Updated January 30, 2018 | Adopted by the Board of Directors March 28, 2018
In support of the Gateway Community Industries, Inc. mission, vision, and core values, and to comply with all Federal, State and Local healthcare regulations and mandates, Gateway and its affiliated entities have adopted this Corporate Compliance Program to ensure our organization provides services to our community with integrity and without waste or fraud.
The law requires all providers to comply with standards and regulations and set organization wide standards to define, communicate and monitor compliance with these standards.
Our Plan documents the systems which are in place to insure efficient, legal and ethical standards. Several key components of the Plan are set forth below and are noted to ensure that we have programs in place to exercise due diligence to prevent, detect, correct and eliminate non-adherence to Standards, Policies and Procedures by our employees or our agents.
Key components of the Plan include the following company wide standards:
- Compliance with all Policies and Procedures
- Appropriate authority and oversight
- Communication of the Corporate Compliance Plan; expected code of conduct, education, training, and communication of updates
- A system for both confidential reporting and investigation of Compliance Concerns
- Enforcement and Discipline
- Internal controls including: methods for audits, ongoing monitoring of practices, identifying concerns, correction and measuring results for verification in a timely and effective manner
- Documentation and Reporting
- Whistleblower Protections
Adhering to and Safeguarding the Plan
This plan has been prepared with the assistance of the executive team, directors, and staff of Gateway through the efforts of the Compliance Team (and is adopted by the Board of Directors). Gateway shall make every effort to assure compliance with the law given limitations imposed by practical and commercial realities.
Authority and Oversight
Ultimate accountability and oversight for Corporate Compliance lies with the Board of Directors and the President & Chief Executive Officer (CEO). Responsibility for the orientation of all initiates lies with the CEO. The Board of Directors is committed to providing both the human and financial resources necessary to develop, implement, support, maintain, and monitor an ethical environment, which complies with all Federal, State, and Local Law. The acceptance of this plan and the designation of a Chief Quality and Compliance Officer (CQCO) evidence this commitment.
The Chief Quality and Compliance Officer is a specific individual within high-level personnel of the organization who is responsible for operational oversight and implementation of Gateway’s compliance activities and reports directly to the President and CEO as well as the Board of Directors.
Additionally, the CQCO can request to meet directly with the Board of Directors in an Executive Session.
The CQCO communicates compliance activities to the Board of Directors on a monthly basis. Additionally, the CQCO presents a comprehensive compliance report to the Quality, Audit, and Compliance subcommittee of the Board of Directors on a quarterly basis.
In order for the CQCO to carry out his/her duties, he/she shall have access and authority to review all documentation relevant to compliance activities as well as seek the advice of outside legal counsel when appropriate. This documentation includes but is not limited to:
- Policies and Procedures
- Service Recipient Records
- Billing Records
- Contracts, Service Agreements, Joint Ventures, Leases
- Any related documentation
Communication, Training and Education
Gateway effectively communicates expected codes of conduct and this Corporate Compliance Plan to all employees, board members, and affiliates through educational programs and periodic updates. Every new employee and board member, and annually for all employees and board members, will be instructed on the Corporate Compliance Plan, expected conduct and instructions on how to access the Corporate Compliance System during the Regulatory orientation process. Attendance is mandatory and documented through the Human Resources Department. Affiliates will receive written information regarding our Corporate Compliance Plan upon engagement and then annually. Interns and volunteers do not receive training in the Corporate Compliance Plan as they are unpaid individuals and always accompanied by paid staff.
As part of the educational program, staff will be made aware that signed acknowledgement and acceptance not only validates receipt of information, but also binds them to follow the Plan and that they are required to bring any violations or perceived violations to the attention of the Chief Quality and Compliance Officer.
Communication updates and enhancements to the Corporate Compliance Program will be continuously communicated to the staff through established channels of communication. (i.e., Bulletin Boards, Leadership Meetings, Staff Meetings, Memos, the Gateway Gazette, etc.)
Investigation of Compliance Concerns
The Gateway Corporate Compliance Plan provides employees, board members, and affiliates of Gateway a means to convey concerns regarding corporate integrity in confidence and without fear of retaliation or intimidation. Every concern can be conveyed to the Chief Quality and Compliance Officer and will be investigated by him/her.
The Chief Quality and Compliance Officer for Gateway Hudson Valley is Courtney Beaupre. If anyone has an issue to bring to Corporate Compliance, Ms. Beaupre can be reached at (845) 331-1261 ext. 227. Written correspondence may be directed to Ms. Beaupre either by e-mail at firstname.lastname@example.org or by mail at Gateway Community Industries, Inc.; 1 Amy Kay Parkway; Kingston, NY 12401
Additionally, anonymous and confidential “good faith” reports can be made via the secure direct hot line: 845-339-6624 or by leaving a message in the secure Compliance Box located in the staff lounge at the Joe Cornelske Center.
The Chief Quality and Compliance Officer is responsible for documenting all concerns brought to his/her attention, initiating a confidential investigation, and reporting findings to the President & CEO and Board of Directors in a confidential manner.
Enforcement and Discipline
All Gateway employees, board members, and affiliates are required under this Compliance Plan to report any suspected compliance concerns to the Chief Quality and Compliance Officer, whether done anonymously or otherwise. It is the expectation that all employees, board members, and affiliates of Gateway will assist in the resolution of compliance issues where applicable. Employees, board members, and affiliates are expected to assist in appropriate disciplinary measures and Corrective Action Plans as part of the resolution process.
Standards, both clinical and non-clinical, will be consistently enforced through appropriate channels for disciplinary action. Individuals who participate in non-compliant behavior, encourage, direct, or permit non-compliant behavior, or who fail to report suspected problems is in direct violation of this Compliance Plan. Disciplinary actions are applicable to all employees, board members, and affiliates and will be enforced and determined on a case-specific basis up to and including termination of employment, or termination of affiliation with Gateway as applicable.
Audits and On-Going Monitoring of Practices
Gateway takes reasonable and prudent steps to achieve compliance with its standards, policies and procedures by utilizing both internal and external auditing systems. Utilizing safeguards to maintain the efficacy of our Corporate Compliance Program and internal auditing systems can reasonably be expected to detect violations in a timely fashion. In addition, on-going monitoring systems and internal auditing systems can reasonably be expected to detect violations in a timely fashion. In addition to ongoing monitoring systems, the Chief Quality and Compliance Officer shall provide a secure medium for employees to report suspected violations without fear of retribution.
Documentation and Reporting:
Gateway has a comprehensive system in place for identifying and correcting compliance problems promptly and thoroughly. Policies and procedures are in place to provide guidance on how potential compliance problems are investigated and resolved. This system regularly conducts internal risk assessments, identifies and prioritizes potential risks, implements corrective action plans to mitigate risk and monitors the effectiveness of the compliance system.
All concerns brought to the attention of the Chief Quality and Compliance Officer will be appropriately documented, including investigation and disposition as well as initiation of steps to insure future prevention. At a minimum, the Board of Directors will be updated on all Corporate Compliance activities by the Chief Quality and Compliance Officer directly or via the President & Chief Executive Officer.
When necessary Gateway will report to the appropriate regulatory body the identified compliance issue in the form/format and time frame prescribed by the regulatory body.
Gateway Hudson Valley requires its employees, board members, and affiliates to observe high standards of business and personal ethics in the conduct of their duties and responsibilities and to comply with all applicable laws and regulations. It is the responsibility of all employees, board members, and affiliates to report violations or suspected violations of business and personal ethical standards and/or violations of applicable laws and regulations. No employee, board member, or affiliate who, in good faith, reports a violation shall suffer harassment, retaliation, intimidation or adverse employment consequence. This includes but is not limited to individuals who report potential issues, have an investigatory role, perform self-evaluations and audits, and institute remedial actions including reporting to appropriate officials. Adverse actions in retaliation against someone who has reported a violation in good faith will be subject to disciplinary action up to and including termination of employment or relationship with the Agency.
STANDARDS OF CONDUCT
The following statement of organizational policy constitutes Gateway’s Standards of Conduct. It affirms our policy of conducting business and delivering services in accordance with both the law and the highest clinical and professional standards. It is our intent to provide clear direction to our employees, board members, and affiliates with respect to behavior within the scope of their practice.
It is the policy of Gateway Community Industries, Inc. to conduct all corporate activities in a responsible and ethical manner. Employees, Board members, and affiliates of GCI must comply with Federal, State, and Local Laws and Regulations and must report any actual or perceived violation of the Corporate Compliance Program or Gateway policy.
The standards of conduct cannot cover every situation that our employees, board members or affiliates may face. If you are unsure of what a proper course of conduct might be in a specific situation, or believe that the standards of conduct set forth in the Code may have been violated, contact the Chief Quality and Compliance Officer.
Gateway will not tolerate any form of unlawful or unethical behavior by anyone associated with this organization. We expect and require all employees, board members, and affiliates to be law-abiding, honest, trustworthy, and fair in all of their business dealings maintaining the highest standards of ethics. To ensure that these expectations are met the compliance program has become an integral part of our business operations.
- Gateway requires compliance by all employees, board members and affiliates with laws to which it is subject. When the application of law, regulation, or other policy is uncertain, the employee, consultants and affiliates must seek the guidance and advice in accordance with the Corporate Compliance Plan.
- When either directly providing or managing the provision of services, Gateway takes all reasonable efforts to insure that the services are appropriately prescribed, medically necessary, and performed in accordance with standards of care.
- Gateway will treat all individuals with dignity, respect, and courtesy. The individuals we serve and their families will be involved in decisions regarding the treatment delivered to the extent practical and possible. In all circumstances will we attempt to treat individuals in a manner appropriate to their background, culture, religion and heritage, and respect their objectives for care.
- Employees, board members, and affiliates shall not engage in any activity that constitutes abuse, neglect, or any kind of unauthorized physical restraints of any kind toward any individual.
- There shall be no discrimination toward any individual for any reason, including race, color, religion, creed, sex, sexual orientation, national origin, ancestry, ethnicity, age, disability, citizenship, marital status, military or veteran status, predisposing violence victim status, domestic violence victim status, HIV status or any other characteristic protected by law.
- Gateway will not refuse, transfer, or discharge individuals who are in need of our services based upon any factor that is unrelated to individual care needs.
- Gateway recognizes that from time to time, conflicts will arise among those who participate in agency and service recipient care decisions. Whether this conflict is between employees, board members, or affiliates or between individual caregivers and the service recipients, Gateway will seek to resolve all conflicts fairly, objectively, and in a timely manner. In cases where mutual satisfaction cannot be achieved, the service recipient, their representative, the administration or appropriate group can engage in the conflict resolution process. Other staff, or if needed, outside experts will be involved and their opinions sought as needed to pursue a mutually satisfactory resolution.
- All service recipient information is private and confidential and as such, staff is charged to protect the privacy and confidentiality of the individuals we serve and to communicate in a professional manner in accordance with all applicable New York State and Federal regulations.
- Service Recipient-Staff Relations: Staff shall keep relations on a professional level that is above question of any kind. The guidelines are as follows:
- There shall be no personal financial transactions between staff and service recipient. This includes accepting gifts of obvious significant value and lending or borrowing money under most normal circumstances.
- Staff will not include service recipients as guests in their home or take them on personal outings unless approved by the program Vice President.
- There is to be no fraternization with service recipients via any form of electronic communication.
- During conversations and treatment, discretion should be exercised in sharing the details of staff private life.
- Sexual contact with a service recipient by staff is prohibited. Contact for hygiene, weather, or medical incidents are permitted based on care needs. (See Sexual Harassment Policy)
- Dating service recipients or similar romantic involvement is not appropriate at anytime or under any circumstances.
- Staff who are assigned, through their job description, the duties and responsibilities of counseling are the only authorized persons to carry out this function.
- Sexual Harassment or the creation of a hostile work or living environment is unacceptable.
- Staff are obligated to report any of the following to a supervisor: suspected abuse and/or neglect of service recipients, situations which may jeopardize quality service delivery, misuse of agency resources, and/or violate agency policy or procedures, and any perceived Corporate Compliance violations.
- Service recipients shall not carry out the duties of staff unless such tasks are described in the participant’s plan of services for the purpose of increasing skills.
- No firearms or other weapons may be stored or brought to any facility or grounds of this agency.
- The unlawful manufacture, distribution, dispensing, possession or use of alcohol, illegal drugs or controlled substances on Agency property, in an Agency vehicle or while engaged in Agency Activities are strictly prohibited.
- Staff shall be models of appropriate and acceptable behavior.
- All staff, when acting as a representative of Gateway must always uphold the integrity of the agency through their words and actions, no matter the format in which it is communicated.
- All Gateway financial transactions must be properly authorized by management and be accurately and completely recorded on Gateway’s books and records in accordance with generally accepted accounting principles and established corporate accounting policies.
- Gateway requires the undivided diligence of its employees, consultants and affiliates while exercising their responsibilities. Except where otherwise approved, personal investments or activities that may create a conflict of interest are prohibited, and situations that may give the appearance of conflict are to be avoided. Outside employment that raises any question in this regard must be disclosed to Gateway and approved in advance by the President & Chief Executive Officer. In the event the President & Chief Executive Officer needs to make disclosure, or needs permission as set forth above, he/she shall address him/herself to the Chair of the Board of Directors of Gateway Community Industries or to the Executive Committee.
- If any circumstance presents itself which casts any doubt on the integrity of services delivered by Gateway operations the employee, consultant or affiliate are directed to contact the Chief Quality and Compliance Officer immediately so that timely investigation and necessary correction may be enacted.
- As Corporate Compliance is a highly complex area, and this document cannot address all situations in which breach or concern may apply, employees, board members and affiliates must contact their supervisor as appropriate, or the Chief Quality & Compliance Officer, who will make necessary determinations. The best policy is “if in doubt, ask”.
In addition, to the information listed above, other rules of staff conduct must be maintained in order for employees to work efficiently and effectively together in an organization such as Gateway Community Industries, Inc. Lack of adherence to the rules will result in disciplinary action, up to and including termination. Infringements are summarized below:
- Habitual absenteeism or lateness
- Failure to properly notify your supervisor when late or absent
- Failure to perform assigned duties as directed
- Insubordinate, unlawful or disorderly conduct
- Verbal or physical altercations with other individuals
- Theft or misappropriation of GCI property
These guidelines are not meant to restrict day-to-day relationships. They are general guidelines of behavior in the course of job performance. If any questions should arise, please discuss the situation with your program director.
GENERAL COMPLIANCE STANDARDS AND APPLICATIONS TO PREVENT CRIMINAL CONDUCT
All personnel associated with Gateway, including all consultants who are contracted by Gateway to deliver services to Gateway service recipients, must avoid all illegal or unethical conduct. No personnel will take any action that he or she believes is in violation of any statute, rule or regulation. In addition, all personnel must strive to avoid even the appearance of impropriety, and must never act in a dishonest or misleading manner when dealing with others, both within and outside Gateway.
Accounting and Financial Reporting
All of Gateway’s payments and other transactions must be properly authorized by management and be accurately and completely recorded on Gateway’s books and records in accordance with generally accepted accounting principles and established corporate accounting policies and procedures. No false, incomplete or unrecorded corporate entries shall be made. No undisclosed or unrecorded corporate funds shall be established for any purpose, nor shall Gateway’s funds be placed in any personal or non-corporate account. All corporate assets must be properly protected, and asset records must be regularly compared with actual assets with proper action taken to reconcile any variances. All internal controls must be followed. The Finance Committee of the Board of Directors will review the expenditures by the President & Chief Executive Officer.
Anti-kickback and False Claims Issues
Both federal and state laws specifically prohibit any form of kickback, bribe or rebate made directly or indirectly, overtly or covertly, in cash or in kind to induce purchase, recommendation to purchase or referral of any kind or goods or services paid for by Federal, State, or Local Programs. The term “kickback” as defined in these statutes means the giving of remuneration, which is interpreted under the law as anything of value. Under the federal law, the offense is classified as a felony and is punishable by fines and imprisonment. Federal and State “anti-referral” laws impose substantial penalties relative to billing for services referred by anyone who has a contractual or business relationship with Gateway. It is an individual’s responsibility to be familiar with these statutes and assure that all activities are conducted in such a manner that no question may arise as to whether any of these laws have been violated. Any questions concerning these statutes or any business arrangement subject to anti-kickback or anti-referral laws must be directed to the Chief Quality and Compliance Officer. No employee, board member or affiliate who in good faith reports a suspected violation shall suffer harassment, retaliation, intimidation or adverse employment consequences as per the False Claims Act qui tam provisions.
The laws prohibit accepting a kickback. In addition, there are laws that prohibit the filing of false claims. As this is a highly complex area of the law, this policy cannot list all situations in which the ant-kickback or false claims laws may apply. Therefore, employees must take special care in this area and promptly refer the question to their supervisor, or the Chief Quality and Compliance Officer if appropriate.
Examples of the types of actions that could violate the Federal Medicare/Medicaid anti-kickback statute and similar State laws include the following:
- Offering or paying anything of value to induce someone to refer an individual to GCI.
- Offering or paying anything of value to anyone (consumer or referral sources) in marketing GCI.
- Soliciting or receiving anything of value for the referral of GCI consumers to others.
Making Political Contributions
Employees may not contribute or donate Gateway funds, products, services or other resources to any political cause, party or candidate. However, employees may make voluntary personal contribution to any lawful political causes, parties or candidates, as long as the individual does not represent that such contributions come from Gateway, and as long as the individual does not obtain the money for these contributions from Gateway for the purpose of making such a contribution.
Providing Business Courtesies to Customer or Sources of Customers
Gateway does not seek to gain an improper advantage by offering business courtesies such as entertainment, meals, transportation or lodging to customer, referral sources or purchasers of Gateway services. Employees should never offer any type of business courtesy to a referral source or a purchaser for the purpose of obtaining favorable treatment or advantage. To avoid even the appearance of impropriety, employees must not provide any referral source or purchaser with gifts or promotional items of more than nominal value (e.g. pens, calendars, and the like).
Employees may pay for reasonable meal, refreshment and entertainment expenses for referral sources and purchasers of Gateway services which are incurred only occasionally, are not requested or solicited by the recipient, and are not intended or likely to affect the recipient’s business decisions with respect to Gateway. An employee may provide or pay travel-lodging expenses of a customer or referral source only with advanced approval of the President & Chief Executive Officer, if the travel or lodging is not for a directly business-related purpose.
Fair Billing Practices
Gateway will bill individuals or third parties only for services actually provided and will give assistance to individuals seeking to understand the costs relative to their care. Gateway will attempt to resolve questions and objections to the satisfaction of the individual while also considering the institution’s best interest.
Examples of the types of action that could violate the federal false billing laws include but are not limited to:
- Filing a claim for services that were not rendered or were not rendered as described on the claim form;
- Filing a claim for services that were rendered, but were medically unnecessary;
- Submitting a claim containing information you know to be false; and
- Misusing Social Security or Medicare symbols, emblems or names in marketing.
In addition, billing personnel should refer to specific departmental policies and procedures for guidance regarding reimbursement and billing practices.
It is the policy of GCI that coding changes on bills or accounts can and will only be made if the medical records documentation supports making the changes.
Conflict of Interest
No employee of Gateway may have employment, consulting or other business relationship with a competitor, customer or supplier, or invest in any competitor, customer or supplier (except for moderate holdings of publicly traded securities) unless disclosure is made to the President & Chief Executive Officer. The President & Chief Executive Officer makes these disclosures to the Chairman of the Board of Directors or the Executive Committee.
Acceptance of Business Courtesies
Gateway employees should never accept anything of value from someone doing business with the Agency or someone whose services are subject to the Agency’s review. To avoid even the appearance of impropriety, the acceptance of gifts or gratuities is not permitted.
An employee may accept meals, drinks or entertainment only if such courtesies are unsolicited, infrequently provided and reasonable in amount. Such courtesies must also be directly connected with business discussions. Gateway employees are not permitted to accept reimbursement for lodging or travel expenses or free lodging or travel without the express written approval of the President & Chief Executive Officer unless such lodging and travel reimbursement is required by contract (e.g. training for computer systems, technological equipment, etc.).
All charitable contributions received from individuals and organizations must directly benefit Gateway. Under no circumstances may a check be made payable to an individual Gateway staff person. Under no circumstances shall donations be accepted that require Gateway to use the donation to purchase supplies or other goods and services from the vendor or persons making the contributions.
Related Policies and Procedures
Case Record Management – Closure
Incident Management Program Policy & Procedure
Medicaid Compliance Policy
Corporate Compliance Hotline Policy
Business Associate Agreement
Medicaid Pre-billing Review and Notification of Billing Concerns
Business Partner Policy and Procedures
Acceptance of Gifts
Board of Directors: By-Laws, Policies and Procedures
Conflict of Interest Policy
EEO Policy and Affirmative Action Program
Finance Billing Procedures
HIPAA Privacy and Security Standards, Policies and Procedures
Quality Assurance Policy
Political Payments Policy
Purchase Order Policy and Procedure
Use of Cell Phones and Corporate Credit Cards
HR 109 – Complaint Resolution Process
HR 202 – Electronic Communications
HR 106 – Employment Clearances
HR 703 – Sexual Harassment and Other Forms of Harassment
HR 719 – Whistleblower
HR – Regulatory Orientation and training Policy
Revised: 06/20/00, 04/25/05 – Approved: 06/23/05 by BOD
Revised: 09/08, 03/09 (addition of “affiliated entities”), 09/09 (change of title: CCL to CCO)
Revised: 01/13/10, 02/22/10 – Approved: 03/31/10 by BOD
Revised: 01/13/10, 02/22/10, 12/15/10 – Approved: 01/26/11 by BOD
Revised: 12/31/16, approved 1/25/17