CORPORATE COMPLIANCE PROGRAM OVERVIEW
The Center for Discovery (“The Center”) prides itself on over 65 years of upholding the highest standards of quality in its programs and services to children, adults, and their families. The Center for Discovery strives to develop and maintain best practices in all areas of service. Consistent with this commitment to quality, the Center for Discovery establishes this Corporate Compliance Program to demonstrate and document our commitment to the highest level of professional integrity and ethics in the agency’s business dealings with the people served, contractors, vendors, employees, funding agencies and the general public.
This Corporate Compliance Program is established for the entire Center for Discovery community, including its employees, contractors, agents, vendors, members and officers of the Board of Directors, volunteers, and employees and others working on behalf of other agencies and businesses doing business with the Center for Discovery and its related corporations. This Corporate Compliance Program is intended to benefit not only the members of the Center for Discovery community, but those governmental and private agencies doing business with the agency, as well as the general public.
This Corporate Compliance Program demonstrates the Center for Discovery’s commitment to Integrity in all business dealings by the following eight elements:
Statement of the Center for Discovery’s Commitment:
The Center for Discovery’s Board of Directors will establish and maintain a Corporate Compliance Program to reinforce their commitment to ethics and integrity in all of the agency’s business dealings.
This will be accomplished by:
- Adoption of a Board Resolution establishing this Corporate Compliance Program and reinforcing the corporation’s commitment to the principles of corporate compliance.
- A Code of Conduct for the Center for Discovery community, upholding the agency’s commitment to ethics and integrity in all of its business dealings, to ensure that all aspects of individual care and business conduct are performed in compliance with our mission/vision statement, policies, and procedures, professional standards and applicable governmental laws, rules and regulations and other payer standards. The Center for Discovery expects every person who provides services adhere to the highest ethical standards and to promote ethical behavior. Any person whose behavior is found to violate ethical standards will be disciplined appropriately.
- The Compilation and Dissemination of Policies and Procedures addressing principles of business integrity and addressing compliance with applicable laws, regulations, and standards. Education and training are critical elements of the Corporate Compliance Program. The Center for Discovery community is expected to be familiar and knowledgeable about the Compliance Program and have a solid working knowledge of his or her responsibilities under the plan. Compliance policies and standards will be communicated to all employees through required participation in training programs.
Program Structure and Oversight Responsibility:
The Center for Discovery is committed to an effective compliance program and has assigned oversight responsibility to the Corporate Compliance Officer (CCO). This CCO maintains supervision of the staff within the Center for Discovery’s Corporate Compliance and Quality Improvement Departments. The Center for Discovery has also established a Governance and Corporate Compliance Committee of the Board of Directors to advise and assist the Corporate Compliance Officer with implementation of the compliance plan. The Corporate Compliance Officer shall investigate compliance concerns, and report compliance concerns to the Committee, the Chief Executive Officer and ultimately to the entire Board of Directors. The Corporate Compliance Officer reports directly to the Chief Executive Officer and to the Center for Discovery’s Board of Directors on the activities of the Corporate Compliance Program.
Education and Training:
All employees and persons associated with the Center for Discovery, including governing body members, will be trained on compliance issues, expectations, and the compliance program operation. Such training initially occurs during the Center for Discovery’s orientation process, and annually thereafter. All employees will be informed about regulatory requirements and Agency policies and procedures relevant to their job duties. Specialized training in Corporate Compliance topics such as service documentation requirements, and personal allowance management requirements shall be conducted as part of the routine staff training programs. Any additional training topics that may be identified as a result of Quality Improvement/Corporate Compliance Department internal audits, billing documentation reviews, or other reviews conducted by regulatory staff will also be incorporated into trainings as needed.
This will be accomplished by:
- Initial and ongoing training on the Code of Conduct and Compliance Guidelines, the False Claims Acts (FCA), as well as other aspects of the Corporate Compliance Program and policies, procedures, and standards for business integrity.
- Communication and publication of the Code of Conduct and Compliance Guidelines, as well as other aspects of the Corporate Compliance Program, and policies, procedures and standards, to all members of the Center for Discovery community.
Additionally, all members of The Center community are instructed to contact the Corporate Compliance Office if they have any questions.
Ongoing Monitoring and Detection:
Each employee has an individual responsibility for reporting any activity by any colleague, clinician, contractor, or vendor that appears to violate applicable laws, rules, regulations, standards of professional practice, accreditation standards, or the Center for Discovery’s Compliance Program. In addition, The Center for Discovery encourages employees, contractors, and family members to report behaviors or actions they believe to be contrary to the intent and provisions of the Corporate Compliance Program. The effectiveness of the Corporate Compliance Program depends on the willingness of all employees and other agents of The Center at all levels and departments to bring forth in good faith, any questions and concerns. The reporting of violations of standards, policies, and procedures for business operations can be made to an immediate supervisor or program administrator in person, via telephone, e-mail or letter. If an individual prefers not to report a potential violation to an administrator or a manager, the information can be reported directly to the Center for Discovery’s Corporate Compliance Officer by calling the Corporate Compliance “HOTLINE” at (845) 707-8811. The “hotline” is established for the purpose of reporting potential compliance issues as they are identified. This hotline number shall be accessible to all employees, persons associated with the Center for Discovery, executives and members of the Board of Directors. Reports of potential violations and all information reported to the hotline will be treated confidentially. The “hotline” shall be monitored by the Corporate Compliance Office.
Failure to comply with the Center for Discovery’s Corporate Compliance Plan, Code of Conduct, Center for Discovery policies and procedures, and/or other applicable laws and regulations will result in disciplinary action. Disciplinary action will occur as a result of failing to report suspected problems; participating in non-compliant behavior; or, encouraging, directing, facilitating, or permitting non-compliant behavior. The degree of discipline may vary from counseling, verbal warnings, written warnings up to and including termination from a position at the Center for Discovery or termination of a contract. If misconduct occurs, and it is determined to be based upon a lack of awareness or understanding of a regulatory requirement or policy by that staff, retraining of that staff will occur if that staff member continues employment with the Center for Discovery. Any form of retaliation against any employee who questions or reports a perceived problem or concern in good faith is strictly prohibited. Enforcement and disciplinary action shall not be determined unilaterally, but will be determined by the program administrator in direct consultation with the Corporate Compliance Office and with appropriate department supervisors. Any employee who deliberately makes a false accusation with the purpose of retaliating against or harming another employee is subject to disciplinary action.
As a result of Corporate Compliance Department internal audits, Quality Improvement Department internal audits, billing documentation reviews, or other reviews conducted internally or externally, any identified areas of compliance risk shall be evaluated for the risk of potential or actual non-compliance. The Center for Discovery will assess the effectiveness of the compliance program to identify potential risk areas by routinely conducting internal audits of concerns which have regulatory or compliance implications. The compliance program itself will be evaluated on an ongoing basis to determine the effectiveness of the required components of the Plan through self-auditing, Corporate Compliance Office reviews and reports to the Board of Directors. When an audit reveals areas needing additional information or education of employees and/or providers, the Center for Discovery will analyze whether these areas should be incorporated into the training and education program.
Prompt and Appropriate Response to Identified Violations:
The Center For Discovery is committed to the prevention, prompt detection and correction of non-compliant behaviors. If an internal investigation substantiates a reported violation, the Center will 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 implementing systemic changes to prevent a similar violation from recurring in the future.
This will be accomplished by:
- Internal investigation procedures in response to compliance issues as they are raised.
- Prompt and appropriate responses to identified violations as a result of self-evaluations and audits.
- Prompt and thorough correction of identified violations.
- Implementing policies, procedures, and systems as needed to reduce the potential for reoccurrence.
- Identifying and reporting identified compliance issues to the appropriate governmental authorities.
- Refunding overpayments.
Non-intimidation and Non-retaliation Policy for Good Faith Participation in the Compliance Program:
The Center for Discovery recognizes that a critical aspect of the compliance program is the establishment of a culture that promotes prevention, detection, and resolution of instances of conduct that do not conform to applicable laws and regulations, professional standards and federal, state, and private payer healthcare program requirements, as well as the Center’s ethical and business policies. To promote this culture, The Center for Discovery established a strict non-retaliation policy to protect from retaliation all employees and others who report problems and concerns in good faith. An Employee or agent may also report his/her concerns about perceived violations of federal and state laws and regulations and/or financial irregularities to appropriate governmental agencies without fear of reprisal or retaliation.
The Center for Discovery, Inc. Compliance Policy
CODE OF BUSINESS CONDUCT
The Center for Discovery (CFD) requires all members of the CFD community, including its employees, contractors, agents, vendors, members of the Board of Directors and employees and others working on behalf of other governmental and private agencies and businesses doing business with CFD and its affiliates, to conform to the highest ethical standards and to meet or exceed legal obligations in the performance of their efforts on behalf of CFD. To this end, we have developed a Code of Business Conduct for the entire CFD community. The appointment and retention of all members of the CFD community is contingent upon acceptance and compliance with this Code of Business Conduct.
The Center for Discovery enjoys a reputation of integrity and excellence in its programs and services. This reputation is one of our strongest assets. It is expected that all members of the CFD community whose actions could be attributed to the work of CFD will adhere to the code of Business Conduct and to the policies, standards and procedures outlined in this program.
The Center for Discovery Code of Business Conduct encompasses commitments by CFD, coupled with related commitments by each member of the CFD community to uphold the highest standards of ethical behavior and practices on behalf of CFD.
Our Compliance with the law
The Center for Discovery is committed to conducting its programs and services in a lawful and ethical manner, in full compliance with federal, state and local laws and regulations. All members of the CFD community will adhere to the highest standards of conduct through strict observation of all applicable legal and regulatory requirements.
The Center for Discovery will only employ or contract with individuals or entities with proper credentials, experience and expertise. All business communications on behalf of CFD with outside individuals or entities, including claims for payment or reimbursement of any kind, will be truthful and, where appropriate, substantiated by accurate and complete records.
Neither The Center for Discovery, its employees nor agents shall pay employees, physicians, or other health care professionals, directly or indirectly, in cash or by any other means, for referrals of patients. Every payment to a referral source must also be supported by proper documentation that the services contracted for were in fact provided.
Employees or agents who perform billing and/or coding of claims must take every reasonable precaution to ensure that their work is accurate, timely, and in compliance with federal and state laws and regulations and CFD policies.
No claims for payment or reimbursement of any kind that are false, fraudulent, inaccurate or fictitious may be submitted. No falsification of medical, time or other records that are used for the basis of submitting claims will be tolerated.
The Center for Discovery will bill only for services actually rendered and which are fully documented in patients’ medical records/consumer charts. If the services must be coded, then only billing codes that accurately describe the services provided will be used.
The Center for Discovery shall act promptly to investigate and correct the problem if errors in claims that have been submitted are discovered.
Our commitment to ethical behavior.
The Center for Discovery is committed to ethical business dealings. All members of the CFD community will adhere to the highest ethical standards of behavior while performing CFD business, including preparing and maintaining accurate and complete records, and truthful communications with other members of the CFD community, and with government and private agencies and individuals doing business with CFD.
The Center for Discovery seeks positive relationships with government programs and third-party payers. Positive relationships require ongoing communication about patient progress and billing.
Employees or agents shall not use or reveal any confidential information concerning CFD or use, for personal gain, confidential information obtained as an employee or agent of CFD.
No employee or agent should subordinate his or her professional standards, judgment or objectivity to any individual. If significant differences of opinion in professional judgment occur, then they should be referred to management for resolution.
Employees and agents should be honest and forthright in any representations made to patients, vendors, payors, other employees or agents, and the community.
All reports or other information required to be provided to any federal, state or local government agency shall be accurate, legible, complete and filed on time.
Employees and agents must perform their duties in a way that promotes the public’s trust in CFD.
Employees and agents shall be honest in doing their jobs.
Our commitment to continuous training and improvement.
The Center for Discovery is committed to the professional development of the entire CFD community. All members of the CFD Community will have access to all applicable laws, rules, regulations, policies and procedures necessary for them to perform on behalf of CFD, and will be regularly trained on those laws, rules, regulations, policies and procedures, as well as this corporate compliance program.
Our commitment to continuous monitoring and enforcement.
The Center for Discovery is committed to full and ongoing enforcement of this Code of Business Conduct and of the standards contained in the Corporate Compliance program. As a condition of employment or appointment, all members of the CFD community are expected to rigorously comply with all applicable laws, rules, regulations, policies and procedures.
All members of the CFD community will report suspected violations of these standards of conduct to their supervisor, an appropriate departmental head, an appropriate staff member of the Human Resources Department or to the Corporate Compliance Committee. CFD assures the entire CFD community that reports of suspected violations may be made without fear of reprisal or retaliation, and that confidentiality will be protected within the limits of the law.
All reports of suspected violations will be fairly, thoroughly and promptly investigated by appropriate individuals, and will be promptly resolved.
Our commitment to our ethical obligations, mission and purposes free of conflicts of interest.
The Center for Discovery is committed to clarity of our mission and purposes, free of any appearance of conflict or impropriety. CFD itself will not pursue any business opportunity or take any other action that will require it to engage in illegal or unethical behavior, or is reasonably likely to fall outside of the CFD mission, purposes or powers.
In all of their activities on behalf of CFD, all members of the CFD community will act in a manner consistent with the agency’s mission, purposes, powers, and consistent with the agency’s reputation for integrity and excellence. Each member of the CFD community will ensure that no activity takes place that in any way jeopardizes the tax exemption, licenses, or governmental authorizations of CFD.
All members of the CFD community will accomplish their business on behalf of CFD without engaging in any business, professional or personal activity that would create a conflict of interest, or an appearance of a conflict of interest, without appropriate disclosure and advance approval by the Board of Directors or the President & CEO or their designee.
Placing business with any firm in which there is a family relationship may constitute a conflict of interest. Advance disclosure and approval are required in such a situation.
Employees and agents should not become involved, directly or indirectly, in outside commercial activities that could improperly influence their actions. For example, an employee or agent should not be an officer, director, manager or consultant of a potential competitor, customer, or supplier of CFD without first disclosing that relationship to management.
Employees and agents should not accept or provide benefits that could be seen as creating conflict between their personal interest and CFD’s legitimate business interests.
Employees and agents should report any potential conflicts of interest concerning themselves, co-workers or family members to management.
Program and other staff should not have direct contact with vendors unless their input is required in the process of determining choice of vendors. CFD will notify vendors and employees of this policy.
Please refer to the Rules Relating to Gifts, and Conflict of Interest Policy, which appear on the following pages.
Our commitment to respecting property rights.
The Center for Discovery is committed to respecting the property rights of all those with which we do business, including consumers and outside businesses. In their actions on behalf of CFD, all members of the CFD community will act in a manner consistent with this respect of the property of others.
Each member of the CFD community will ensure that all applicable laws, standards and policies regarding the confidentiality of agency records are upheld.
Each member of the CFD community will ensure that all private information owned by others, but in the custody and possession of CFD, be held in confidence and not utilized outside of the use contemplated by the owner of the information without the express permission of the owner. This includes prohibition against unauthorized use and/or copying of computer software not contained in the license granted to CFD, and installation of unauthorized software on agency computers. Employees shall take all reasonable steps to protect computer systems and software from unauthorized access or intrusion.
All employees and agents are personally responsible and accountable for the proper expenditure of CFD funds and for the proper use of company property.
All employees and agents must obtain authorization prior to committing or spending CFD funds.
Employees and agents may not use CFD or a consumer’s resources for personal or improper purposes, or permit others to do so.
Surplus, obsolete or junked property shall be disposed of in accordance with CFD’s procedures. Unauthorized disposal of property is a misuse of assets.
Any improper financial gain to the employee, or agent, through misconduct involving misuse of CFD’s or a consumer’s property is prohibited, including the outright theft of property or embezzlement of money.
CFD’s confidential and proprietary information is valuable, and should be protected from unauthorized use or exploitation. Employees and agents are expected to respect the intellectual property rights of others with whom we do business.
Employees and agents are expected to report any observed misuse of CFD’s property to management.
RULES RELATING TO GIFTS:
The following rules apply to all employees and agents of The Center for Discovery;
Employees and agents may never accept gifts in the form of cash or cash equivalents from any individual or business entity that does business with CFD.
Employees and agents may never accept gifts of any kind from individuals or business entities who are in the process of competitive bidding for a contract with CFD, or whose contracts are under review as to whether the contract should be continued.
Outside vendors will be notified on an annual basis, in advance of the winter holiday season, of CFD’s policies with regard to gifts. In that notice, outside vendors will be requested to refrain from giving gifts to individual CFD employees or agents. The notice will also suggest that if the vendor wishes to make a gift, it be done to the agency’s holiday fund; alternately, an in-kind gift can be made for a consumer or staff holiday party.
All CFD staff will be notified on an annual basis, in advance of the winter holiday season, of CFD’s policies with regard to gifts.
CONFLICT OF INTEREST POLICY
No person who is an employee of CFD shall serve as a Director or Officer of another agency that primarily provides services to individuals with disabilities in programs or services under license issued by New York Office for Persons with Developmental Disabilities or Office of Mental Health, or their successors, without first obtaining approval of the President/Chief Executive Officer.
No person who is an employee of CFD shall also be a paid employee or consultant to an agency that primarily provides services to individuals with disabilities in programs or services or under license issued by New York Office for Persons with Developmental Disabilities or Office of Mental Health, or their successors, where the individual’s work on behalf of the other agency involves formation or communication on issues of public policy, without first obtaining approval of the President/Chief Executive Officer.
Note that compliance with this Code of Business Conduct, as well as other codes of conduct established by CFD, is mandatory for all employees and consultants of CFD. However, these codes of conduct are not, and shall not be construed as, a contract of employment or any other type of contract. Unless specifically governed by a collective bargaining agreement that states otherwise, employment with CFD is at all times strictly “at will”, as defined by New York law, and either the employee or CFD has the right to terminate the employment relationship at any time for any reason or for no reason.
THE FALSE CLAIMS ACTS
Under the United States and New York False Claims Acts (the “FCA”), the government and private citizens are entitled to bring lawsuits against organizations or other individuals who defraud the government.
Persons or agencies found to have violated the FCA may be required to pay triple damages done to the government and a fine between $5,000 and $11,000 for every false claim. In addition, there can be criminal penalties of up to five years in prison and/or up to a $10,000 fine.
Private citizens who institute an FCA claim must provide to the government all of the information he or she has about the claim. If the government intervenes in the case, the relator may be entitled to a share in the eventual recovery.
The FCA provides protection to shield private citizens from retaliation for starting a qui tam case in good faith.
If you suspect any activity that may be considered a violation of the federal or New York State law, you should report it immediately to your supervisor or another appropriate Center for Discovery director, or the Corporate Integrity Hotline at (845) 707-8811.
NON-RETALIATION POLICY STATEMENT
The Center for Discovery (CFD) encourages its employees and independent contractors to disclose and report concerns regarding perceived violations of federal and state laws and regulations and/or financial irregularities. Reports may be made by any employee or independent contractor openly, confidentially or anonymously, and may be made in writing, by telephone (to an individual or to the Corporate Integrity Hotline), or in person without fear of reprisal to any CFD Administrator. Employees who wish to remain confidential or anonymous may do so in writing by sending their concerns by US Mail or by interoffice mail to the In House Counsel marked “personal and confidential”, or by leaving a message on the Corporate Integrity Hotline at (845) 707-8811.
Employees and independent contractors may also report their concerns about perceived violations of federal and state laws and regulations and/or financial irregularities of federal and state laws and regulations to appropriate governmental agencies without fear of reprisal or retaliation. CFD may take appropriate action in the event that, after investigation, it is determined that a complaint was false and malicious. CFD complies with all of the requirements of federal and state statutes and regulations concerning employee disclosure.
Please refer to the Code of Business Conduct contained in the CFD Corporate Integrity Program for additional guidance.
Corporate Compliance Handbook July 2019
CC-1.1 Corporate Compliance Program Overview
CC-1.2 Code of Conduct Development and Dissemination
CC-1.3 Code of Conduct
CC-1.4 Conflict of Interest Policy and Procedure
CC-1.4A Conflict of Interest Disclosure Statement (General Employees)
CC-1.5 Ethical Standards for Officers, Directors and Key Employees
CC-1.5A Conflict of Interest Disclosure Statement (Officers, Directors and Key Employees)
CC-1.6 Policy Development and Implementation
CC-1.7 Gift Acceptance Policy and Procedure
CC-1.7A Holiday Gift Giving Letter
CC-2.1 Role and Responsibilities of the Corporate Compliance Officer
CC-2.2 Corporate Compliance Officer Position Description
CC-2.3 Compliance Office Confidentiality
CC-2.4 Compliance Officer, Legal Counsel Coordination
CC-2.5 Board of Directors Quality Improvement and Corporate Compliance Committee
CC-4.1 Corporate Compliance Hotline
CC-4.2 Hotline Tracking Form
CC-4.3 Investigation of Compliance Issues
CC-4.4 Compliance Issue Resolution
CC-4.5 Protecting Reporter Confidentiality
CC-4.6 Protocol for the Office of People Operations
CC-4.7 Corporate Compliance Office Records Management
CC-4.8 Reporting Findings from Compliance Program Audits
CC-9.1 Audit Outlines
CC-9.1A Clinic Chart Audit Outline
CC-9.1B Day Hab Billing Audit Outline
CC-9.1C IRA/Res Hab Billing Audit Outline
CC-9.1D Program Petty Cash Audit Outline
CC-9.1E Resident Funds Audit Outline
CC-9.1F Residential Petty Cash Audit Outline
CC-9.2 Audit Forms
CC-9.2A Fiscal Audit – Internal Control Audit Form
CC-9.2B Group Day Habilitation Billing and Claiming Internal Audit Form
CC-9.2C IRA Residential Habilitation Billing and Claiming Internal Audit Form
CC-9.2D MSC Billing and Claiming Internal Audit Form checklist
CC-9.2E IRA, Day Hab, MSC checklist
CC-9.2F Documentation/Regulation Checklist for Article 28 Services
CC-9.2G Administrative, QA, and Corporate Compliance Checklist for Article 28 Services
CC-9.2H Criminal Background Check Audit Form
CC-9.2I Article 28 Individual Case Review Worksheet
CC-9.2J ICF Audit Form
CC-9.2K POCA Form
CC-9.2L Program Petty Cash Audit Form
CC-9.2M Residential Petty Cash Audit Form