct and actions of every employee reflects on Adult Resources Center, Inc. and the people we serve. Our employees are the first line of contact with the program participants and we expect them to provide a suitable and satisfactory role model to emulate.
- All employees are to familiarize themselves with all program rules and guidelines relative to fire drill procedures and emergency procedures so as to be able to respond to any situation without hesitation.
- Employees shall not distribute, sell, possess, purchase or consume illegal substances while at the work place or while performing in a work related capacity.
- Employees shall not come to work, or be permitted to work if their ability to perform their job is impaired due to the use of alcohol, a controlled substance, or a prescribed substance.
- Individuals receiving services at the facility shall not be made to carry out the duties or to take the place of the employees unless such tasks are described in his or her plan or services by the program planning team for the purpose of increasing the person's skills or as deemed appropriate.
- Individuals receiving services at any program site shall not be subject to inappropriate exposure to firearms or other weapons in or on the grounds of the facility.
- There shall be no financial transactions between employees and persons receiving services; which may be constructed as exploitation of that person or result in greater benefit to the employee than the person.
- Ethical standards of professional conduct will be recognized as applying in all program facilities. Personnel will be held responsible for becoming familiar with their own professional standards and conforming to them.
- Employees shall treat all individuals' information as confidential and utilize such information in a professional manner at all times.
- Use of inappropriate or profane language is strictly prohibited.
- No employee is to ever threaten an individual with discharge or restriction. Any ongoing problems should be discussed with your immediate supervisor or may be brought to a program administration.
- There should be no discriminatory actions taken against individuals or employees for any reason, including, but not limited to race, religion, national origin, creed, sex, age, sexual orientation, developmental disability or other handicapping conditions.
Conflict of Interest Policy Statement
Adult Resources Center, Inc. policy regarding Conflict of Interest is that no employee or Board member of Adult Resources Center, Inc. shall benefit by the actions of the Board or the Management of Adult Resources Center, Inc..
For employees, in the event that circumstances arise that best meet the needs of the Individuals through the purchase of goods or services from a firm in some way connected to the employee, this should be made clear to the management of Adult Resources Center, Inc..
For Board members, in the event that circumstances arise that best meet the needs of the consumers through the purchase of goods or services from a firm in some way connected to the Board member, this would be made clear to the Board of Directors prior to a vote. The person with the potential conflict should abstain from being present during the discussion as well as voting on the issue
See Form A-1 and A-2 attached to be completed by the Board of Directors members as well as the employees on an annual basis.
If the Executive Director's wife is the CFO of a paper supply company that Adult Resources Center, Inc. may include in the bidding to select as the company to supply the agency with paper goods the Executive Director should note this on the Conflict of Interest Policy.
If a Board member has a child in one of the residences and there is an issue that arises with the child and there may be any type of action taken the member should exclude themselves from the conversation and abstain from any vote that is taken.
Employee Conflict of Interest Policy
Purpose of Policy
The purpose of this policy is to protect the interest of the Adult Resources Center when it is contemplating entering into a Transaction (as defined below) that might, directly or indirectly, benefit the private or outside interests of one of the Adult Resources Center employees. This policy is also designed to ensure that any outside activities of employees do not conflict with their duty of loyalty to the Adult Resources Center.
The Adult Resources Center makes business decisions impartially, fairly and without favoritism, for the purpose of advancing the Adult Resources Center's mission and interests. All employees must conduct themselves in a way that avoids conflicts of interest and protects the Adult Resources Center's resources as well as its reputation for fair and ethical business conduct. No Transaction between the Adult Resources Center and any vendor or other outside party shall be influenced, or appear to be influenced, by an employee's personal interest or relationships. Any personal or outside investments, relationships, transactions or interest, whether direct or indirect, that would or could have an adverse affect on the Adult Resources Center or an employee's prudent, objective and independent business judgment constitute an unacceptable conflict of interest and are prohibited.
The "Family" of an individual includes (i) such individual's parents, spouse, children, brothers and sisters, (ii) the parents, brothers and sisters of the individual's spouse and (iii) the spouses of the individual's parents, children, brothers and sisters.
Substantial Financial Interest:
A person has a "Substantial Financial Interest" in any corporation, firm, association or other entity if such a person receives compensation (i.e., wages, fees, other direct or indirect remuneration, gifts or favors that are substantial in nature, etc.) from or has, directly or indirectly, through business, investment or Family, an aggregate beneficial equity interest of 10 percent or more in such corporation, firm, association or other entity.
The term "Transaction" means any contract, investment, loan, lease, joint venture or other business or financial arrangement, whether direct or indirect.
Statement of Policy
Prohibited Activities Representing a Conflict of Interest
Personnel are prohibited from engaging in any of the following activities:
- Using their position with the Adult Resources Center to profit, directly or indirectly in any Transaction to which the Adult Resources Center is a party. This prohibition includes any involvement by an employee in negotiating, recommending, approving or otherwise influencing the terms of a Transaction between the Adult Resources Center and an entity in which the employee has a Substantial Financial Interest.
- Engaging in outside employment, self-employment or volunteer work that interferes with the performance of their duties for the Adult Resources Center, impairs their prudent and independent business judgment as an Adult Resources Center employee or otherwise conflicts with their obligations to the Adult Resources Center.
- Using or disclosing to a third party any non-public information obtained as a result of their employment for purposes unrelated to the performance if their duties as an Adult Resources Center for any purpose unrelated to the performance of their duties as an Adult Resources Center employee.
- Using any property, including but not limited to, intellectual property belonging to the Adult Resources Center for any purpose unrelated to the performance of their duties as an Adult Resources Center employee.
- Taking advantage of or otherwise acting upon, for their own personal benefit or the benefit or another party, any business, financial or other opportunity discovered in the course of their employment with the Adult Resources Center that is within the scope of the Adult Resources Center existing or contemplated operations unless (i) the opportunity is disclosed fully in writing to the Adult Resources Center's Board of Directors, (ii) the Board of Directors declines to pursue such opportunity within a reasonable time period and (iii) such opportunity does not otherwise result in a conflict of interest or otherwise violate the Adult Resources Center's policies.
Potential Conflicts of Interest Requiring Prior Approval
- Obtaining a Substantial Financial Interest in, or serving as a Director or Officer of, any entity with which the Adult Resources Center has conducted, or is contemplating the implementation of, a Transaction.
- Obtaining a Substantial Financial Interest in, or serving as a Director or Officer of, any competitor of the Adult Resources Center of the Adult Resources Center. The Compliance Officer shall provide guidance to personnel regarding the types of entities that are deemed competitors of the Adult Resources Center.
- Conducting business on behalf of the Adult Resources Center with a former Board Member, Officer or Personnel of the Adult Resources Center or an entity in which a former Board Member, Officer or Employee has a Substantial Financial Interest.
- Working as an Employee or contractor of any entity other than the Adult Resources Center including their own business, for more than (16) hours per week.
Reporting and Disclosure Requirements
In order for the Adult Resources Center to be able to monitor potential Conflicts of Interest, all personnel shall promptly report to the Compliance Officer any existing, proposed or potential Transaction of which they are aware that could represent a Conflict of interest under this policy.
The Adult Resources Center will request that certain personnel, including personnel responsible for purchasing goods or services on behalf of the Adult Resources Center complete a Disclosure Statement or an annual basis in order to identify actual or potential conflicts of Interest. The Compliance Officer will develop and maintain a list of job positions requiring completion of the Disclosure statement, and coordinate the dissemination and review thereof. Personnel required to complete the Disclosure Statement must do so in a truthful, complete and timely manner. (See Form #3)
Referral to Counsel
Questions regarding interpretation or application of this policy should be referred to the Adult Resources Center for clarification.
Enforcement of Policy
Personnel who do not comply with this policy will be subject to disciplinary action by the Adult Resources Center. Depending on the facts and circumstances of each case (and in compliance with any applicable collective bargaining agreements), the Adult Resources Center may reprimand, suspend or dismiss any employee who fails to comply with this policy.
Issued By: Francois Ledee
Date Issued: 5/14/12
Amendment to existing Conflict of Interest Policy
Corporate Compliance Policy
Exclusion (Sanction )Screening:
The purpose of this policy is to establish safeguards to prevent the employment of individuals who have engaged in fraud or other dishonest conduct. This policy should include current employees, new hires, independent contractors and vendors.
- Independent Contractors-There should be a Consistent, centralized exclusion screening process which is performed initially and then again on an annual basis. Each contract should include certification that the contractor has not been excluded from participation.
- Employees-This screening should be conducted as part of employment prescreening for ALL employees. This should be done on an annual basis and all results should be documented. This screening should include license/certification verification. No employee should be made an offer of employment either orally or in writing until this screening process is completed. If this is done any offer may be retracted.
The basic screening (per the policies and procedures of the agency should be performed)
LEIE and EPLS Screening:
An additional screening should be the List of Excluded Individuals and Entities (LEIE) and the Excluded Parties List System (EPLS). There is also a NYS Medicaid Fraud Database that should be checked. All employment application forms will require applicants for employment to indicate whether they have been excluded from participation in the Medicare or Medicaid program or otherwise disbarred by a federal health care program. Applicants will certify on such forms that the information they have provided regarding such exclusions is accurate and complete.
Upon receipt of notification from the U.S. Department of Health and Human Services Office of Inspector General that personnel have been excluded from a federal health program, Adult Resources Center, Inc. will promptly terminate their employment. If any personnel obtains information indicating that other personnel are subject to such an exclusion, the person must promptly notify the Compliance Officer, who will be responsible for investigating the matter.
Criminal Background and Credit History Checks:
Human Resources along with the Compliance Officer will designate which positions are subject to pre-employment criminal background and/or credit history checks. All Department directors should receive a listing of such positions within their department. Any changes to the list should be communicated immediately. All criminal background checks and credit history checks should be completed by Human Resources.
As part of the employment application, Adult Resources Center, Inc. should obtain written authorization by the candidate and provide them with the name, address and telephone number of the consumer reporting agency used by Adult Resources Center, Inc. together with a complete and accurate disclosure of the nature and scope of the investigation requested by Adult Resources Center, Inc. as well as a written summary of the candidate's rights under the Fair Credit Reporting Act.
Before taking any adverse action, in whole or in part, of the information on the consumer report, Adult Resources Center, Inc. will provide the candidate with a copy of the report, along with a written description of their rights under the applicable law. Candidates will be afforded a reasonable time period to review the report for errors that might affect an adverse employment decision.
All records relating to criminal background and credit checks shall be retained in files separate from the employee's personnel file. These records will be treated as confidential and may only be disclosed with the approval of the Human Resources Director, consistent with applicable laws.
Personnel who do not comply with this policy will be subject to disciplinary action including reprimand, suspension or dismissal.
VI. Compliance Program Oversight
- The Role of the Compliance Officer
- The Structure, Duties and Role of the Compliance Committees
The Role of the Compliance Officer:
The Compliance Officer is the person that is designated by the agency as having the overall responsibility of the compliance program. The Compliance Officer works with the Governance Compliance Committee, the Board of Directors, the Executive Director, managers, staff, legal team, police, regulatory bodies, and regulatory and quality auditors.
The Compliance Officer serves as the internal resource to whom employees may communicate about compliance issues and concerns and serves as a channel of communication to receive direct compliance issues to appropriate for investigation and resolution.
The following is a listing of Compliance Officer responsibilities. It should not be viewed as an all - inclusive list:
- Develops, initiates, maintains and revises policies and procedures for the general operation of the Compliance Program and its related activities to prevent illegal, unethical, or improper conduct.
- Manages day-to-day operation of the Compliance Program.
- Oversees and monitors the implementation of the Compliance Program on a regular basis
- Develops and periodically reviews and updates the Code of Conduct to ensure continuing relevance and guidance to management and employees.
- Collaborates with other departments to direct compliance issues through appropriate channels and investigation. Consults with counsel if needed for legal compliance issues.
- Reviews Risk assessment results and helps to identify potential areas of compliance vulnerability and risk, along with developing and implementing corrective action plans and providing general guidance
- Develops a strategy (work plan)
- Implements training to Board of Directors all the way through staff level employees
- Ensures proper reporting of violations and potential violations to duly authorized enforcement agencies as appropriate
- Provides reports on a regular basis, and special reports if necessary, to the Board of Directors and Senior management
- Works with Human Resources and others to develop an effective compliance training program, including appropriate introductory training to new employees as well as ongoing training for all Board members, managers, and employees.
- Monitors the performance of the Compliance Program and related activities on a continuing basis, taking the appropriate steps to keep it in compliance and improve effectiveness.
- The Compliance Officer will be supervised and report directly to the Executive Director.
- Certification on an annual basis that requirements have been met.
The Structure, Duties and Responsibilities of the Compliance Committees:
The Governance Compliance Committee is a specific Group of senior level management along with the Executive Director and the Compliance Officer. There may also be a board member included on this committee if deemed necessary. The members should be made up of representations from all major services, a Human Resources representative, a Finance Representative, and an IT representative.
The Committee should meet regularly (monthly or quarterly) and there should be minutes recorded and maintained.
The purpose of the Governance Compliance Committee is to advise and assist the Compliance Officer with the implementation of the Compliance Plan. The Committee assists with, and makes recommendations for the development of polices which are set by the Board of Directors.
The Governance Compliance Committee is responsible for:
- Ongoing analysis of the environment in which ARC conducts its operations, including legal requirements with which it must comply.
- Ongoing review, modification and creation, where necessary, of policies and procedures which address areas of risk, and which respond to new legislation and other mandates.
- Monitoring internal systems and controls to enforce compliance standards, policies and procedures.
- Monitoring internal and external audits to identify and address potential areas of non-compliance.
- Implementing corrective and preventive action plans.
- Participating in processes designed to solicit, evaluate and respond to compliance complaints and issues.
- Preparing agendas and minutes of all Governance Compliance Committee meetings.
- There should be initial Governance Compliance Committee training as well as refresher courses given on an annual basis.
- The Governance Compliance Committee should have regular communication with the Corporate Compliance Officer in regard to the status of the compliance work plan, compliance issues, investigations and results, training status, and regulatory environmental changes.
VII. Education and Training
Compliance training is a critical element to the Adult Resources Center, Inc. Compliance Plan. Every employee, independent contractor, agent and vendor is expected to be familiar and knowledgeable about Adult Resources Center, Inc.' Compliance plan and to have a solid working knowledge of his or her responsibilities under the Plan. Compliance policies and standards will be communicated to all employees through training programs that are mandatory.
There will be an agency-wide training to all new employees and then an annual refresher will be given to employees. These trainings will be organized by the individual departments to focus on specific department functions.
As part of the orientation, each employee and independent contractor will receive a written copy of this Compliance Plan, policies and procedures and specific standards of conduct that affect his/her position. As a routine part of orientation, new employees and independent contractors are required to attend a mandatory training on compliance during which the Compliance Plan and Code of Ethics are reviewed during orientation and annually thereafter. Each employee is required to document all relationships that are or could be perceived to be a conflict of interest during the orientation and annually thereafter. Each agent and vendor will receive a notification of the Compliance Plan and will receive a copy upon entering into an agreement.
The following are items that should be discussed during the general training for all administrative personnel and members of the Board of Directors:
- Government and private payor reimbursement principles
- Government initiatives
- General prohibitions on paying or receiving remuneration to induce referrals
- Prohibitions against submitting a claim for services when there is no documentation
- Prohibitions against signing for the work of another employee
- Prohibitions against inappropriate alterations to any records
- Prohibition against rendering services without the appropriate approvals
- Proper documentation of services rendered
- Duty to report misconduct
- Federal and NYS False Claims Act provisions
- Anti-Kickback Law training
- Whistleblower protection
- Non-Retaliation Policy and Procedure
- How to report suspected non-compliance
- Steps to be taken to identify, address, and prevent fraud and abuse
- Record retention.
All education and training relating to the Compliance Plan will be verified by attendance and a signed acknowledgement of receipt of the Compliance Plan.
Attendance at compliance training sessions is mandatory and a condition of continued employment.
Compliance Officer Training
Adult Resources Center, Inc. should ensure that the Compliance Officer has sufficient opportunities to receive training on compliance issues through attendance at outside conferences and subscriptions to trade periodicals as well as by any other necessary means.
The Compliance Officer will be responsible, on a regular basis, for preparing and distributing to relevant employees any updates addressing new fraud and abuse or other compliance issues of which the Compliance Officer becomes aware. These updates should cover any changes in government contracts, new interpretations of laws or rules, revisions to Adult Resources Center, Inc. policies and procedures, and industry trends and developments. Department directors should notify the Compliance Officer of any significant matters they deem appropriate for inclusion in updates.
VIII. Effective Confidential Communication
There will be open lines of communication between the Compliance Officer and every employee, independent contractor, agent and vendor subject to this Plan. Every employee, independent contractor, agent and vendor has an obligation to refuse to participate in any wrongful course of action and to promptly report the actions according to the procedure documented below.
If any of the above listed parties is asked to participate in any activity that could violate or is suspected to violate any Adult Resources Center, Inc. policy or any law or regulation, they are required to report this activity immediately. Employees should first contact their immediate supervisor if possible and independent contractors, agents, and vendors should notify the Corporate Compliance Officer immediately. If this person is not available, or it is believed that the supervisor may be involved with the activity, the Corporate Compliance Officer should be notified.
When there is a complaint made, immediately, the supervisor should document the issue and report it to the Corporate Compliance Officer.
The Corporate Compliance Officer shall document the information necessary to conduct an appropriate investigation of all complaints. Adult Resources Center, Inc. will, as much as is possible, protect the anonymity of the employee or vendor who reports the complaint or question.
All reports of fraudulent, abusive or other improper conduct, will be promptly reviewed and evaluated by the Compliance Officer. The Compliance Officer will determine in consultation with outside counsel and other Adult Resources Center, Inc. employees if necessary, whether the report warrants an internal investigation. If an internal investigation is warranted, the Compliance Officer coordinates the investigation and will issue a written report of its findings and propose corrective action if appropriate.
Government Audits and Investigations:
All personnel and independent contractors are expected to fully cooperate in all government audits and investigations. Any employee who fails to provide such cooperation will be subject to termination of employment.
All subpoenas and other governmental requests for Adult Resources Center, Inc. documents should be forwarded immediately to the Executive Director and the Compliance Officer. Employees are strictly prohibited from destroying, improperly modifying or otherwise making inaccessible any documents that the employee knows are the subject of a pending government subpoena or document request. Employees are also forbidden from directing or encouraging any other person to take such action.
If any personnel receive a request from a government investigator for an interview they must immediately notify their supervisor who should notify the Executive Director and the Corporate Compliance Officer. If necessary an attorney will be contacted to coordinate and schedule all interviews. Personnel are expected to answer all questions posed by government investigators truthfully and completely.
The identity of the person making the complaint will be safeguarded to the fullest extent that is possible. Employees, independent contractors, agents and vendors will be protected against retaliation of any kind. Any threat of retaliation against a person who acts pursuant to his or her responsibilities under this Plan is acting against the Adult Resources Center, Inc. Compliance Plan. This can result in discipline up to and including termination of employment if the retaliation is proven.
IX. Enforcement of Compliance Standards
Disciplinary Action – General
Employees who fail to comply with Adult Resources Center, Inc.' Compliance Plan, or who have engaged in conduct that has the potential of impairing Adult Resources Center, Inc.' status as a reliable, honest, and trustworthy service provider will be subject to disciplinary action, up to and including termination. Any discipline will be appropriately documented in the employee's personnel file, along with a written statement of reason(s) for such discipline. The Corporate Compliance Officer shall maintain a record of all disciplinary actions involving the Compliance Plan and report at least annually, or as needed, to the Board of Directors regarding such actions.
Disciplinary Action – Supervisory
Managers and their equivalent will be disciplined for failure to adequately instruct their subordinates or failure to detect noncompliance with applicable policies and legal requirements, where reasonable diligence on the part of the manager or equivalent would have led to the earlier discovery of any problems or violations and would have provided Adult Resources Center, Inc. with the opportunity to correct problems or violations.
Performance evaluations (per the Personnel Manual) will be utilized annually after the probationary period evaluation, to assist the Department Head and the Personnel Department in determining eligibility for promotion, salary increases and other terms and conditions of employment.
In addition to the elements that are included within the core evaluation, the promotion of, adherence to, and the elements of the Corporate Compliance Plan should be a factor in evaluating the performance of Adult Resources Center, Inc. employees, independent contractors, agents, and vendors.
X. Auditing and Monitoring of Compliance Activities
The ongoing evaluation of the Plan is critical in detecting non-compliance. This is imperative to having the Plan be a success. There should be routine internal audits of the Plan to help identify areas of non-compliance with policy and procedure and to monitor compliance with the ever changing government regulations. This ongoing evaluation shall include internal auditing and monitoring of the following:
- Relationships with third-party vendors
- Review of contracts for professional services (including administrative)
- Compliance audits of compliance policies and standards, including, but not limited to, discipline, non-retaliation, attendance at mandatory trainings, signature of Code of Ethics, identification of actual or potential conflicts of interest, and use of corporate credit cards and other payment vouchers (e.g. food stamps)
- Review of documentation and billing relating to claims made to federal, state and private payors for reimbursement
The audits will examine Adult Resources Center, Inc. compliance with specific rules and policies through on-site visits; employee, independent contractor, agent and/or vendor interviews; review of contracts, personnel records, training records, billing and other financial records; and client record documentation reviews.
At the beginning of each year, the Compliance Officer should develop a work plan, setting forward the internal audits for the upcoming year. The Compliance Committee approves the work plan. The audits should cover aspects of agency operations that pose a heightened risk of non-compliance, including but not limited to, Medicaid billing, cost reporting and access to medical care. A written report is prepared summarizing the finding of each audit, recommending any appropriate corrective action.
All employees are required to participate in and cooperate with internal audits as requested by the Compliance Officer. This includes assisting in the production of documents, explaining program operations or rules to auditors and implementing corrective action plans.
XI. Detection and Response
The Compliance Officer along with the Compliance Committee shall determine whether there is a basis to suspect that a violation of the Compliance Plan has occurred.
If it is determined that a violation may have occurred, the matter shall be discussed with the Governance Compliance Committee and with the Executive Director. In the event that the violation or potential violation appears to have merit, the Compliance Officer, with the input and approval of the Executive Director, will refer the matter to legal counsel who, with the assistance of the appropriate personnel, shall conduct a more detailed investigation. The investigation may include, but is not limited to, the following:
- Interviews with individuals having knowledge of the alleged facts
- A review of documents
- Legal research
- Contact with governmental agencies for the purpose of clarification
If advice is sought from any governmental agency, the request and any written or oral responses should be documented and communicated to the Governance Compliance Committee for discussion and potential further action
At the conclusion of the investigation involving legal counsel, counsel should be asked to write a written report to summarize the findings, conclusions, and recommendations and rendering an opinion as to whether a violation of the law has occurred. Any written report should be sent to the Executive Director as well as the Corporate Compliance Officer.
Repayment of Any Substantial Overpayment:
If Adult Resources Center, Inc. identifies an overpayment has been received by any third party payor, including Medicaid, Medicare, private parties, or other funding sources, the overpayment shall be promptly and fully repaid to the affected payor. Systems that allowed for the overpayment will be examined, modified, and monitored so as to prevent such overpayments in the future.
A record of the investigation, regardless of whether a report is made to a governmental agency should be maintained. This should include the record of the investigation along with copies of all pertinent documentation. The record will be considered confidential and privileged to the fullest extent permitted by law and will not be released without prior approval of the Executive Director and legal counsel. All compliance records will be kept in a secure area accessible to authorized personnel only.
XII. Whistleblower Provisions and Protections
The False Claims Act provides protections to qui tam realtors who are discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in terms and conditions of their employment as a result of their furtherance of any action under the False Claims Act. Federal law also prohibits intimidation and retaliation against whistleblowers.
In compliance with federal and state law, Adult Resources Center, Inc. will not permit any intimidation or retaliation against any individual who raises questions or concerns about misconduct. Adult Resources Center, Inc. will not assume intimidation tactics or take any retaliatory action against an employee if the employee, in good faith, discloses information about Adult Resources Center, Inc.’s policies, practices, or activities to a regulatory, law enforcement, or other similar agency or public official. Protected disclosures includes those that, in good faith, assert that the employer is in violation of a law that creates a substantial and specific danger to the public health and safety or which constitutes healthcare fraud under the law, or that assert that the employee believes constitute improper quality of consumer care. This policy applies to all employees, vendors/contractors, consultants and agents of Adult Resources Center.
- If you are aware of a situation that you feel may be a violation of federal or state law or regulation, Adult Resources Center, Inc. Policies and Procedures, or the Adult Resources Center, Inc. Code of Conduct, you must raise the concern and ask for advice.
- You may report your concern to the person who supervises your work, Human Resources, The Compliance Department, or through the Compliance Line (347-683-6667). You may also report concerns directly to the federal or state agency that are responsible for those programs.
- All questions/concerns, complaints of intimidation and retaliation will be fully investigated by the Compliance Office and/or his/her designee. Any concerns that are substantiated will be addressed and corrective action taken to resolve any problems.
- If you believe you are experiencing intimidation or retaliation as a result of reporting a concern, you have the right to report this situation to OMIG. Examples of intimidation and retaliation include but are not limited to, termination of employment, suspension, demotion, unjustified negative performance reviews, harassment, or exclusion from department meetings or social activities.
- The Compliance Department shall refer any matter in which it determines that an act of intimidation or retaliation has occurred to the Human Resources Department for appropriate action.
- The Human Resources Department shall take appropriate disciplinary action against any individual found to have intimidated or retaliated against any person who reports a concern or question as outlined above, in accordance with any documents governing disciplinary actions e.g. the Personnel Manual, Union Contracts, etc.
An employee’s disclosure is protected only if the employee (or former employee) first brought up the matter with a supervisor and gave the employer a reasonable opportunity to correct the alleged violation, unless the danger is imminent to the public or patient and the employee believes in good faith that reporting to a supervisor would not result in corrective action.
Additional details regarding these laws may be obtained by contacting Human Resources, the Corporate Compliance Officer, or visiting the New York State Department of Labor website.
XIII. Health Insurance Portability and Privacy Act (HIPAA) Compliance
The Health Insurance Portability and Accountability Act (HIPAA) is a federal health regulation. It is intended to assure the portability of health insurance, to reduce health care fraud, and to guarantee the privacy and security of health information and implement standards for health information transaction.
All employees of Adult Resources Center, Inc. are covered under HIPAA.
The HIPAA Compliance Plan contains Practice policies, procedures, and standards of conduct designed to ensure the agency’s compliance with applicable rules, policies and procedures established by this Plan or behavior in violation of any HIPAA law, regulation or rule may result in disciplinary action. Willful failure by any employee to comply with the policies and procedures contained in this plan, will result in termination. Consult with the Compliance Officer if you have any questions about the agency’s commitment to effective compliance routines.
The agency strives at all times to maintain the highest degree of integrity in interactions with Individuals served and the delivery of service that the agency provides. The agency as a whole, along with all its Board members and employees will strive to maintain compliance with all laws, rules, regulations and requirements affecting the consumer care provided and the handling of consumer information. The protection of the privacy of an individual’s health information is of utmost concern to the agency.
There should be an individual that is identified to fulfill the role of Privacy and Security Officer. The following are the responsibilities of that role:
- Oversee and monitor implementation of the Privacy and Security components of the HIPAA Compliance Plan.
- Prepare and present reports to the Board of Directors on agency compliance; when necessary or requested.
- Develop and implement a training program to focus on the privacy and security components of the HIPAA Compliance Program, and ensure that training materials are appropriate for all employees.
- Ensure that independent contractors who furnish services to the agency are aware of the privacy and security requirements of the agency’s HIPAA Compliance Plan.
- Revise the HIPAA Compliance Program periodically, in light of changes in the needs of the agency or changes in law of Government and private payors.
- Develop mechanisms to receive and investigate reports of privacy abuse and monitor subsequent corrective action and/or compliance.
- Develop policies and programs that encourage employees to report non-compliance without fear of retaliation.
- Coordinate security compliance efforts and establish methods such as periodic audits, both to improve the efficiency and quality of services and to reduce the agency’s vulnerability to security abuse.
Every employee of the agency is expected to be familiar with the agency’s commitment and to cooperate with the Compliance Officer. Failure to comply fully may result in disciplinary action appropriate to the non-compliance-up to and including possible termination.
Training and Education
The agency will conduct periodic training on an ongoing basis to help employees to perform their functions in compliance with the standards of the agency and applicable regulations as well as to understand that HIPAA compliance is a condition of continued employment.
Communication and Reporting
All information obtained by the agency including manuals, changes in regulations shall be promptly made available to all Affected Employees. Employees who receive information which they believe is relevant to HIPAA compliance efforts are required to furnish the information to the Compliance Officer.
All employees are expected to read this HIPAA Compliance Plan and understand its principles. If there are any questions or further clarification is needed the agency strongly encourages employees to seek answers to and/or clarification of any questions by the Compliance Officer.
Reporting of Violations or Suspected Violations
An employee who is aware of actual or a suspected violation of the Compliance Plan is required immediately to report this to the Compliance Officer for investigation. Violations may include: an actual or suspected violation of Federal or State legislation, regulations, or requirements pertaining to the security, integrity, or confidentiality of individually identified health information. If the Compliance Officer is not immediately available or the reporting employee is concerned that the Compliance Officer are involved with the violation they may report to any of the Governance Compliance Committee members or the Executive Director.
There should be no retaliatory action taken against any employee that makes a report, if the report is made based upon a good faith belief that a Violation has occurred, is occurring, or is likely to occur in the near future, and the employee follows the procedures required herein. In addition, whenever possible the agency will make all reasonable efforts to keep confidential the identity of the reporting employee.
Investigation and Remedial Action
The Compliance Officer shall consult with legal counsel with respect to any reported Violation to ascertain the most appropriate means of investigating and responding to such a report. All investigations should be performed in a timely manner. Based upon the findings of the investigation, as appropriate remedial action will be taken to ensure that the violation ceases immediately and that the violation will be prevented from occurring in the future. All reports of violations (suspected or deemed actual after investigation), investigative findings, and remedial actions taken shall be documented and maintained by the Compliance Officer.
An employee who is found to have committed actual violations shall be subjected to immediate disciplinary action. The extent of the disciplinary action to be taken shall be determined by the Governance Compliance Committee. In addition to the disciplinary action(s) set forth above, and on the advice of legal counsel, the agency may turn an employee who has committed a violation over to the appropriate authority for criminal prosecution, as appropriate or as required by law.
Auditing and Monitoring
To ensure ongoing HIPAA Compliance, the Compliance Personnel shall conduct regular auditing of agency functions and operations subject to HIPAA laws and regulation. These functions/operations include, but are not limited to the following:
- Protection of patient information
- Security measures for information systems
Audits will include complete evaluation of agency procedures, a detailed examination of randomly selected transactions, and a report of the findings for the Compliance Officer’s records. If based upon audit, the agency if found to be non-compliant with any HIPAA law or regulation, Compliance Personnel, in conjunction with legal counsel, as appropriate, shall take prompt remedial action.
Responding to Inquiries
If any employee of the agency receives oral or written inquiry regarding the agency’s compliance with any HIPAA law or regulation or any other governmental or private payor requirement the employee should immediately notify the Compliance Officer prior to responding to the inquiry.
XIV. Compliance Forms
- Form A Conflict of Interest Affirmation
- Form B Compliance Training Acknowledgement
- Compliance Officers & Executive Directors Contact Information
FORM A Conflict of Interest Affirmation
Compliance Officers and Executive Directors-Contact Information
Corporate Compliance Officer
Phone: (718) 531-7500 ext. 342
Cell: (347) 683-6667
Phone: (718) 531-7500 ext. 313