Corporate Compliance Program by alicejenny

VIEWS: 30 PAGES: 16

									COMPLIANCE POLICY STATEMENT
Person Centered Care Services, Inc. (“PCCS”) is dedicated to maintaining excellence and
integrity in all aspects of its operations and its professional and business conduct. Accordingly,
PCCS is committed to conformance with high ethical standards and compliance with all
governing laws and regulations not only in the delivery of services but in its business affairs and
its dealings with trustees, officers, employees, medical staff and contractors and the communities
it serves. It is the personal responsibility of all who are associated with PCCS to honor this
commitment in accordance with the terms of the PCCS Code of Conduct, and related policies,
procedures and standards developed by PCCS in connection with the Corporate Compliance
Program.

PURPOSE OF COMPLIANCE PROGRAM
The PCCS Corporate Compliance Program (the “Program”) is intended to provide reasonable
assurance that PCCS:

1. complies in all material respects with all federal, state and local laws and regulations that are
    applicable to its operations;

2. satisfies the conditions of participation in health care programs funded by the state and federal
    government and the terms of its other contractual arrangements;

3. detects and deters criminal conduct or other forms of misconduct by trustees, officers,
    employees, medical staff and contractors that might expose PCCS to significant civil
    liability;

4. promotes self-auditing and self-policing, and provides for, in appropriate circumstances,
    voluntary disclosure of violations of laws and regulations;

5. establishes, monitors, and enforces high professional and ethical standards.

SCOPE OF COMPLIANCE PROGRAM
The provisions of the Program apply to all program and health services, business, and legal
activities performed by PCCS trustees, officers, employees, medical staff and contractors. The
expectations for PCCS employees regarding compliance with the Program are as follows:

1. comply with the PCCS mission statement and vision and the PCCS Code of Conduct

2. familiarize themselves with the purpose of the Program;

3. perform their jobs in a manner which demonstrates commitment to compliance with all
    applicable laws and regulations;

4. report known or suspected compliance issues to the Compliance Officer or his/her designee
     and investigate or participate in investigations to the point of resolution of all alleged
     violations;
5. strive to prevent errors and provide suggestions to reduce the likelihood of errors.




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  PCCS COMPLIANCE PROGRAM ELEMENTS
  The PCCS Compliance Program contains several elements. All elements are designed to prevent,
  detect, and respond to business conduct that does not conform to applicable laws or regulations.
  The program is based on the a new Part 521, entitled “Provider Compliance Programs,” added to
  Title 18 of the Codes, Rules and Regulations of the State of New York

1. Code of Conduct -
  Corporate Compliance, also known as Corporate Ethics, for Not-for-Profit Agencies that utilize public funds
  is mandated by law, most specifically the Social Security Law §363-d of New York State. In the for-profit
  sector, the concept of corporate compliance is defined in the Public Company Accounting Reform and
  Investor Protection Act of 2002. This act is commonly referred to Sarbanes-Oxley, and serves as the model
  for corporate compliance for all business entities.
  Within New York State, not-for-Profit corporate compliance is monitored and enforced by the New York
  State Attorney General, and for corporations that are the recipients of Medicaid funds corporate compliance is
  additionally monitored and enforced by the New York State Office of the Medicaid Inspector General
  (OMIG). Under New York State law, the consequences of not adopting a system of corporate compliance can
  be fines, penalties and possibly criminal charges.
  For Person Centered Cares Services, Inc. (PCCS), the essence of Corporate Compliance lies in the prevention,
  detection and reporting of Medicaid fraud, abuse and waste which includes the misuse of company resources
  for non-company purposes. In addition, as a recipient of public finds, PCCS has an obligation to operate
  within the highest of ethical standards, which it has always done. However, with the advent of regulations
  detailing Corporate Compliance regulations, refinements of PCCS’s practices became necessary. To achieve
  Corporate Compliance as defined by these new laws, PCCS has enhanced its policies and procedures to
  address all possible contingencies and remedies wherein funds received from Medicaid might be misused,
  where billing might not be accurate or where errors might not be detected due to inadequate monitoring
  systems.
  This requirement extends to PCCS’s responsibility to implement systems that assure that the aforementioned
  policies and procedures are put into practice, and that agency staff are well trained in its utilization.
  Towards the development and implementation of Corporate Compliance policies and procedures, this manual
  is the culmination of the deliberations of PCCS’s Board of Directors, executive and administrative staff, as
  well as legal and program consultants who are experts in the field of corporate compliance. These
  deliberations have resulted in the development of mechanisms for detecting and reporting allegations of
  Medicaid fraud, waste and abuse: as sets forth a system to train staff in its implementation and to track staff
  training. The policies developed annunciate methods for reporting Medicaid fraud waste and abuse in a
  manner that assures anonymity and non-retaliation. The policies also designate a PCCS Corporate
  Compliance Officer and a Corporate Compliance Committee, the purpose of which is to assure abidance with
  the Agency’s Corporate Compliance Policies and Procedures. Together these efforts are known as the
  Corporate Compliance Plan.

  2. Compliance Officer (CO)– primary responsibilities of the Compliance Office is the Chair of
  the Corporate Compliance Committee.
  The CO has direct lines of communication to the Chief Executive Officer, the Board of Directors and legal
  counsel. (See organization chart).

  Job Duties: The CO is directly obligated to serve the best interests of PCCS, its consumers and
  employees. Responsibilities of the CO include, but are not limited to:

  • Developing and implementing compliance policies and procedures (P&P).
  • Overseeing and monitoring the implementation of the compliance program.
  • Directing Agency internal audits established to monitor effectiveness of compliance standards



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• Providing guidance to management, medical/clinical program personnel and individual departments
regarding P & P and governmental laws, rules and regulations.
• Updating, periodically, the Compliance Plan as changes occur within Person Centered Care Services.,
and/or in the law and regulations or governmental and third party payers. Overseeing efforts to
communicate awareness of the existence and contents of the Compliance Plan
• Coordinating, developing and participating in the educational and training program.
• Guaranteeing independent contractors (consumer care, vendors, billing services, etc.) are aware of the
requirements of Agency’s Compliance Plan.
• Actively seeking up-to-date material and releases regarding regulatory compliance.
• Maintaining a reporting system (hotline) and responding to concerns, complaints and questions related
to the Compliance Plan.
• Acting as a resourceful leader regarding regulatory compliance issues.
• Investigating and acting on issues related to compliance
• Coordinating internal investigations and implementing corrective action.
• Assists in the development and coordination of educational and training programs regarding elements of
PCCS’s compliance program such as appropriate documentation and accurate coding.
• Enforces PCCS’s Corporate Compliance Plan as per OMIG regulations
• Conducts regular audits and coordinates ongoing monitoring of coding accuracy and documentation
adequacy in order to identify systemic and process problems.
• Provides feedback on the results of auditing and monitoring activities to appropriate department
personnel.
• Conducts internal investigations of allegations of corporate compliance violations within the Agency.
• Initiates corrective action plans to ensure resolution of problem areas identified during an internal
investigation or auditing/monitoring activity.
• Recommend disciplinary action for violations of the compliance program to the Director of Program
Services.
• Ensures the appropriate dissemination and communication of all regulation policy and guideline changes
to affected personnel.
• Serves as a resource for Residential Managers and Clinicians to obtain information or clarification on
accurate and appropriate documentation standards.
• Revises PCCS’s corporate compliance program in response to changing organizational needs or new
revised regulations policies and guidelines.
• Recommends revisions to the PCCS’s Corporate Compliance program to improve its effectiveness.
• Disseminates audit information to executives, program administrators, and the Corporate Compliance
Committee
• monitoring ComplyLine to ensure that members of the PCCS community are able to report
suspected improprieties without fear of retribution, and implementing processes to investigate,
resolve and document all issues reported via ComplyLine;
• Train all staff on the principles of Corporate Compliance




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3.Corporate Compliance Committee
PCCS shall have a Corporate Compliance Committee (“Compliance Committee”) that meets
quarterly, comprised of representatives from appropriate clinical and administrative areas. The
Compliance Committee members should have broad backgrounds and experience levels and
expertise in operations, monitoring quality, service delivery and legal/regulatory compliance. The
purpose of the Compliance Committee is to provide tactical leadership to the program. This
includes identifying risk areas, initiating audits and reviewing the results of investigations.

PCCS engages a Management Compliance Committee comprised of PCCS’S Executive Director,
Chief Financial Officer, CCO and such other members as are necessary to be effective in its
responsibilities. Meeting quarterly, the CCO chairs the Committee and the CCO shall provide
staff support to the Committee.
The Committee assists the CCO and executive director in fulfilling responsibilities in developing,
implementing and monitoring the Compliance Program. The purpose of the Committee is to
provide strategic direction for the program. This includes monitoring changes in the healthcare
environment and identifying the impact of such changes on specific compliance risk areas,
recommending the adoption or revisions of policies and procedures necessary for an effective
Compliance Program, and monitoring internal and external compliance audits and investigations
and calls coming through the ComplyLine telephone service.


4. Structure and Oversight of the Compliance Program– Compliance Committee designations;
Corporate Compliance Committee (CC) members are senior management of the Agency, all of whom are
well-versed with Corporate Compliance and its impact upon the functions of the Agency within their locus of
responsibility. The CC’s purpose is to advise and assist the CO with the implementation of the Compliance
Plan. Compliance issues are reported to the CC by the CO, and then by the CC to the Executive Director and
when appropriate to the Board.

The roles of the Compliance Committee include:
• Analyzing the environment where the Agency does business, including legal requirements with which it
must comply.
• Reviewing and assessing existing Policies & Procedures (P&P) that address risk areas for possible
incorporation into the Compliance Plan.
• Working with departments to develop standards and P & P that address specific risk areas and encourage
compliance according to legal and ethical requirements.
• Advising and monitoring appropriate departments relative to compliance matters.
• Developing internal systems and controls to carry out compliance standards and policies.
• Monitoring internal and external audits to identify potential non-compliant issues.
• Implementing corrective and preventive action plans.
• Developing a process to solicit, evaluate and respond to complaints and problems.

5. Education and Training Program Development and Implementation– to provide general
compliance information to the entire employee population as well as focused technical training of
those functional areas that have the ability to put PCCS at a greater degree of compliance
exposure;
The proper education and training of agency officers and administration, managers, employees, and
clinical staff are significant elements of an effective compliance program.
As part of a compliance program, PCCS requires personnel to attend specific training on a periodic
basis, including appropriate training in federal and state regulations, guidelines, corporate ethics, and
any other topic that has been deemed at risk for non-compliance with the Principles of Corporate


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   Compliance. Corporate Compliance sessions are designed to emphasize the organization’s
   commitment to compliance with these legal requirements and internal policies and procedures.
   Compliance training specific to identified risk areas is also incorporated into in-service training.
   Policy: All employees are required as a condition of employment to attend Corporate Compliance
   training within (90 days) ninety days of hire and annually thereafter.
   Corporate Compliance training includes:
   • Introduction of the Agency Compliance Program;
   • Documentation issues relative to government payer regulations, including the requirement that
   documentation must include the identity and title or professional certification of the individual
   providing or ordering the service;
   • Risk areas specific to the Agency;
   • Standards of conduct; and
   • Duty to report misconduct and the non-retaliation policy.
   Procedures: All employees will receive training in the above listed areas. Certification of training will
   be contained in the staff member’s personnel folder. The Quality Assurance Department will schedule
   all training.
   Policy: PCCS is committed to accuracy and integrity in all its billing, coding, and other
   reimbursement operations. Further, PCCS prohibits the intentional submission for reimbursement any
   claim that is false, fraudulent, or fictitious. Through staff training, and other methods, the Agency is
   committed to ensuring against Agency personnel submitting any claim that is accidentally false,
   fraudulent or inaccurate. The Chief Financial Officer is responsible for general oversight of billing,
   coding, and other reimbursement operations in accordance with this policy. The Compliance Officer
   will assist in the accuracy of billing through periodic audit and recommendations.
   To assure accuracy in billing, the Agency’s business office personnel will receive training specific to
   all of the elements of billing and the importance of accuracy along with the consequences of
   inaccurate billing.
   Procedures: Each Agency program type has and maintains written procedures for the documentation
   of services upon which billing to Medicaid is based. Procedures include the following:
   • Maintenance of attendance records
   • Receipt and maintenance of service plans, including but not limited to ISP, and Habilitation Plans,
   as appropriate.
   • Service documentation requirements specific to the respective program
   • Definition of contemporaneous documentation
   • Attestation and review prior to submission to billing personnel
   • The forms used for documentation and billing purposes. So that business office staff are aware of
   these principles, the CO, is responsible for ensuring that training regarding services and billing
   practices that offers guidance towards accurate billing is conducted. In this manner, billing procedures
   contained in this policy are integrated into the operations of the organization.

   PCCS is committed to prompt, complete and accurate billing of all services provided to individuals.
   PCCS and its employees, contractors and agents shall not make or submit any false or misleading
   entries on any claim forms. No employee, contractor or agent shall engage in any arrangement or
   participate in such arrangement at the direction of another person, including any supervisor or manager
   that results in the submission of a false or misleading entry on claims forms or documentation of
   services that result in the submission of a false claim.

6. Hotline Process Maintenance - to receive complaints confidentially and to provide protection
    from retaliation to all individuals who report in good faith concerns via a ComplyLine call; 1-
    347-498-4344.




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Policy: Any PCCS employee, contractor or agent who has any reason to believe that anyone is engaging
in false billing practices or false documentation of services is expected to report the practice according
to PCCS’s “REPORTING OF COMPLIANCE CONCERNS AND NON RETALIATION”. PCCS
employees have direct and, as desired, anonymous communication with the CO and, if preferred, with
the appropriate governmental agencies. In all cases, the CO will protect the anonymity of the staff
member, to the greatest extent practicable, and regardless to whom the alleged impropriety is reported,
staff can report alleged improprieties without the fear of retribution.
Procedures: There are several methods through which the report of an alleged impropriety can occur.
First and foremost is that the CO has an “open door” policy to all PCCS personnel.
Through training, staff members are advised that any staff member can call or visit or call the CO.
This is designed so that staff are encouraged to report alleged improprieties as soon as the staff
member becomes concerned.
All employees have an affirmative duty and responsibility for promptly reporting any known or
suspected misconduct, including actual or potential violations of laws, regulations, policies, and
procedures, Agency’s Corporate Compliance Plan or the Agency’s Code of Corporate Compliance.
PCCS also has an Anonymous Reporting Hotline. Employees may report their compliance concerns
confidentially to the Compliance Officer through use of the Anonymous Reporting Hotline. Any form
of retaliation against any employee who reports a perceived problem or concern in good faith is
strictly prohibited. Any employee who commits or condones any form of retaliation will be subject to
discipline up to, and including, termination. However, employees cannot exempt themselves from the
consequences of their own misconduct by reporting the issue, although self-reporting may be taken
into account in determining the appropriate course of action. Staff can also report their concerns
directly to appropriate governmental agencies.
Staff can report a suspected breech of conduct or false claim as follows, but in no preferential order,
but which must be posted in all of PCCS’s programs:
1. To the CO in person at 1811 Victory Blvd., Staten Island, NY 10314
2. To the CO at 1-347-498-4344 which can be anonymous
3. To the PCCS Anonymous Reporting e-mail at dotherightthing@pccsny.org
4. To the New York State Office of the Medicaid Inspector General at 1-877-87FRAUD or by
completing an online complaint form at: www.omig.state.ny.us
Procedures that apply to all employees:
• Knowledge of misconduct, including actual or potential violations of laws, regulations, policies,
procedures, or the organization’s Code of Conduct, must be immediately reported to administration,
the Compliance Officer, or the Compliance Hotline.
• Confidentiality will be maintained to the extent that is practical and allowable by law. Employees
should be aware that PCCS is legally required to report certain types of crimes or potential crimes and
infractions to external governmental agencies.
• Employees may report their compliance concerns confidentially to the PCCS Anonymous Reporting
Hotline and provide his or her identity. Callers should be aware, however, that it may not be possible
to preserve anonymity if they identify Corporate Compliance.
• If the caller wishes to make the report anonymously to the Hotline, no attempt will be made to trace
the source of the call or identify of the person making the call.
• The Compliance Hotline number is contained within this manual and is visibly posted in locations
frequented by Agency employees.
• Management must take appropriate measures to ensure that all levels of management support this
policy and encourage the reporting of problems and concerns. At a minimum, the following actions
should be taken and become an ongoing aspect of the management process:
• Meet with department staff and discuss the main points within this policy; and
• Provide all department staff with a copy of this policy.
Procedures that apply to the Compliance Officer:



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   • The Compliance Officer will be responsible for the investigation and follow-up of any reported
   retaliation against an employee for reporting a compliance concern or participating in the
   investigation of a compliance concern.
   • The Compliance Officer will report the results of an investigation into suspected retaliation to the
   governing entity deemed appropriate, such as the Corporate Compliance Committee or the Board of
   Directors.

   Employee Protections:
   The False Claims Act prohibits discrimination by PCCS against any employee for taking lawful
   actions under the False Claims Act. Any employee who is discharged, demoted, harassed, or
   otherwise discriminated against because of lawful acts by the employee in False Claims actions is
   entitled to all relief necessary to make the employee whole. Such relief may include reinstatement,
   double back pay, and compensation for any special damages, including litigation costs and reasonable
   attorney fees.

   7. Sanction or Disciplinary Action Enforcement - the enforcement of appropriate sanctions or
   disciplinary actions against trustees, officers, employees, medical staff or contractors who violate
   compliance policies, applicable laws or regulations or federal health program requirements;

   PCCS believes that all members of the PCCS community are responsible for complying with the
   PCCS Corporate Compliance Program, Code of Conduct and related policies and procedures.
   Corrective action for noncompliance will be initiated by the appropriate management personnel,
   who must notify Human Resources in accordance with the standard disciplinary policies and
   procedures of PCCS. Enforcement will be administered by the parties identified by the CCO in
   consultation with the immediate supervisor and, if appropriate, Human Resources. Disciplinary
   actions will be determined on a case-by-case basis and will be taken appropriately, equitably and
   consistently, given the underlying circumstances and the degree of negligence or reckless
   conduct.

8. Monitoring - the performance of audits and risk assessments to identify problems and conduct
    ongoing compliance monitoring of identified problem areas;

 Policy: Within the realms of the Corporate Compliance regulations, risk areas in general and those
 contained in the periodic internal audits of records conducted by the CO. Through the on-going audit of
 records, the CO can proactively determine what, if any, problem areas exist and focus on the further risks
 areas that are associated with those problems. The CO can also recommend remedial measures that will
 avoid future problems. The CO will audit programs on a rotating basis and will audit vehicle logs and
 related documents to assure that staff are abiding by policies governing the use of Agency resources.
 Procedure: Each calendar year, an “initial audit” will be performed to reveal areas of risk, but also to
 serve as a baseline audit with which to benchmark future compliance performance. This initial audit will
 be submitted to the CC as described above. During each audit, a randomly selected number of consumer
 records will be reviewed to ensure compliance with regulations relative to documentation and
 reimbursement.

 Examples include, but are not limited to:
 • Service planning and review (Existence, timing, quality and content)
 • Progress notes (Existence, quality, content)
 • Discharge planning
 • Billing for services not actually rendered
 • Duplicate billing


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 A basic guide is three or more records per risk area. The CO will also periodically review records related
 to staff use of Agency resources.
 In all cases, if problems are identified, the CO will determine whether a focused review should be
 conducted on a more frequent basis. When audit results reveal areas needing additional information or
 education of employees and/or providers, the Agency, through the CO and CC will analyze whether these
 areas should be incorporated into the training and education program.
 An important component of a successful compliance audit is an appropriate response to the problems
 identified. In case of the review of consumer records, the Agency’s response may generate a repayment
 with an appropriate explanation to the payer. Any uncovered use of an Agency resource by a staff
 member will result in repayment to PCCS or an equivalent tax liability to the employee, and, as
 appropriate, disciplinary action which can include termination of employment.
 The CO will review audit results and recommend remedies to the CC, which ultimately will be presented
 by PCCS’s Executive Director to PCCS’s Board of Directors for final action.

9. Investigation and Remediation - the investigation and remediation of identified systemic
    problems and the development of appropriate corrective action plans to remediate such problems.

   PCCS intends that its compliance program will significantly reduce the risk of unlawful conduct
   in our operations. This program will demonstrate our good faith effort to comply with applicable
   statutes, regulations, and other Federal health care program requirements.

 INVESTIGATION OF COMPLIANCE ISSUES
 PCCS has implemented a Corporate Compliance Program in an effort to establish a culture within the
 organization that promotes prevention, detection and resolution of misconduct.
 This is accomplished, in part, by establishing communication channels for employees to report problems and
 concerns. Employees are encouraged to report issues via the traditional chain of command, Compliance Hotline,
 or directly to the Compliance Officer. Therefore, the Compliance Officer is responsible for responding to
 compliance issues that are raised through the various communication channels. This policy is designed to
 establish a framework for managing and responding to compliance issues that are raised to the Compliance
 Officer.
 Policy: PCCS will respond to reports or reasonable indications of suspected non-compliance with the rules and
 regulations of Medicaid and Medicare and other principles contained herein by commencing a prompt and
 thorough investigation of the allegations to determine whether a violation has occurred.
 Note: The Compliance Officer is only responsible for resolving compliance-related issues; however, employees
 should not be discouraged from using any specific communication channel. Employees who report non-
 compliance related issues or concerns to the Compliance Officer or the Compliance Hotline will be politely
 redirected to the appropriate department or individual. In instances where the employee seeks confidentiality or
 reports anonymously, the Compliance Officer shall redirect the report to the appropriate department or
 individual.
 Procedures:
 1. The Compliance Officer, in concert with executive staff, will conduct or oversee all internal investigations
 involving compliance-related issues and shall have the authority to engage [inside legal counsel/outside legal
 counsel] or other consultants, as needed. Before conducting an investigation of any compliance-related issue,
 the Compliance Officer shall have a full understanding of the relevant laws, regulations, and government
 issuances.
 2. Upon report or notice of alleged non-compliance, the Compliance Officer will conduct an initial inquiry into
 the alleged situation. The purpose of the initial inquiry is to determine whether there is sufficient evidence of
 possible noncompliance to warrant further investigation. The initial inquiry may include documentation review,
 interviews, audit, or other investigative technique. The Compliance Officer should: (a) conduct a fair impartial
 review of all relevant facts; (b) restrict the inquiry to those necessary to resolve the issues; and (c) conduct the
 inquiry with as little visibility as possible while gathering pertinent facts relating to the issue.


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3. If, during the initial inquiry, the Compliance Officer determines that there insufficient evidence of possible
noncompliance of any criminal, civil, or administrative law to warrant further investigation, the issue should be
referred to legal counsel. A memorandum to this effect should be directed to legal counsel with a copy to the
Executive Director. The memorandum should state whether legal counsel or the Compliance Officer will be
leading the investigation. All documents produced during the investigation by legal counsel to be possibly
protected from disclosure should include the notation: “Privileged and Confidential Document; Subject to
Attorney-Client Privileges; Attorney Directed Work Product.”
4. For investigations that do not involve legal counsel, the Compliance Officer will determine what personnel
possess the requisite skills to examine the particular issue(s) and will assemble a team of investigators, as
needed. The Compliance Officer will also decide whether the Agency has sufficient internal resources to
conduct the investigation or whether external resources are necessary.
5. The Compliance Officer shall work with the investigation team to develop a strategy for reviewing and
examining the facts surrounding the possible violation. The Compliance Officer will consider the need for an
audit of billing practices and determine the scope of interviews.
6. The Compliance Officer will maintain all notes of the interviews and review of documents as part of the
investigation file. The Compliance Officer should ensure that the following objectives are accomplished:
• Fully debrief complainant;
• Notify appropriate internal parties;
• Identify cause of problem, desired outcome, affected parties, applicable guidelines, possible regulatory or
financial impact;
• Provide a complete list of findings and recommendations;
• Determine the necessary corrective action measures, (e.g., policy changes, operational changes, system
changes, personnel changes, training/education);
• Document the investigation
7. Upon receipt of the results of the investigation, depending upon the scope and severity of the identified
violations, the Compliance Officer should consult with the Executive Director, the Corporate Compliance
Committee and as directed by the aforementioned consult with inside/outside legal counsel to determine: (a) the
results of the investigation and the adequacy of recommendations for corrective actions, (b) the completeness,
objectivity and adequacy of recommendations for corrective actions; and/or (c) further actions to be taken as
necessary and appropriate, the results of which will be submitted to the Board of Directors for review.
8. Upon conclusion of the investigation, the Compliance Officer will organize the information in a manner that
enables the Agency to determine if an infraction did, in fact, occur. The Corporate Compliance Officer will
track the investigation, responsible parties and due dates in a compliance log. The log will include the resolution
of the investigation as closed or fully resolved.
9. The Compliance Officer will be responsible for reporting the results of all investigations to the Executive
Director, Corporate Compliance Committee and to the Board.

ENFORCEMENT OF COMPLIANCE STANDARDS
Disciplinary Actions
Policy: PCCS is committed to conducting its business ethically and in conformance with all federal and state
laws, regulations, interpretations thereof, and the Agency’s Code of Conduct. To support this commitment,
PCCS has developed procedures for disciplinary actions to be taken for violations of the Corporate Compliance
Program and/or Code of Conduct by employees and/or independent contractors.
Employees and independent contractors who, upon investigation, are found to have committed violations of
applicable laws and regulations, the Corporate Compliance Program, the Code of Conduct, or the Agency’s
policies and procedures will be subject to appropriate disciplinary action, up to and including termination of
employment or contract.
The following actions may result in disciplinary action:
1. Authorization of or participation in actions that violate the law, regulations and Corporate Compliance
Program, including the Code of Conduct, and all related policies and procedures;
2. Failure to report a violation by a peer or subordinate;


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3. Failure to cooperate in an investigation;
4. Retaliation against an individual for reporting a possible violation or participating in an investigation;
5. Failure to act as an honest, reliable and trustworthy service provider; and any other infraction.
Discipline will be appropriately documented in the disciplined employee’s personnel file (or in the independent
contractor’s file), along with a written statement of reason(s) for imposing such discipline. Such documentation
will be considered during regular and promotional evaluations.
The Compliance Officer and Director of Human Resources will be responsible for assuring that disciplinary
actions related to non-compliance with the law, regulations and Corporate Compliance Program, including the
Code of Conduct, are consistent with actions taken in similar instances of non-compliance.
Procedures: The Corporate Compliance Officer, or designee, will conduct periodic audits of the Agency’s
compliance with Medicaid rules and the corporate compliance in accordance with standards set forth herein. So
as to uncover any infraction, the Corporate Compliance Officer, or designee, shall investigate all complaints of
non-compliance. Based upon the results of audits and investigations, for any uncovered infraction, progressive
discipline will be implemented as decided by the PCCS Director of Program Services, based upon input from
the Corporate Compliance Officer and/or other Agency administrative personnel, which will be reported to the
Corporate Compliance Committee and the Board of Directors.
The Agency shall apply progressive discipline consistent with the violation and consistent with other
disciplinary actions for similar infractions. Examples of the disciplinary action that may be taken in accordance
with the nature and scope of the infraction include but are not limited to: (a) verbal counseling or warning; (b)
counseling with written warning; (c) retraining; (d) reassignment or demotion; (e) suspension without pay; and
(f) termination of employment, or in the case of an independent contractor, termination of the
agreement/contract.

To the extent possible, disciplinary action will be taken in accordance with the Agency’s Employees Handbook.
When the determination is made that a compliance violation has occurred, the Compliance Officer will notify
the Director of Program Services, and the individual’s supervisor, or for independent contractors, the
contractor’s representative. The Compliance Officer will notify the Compliance Committee before the next
regularly scheduled CC meeting when a full report of compliance-related disciplinary actions would normally
be presented. The Executive Director will notify the Board of Directors of the violation.
The Compliance Officer and Director of Program Services shall work in collaboration with the appropriate
supervisor/manager in determining disciplinary action related to an instance of non-compliance. The
Compliance Officer shall have the discretion to recommend a disciplinary process or disciplinary action other
than the normal disciplinary procedures and actions, as deemed necessary. The Compliance Officer shall
consult with the Director of Program Services, legal counsel, as necessary to determine the appropriate
disciplinary action to be taken.
The Director of Program Services is responsible for assuring that disciplinary action(s) taken as a result of the
violation(s) of PCCS’s Code of Conduct and/or Corporate Compliance Program is maintained in the staff
member’s personnel file, and considered during the evaluation process. The Compliance Officer will maintain a
written record of all disciplinary actions of infractions including verbal warnings, and will reference these
records when necessary to ensure consistency in the application of disciplinary measures and to determine
trends of infraction, if any, to assess future risk. The record of all infractions will be reported regularly to the
Corporate Compliance Committee and not less than annually to the Board of Directors.

RISK AREAS MANAGED BY THE COMPLIANCE PROGRAM
PCCS operates in a complex environment, needs to recognize numerous regulatory bodies, and is
exposed to various risks. Multiple individuals and groups throughout the organization are charged
with managing our compliance with various agencies. All necessary resources are engaged to fully
discharge our various responsibilities throughout the organization. The compliance program is
designed to focus on those areas of potential risk that are most relevant as a result of our
participation in Federal and State healthcare programs.



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 Policy: On an annual basis, the CO will convene and, as part of that meeting, will review the Agency’s
 performance regarding Corporate Compliance in the prior year and set forth future compliance efforts. In
 considering future compliance efforts, the committee’s deliberations are to be based upon an assessment of the
 areas that present a risk for non-compliance. Said risk assessment will be based upon a report from the CO
 regarding the prior year’s experience and the results of an annual audit performed by the CO. The CC’s
 deliberations will be documented and serve as the roadmap for Corporate Compliance for the upcoming year.
 Procedure: The Committee is to convene during June of each year, discuss and decide upon the risk areas, and
 publish its findings so that at the beginning of the next fiscal year the risk areas can be incorporated into the
 Corporate Compliance efforts.


 PCCS CODE OF CONDUCT
                                          Do the RIGHT THING
                                          CODE OF CONDUCT
 Person Centered Care Services, Inc. (“PCCS”) is dedicated to maintaining excellence and integrity
 in all aspects of its operations and its professional and business conduct. As members of the PCCS
 community, we are committed to “Do the RIGHT THING” in all our affairs. This Code of
 Conduct is our blueprint to “Do the RIGHT THING”. It provides the guiding standards for our
 decisions and actions as members of the PCCS community. Although the Code of Conduct can
 neither cover every situation in the daily conduct of PCCS’s many varied activities nor substitute
 for common sense, individual judgment or personal integrity, it is the duty of each member of our
 community to adhere, without exception, to the principles set forth herein.
 The Code of Conduct has been designed to be consistent with PCCS’s Mission Statement that is
 summarized as follows:

 MISSION - Provide services for people with developmental disabilities and through
 encouragement and support enable the exploration and expression of their unique talents to
 lead creative and successful lives.
 OUR CODE OF CONDUCT
 At Person Centered Care Services, Inc., we are guided by the following general principle: all
 patients, visitors, physicians, employees, volunteers, and students deserve to be treated with
 dignity, respect, and courtesy.
 Existing institutional policies reinforce and expand on the institution’s adherence to this general
 principal and to the principles set forth in the Code:

1. PCCS Shall Comply With All Applicable Laws.

   It is the duty of PCCS and each member of its community to uphold all applicable laws and
   regulations. All members of the PCCS community must be aware of the legal requirements and
   restrictions applicable to their respective positions and duties. PCCS expects each of its
   employees to refrain from engaging in activity, which may jeopardize the tax-exempt status of
   the organization, including inappropriate lobbying and political activities.
   PCCS shall implement programs necessary to further such awareness and to monitor and promote
   compliance with such laws and regulations.
   Any questions about the legality or propriety of any actions undertaken by or on behalf of PCCS
   should be referred immediately to one's supervisor, the PCCS Compliance Officer, or the PCCS
   General Counsel. To provide further assistance, PCCS has implemented ComplyLine, a


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   confidential telephone service that can be reached by dialing 1-347-498-4344 should a member
   of the PCCS community feel uncomfortable reporting violations or ethical concerns to any of the
   above.

2. PCCS Shall Conduct Its Affairs in Accordance With the Highest Ethical Standards.

   PCCS and all of its employees and other members of the PCCS community shall conduct all
   activities in accordance with the highest ethical standards of the community and their respective
   professions at all times and in a manner which shall uphold PCCS’s reputation and standing. No
   member of the PCCS community shall make false or misleading statements to any patient, person
   or entity doing business with PCCS.

3. All PCCS Community Members Shall Support PCCS’s Goals and Avoid Conflicts of
    Interest.

   PCCS is a non-profit organization dedicated to the provision of health care, education of health
   professionals and performance of health-related research. All members of the PCCS community
   must faithfully conduct their duties, in their assigned roles and tasks, for the purpose, benefit and
   interest of PCCS and those that it serves.
   All PCCS community members have a duty to avoid conflicts with the interests of PCCS and
   may not use their positions and affiliations with PCCS for personal benefit. Members of the
   PCCS community must consider and avoid not only actual conflicts but also the appearance of
   conflicts of interest.

4. PCCS Shall Strive to Attain the Highest Standards for All Aspects of Patient Care.

   All members of the PCCS community must support its mission to provide health services of the
   highest quality that respond to the needs of our patients, their families and the community as a
   whole. The care provided must be reasonable and necessary to the care of each patient, as
   appropriate to the situation, and, properly qualified individuals must provide such care. All such
   care must be properly documented as required by law and regulation, payor requirements and
   professional standards.

5. PCCS Shall Provide Equal Opportunity and Shall Respect the Dignity of all Members of the
    PCCS Community.

   PCCS is committed to providing educational and employment opportunities for all persons,
   without regard to race, color, national or ethnic origin, religion, gender, sexual orientation,
   disability or veteran's status. PCCS is committed to providing an academic, patient care and
   workplace environment that respects the dignity of each individual in the community. Therefore,
   sexual harassment and any other types of prohibited discrimination in any form or context will
   not be tolerated.

6. PCCS Shall Maintain the Appropriate Levels of Confidentiality for Information and
    Documents Entrusted to It.

   PCCS, its employees and other members of the PCCS community possess and have access to a
   variety of sensitive and proprietary information the confidentiality of which they are obligated to
   protect. All members of the PCCS community must adhere to the appropriate laws, regulations,


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    policies and procedures to ensure that confidential information is properly maintained and to
    prevent inappropriate or unauthorized release. PCCS and its community members shall create
    and keep records and documentation that conform to the legal, professional and ethical standards.

7. PCCS Shall Maintain a Relationship of Integrity With Each Payor Source.

    PCCS and the members of its community shall ensure that all of its requests for payment are for
    services that are reasonable, necessary and appropriate, are provided by properly qualified
    persons, and the claims for such services are billed in the correct amount and supported by
    appropriate documentation.

8. PCCS and Members of the Community Shall Conduct All Business Practices With Honesty
    and Integrity.

    All business practices of PCCS must be conducted with honesty and integrity and in a manner
    that promotes PCCS’s reputation with patients, payors, vendors, competitors and the academic
    community. All members of the PCCS community must:

• adhere to proper business practices and federal and state fraud and referral prohibitions in dealing
    with vendors and referral sources;

• conduct business transactions free from offers or solicitation of gifts, favors or other improper
    inducements;

• conform to all applicable antitrust laws and regulations, and ensure that PCCS does not violate laws
    and regulations with respect to (i) pricing or other sale terms or conditions, (ii) improper

• sharing of competitive information, (iii) the allocation of territories or (iv) the impermissible
    exclusion of others from economic activities;

• maintain and protect the property and assets of PCCS, including intellectual property and
   proprietary information, controlled substances and pharmaceuticals, equipment and supplies, and
   funds of PCCS and refrain from converting PCCS assets to personal use;

• maintain the confidentiality of proprietary information belonging to other persons or entities doing
   business with PCCS; and

• prepare accurate financial reports, accounting records, research reports, expense accounts, time
    sheets and other documents so that they completely and accurately represent the relevant facts
    and true nature of all PCCS business transactions.

9. PCCS Shall Have Proper Regard for Safety Within and Without the Community.

    PCCS and members of the PCCS community shall work to ensure a workplace that conforms
    with regulations regarding occupational health and safety. PCCS is committed to proper
    maintenance of the earth's environment, therefore, all medical waste, hazardous waste and other
    products shall be used and disposed of in accordance with all applicable environmental laws and
    regulations.



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10. The Code of Conduct Shall Be Integral to the Operation of PCCS and the Activities of the
    Community.

   The Code of Conduct exists for the benefit of PCCS and all members of the PCCS community. It
   is a dynamic document that will grow over time through the contributions of all PCCS members.
   All members of the PCCS community are encouraged to suggest changes or additions to the
   Code. The Code must be incorporated into the daily activities of PCCS and the community.
   The Code of Conduct augments, but does not limit, specific policies and procedures of PCCS,
   and PCCS community members must perform their duties in accordance with such policies and
   procedures.
   The PCCS commitment to excellence and integrity means more than just doing the best job
   possible. It is our commitment to Do the RIGHT THING. Our success and future depend on it.

   OBLIGATION TO REPORT
   As an organization, we are committed to delivering superior services within the appropriate
   regulatory framework and in compliance with all applicable laws, statutes, regulations and
   guidance. All members of our community have a fundamental responsibility to report possible
   compliance issues.
   Any PCCS employee who reports suspected misconduct and does so with a reasonable belief that
   the activity is a violation of a state, federal, local law or regulation is protected from retaliation
   by our non-retaliation policy (whistleblower protections). This policy protects employees from
   adverse actions or credible threats of adverse actions taken against them as a result of a good
   faith allegation of misconduct.

   REPORTING PROCEDURES
   Any illegal, unethical, or improper activities need to be reported, investigated and rectified.
   Violations of the PCCS Code of Conduct and the Compliance Program include, but are not
   limited to, violations of any of the following:

   • reimbursement regulations

   • health, safety and environmental laws

   • harassment/discrimination laws

   • conflicts of interest

   • unauthorized access and/or wrongful disclosure of confidential information

   • other HIPAA related privacy matters

   • internal accounting controls

   • government contracts

   DISCIPLINARY ACTION
   Disciplinary action for violations of the Code of Conduct and other PCCS policies and
   procedures shall be enforced through the disciplinary policies and procedures of PCCS,
   disciplinary actions will be determined on a case-by-case basis and may include dismissal from


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employment. PCCS will cooperate with law enforcement authorities in connection with the
investigation and prosecution of the offender.

How to Report a Violation of the Code
As a member of the PCCS community, you have a responsibility to “Do the RIGHT THING.” It
is the duty of each member of the PCCS community to uphold the standards set forth in the Code
of Conduct and to report violations by following the reporting procedures outlined by PCCS as
then in effect. Alleged violations of the Code of Conduct or other policies and procedures of
PCCS will be investigated by persons designated by, and pursuant to procedures established by,
PCCS.
You should report a violation of the Code to your immediate supervisor, manager or team leader.
Officers, managers and supervisors of PCCS have a special duty to adhere to the principles set
forth in the Code of Conduct, to support other members of the community in their adherence to
the Code, to recognize and detect violations of the Code, and to enforce the standards set forth
herein.
If you are not comfortable talking with your supervisor or not satisfied with the answer, go to the
next higher level. We encourage you to seek out another PCCS resource such as Human
Resources, Risk Management, General Counsel or Internal Audit. If your previous reports have
not been acted upon, or for any other reason, you should call or notify:
PCCS’s Corporate Compliance Office at 1-347-498-4344
PCCS’s Compliance Hotline at 1-347-498-4344
As stated above, all reports to the Compliance Hotline may be made on a confidential, no-name
basis.

WHISTLEBLOWER PROTECTIONS
It is a violation of the Code of Conduct to take any action in retaliation against anyone who
reports, in good faith, suspected violations of the Code of Conduct or other PCCS policies and
procedures. Please refer to PCCS’s Code of Conduct, and the non-retaliation policy titled
Whistleblower Protections, In addition, refer to PCCS’s policy “Preventing Fraud, Waste and
Abuse and the Federal False Claims Act”, Policy No. 102.50. This written policy includes
information about the federal False Claims Act, pertinent State laws that address false claims,
and whistleblower protections under such laws. The policy additionally provides information
with respect to the role of such laws, and the role of PCCS employees, contractors and agents in
preventing and detecting fraud, waste and abuse in federal health care programs.
Please note that the Code of Conduct does not create any contract of employment, express
or implied, between PCCS and any individual. PCCS reserves the right to amend the Code
of Conduct at any time in its sole discretion. The Code will be reviewed on an annual basis,
if not more frequently, for required changes by the Chief Compliance Officer.

RECORD RETENTION
PCCS shall document and retain records of all requests for information regarding payment policy
from a government agency and all written or oral responses received. Such records are critical if
PCCS intends to rely on such responses to guide them in future decisions, actions or claim
reimbursement requests or appeals, while further underscoring PCCS’s commitment to
compliance with the law.

PCCS is committed to complying with the record and documentation requirements under federal
or state law and to the maintenance and retention of records and documentation necessary to
confirm the effectiveness of PCCS’s Compliance Program. Such documentation includes, but is


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not limited to, a ComplyLine log, minutes of Compliance Committee meetings, educational
presentation overviews, handouts and attendance sheets and documentation of ongoing auditing
and monitoring efforts.

SUMMARY
The PCCS commitment to excellence and integrity means more than just doing the best job
possible. It is our commitment to Do the RIGHT THING. Our success and future depend on it




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