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Cambridge Counseling Center

 

　

Corporate Compliance Plan

　

2014 Update

　

Article 1. Introduction.

This Corporate Compliance Plan has been adopted by the Executive Committee of Cambridge Counseling Center, Inc. to promote adherence to applicable Federal and state laws, rules and regulations and the program requirements of Federal, state and private health plans (collectively, "Program Requirements").

The principal objective of this Corporate Compliance Plan is to develop implement and maintain effective internal controls that will help to (a) prevent, detect, report and correct violations of Laws and Program Requirements, (b) advance the prevention o fraud, abuse and waste; and (c) further the mission of Cambridge Counseling Center to provide quality care to consumers.

It is the policy of Cambridge Counseling Center, to conduct and oversee their operations as model corporate citizens; to assure the establishment of operational procedures that comply with all Laws and Program Requirements; to monitor activities and remedy any harm caused by the violation of such Laws and Program Center staff as defined below); to maintain a zero tolerance for violations of Laws and Program Requirements, fraud, waste, or abuse, and of this Corporate Compliance Plan (collectively, "Policies and Procedures"); and to enforce or cause the enforcement of sanctions on those who violate these principles.

This Corporate Compliance Plan has been developed with the intention of complying substantially with the Compliance Program for Agencies issued by the Ohio Department of Mental Health.

Appropriate Policies and Procedures shall be developed, implemented and maintained to effectuate the purposes, objectives, and policies explicitly and implicitly embodied in this Corporate Complicate Plan.

Applicability.

Cambridge Counseling Center shall be subject to this Plan.

The provisions of this Corporate Compliance Plan apply to everyone involved in overseeing, managing and operating all components of Cambridge Counseling, including members of the Executive Committee, corporate officers, Directors, supervisors, employees, students, volunteers and , as applicable, contractors. All such individuals shall be referred to collectively as "Cambridge Counseling Center staff" throughout this Corporate Compliance Plan.

Cambridge Counseling expects all Cambridge Counseling Center staff to be familiar with all Laws and Program Requirements applicable to Cambridge counseling operations and business conduct and to comply with them. Each individual who is classified as Cambridge Counseling Center staff, no matter what position he or she may hold at Cambridge Counseling, is responsible for compliance with such Laws and Program Requirements.

Cambridge Counseling cannot and does not approve of an action by any Cambridge counseling Center staff that violates any Law or Program Requirement. No Cambridge Counseling Center staff, whatever his or her position, is authorized to depart from this Corporate Compliance Plan or the Policies and Procedures or to condone a departure by anyone else. Any Cambridge counseling Center staff who knowingly participates in, or who directs, authorizes or permits a subordinate to engage in any violation of this Corporate Compliance Plan or the Policies and Procedures will be subject to disciplinary action, including discharge or termination, when appropriate and in accordance with Cambridge Counseling disciplinary policies.

Governance and Organization.

Executive Committee. The Executive Committee of Cambridge counseling Center has overall authority and responsibility for oversight of this corporate Compliance plan. The Executive Committee

Audit and Corporate Compliance Committee. The Executive Committee of Cambridge Counseling Center has appointed a Corporate Compliance Team, whose principal purpose is to assist the Executive Committee of Cambridge counseling in fulfilling the responsibilities relating to, among other things, the adequacy of processes to assure compliance with all Laws and Program Requirements.

Corporate Compliance Officer. Cambridge Counseling Executive Director, with the concurrence of the Executive Committee of Cambridge Counseling Center, has appointed a Corporate Compliance Officer. The Corporate Compliance Officer shall report directly to the Executive Director, and to the Executive Committee.

The Corporate Compliance Officer shall have the authority and responsibility to take all appropriate action deemed reasonably necessary for the establishment and operation of the compliance program contemplated by this Corporate Compliance Plan. The Corporate Compliance Officer’s primary responsibilities shall include: (i) overseeing, monitoring and enforcing this Corporate Compliance Plan and the Plicies and Procedures; and (ii) reporting on a regular basis, and not less than quarterly, to the Executive Director, and the Executive Team of Cambridge counseling Center o n the progress of the implementation of this Corporate Compliance Plan.

Without limiting the generality of the foregoing, the duties, responsibilities and authority of the Corporate Compliance Officer shall include the following:

Working with Cambridge Counseling Executive Director, General Counsel, and other officers, managers, supervisors and personnel in the preparation and development of, and overseeing the implementation, monitoring and enforcement of, written Policies and Procedures on specific Laws and program Requirements and matters involving ethical, legal and business practices;

Developing, coordinating, implementing and participating in a multi-faceted educational and training program for Cambridge Counseling Center staff that focuses on the elements of this Corporate Compliance Plan and the Policies and Procedures, and seeks to ensure that all Cambridge Counseling Center staff are knowledgeable of, and comply with, all Laws and Program Requirements and ethical, legal and business practices;

Handling inquiries by Cambridge Counseling Center staff regarding any aspect of this Corporate Compliance Plan or any matters that may concern any Cambridge Counseling Center staff with respect to compliance under this Corporate Compliance Plan;

Independently investigating and acting on all matters related to compliance with or violations of Laws and Program Requirements, and any information or allegation concerting possible unlawful, unethical or improper business practices and recommending corrective action when necessary, all in coordination with the General Counsel;

Planning and overseeing regular, periodic audits of the operations of Cambridge Counseling in order to identify and rectify any possible barriers to the efficacy of this Corporate Compliance Plan;

Coordinating personnel issues with Cambridge Counseling human resources, purchasing and criminal reports have been checked with respect to applicable Cambridge Counseling Center staff;

Assisting Cambridge Counseling financial management in coordinating internal compliance review and monitoring activities, including annual or periodic reviews of programs;

Ensuring that independent contractors and agents who furnish services, coding or billing services to Cambridge Counseling are aware of the requirements of this Corporate Compliance Plan and the relevant Policies and Procedures with respect to coding, billing, and other matters;

Periodically recommending revisions to this Corporate Compliance Plan and the Policies and Procedures in light of changes in Cambridge Counseling needs, and in the Laws and Program Requirements;

Developing Policies and Procedures that encourage Cambridge Counseling Center staff to report suspected fraud and other improprieties and violations of Laws an d Program Requirements without fear of retaliation; and

Performing such other activities and assuming additional responsibilities as the Executive Director or Executive Team may direct.

All Cambridge Counseling programs, and all Cambridge Counseling Center staff, shall cooperate with the Corporate Compliance Officer in the conduct of the Corporate Compliance Officer’s responsibilities.

Corporate Compliance Team. There shall be a Corporate Compliance Team to advise the Corporate Compliance Officer and assist in the implementation of this Corporate Compliance Plan. The Corporate Compliance Team shall be chaired by the Corporate Compliance Officer and shall be composed of Cambridge Counseling Director of Operations, Chief Financial Officer, and other members of management of Cambridge Counseling necessary to support the Corporate Compliance Officer in fulfilling his or her responsibilities under this Corporate Compliance Plan. Membership on the committee shall be representative of Cambridge Counseling operations functions related to records, billing, human resources, finance, and general operations. The Compliance Committee shall meet at those times as determined by the Corporate Compliance Officer.

Policies and Procedures. Policies and Procedures shall be developed that specify the functions of the Corporate Compliance Team, which shall be substantially in compliance with the Corporate Compliance Guidance, with such modifications thereto as shall be necessary or appropriate in view of the needs of, and particular circumstances affecting, Cambridge Counseling.

All Cambridge Counseling programs, and all Cambridge Counseling center, staff, shall cooperate with the Corporate Compliance Team in the conduct of the Committee’s responsibilities.

Legal Counsel. Cambridge Counseling General Counsel shall be available to provide legal advice and counsel to the Executive Team, the Corporate Compliance Officer and the Corporate Compliance Team in connection with all compliance matters.

Development of Policies and Procedures.

The Corporate Compliance Officer, working with Cambridge Counseling Executive Director, General Counsel, other officers, managers, supervisors and personnel, shall develop and oversee the implantation, monitoring and enforcement of written Policies and Procedures on specific Laws and Program Requirements and matters involving ethical, legal and business practices, with particular attention to the areas that have been identified as potentially involving greater risk: Federal False Claims Act and billing accuracy; Health Insurance Portability and Accountability Act of 1996 ("HIPAA"_ Privacy and Security and Patient Confidentiality; Medicare and Medicaid regulations; accuracy, retention and disposal of records; workplace harassment; and individual excluded from participation in Medicare, Medicaid and other Federal and state health care programs.

Policies and Procedures developed by the Corporate Compliance Officer relating to the implementation of this Corporate Compliance Plan shall be subject to the approval of Executive Team of Cambridge Counseling center in those instances in which Executive Team deems such approval to be necessary or advisable.

Policies and procedures developed at the department level shall be subject to the approval of the Corporate Compliance Officer, and of Executive team in those instances in which the Corporate Compliance Officer, the General Counsel deems such approval to be necessary or advisable.

It is the intention that all Policies and Procedures shall comply substantially with the Compliance Program Guidance, with such modifications thereto as shall be necessary or appropriate in view of the needs of, and particular circumstances affecting, Cambridge Counseling.

Training Requirements. In order to assure that all Cambridge Counseling Center staff understand their obligations under this Corporate Compliance Plan, program within Cambridge Counseling, under the guidance of the Corporate Compliance Officer, will develop training programs related to that programs responsibilities with respect to compliance. Training shall be required for all new employees and, at least annually, for all existing employees. Additional training will be required for those programs and those Cambridge Counseling center staff identified by the Corporate Compliance Officer who are involved in consumer care, billing, coding or other specific activity identified as high risk areas of health care compliance. All training required by Laws and Program Requirements shall be conducted in a manner, and as frequently, as is consistent with such requirements.

Training Schedules and Materials. Each director, manager or program administrator within Cambridge Counseling, on an annual basis, shall submit to the Corporate Compliance Officer a schedule of trainings, an outline of the training materials, the identity and qualifications of the trainers, and the Cambridge Counseling Center staff who will be trained for each program for which he/she has responsibility.

Supervision Notes. Each Cambridge Counseling supervision meeting shall maintain minutes for periodic review by the Corporate Compliance Officer.

Employee Performance Reviews. Adherence to the provisions of this Corporate Compliance Plan, including attendance and completion of compliance training, will be a factor in each employee’s annual performance evaluation. Failure to attend and participate in compliance training may be grounds for disciplinary action, including termination of employment.

Policies and Procedures. Appropriate Policies and Procedures shall be adopted to implement the foregoing.

Monitoring and Auditing.

Audits. Cambridge Counseling records administrator shall submit to the Corporate Compliance Officer, on an annual basis, a schedule and plan for monitoring and/or auditing designed to prevent and detect material and substantial violations or imminent violations of Laws and Program Requirements. The Corporate Compliance Officer may authorize a full review of any record in order to evaluate systems and practices for complying with the applicable Laws and Program Requirements.

Protocols. The Corporate Compliance Officer and Corporate Compliance Team shall establish protocols for the ongoing monitoring and enforcement of compliance with Laws and Program Requirements. These protocols shall include systematic methods for reviewing delegated compliance initiatives (such as training and education) to ensure that all staff is conforming to the established compliance standards.

Internal Audits. The Corporate Compliance Officer shall have the authority and responsibility to conduct audits of Cambridge Counseling Center staff to determine compliance with laws, Program Requirements, this Corporate Compliance Plan, and Policies and Procedures.

External Reviews. The Corporate Compliance Officer shall have the authority to engage outside auditors or consultants to conduct audits to determine compliance with Las, Program Requirements, this Corporate Compliance Plan, and Policies and Procedures.

Cooperation. All Cambridge Counseling program, and all Cambridge Counseling Center staff, shall cooperate with the Corporate Compliance Officer and others under his or her direction in the conduct of all internal and external audits and reviews.

Remedies for Potential Violations. If a review or audit uncovers a substantial and material violation or potential violation of Laws, Program Requirements, this Corporate Compliance Plan or Policies and Procedures, or raises the possibility that policies or procedures are not in place to prevent such violation, then Cambridge Counseling Center staff shall diligently respond by (a) remedying the situation in consultation with the Corporate Compliance Officer and the General Counsel, and (b) reporting all violations as may be required by law in consultation with the Corporate Compliance Officer and the General Counsel.

Records. All Cambridge Counseling program, and all Cambridge Counseling Center staff, shall document their efforts to comply with Laws, Program Requirements, this Corporate Compliance Plan, and Policies and Procedures, All records and reports created in conjunction with Cambridge Counseling adherence to this Corporate Compliance Plan are confidential and shall be maintained in a secure location until such time as the Corporate Compliance Officer, through consolation with the General Counsel determines that the destruction of such documentation is appropriate.

Policies and Procedures. Appropriate Policies and Procedures shall be adopted to implement the foregoing.

　

Investigations.

Investigations. Every supervisor and manager who receives a report of possible unethical or illegal activity shall immediately forward such report to the Corporate Compliance Officer. Upon Receipt of the report, the Corporate Compliance Officer shall consult with the General Counsel (i) to discuss and evaluate the report’s veracity and seriousness; (ii) conduct and direct such preliminary investigation as is necessary to assess the need for further action; and (iii) make a determination as to the need for, and appropriateness of, further investigation or action. All such investigations shall be conducted pursuant to Policies and Procedures applicable thereto.

Evidence. Cambridge Counseling Center staff shall promptly take measures to assure that documents and other items that may be regarded as helpful in an investigation are preserved. It will be a violation of this Corporate Compliance Program to conceal an offence or to alter or destroy such documents or other evidence.

Reports. A written report on all substantial and material matters investigated shall be prepared under the direction of the Corporate Compliance Officer and the General Counsel. All reports shall be delivered to the executive director having responsibility for the matters investigated, and to appropriate directors in those instances in which the Corporate Compliance Officer, General Counsel, or Executive Director deems the same to be necessary or desirable.

Cooperation. All Cambridge Counseling programs, and all Cambridge Counseling Center staff, shall cooperate with the Corporate Compliance Officer, General Counsel and others acting under their direction in the conduct of all investigations.

Policies and Procedures. Appropriate Policies and Procedures shall be adopted to implement the foregoing.

Disclosure and Reporting.

Compliance. Cambridge Counseling has established a P.O. Box and shall maintain the Cambridge Counseling Center P.O. Box to receive reports of questionable, unethical, or illegal conduct. The P.O. Box is Cambridge Counseling Center, P.O. Box 1295, Cambridge, OH 43725. Mail to this box may be made anonymously. The person reporting a violation or suspected violation may utilize the P.O. Box or any other effective means in order to obtain a progress report on the handling of the report.

Obligation to Report. All Cambridge counseling Center staff are encouraged to, and shall be responsible for, reporting to supervisors, or, at the option of the individual, to any member of the Executive Committee, the Corporate Compliance Officer, the General Counsel, or the Cambridge Counseling Center P.O. Box any suspected violation of Laws, Program Requirements, this Corporate Compliance Plan, or Policies and Procedures.

Prohibition of Retaliatory Action. Cambridge Counseling shall not take any retaliatory action against any Cambridge Counseling center staff who reports a violation or suspected violation as set forth in the previous section. A prompt and forthright disclosure of an error by any Cambridge Counseling Center staff will generally be considered a constructive action by the reporting individual. Cambridge Counseling Center staff are not permitted to engage in retaliation or any form of harassment directed against an individual who reports a concern or participates in an investigation, compliance review or hearing. In regard to Protected Health Information under HIPAA, retaliation is prohibited against anyone who opposes any act the person believes in good faith to be unlawful, provided the manner of opposition is reasonable and does not involve a disclosure of Protected Health Information that in itself constitutes a violation of law or organization policy. Any manager, supervisor or employee how engages in such retaliation or harassment is subject to discipline up to and including dismissal.

Policies and Procedures. Appropriate Policies and Procedures shall be adopted to implement the foregoing.

Discipline and Sanctions.

Appointments. Any Cambridge Counseling Center staff, including the Corporate Compliance Officer, who is responsible or assigned to oversee compliance with the standards and procedures required by this Corporate Compliance Plan, shall be evaluated periodically in order to determine whether the individual has the good moral character and integrity necessary to perform duties in such position.

Violations of Corporate Compliance Plan and Policies. A violation of Laws, Program Requirements, this Corporate Compliance Plan or any Policies and Procedures by any Cambridge Counseling Center staff will subject the involved individual to disciplinary action, including dismissal or termination of the relevant contract.

Violations of Applicable Statutes and Regulations. Any Cambridge Counseling Center staff who is convicted of a criminal offense related to the business of Cambridge Counseling or Laws or Program Requirements, or who is listed by a Federal or State agency as debarred, excluded or otherwise ineligible for participation in federally or state funded programs, shall be terminated from his or her employment, engagement, or association with Cambridge counseling in accordance with Cambridge Counseling disciplinary policies. Until resolution of any criminal charges or proposed debarment or exclusion, Cambridge Counseling center staff who are charged with criminal offenses or proposed for debarment or exclusion may be removed from direct responsibility for, or involvement in any federally or state funded program, in the discretion of the Executive Director responsible for the oversight of such individual in consultation with the Director of Operations, the Corporate Compliance Officer and the General Counsel.

Policies and Procedures. Appropriate Policies and Procedures shall be adopted to implement the foregoing.

Violations of Corporate Compliance Plan, etc.

Violations of Laws, Program Requirements, etc. If any Cambridge Counseling Center staff violates any Laws, Program Requirements, this Corporate Compliance Plan or Policies and Procedures in the course of his/her employment, engagement, or association with Cambridge Counseling, such individual will be subject to sanctions in accordance with Cambridge Counseling disciplinary policies.

Other Violation of the Corporate Compliance Plan. In addition to direct participation in a violation of Laws, Program Requirements, this Corporate Compliance Plan or Policies and Procedures, Cambridge Counseling Center staff, other actions or omissions that will subject Cambridge Counseling Center staff to discipline on this basis include, but are not limited to the following:

Failure to report a suspected or actual violation of law or a breach of Laws, Program Requirements, this Corporate Compliance Plan or Policies and Procedures;

Failure to make, or falsification of, any certification required under this Corporate Compliance Plan;

Lack of attention or diligence on the part of supervisory personnel that directly or indirectly leads to a violation of Laws, Program Requirements, this Corporate Compliance Plan or Policies and Procedures; and/or

Direct or indirect retaliation against any Cambridge Counseling Center staff who report a violation of Laws, Program Requirements, this Corporate Compliance Plan or Policies and Procedures.

Possible Sanctions. Possible sanctions include, but are not limited to, termination, suspension, demotion, reduction in pay, ongoing counseling, reprimand, and/or re-training. Cambridge Counseling center staff who engage in intentional or reckless violation of Laws, Program Requirements, this Compliance Plan or Policies and Procedures will be subject to more severe sanctions than accidental transgressors.

Employee Evaluation. Employee participation in, and adherence to, this Corporate Compliance Plan and related activities will be an element of each employee’s annual personnel evaluations. As such, it will affect decisions concerning compensation, promotion and retention.

Acknowledgement Statement. All Cambridge Counseling Center staff must complete and sign from time to time an Acknowledgment Statement to the effect that the individual has received a copy of and understands his or her responsibilities under this Corporate Compliance Plan, and acknowledges his or her commitment to comply with the same and all Policies and Procedures. Each Acknowledgment Statement shall form a part of the personnel file of each Cambridge Counseling employee.

Policies and Procedures. Appropriate Policies and Procedures shall be adopted to implement the foregoing.

　

Stephanie Cobb appointed by the Executive Team to continue to serve as Corporate Compliance Officer from January 1, 2014 – January 1, 2017.