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The Arc of Livingston-Wyoming Corporate Compliance Plan
As a not-for-profit health and human services organization dedicated to improving the everyday lives of people with intellectual and other disabilities, The Arc of Livingston-Wyoming is committed to complying with the rules and regulations of federal, state and local government, including but not limited to those promulgated by the U.S. Centers for Medicare and Medicaid Services (“CMS”), NYS Office of Medicaid Inspector General (OMIG) and the New York State Office for People With Developmental Disabilities (OPWDD). The Arc of Livingston-Wyoming seeks to provide a work environment where high standards of ethical and legal behavior are recognized and practiced.
Because Medicaid funding makes up a significant portion of The Arc of Livingston-Wyoming operating budget, we are under ongoing scrutiny to ensure that our services are appropriate, timely and properly reimbursed. As Medicaid providers, we are subject to the federal and state laws that govern this program.
In developing this Corporate Compliance Plan, we have relied upon a number of resources including The Arc New York’s Corporate Compliance Plan and numerous government issuances. In summary, in order to demonstrate that we have developed an effective compliance program, we must demonstrate that we have (1) developed standards and procedures in order to reduce the prospect of improper conduct; (2) designated a high-level individual to oversee compliance; (3) not delegated authority to individuals who have exhibited a propensity for misconduct; (4) taken steps to communicate the standards to our employees and agents; (5) engaged in auditing and monitoring activities and established a reporting system in which employees can report potential misconduct without fear of retribution; (6) taken appropriate disciplinary measures against individuals found to have violated the Corporate Compliance Plan or related policies and procedures; (7) taken reasonable steps to respond and prevent future violations; and (8) ensure a culture of non-intimidation and non-retaliation in regards to reporting compliance issues.
The Corporate Compliance Plan was instituted by the Board of Directors on June 26, 2002, with updates and Board of Directors’ approval on an annual basis. Our Corporate Compliance Plan also supports and complies with The Arc New York Board of Governors’ policy requiring that each chapter of NYSARC, Inc. implement an effective Corporate Compliance program.
The Arc of Livingston-Wyoming developed this Corporate Compliance Plan, including our Code of Conduct and a wide array of policies and procedures that address key risk areas, to guide our best efforts to operate under ethical and legal standards. The Arc of Livingston-Wyoming expects that all aspects of customer care and business conduct will be performed in compliance with this Corporate Compliance Plan, professional standards, and applicable governmental laws, rules and regulations. The plan is applicable to all employees, volunteers, students, interns, and Board of Directors members, as well as independent contractors (e.g., vendor, consultant, agent / appointee) that contribute to The Arc of Livingston-Wyoming’s entitlement to payment under the Medical Assistance Program (affected individuals).
A complete list of policies is available in the Corporate Compliance Plan Table of Contents and with Element I below. The content of these policies covers all elements of this compliance plan and gives further guidance for implementing our compliance program.
Element I: Corporate Compliance Plan – Written Policies and Procedures
Our compliance philosophy is expressed within this Corporate Compliance Plan and related documents, including our Code of Conduct, and other policies and procedures related to compliance, clinical operations, human resources and fiscal management. Collectively, these documents establish standards and procedures that must be followed by The Arc of Livingston-Wyoming employees, volunteers, students, interns, the Board of Directors, and independent contractors (e.g., vendor, consultant, agent / appointee) that contribute to The Arc of Livingston-Wyoming’s entitlement to payment under the Medical Assistance Program. Understanding and following these standards will reduce the prospect of unethical, illegal and criminal conduct.
A. Code of Conduct
The purpose of The Arc of Livingston-Wyoming Code of Conduct is to provide information and guidance to all employees, volunteers, students, interns, independent contractors and the Board of Directors to assist in carrying out the day-to-day responsibilities within legal and ethical standards.
The Arc of Livingston-Wyoming Code of Conduct (Policy # 304) is a set of guiding principles that are more completely developed in the Corporate Compliance Plan and its related policies and procedures. Our Code of Conduct, which reflects our tradition of caring, provides guidance to ensure our work is done in an ethical, legal manner. Our Code of Conduct emphasizes our mission, vision and the shared common values and culture we seek to cultivate that guides our actions each day. It is updated as necessary based on implementation of the Corporate Compliance program.
The Arc of Livingston-Wyoming requires that each employee, volunteer, student, intern, independent contractor that contributes to The Arc of Livingston-Wyoming’s entitlement to payment under the Medical Assistance Program, and Board member sign a written acknowledgment that he or she understands and will follow the Agency’s Code of Conduct. Suspected violations of the code of conduct may be investigated by the Human Resources Director, Corporate Compliance Officer, or any key employee designated by the Executive Director. All who acknowledge receipt of the Code of Conduct also acknowledge that they understand that violations may result in disciplinary and / or corrective actions.
B. Other Written Policies and Procedures
The Arc of Livingston-Wyoming has developed and continues to develop, review or revise policies and procedures to implement the Corporate Compliance Plan. These policies and procedures establish the activities and processes that the Agency will undertake to operate in conformance with all applicable laws and regulations. The Arc of Livingston-Wyoming will review, revise and develop new policies and procedures, annually, to ensure that the Agency’s operations are conducted following regulatory requirements and using “best practices.” The policies and procedures of not only the health regulatory components of The Arc of Livingston-Wyoming, but also those related to human resources, environmental health and safety, and financial operations shall apply broadly to each employee through this Corporate Compliance Plan. The following policies, along with our Code of Conduct, offer guidance for all affected individuals to implement this compliance plan:
- Corporate Compliance Structure – Policy # 308
- Documentation of Compliance Activity – Policy # 312
- False Claims Act – Policy # 316
- Code of Conduct – Policy # 304
- Reporting Compliance Concerns/Anti-Retaliation – Policy # 323
- Conflict of Interest – Policy # 305
- Political Contributions/Lobbying – Policy #320
- Compliance Investigations – Policy #318
- Gifts and Entertainment to referral Sources – Policy # 317
- Documentation of Services – Policy # 311
- Exit Interviews – Policy # 315
- Exclusion Checks – # 314
- Compliance Education and Training – Policy # 313
- Discipline and Incentive Program – Policy # 310
- Contractual/Financial Arrangements with Physicians – Policy # 306
- Background Checks for Employees and Others – Policy # 301
- Prohibition of Inducements: – Policy # 303
- Billing Third Party Payors – Policy # 302
- Responding to Government Inquiries Policy # 324
- Auditing and Monitoring – Policy # 300
- Detecting and Responding to Compliance Violations Policy # 309
- Policy Management – Policy # 319
- Training and Education – Policy # 350
- Record Retention – Policy # 322
- HIPAA Privacy Plan -Policy # 345 (and all policies within)
- Confidentiality – Policy # 352
- Review of IRS Form 990 – Policy #326
- Access to Forms 1023, 990, 990-T, Conflict of Interest and Financial Statement – Policy # 327
- Red Flag Identity Theft Program – Policy # 330
- CEO Performance and Compensation – Policy # 328
- Whistleblower Protections – Policy # 351
Element II: Designation of Employee with Responsibility for the Day-to-Day Operations of the Compliance Program
The Arc of Livingston-Wyoming is committed to the operation of an effective compliance program and has assigned compliance oversight responsibilities to individuals at the management level. The designated Corporate Compliance Officer (Director of the Corporate Compliance Department) is ultimately responsible for the daily operation of the compliance plan. Other individuals with day-to-day compliance oversight authority occupy high levels (Department Directors, Program Coordinators / Managers, and other Supervisors as deemed appropriate by Department Directors or the Corporate Compliance Officer) in The Arc of Livingston-Wyoming organizational structure, to ensure a culture of compliance. They are empowered to implement the Corporate Compliance program, investigate compliance concerns, and report compliance concerns directly to those in higher positions of authority, up to and including, The Arc of Livingston-Wyoming Board of Directors and the Executive Director. The Corporate Compliance Officer reports to the Executive Director and also has direct access to the Board of Directors and legal counsel at her discretion. At least once per year the Compliance Officer meets with the Board of Directors in Executive Session to review the compliance plan and hear any concerns. At this meeting all are encouraged to contact the Compliance Officer at any time with concerns or complaints about the compliance program and its operations. The Compliance Officer also provides annual compliance training to the Board of Directors and other training as deemed necessary or requested.
The Arc has established a Corporate Compliance Committee comprised of all Program Directors and three Arc of Livingston-Wyoming Board of Director members (one of whom is the chairperson) with responsibility to meet regularly to advise the Corporate Compliance Officer, to identify and resolve compliance concerns and to continue to improve and refine the Agency’s overall compliance activities. The Arc of Livingston-Wyoming Board of Directors is an integral part of the Corporate Compliance program, will be knowledgeable about the content and operation of the Agency’s Corporate Compliance Plan and will exercise oversight with respect to the implementation and effectiveness of the Corporate Compliance Plan. Effective 2014, the Board of Directors visit program sites, which increases their opportunities to report any concerns to the Corporate Compliance Department. The Corporate Compliance Committee provides regular reports to the Board of Directors on compliance activity and concerns.
Element III : Education and Training
The Board of Directors, all employees, volunteers, students, interns, and, as applicable, independent contractors, must be informed about regulatory requirements and The Arc of Livingston-Wyoming policies and procedures that implement these requirements, as they apply to each individual. Therefore, The Arc of Livingston-Wyoming trains the Board of Directors, high-level personnel, substantial authority personnel, employees, volunteers, students, interns, and affected independent contractors on the organization’s standards and procedures, commensurate with their responsibilities and /or affiliation with the agency. The Agency continuously identifies training topics, including those arising as a result of self-monitoring, audits by regulatory agencies, and regulatory developments, and provides ongoing education to applicable personnel.
New employees will receive training in The Arc of Livingston-Wyoming Code of Conduct, this Corporate Compliance Plan and those policies and procedures relevant to their job duties as part of an orientation program, and annually thereafter. The Arc of Livingston-Wyoming tailors its training based on the roles and responsibilities of each group of individuals and in a manner that the individual can understand. Site / program specific training on compliance and documentation responsibilities also occurs during the orientation period and ongoing as needed.
Element IV: Lines of Communication to the Responsible Compliance Position
Each affected individuals is made aware of his/her responsibility to report through our compliance processes any activity by any colleague, clinician, independent contractor or anyone else that appears to violate applicable laws, rules, regulations, accreditation standards, standards of medical practice or the Corporate Compliance Plan. We encourage a culture in which all affected individuals feel free to report behaviors or actions which they believe should be reported. Therefore, the effectiveness of our Corporate Compliance program depends on the willingness and commitment of these affected individuals in all relationships and at all levels of The Arc of Livingston-Wyoming to step forward, in good faith, with questions and concerns. Therefore, we are committed to making every effort to maintain, within the limits of the law, the confidentiality of the identity of any individual who reports a concern in good faith. Affected individuals receive training on what to report and how to do so. Various policies within this compliance plan offer more specific guidance.
It is an expected good practice, when one is comfortable with it and thinks it is appropriate under the circumstances, for concerns to be raised first with a supervisor of the program. If this is not comfortable or not a viable option, then affected individuals are encouraged to contact the Corporate Compliance Hotline at 585-658-2023 where reports may be made confidentially. This hotline number, along with the name and number of the Corporate Compliance Officer, is posted at all Arc of Livingston –Wyoming locations to ensure accessibility. Reports may also be made directly to the Corporate Compliance Officer, Lori Peraino, at any time via telephone at 585-658-2828, ext 127, email correspondence at firstname.lastname@example.org or in person at 18 Main St. Mt. Morris, NY 14510.
Element V: Disciplinary Action and Incentives to Encourage Good Faith Participation
The Arc of Livingston-Wyoming also seeks to reward employees who foster a culture of compliance. The Corporate Compliance Officer encourages all to recognize others for compliance efforts during initial compliance training, and strives to send personal as well as public messages for same.
Failure to comply with the Corporate Compliance Plan, the Code of Conduct and/or laws and regulations applicable to The Arc of Livingston-Wyoming and our operations may result in disciplinary action. Retraining of staff will occur if misconduct is based on a lack of awareness or understanding of a regulatory obligation, policy or procedure. Resolution of disciplinary issues will be determined through the Corporate Compliance Plan structure in direct cooperation with the appropriate manager, Human Resources Director, and the Corporate Compliance Officer and, as appropriate, legal counsel and the Executive Director of The Arc of Livingston-Wyoming. The degree of discipline may include counseling, verbal warnings, written warnings, recommended change or discontinuation of privileges, termination of a contract, termination of employment or removal from a particular position or function. The Agency endeavors to be consistent in its approach to discipline, with similar disciplinary action for similar offenses.
Any employee who intentionally makes a false accusation with the purpose of harming or retaliating against a colleague will be subject to appropriate disciplinary action.
Element VI: A System for Routine Identification of Compliance Risk Areas
The Arc of Livingston-Wyoming is committed to routinely conducting internal audits of concerns that have regulatory or compliance implications. The Corporate Compliance Department annually conducts quality and limited fiscal audits of all programs, based on a schedule recommended by the Corporate Compliance Committee and approved by the Board of Directors. Internal auditing and monitoring activities increase as new services are begun, as billing standards change, and anytime deemed necessary by the Corporate Compliance Committee based on implementation of the compliance program. Risk areas identified by internal and external audits are incorporated into the compliance work plan.
As each annual compliance work plan is updated, program directors review the prior year’s risk areas and progress to date toward mitigation with the Corporate Compliance Committee. It is then determined whether or not the risk needs to be a focus area for the new plan. They also determine new risk areas, based on their knowledge of upcoming changes or focus areas from external auditors or other resources, including but not limited to, NYSARC, OPWDD, OMIG, and OIG.
Risk areas may also be identified via mandatory reporting of compliance issues and investigation findings; monitoring of billing and payment activities; interviews with affected individuals; background, credentials, or excluded provider checks; compliance program assessments; or any other compliance activities.
Appropriate individuals in key management positions are responsible for engaging in self-monitoring processes conducted within specific departments/divisions. All service programs have routine auditing practices in place to ensure that billing information sent to the Finance department is timely, accurate and complete.
The Arc of Livingston-Wyoming will also contract with external auditors on an as needed basis. We believe that a combination of various compliance reviews will permit us to maintain a consistent conformity to relevant laws and regulations, while fulfilling a commitment to identify and share best practices.
Element VII: A System for Responding to Compliance Issues
The Arc of Livingston-Wyoming is committed to fostering our culture of compliance through detecting, correcting and preventing non-compliance behaviors. Through the process of our corporate compliance reporting structure and the articulation of compliance-related roles and responsibilities at every level of the Agency’s operations, detection and correction of problems is expedited.
Risk areas identified are incorporated into the compliance work plan. Risks are identified by the Corporate Compliance Committee based on review of quality and compliance data, which includes internal and external audits, training and incident reporting compliance, compliance investigations, and billing adjustments, voids and self-disclosures. The Compliance Officer also works with all program directors to identify areas of focus based on upcoming regulatory changes and trends in audit findings in the health care field.
Compliance issues may be detected by mandatory reporting by affected individuals via direct report or the confidential hotline; as a result of program or compliance department internal audits; as a result of an external audit; during the course of an investigation of a different issue; or as a result of compliance program assessments.
Corporate Compliance issues are formally documented and investigated by the Corporate Compliance Officer, based on the nature of the complaint. The Compliance Officer may delegate the investigation at her discretion, barring no conflicts of interest, or may choose to refer the matter to legal counsel. In all cases, the Corporate Compliance Officer works with the department to ensure that the investigation is thorough, a root cause is explored, and strategies are implemented to prevent recurrence. In the event that a concern is raised that is not a compliance issue, the Compliance Officer refers to the appropriate personnel for review and follow-up.
If an internal investigation substantiates a reported violation, then it is our policy to engage in a two-fold process: (1) to initiate corrective action, including, as appropriate, making prompt restitution of any overpayment amounts, notifying the appropriate governmental agency, instituting whatever disciplinary action is necessary; and (2) implementing systemic changes to prevent a similar violation from recurring in the future. The Compliance Officer and Program Directors work in collaboration to ensure implementation of the above.
Results of compliance investigations are minimally shared with the Corporate Compliance Committee and additionally with others as deemed appropriate for learning and compliance purposes.
Element VIII: Non-intimidation and Non-retaliation
The Arc of Livingston-Wyoming strives to provide an environment that encourages individuals to report any suspected violation without fear of retaliation, intimidation or retribution. Strict adherence to The Arc of Livingston-Wyoming’s Corporate Compliance Plan and Code of Conduct is vital. The Arc of Livingston-Wyoming requires all affected individuals to promptly report any known or suspected violations of the Corporate Compliance Plan, Code of Conduct, policies and procedures or any of the laws, rules or regulations by which this Agency is governed.
The Arc of Livingston-Wyoming will not impose any disciplinary or other action in retaliation against individuals who make a report or complaint in good faith regarding a practice that the individual believes may violate any of the above.
Employees are trained on how to report compliance concerns upon hire and annually. Initial Corporate Compliance training is conducted by the Corporate Compliance Officer / designee, to ensure thorough understanding by employees, comfort with reporting, and accessibility of the Corporate Compliance Officer. Review of the Code of Conduct, the False Claims Act, Reporting Compliance Concerns, Conflict of Interest, and Whistleblower Protection policies are part of Corporate Compliance training. These policies are also shared with all other affected individuals.
The Arc of Livingston-Wyoming uses due care not to employ, contract with or delegate substantial discretionary authority to any individual with a propensity to engage in illegal activities. In order to maintain the integrity of our services and financial and business operations, it is critical that The Arc of Livingston-Wyoming hire and contract with individuals and entities that have the same respect for applicable legal and ethical obligations that the Agency has. This standard applies to personnel in positions with “substantial” control over The Arc of Livingston-Wyoming, including, but not limited to those having the ability to affect and determine policy and to negotiate contracts. All current and prospective employees will be required to disclose, on a periodic basis, whether he or she has committed a crime, including health care related crimes.
The Arc of Livingston-Wyoming also complies with requirements promulgated under state law with respect to background checks and appropriate screening activities as those requirements apply to personnel within the Agency’s operations.
Further, The Arc of Livingston-Wyoming checks, prior to employment / service and periodically thereafter, to determine if new hires or existing employees and independent contractors have been excluded from participation in the federal healthcare programs by checking the Office of the Inspector General’s “List of Excluded Individuals/Entities,” (a database which provides a list of parties excluded from participation in federal healthcare programs) and the NYS Office of the Medicaid Inspector General’s list of Restricted, Terminated or Excluded Individuals or Entities. Similarly, the General Services Administration maintains the List of Parties Excluded from Federal Procurement and Non-procurement Programs, which identifies those parties excluded from receiving federal contracts or certain subcontracts and certain types of federal financial and non-financial assistance and benefits.
Prior to hiring or contracting with licensed clinical staff or providers, screening occurs with The Office of Professions to ensure they have a current NYS license and are meeting the requirements of The NYS Education Department. Monthly checks of continued licensure occur.
Compliance Officer and Board of Directors Communication:
At least once each calendar year, the compliance officer provides compliance training to the entire board of directors. She also attends monthly board of directors meetings and serves as staff liaison to the Corporate Compliance Committee. Verbal updates are provided at these monthly meetings and compliance committee meeting minutes are shared with the entire board of directors. These minutes include annual data, which is also made available for review in a secured portal. In addition to this contact with the full board, the compliance officer meets at least once per year in executive session to ensure that any compliance concerns can be raised in the absence of the Senior Management team. As stated above, the compliance officer has unrestricted access to the board of directors as necessary or appropriate.