Ontario ARC Corporate Compliance Plan

As a not-for-profit human services organization dedicated to improving the lives of people with intellectual and developmental disabilities, Ontario ARC is committed to complying with the rules and regulations of federal, state and local government.  This includes but is not limited to those issued by the Centers for Medicare and Medicaid Services (CMS) and the New York State Office for Persons with Developmental Disabilities (OPWDD).  The agency seeks to provide a work environment where high standards of ethical and legal behavior are recognized and practiced. 

 

ELEMENTS OF OUR COMPLIANCE PLAN

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 may not have abided by the agency Code of Conduct ;

  4. Taken steps to communicate the standards to our employees and agents;

  5. Engaged in auditory and monetary compliance 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.

  8. A policy of non-intimidation and non-retaliation for good faith participation in the compliance program.

The Corporate Compliance Plan was instituted by the Board of Directors September 14, 2009.  Our Corporate Compliance Plan also supports and complies with the Arc NY Board of Governors’ policy requiring that each chapter of Arc NY implement an effective Corporate Compliance Plan. 

Ontario ARC 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 agency expects that all aspects of business conduct and supports to individuals will be performed in compliance with this Corporate Compliance Plan, professional standards and applicable governmental laws, rules and regulations.   

ELEMENT I: Corporate Compliance Plan - Policies & Procedures

Our compliance philosophy is expressed within this Corporate Compliance Plan and related documents, including our Code of Conduct, our 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 Ontario ARC employees and, as applicable, independent contractors, volunteers and the members of the governing Board and Foundation Board.  Understanding and following these standards will reduce the prospect of unethical, illegal and criminal conduct.

A. Code of Conduct

The purpose of the agency’s Code of Conduct is to provide information and guidance to all employees, independent contractors and the Board to assist in carrying out the day-to-day responsibilities within legal and ethical standards. 

Ontario ARC’s Code of Conduct is a set of guiding principles that are more completely developed in the Corporate Compliance manual and its related policies and procedures.  The Code of Conduct reflects our tradition of caring, provides guidance to ensure our work is done in an ethical, legal manner.  It emphasizes the shared common values and culture we seek to cultivate that guides our actions each day.

We require that each employee, independent contractor and Board member sign a written acknowledgment that he or she understands and will follow our Code of Conduct.

B. Policies and Procedures

Ontario ARC has developed and will continue to develop 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.  We review the policies and procedures on an annual basis, revising and developing new policies and procedures, as necessary, to ensure that Ontario ARC’s operations are conducted with “best practices.”  The policies and procedures are not only the health regulatory components of the agency, but also those related to human resources, environmental health, safety and financial operations and shall apply broadly to each employee through this Corporate Compliance Plan.

ELEMENT II: Compliance Program Structure & Oversight Responsibilities.

We are committed to the operation of an effective compliance program and have assigned compliance oversight responsibilities to individuals at the management level.  Individuals with day-to-day compliance oversight authority occupy high levels in the agency’s organizational structure, including a Corporate Compliance Officer, and are empowered to implement the Corporate Compliance Plan, investigate compliance concerns, and report compliance concerns directly to those in higher positions of authority, up to and including, the Board President, the Board of Directors and the Executive Director. 

We have established a Corporate Compliance Committee comprised of key management and operations staff and agency leadership with responsibility to meet regularly to advise the Corporate Compliance Officer.  This committee identifies and resolves compliance concerns and continues to improve and refine the agency’s overall compliance activities.  The Board of Directors will be an integral part of the Corporate Compliance Plan and will be knowledgeable about the content and operation of the agency’s Corporate Compliance Plan.  The Board will exercise oversight with respect to the implementation and effectiveness of the Corporate Compliance Plan.

ELEMENT III: Due Care in Assignment of Responsibilities - Background Checks

Ontario ARC agency will use due care not to employ or contract with any individual who may not have abided by the agency Code of Conduct.   In order to maintain the integrity of our services and financial and business operations, it is critical that the agency hire and contract with individuals and entities that have the same respect for applicable legal and ethical obligations that the Ontario ARC possesses.   This standard applies to personnel in positions with “substantial” control over the agency, 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, upon hire, whether he or she has committed a crime, including health care related crimes.  The Criminal Background Check database informs Human Resources when any current employee is convicted of an offense that would disqualify him/her from employment.

Further, Ontario ARC will check employees upon hire, check existing employees, independent contractors and Board members monthly to determine whether they have been excluded from participation in the New York State or federal healthcare programs by checking the following exclusion list databases:

  1. 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. 

  2. The Excluded Parties List System, which identifies those parties excluded from receiving federal contracts or certain subcontracts and certain types of federal financial and non-financial assistance and benefits. 

  3. The New York State Office of Medicaid Inspector General Exclusion List database.

The agency also checks the New York State Education Department licensing database monthly to confirm that agency clinicians have valid clinical licensure. 

The agency will comply with requirements promulgated under state law with respect to background checks and appropriate screening activities as those requirements apply to personnel within the agency operations.

ELEMENT IV: Education &Training

The Board of Directors, all employees and, as applicable, independent contractors, must be informed about regulatory requirements and agency’s policies and procedures that implement these requirements, as they apply to each individual.  Therefore, Ontario ARC will adequately train the Board, high-level personnel, substantial authority personnel, employees and independent contractors on the organization’s standards and procedures.  The agency will continuously identify training topics, including those arising as a result of self-monitoring, audits by regulatory agencies and regulatory developments.

All new employees will receive training regarding our Code of Conduct, this Corporate Compliance Plan and those policies and procedures relevant to their job duties as part of an orientation program.  Ontario ARC will tailor its training based on the roles and responsibilities of each group of individuals and in a manner that the individual can understand. 

 

ELEMENT V: Auditing & Reporting

A. Internal Auditing and Monitoring

Ontario ARC is committed to routinely conducting internal audits of concerns that have regulatory or compliance implications.  Agency Quality Assurance staff will be responsible for conducting internal audits within all program services and selected support services,  as identified by risk assessment. 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.

B. Reporting by Employees

Each employee has a responsibility to report through our compliance processes any activity by any colleague, supervisor, clinician, independent contractor or client 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 employees feel free to report behaviors or action, which they believe should be reported.  Therefore, the effectiveness of our Corporate Compliance Plan depends on the willingness and commitment of the employees in all parts of the agency to step forward, in good faith with questions and concerns.  Likewise, we are committed to making every effort to maintain, within the limits of the law, the confidentiality of the identity of anyone (individual) who reports a concern in good faith. 

It is an expected good practice, for concerns to be raised first with a supervisor.  If this is not comfortable or not a viable option, then employees are encouraged to either contact the Corporate Compliance Officer or the Corporate Compliance Hotline, at (585) 393-5678, where reports may be made anonymously and confidentially.   

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: Supervisory Incentives & Actions

Ontario ARC seeks to reward employees who foster a culture of compliance.  This is demonstrated through a variety of reward and recognition activities, positive feedback and continued business relations with contractors.             

Failure to comply with the Corporate Compliance Plan, policies and procedures, the Code of Conduct and/or laws and regulations applicable to the agency may result in supervisory 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 supervisory issues will be determined through the Corporate Compliance Plan structure in direct cooperation with the appropriate director, Human Resources Director, Senior Associate Executive Director and the Corporate Compliance Officer and, as appropriate the agency Executive Director.  The degree of supervisory action may range from 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 will strive to be consistent in its approach to use the same supervisory action for similar offenses.

ELEMENT VII: Detection & Response

Ontario ARC is committed to fostering our culture of compliance through detecting, correcting and preventing non-compliance actions.  Through the process of our corporate compliance reporting and communication of our compliance-related roles and responsibilities at every level of the agency’s operations, detection and correction of problems is expedited.

If an internal investigation substantiates a reported violation, then it is our policy to:

(1)  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)  Implement systemic changes, as indicated, to prevent re-occurrence of a similar violation.

 

ELEMENT VIII: Non-Intimidation and Non-Retaliation

Ontario ARC requires all employees, Board members and volunteers 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 the agency is governed.   Ontario ARC provides an environment that encourages individuals to report any possible violations without fear of retaliation or retribution. 

Intimidation or retaliation will not be permitted against anyone who in good faith participates in the Compliance Plan, to include, but not limited to: reporting potential issues, investigating issues, self-evaluations, audits and remedial actions and reporting to appropriate officials.  If an employee engages in such actions of retaliation or intimidation, it may result in disciplinary action, up to and including termination. 

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