CORPORATE COMPLIANCE PLAN

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Community Service for the Developmentally Disabled, Inc.

Corporate Compliance Plan

Table of Contents

I.Organization Overview...... 1

II. Mission Statement...... 1

III. Vision Statement...... 1

IV. Corporate Compliance Overview...... 1

V. Code of Business Conduct & Ethics...... 2-13

A. Overview...... 2

B. Displaying Good Character...... 2

C. Standard of Conduct...... 2-13

  1. Business Principles...... 3
  2. Maintain the Confidentiality of Agency Records...... 3
  3. Cooperate and Maintain Confidentiality During an Agency Investigation...... 3
  4. Protect Agency Assets...... 3
  5. Maintain the Corporate Image...... 4
  6. Have Job Accountability...... 4
  7. Avoid Conflicts of Interests...... 5
  8. Display Caution when Offered Gratuities...... 6
  9. Adhere to the Agency Media Communication Policy...... 6
  10. Quality of Care...... 7
  11. Adhere to Individual’s Rights and Responsibilities...... 7
  12. Follow Individual’s Service Plan...... 7
  13. Maintain Appropriate Interactions with Individuals...... 7
  14. Safeguard Individuals Privacy...... 8
  15. Medical Practices...... 8
  16. Follow Regulations Regarding Control of Medications...... 8
  17. Legal Obligations & Compliance...... 8
  18. To Maintain a Safe and Healthful Workplace...... 8
  19. Refrain from Misrepresentation...... 9
  20. Refrain from Engaging in Unfair Trade Practices...... 9
  21. Adhere to Tax-Exempt Requirements...... 9
  22. Comply with Fundraising Standards...... 9
  23. Submit Accurate Billings and Financial Reports...... 10
  24. Refrain From Accepting Kickbacks...... 11
  25. Follow Research Grant Standards...... 11
  26. Be Familiar with Regulations Governing Areas of Responsibility...... 11
  1. Human Resources Principles & Community Involvement...... 12
  1. Comply with Labor & Employment Laws...... 12
  2. Comply with Payroll Deductions12
  3. Embrace Diversity 12
  1. Display Ethical Personal Conduct...... 12
  1. To Maintain Agency Representative Privacy...... 13
  2. Refrain from Substance Abuse and Unsafe Workplace Behavior...... 13

VI. Board Member Code of Ethics...... 14

VII. Standards & Expectations...... 15

VIII. Screening Applicants...... 15

IX. Compliance Officer & Compliance Committee...... 15

X. Outside Legal Counsel...... 16

XI. Reporting Suspected or Known Violations...... 16

XII. Whistleblower Protection...... 17

XIII. Investigations & Corrective Action...... 17

XIV. Response & Discipline for Violations...... 18

XV. Compliance Training...... 18

XVI. Compliance Auditing...... 18

XVII. Wrongful Billing...... 19

XVIII. Certification...... 19

XIX. Conclusion...... 19

Attachment

Attachment A: Role of the Corporate Compliance Officer...... 20

Attachment B: Corporate Compliance Committee...... 23

Attachment C: Report of a Corportate Compliance Concern...... 26

Attachment D: Zero Tolerance Statement...... 27

Attachment E: Federal and New York Statutes Filing False Claims...... 28

Attachment F: Confidentaility Agreement Obligation Regarding Confidentiality...... 31

Community Service for the Developmentally Disabled, Inc.

Corporate Compliance Plan

II.Organization Overview

Community Services for the Developmentally Disabled, Inc. has many years of experience assisting individuals with developmentally disabilities living in Western New York. Our agency is committed to providing services that help individuals reach their highest level of independent living possible. Our comprehensive programs fall under fourmain categories of service:

  • Housing & Shelter Services
  • Habilitation Services
  • Service Coordination
  • Clinical Services

III.Mission Statement

Our mission is to provide or obtain services for people with developmental disabilities and their families in Western New York, which will:

  • Assist in achieving their highest level of independent living;
  • Enable their fullest participation in society;
  • Ensure that their civil and human rights are protected;
  • Promote their ability to be productive, contributing members of the community.

IV.Vision Statement

Striving for Excellence

Supporting Partnerships

Creating Solutions

…Fulfilling Dreams

V.Corporate Compliance Overview

Community Services for the Developmentally Disabled, Inc. has established a Corporate Compliance Plan tailored to the agency’s principle lines of business. We are dedicated to managing and operating its programs in keeping with the highest of business, ethical and moral principals. Each employee agent, member of the Board of Directors, consultant, and volunteer contributes to achieving these principals by conducting business activities for the agency with integrity and high ethical standards. Supervisors and managers also contribute to achieving these principles by exercising good leadership and being a good example in creating and promoting a workplace environment in which compliance and ethical business conduct are expected.

Community Service for the Developmentally Disabled, Inc. has adopted the following definition of Corporate Compliance:

“A Corporate Compliance plan is a system which is designed to detect and prevent violations of law, as well as the likelihood of unethical activity by agency employees, volunteers, contractors, officers and directors.”

Community Service for the Developmentally Disabled, Inc. will transact its business in compliance with the laws of the jurisdiction in which it does business, including local, state and federal jurisdictions. As a not-for-profit agency, Community Services for the Developmentally Disabled, Inc. will conduct business in compliance with all IRS regulations governing tax-exempt organizations and refrain from any private inurement and benefit issues. Instances where questions arise concerning interpretation or applications of laws and regulations should be referred to the President & CEO or Corporate Compliance Officer. Applicable laws include, but are not limited to, anti-kickback statutes, labor laws, tax code and regulations, antitrust laws, copyright laws, false claims laws, rights of individuals receiving services and environmental laws.

As used in this Corporate Compliance Plan, the following definitions apply:

  1. Community Services for the Developmentally Disabled, Inc. representatives: employees, agents, board members, committee members, volunteers, contractors, and others working for or on behalf of Community Services for the Developmentally Disabled, Inc.
  1. Agency: Community Services for the Developmentally Disabled, Inc.

VI.Code of Business Conduct & Ethics

  1. Overview

The Code of Business Conduct & Ethics provides Community Services for the Developmentally Disabled, Inc. employees, agents, member of the Board of Directors, consultants, and volunteers with information necessary to adhere to the high ethical principles the agency lives by. Community Services for the Developmentally Disabled, Inc. is accountable for compliance not only with the Code of Business Conduct & Ethics, but also with all laws and regulations applicable to our activities, and other policies and procedures prepared by our agency and oversight bodies.

B. Displaying Good Character

Good character is what this Code of Business Conduct & Ethics is all about. Honesty and Integrity defines our relationships with people receiving services, outside agencies, business partners, and each other. By maintaining the highest level of corporate integrity through open, honest and fair dealings, we earn trust for our services and ourselves from everyone with whom we come in contact. Showing respect and empathy to all those we interact with is crucial to our mission.

C. Standards of Conduct

Community Services for the Developmentally Disabled, Inc. representatives are expected to comply with the following standards:

  1. Business Principles
  2. Maintain the Confidentiality of Agency Records

The agency is responsible and accountable for the integrity and protection of its business information. All agency records and documents (in any form or media) are the sole property of the agency and thereby considered confidential by its nature, except as provided by law or regulation. All agency information (i.e. policies, procedures, strategic or business plans, administrative memos, financial document, etc.), whether in electronic or written format, is confidential and may not be released or shared with others outside the agency without proper prior authorization.

No Community Services representative shall disclose to others any confidential information obtained during the course of employment, work (paid or unpaid) or receipt of reports, which have not been published or disclosed, to the public. Documents and electronic media containing sensitive information on people receiving services, staff, consultants, volunteers, board members and other representatives of the agency must be carefully handled and properly secured. Once an agency representative terminates the relationship with the agency, they have noright to access or use agency information.

If any Community Services representative observes or becomes aware of a breach of this policy including misuse of confidential information, or an unauthorized or unrecognized individual using a computer terminal in an area familiar to you, immediately contact a supervisor.

  1. Cooperate and Maintain Confidentiality During an Agency Investigation

Agency representative that become aware of a situation that is in violation of agency policy, regulatory requirements, and/or law they are expected to report such violation to the appropriate agency personnel (see Reporting Suspected or Known Violation). Should an agency representative be contacted by an assigned agency investigator to provide statement regarding their knowledge of an incident or event they are expected to cooperate with the investigator by responding timely to phone calls and/or requests to meet.

The Agency has a compelling interest in protecting the integrity of all investigations, including evidence protection and ensuring that witnesses do not experience any intimidation or harassment for their participation in an investigation. In some situations, it is necessary that the Agency require strict confidentiality of all information during the course of an internal investigation and in those situations, all persons involved in the investigation should avoid disclosing information about an ongoing investigation in order to avoid:

Harassment and intimidation of an investigation witnesses.

Destruction of evidence.

Fabrication of testimony.

Attempts to cover up the event(s) that occurred.

  1. Protect Agency Assets

It is the obligation of all Agency representatives to protect the assets of the Agency. Agency property, such as office supplies, office equipment, vehicles, and property may not be used for personal reasons. Computers, printers, fax machines, copiers, audio visual equipment, bulletin boards, phones, and other agency office equipment are the property of Community Services. The use of this equipment and the information conveyed through them may be reviewed or restricted by the Agency at any time. Employees are expected to restrict the use of all Agency equipment to professionally related material and to represent the Agency in a positive manner at all times. This equipment is provided for Agency use. The use of Agency property to view or transmit sexual material, racial slurs, or any other material that could be interpreted as such will not be permitted at any time and will result in disciplinary action.

Any misuse or misappropriations of agency funds, information, equipment, facilities or other assets may be considered criminal behavior and can bring severe employment and legal consequences. Agency funds include, but are not limited to bank accounts, credit and debit cards, and business accounts. In addition, agency property such as janitorial and office supplies are available for business needs. Removal of such supplies from agency property for personal use may also be considered criminal.

  1. Maintain the Corporate Image

The agency’s reputation and identity are among its most valuable assets. No one should act in a way that adversely affects the reputation or image of the agency with employees, volunteers, people receiving services or with the community at large.

Recognizing the accomplishments of others, both internally and externally, shows appreciation for the value another person brings toward achieving our common goals.

Each agency representative should endeavor to deal fairly with the people receiving services, consultants, suppliers, competitors and other employees. No one should take advantage of anyone else through manipulation, concealment, abuse of privileged information, misrepresentation of material facts, or other unfair-dealing practice.

While the agency cannot control what its representatives do during non-working hours, it is important to understand that information posted online may be public and comments made about the agency or agency representatives that are discriminatory or violate agency policy (i.e. confidentially, conflict of interest, harassment) can result in disciplinary action, no matter whether the employee wrote it from work or outside of work.

  1. Have Job Accountability

Each agency representative is responsible for adhering to agency policy and for knowing and executing the responsibilities of his or her job independently. This means the individual is held accountable for the quality of the work he or she produces. Each agency representative should be timely in their attendance and value the deadlines and schedule of others. In addition, management is responsible for ensuring that they have provided their employees with the necessary information to do their jobs.

Each agency representative shall display teamwork by assisting and being a resource to others. This includes communicating information, clearly and consistently, to all necessary parties and being open to constructive feedback. Positively resolving conflicts and effective problem solving are important traits in being a contributing part of the Community Services Team. Planning ahead and prioritizing of workload are important attributes of an agency representative.

  1. Avoid Conflicts of Interests

Each agency representative has a primary business responsibility to the agency and is expected to avoid any activity that may interfere or have the appearance of interfering with their performance. A conflict of interest exists if an agency representative’s outside business or other interests may affect adversely, or have the potential to affect adversely, his or her motivation, objectivity, loyalty or performance. In addition, a potential conflict of interest occurs when an individual’s personal or private interests might lead an independent observer to reasonably question whether the individual’s professional actions or decisions are influenced by significant personal interest, financial or otherwise.

Agency Representatives shall not participate in the selection, award or administration of a contract supported by Federal, State or other government funds if a real or apparent conflict of interest would be involved. Such a conflict would arise when the employee, officer, or agent, any member of his or her immediate family, his or her partner, or when the agency employs or is about to employ any of the parties indicated herein, has a financial or other interest in the firm selected for an award.

Some additional situations in which agency representatives might encounter that would be considered a conflict of interests are:

Having a relationship with a person receiving services outside of the workplace and/or employment by a person receiving services and/or the family member of a person receiving services;

Directly supervising a family member as a contractor, supplier or employee of the agency;

Romantic relationships between a supervisor and a subordinate. Supervisor is defined as “a person who has authority, direct or indirect, over another by virtue of their job classification. Subordinate is defined as “a person who is answerable to another person based on their job classification.” While the supervisor is ultimately held responsible for ensuring that this type of relationship does not occur, it does not absolve the subordinate of any wrong doing.

Using agency assets, including agency time, name, information equipment or facilities, for personal use without prior permission;

Misuse of information obtained by an agency representative during the course of his or her employment;

Soliciting personal cash or non-cash gifts of any amount or value from any person or business that has a relationship with the Agency;

Accepting personal cash gifts of any amount from any person or business that has a relationship with the Agency;

Financial transactions between people receiving services and/or their family members/responsibility parties;

Outside employment that interferes with the employees job responsibilities and/or is in conflict with agency interests.

Use of information created by or for the agency for personal gain or use by others outside the agency without prior permission.

Working directly with someone that you have personal relationships with, whether due to a family connection or not, that interferes with work productivity and/or service delivery.

Certain agency representatives, as identified in the agency “Conflict of Interest Policy & Procedure, are required to complete the Agency “Conflict of Interest Disclosure/Confidentiality Agreement” form upon the beginning of the relationship with the agency and annually thereafter.

The above situations identified as “conflicts of interests” are notall inclusive. Agency representatives are expected to exercise good judgment and be mindful of how their personal relationships and outside activities may be affecting the workplace. Agency representatives may also find themselves in a situation where they do not feel like they can be objective in their decision making due to their personal relationship or beliefs. Should an agency representative feel that they are not able to be objective in making a business related decision they should voluntarily abstain/refrain from participating in the decision making process. Furthermore, if any matter exists that might be a conflict of interest or creates the appearance of a conflict of interest, agency representatives are required to consult their supervisor, Corporate Compliance Officer or Human Resources Representative to assess whether a problem exists.

  1. Display Caution when Offered Gratuities

In the course of performing their jobs, agency representatives may be offered gratuities which usually are intended as gestures of goodwill or appreciation. These include gifts, entertainment, gift cards, meals and beverages, tickets to sporting or cultural events, services or other similar favors. Agency representatives may not accept, individually or as part of a group, anything that could reasonably be thought to have more than a nominal intrinsic value (nominal intrinsic value: e.g. promotional or advertising pens, pencils, notepads, calendars, greeting cards, trinkets, baked goods or other similar gifts of limited value).

Gifts, gratuities, or attendance at events exceeding nominal intrinsic, typically greater than $25.00, should be refused or returned unless the Corporate Compliance Officer approves of acceptance as part of a business need or special occasion i.e. holiday gift basket during holidays to be shared amongst representatives.

Even nominal gifts can be inappropriate if used in a way which creates the impression that a certain vendor or person is receiving or attempting to obtain preferential treatment, therefore the acceptance of any gift, regardless of its value, must be done so with caution and when in doubt needs be reported to a supervisor in order to determine whether the gift may or may not be accepted to avoid a conflict of interest.

Acceptance or participation in a business meal situation is appropriate when based on a business need and such dining occurs in conjunction with business discussions.