Purpose:
- To commit the Agency to maintaining compliance with all laws, regulations, program requirements and guidelines and operating the agency in an ethical manner.
- To provide the Agency with a mechanism to ensure compliance to all laws, regulations, program requirements and guidelines and ethical business practices.
Policy Guidelines:
- It is the determined policy of Visiting Homemaker Service of Passaic County, Inc. and its employees to adhere to sound and lawful business practices and comply with all program requirements, regulations and guidelines. Therefore, the Agency will cooperate with all reasonable and lawful demands made by governmental investigations or law enforcement agents. Written, copied or electronic documentation is not to be altered or destroyed in anticipation of a request or as a result of a request for those documents by any authorized, lawful investigation.
- The Board of Trustees shall have final authority on all business ethics and compliance decisions. The Board of Trustees shall appoint an independent Compliance Officer and assign a Compliance Committee of the Board with the charge of establishing and advising the organization on business ethical issues and practices and for overseeing compliance with all laws, regulations, program requirements and guidelines.
- The Compliance Committee shall review, at least annually, all reported violations or incidents of misconduct and compliance and business ethics policies, and report to the Board of Trustees the activity of the Committee. Minutes shall be kept of all Compliance Committee meetings.
- The Agency shall adopt a Code Of Business Ethics that clearly outlines expected conduct and is to be displayed in each office and included in new hire orientation.
- The Agency will on an annual basis conduct internal audits on admissions, payments and reimbursement, accounts receivable, delinquent accounts, and staff expenses to ensure adherence to all laws, regulations, program requirements and guidelines and policies. The results of these audits are to be reported at least annually to the Compliance Committee for their review and recommendations to the Board of Trustees.
- It is the policy of VHSPC to prohibit kickbacks from being paid or received. The administrative staff and the members of the governing body will sign a No Kickback Policy statement annually. The statement will include a list of any payments, income, gifts, special consideration, or remuneration of any kind that results from any vendor relationship with VHSPC. These disclosure statements will be reviewed each year by the Ethics Committee.
- It is the policy of VHSPC to comply with all Federal HIPAA and State HINT regulations regarding confidentiality of patient information. All Agency staff and volunteers shall sign a Confidentiality Agreement in this regard. Each patient will receive a privacy statement that will be explained to them and that they will acknowledge on the Informed Consent form.
- This policy shall be part of new hire orientation and be signed, dated and kept in the individual personnel record. All staff shall have access to current program regulations and requirements at all times.
- The Agency shall communicate the Business Ethics and Compliance policy to the public and referral sources annually. All clients will be informed of methods to report misconduct.
- Reports of any misconduct, unethical business practice or violation of program regulation or guidelines can be made by anyone. These occurrences must be reported, in writing or verbally, to a Supervisor or Agency Executive Director immediately and will be kept in strict confidence. This report must include the name of the person(s), act(s), and date(s) of the suspected violation(s). The person reporting the incident can also make the initial report to the Compliance Officer: (Nancy Eberhardt., c/o Pro Bono Partnership, 973-240-6955, fax 973-240-6966, 300 Lanidex Plaza., Suite 3203, Parsippany, NJ 07054) in writing, in person or by phone or fax.
- Upon receipt of a reported incident the Supervisor and Agency Executive Director must investigate the allegation within five (5) days of the report. The Compliance Officer must make a referral to the Agency Executive Director or appropriate staff member for an investigation within five (5) days of the report or investigate the allegation independently within five (5) days of the report.
- If, in the judgment of the Executive Director or Compliance Officer, an incident is a significant event a report to the Board of Trustees may be made immediately upon the completion of the investigation. Otherwise, all reported violations and their resolutions will be reported to the Compliance Committee immediately for presentation to the Board of Trustees.
- Failure, by any employee, to report unethical business practices or unlawful actions by the organization and its employees is misconduct warranting disciplinary action up to and including termination. The Board of Trustees has the final determination on appropriate disciplinary action for the failure to report.
- The Agency abides by the Conscientious Employee Protection Act (Whistleblower Act) and provides notices to employees as per the Act, upon hire and annually thereafter.
Approved by Compliance Committee with revisions: 7/14/99
Approved by Board of Trustees: 9/27/99
Rev: 10/22/01, 2/25/02, 6/18/04, 3/20/06, 3/6/07, 8/10/07, 5/24/10, 9/27/10