Corporate Compliance Program
Compliance Officer - Carol Ann Rizzi
Compliance Hotline - 631-473-4284 ext 200
CORPORATE COMPLIANCE PROGRAM
Corporate Compliance Plan Overview:
New York Therapy Placement Services, Inc. ("NYTPS) established a Corporate Compliance Plan ("The Plan") which promotes an organizational culture that encourages ethical conduct and a commitment to compliance with laws, rules and regulations which govern our operations. The Plan encompasses all of the following requirements with an emphasis on ethics, integrity and open lines of communication. The Plan is then incorporated into our operation which is committed to high standards of performance and quality of services.
The Plan, at a minimum, is applicable to billings to and payments from the Early Intervention & School Programs. The law contains only the minimum requirements for such plans. In order to be in compliance with additional federal and state requirements, we have adopted the following requirements for compliance plans beyond the basic statutory requirements which are as follows:
-- Written policies and procedures that describe compliance expectations as embodied in a code of conduct or code of ethics, implementation of the operation of the compliance program, provision of guidance to employees and others on dealing with potential compliance issues, identification of how to communicate compliance issues to appropriate compliance personnel and describe how potential compliance problems are investigated and resolved.
-- Designation of an employee vested with responsibility for the day-to-day operation of the compliance program.
-- Training and education of all affected employees and individuals.
-- Development of communication lines to the responsible compliance position that are accessible to all employees and affected persons associated with our agency.
-- Development of disciplinary policies to encourage good faith participation in the compliance program by all affected individuals, including policies that articulate expectations for reported compliance issues and assist in their resolution and outline sanctions for:
(1) Failing to report suspected problems;
(2) Participating in non-complaint behavior; or
(3) Encouraging, directing, facilitating, or permitting non-compliant behavior; such disciplinary policies shall be fairly and firmly enforced.
-- Establishment of a system for routine identification of compliance risk areas.
-- Establishment of a system for responding to compliance issues as they are raised; for investigation potential compliance problems; responding to compliance problems as identified in the course of self-evaluations and audits; correcting such problems promptly and thoroughly and implementing procedures, policies and systems as necessary to reduce the potential for recurrence; identifying and reporting compliance issues to the OMIG or the DOH; and refunding overpayments.
-- A policy of non-intimidation and non-retaliation for good faith participation in the compliance program, including but not limited to reporting potential issues, investigating issues, self-evaluations, audits and remedial actions, and reporting to appropriate officials as provided in sections seven hundred forty and seven hundred forty-one of the labor law (new whistleblower provisions for health care fraud).
Implementation of the Plan:
The Plan is effective immediately. All employees, officers, directors, and agents of NYTPS are provided a copy of the Plan and shall execute an acknowledgement. At this time they shall be expected to comply with the terms of the Plan. All employees, officers, directors and agents shall be instructed to direct any questions of concerns about the Plan to the Compliance Officer.
Code of Conduct and Ethics:
We are committed to conducting business ethically and in conformance with all applicable laws, regulations, and standards. This policy applies to all employees, including the CEO, financial officers and agents of NYTPS. It is our commitment to maintain a written Code to provide guidance on organizational responsibilities related to compliance with all applicable laws and regulations. We have developed a written Code to provide all employees, officers, directors and agents of NYTPS with guidance on expectations for workplace conduct.
1. All employees, officers, directors and agents of NYTPS are expected to be truthful at all times in conducting the affairs of NYTPS. This will include, but not be limited to, truthfulness in processing internal and external copy and electronic documents and oral and written communications on behalf of NYTPS. Honest and ethical conduct also includes the ethical handling of actual or apparent conflicts of interest between personal and professional relationships.
2. All employees, officers, directors and agents of NYTPS are expected to conduct business in compliance with applicable governmental laws, rules and regulations.
3. All employees, officers, directors and agents of NYTPS are expected to promptly report of violations of the Code of Ethics to an appropriate person or persons identified in the Plan.
4. All employees, officers, directors and agents of NYTPS are expected to engage in good faith participation in the compliance program. We have developed sanctions that will apply for failing to report suspected problems, participating in non-complaint behavior and encouraging, directing or facilitating or permitting non-complaint behavior.
Duty to Report/Hotline Policy:
We recognize that a critical aspect of our Plan is the establishment of a culture that promotes prevention, detection and resolution of instances of conduct that do not conform to federal and state and private payer requirements, as well as the organization's ethical and business policies. To promote this culture, we have established a policy that permits all employees, officers, directors and agents to report in confidential/anonymous manner by calling the hotline on all problems, concerns, and potential violations of federal, state and local laws and regulations.
1. All employees, officers, directors and agents are responsible for reporting misconduct, including actual or potential violations of law, regulation, Code, problems and concerns regarding questionable accounting, internal accounting controls, or auditing matters.
2. We have established a telephone hotline to receive complaints and concerns and relay them directly to a designated representative of the CEO without the caller having to go through management channels. Reporting can be done directly to the hotline 24 hours a day, 365 days a year.
3. We have a designated Compliance Officer, Carol Ann Rizzi, who can be reached at (631) 473-4284 Ext. 105.
4. Anyone with knowledge of a potential violation of law, regulation, Code of Conduct, policies or procedures has an affirmative duty to report that information. Failure to report a potential violation may result in appropriate disciplinary action.
5. All employees, officers, directors and agents who report problems and concerns via the hotline in good faith will be protected from any form of retaliation or retribution. (Non-retaliation/Non-retribution Policy).
6. Callers shall be assured of their rights to anonymity or, if they identify themselves, confidentiality within the limits allowed by law.
7. All employees, officers, directors and agents cannot exempt themselves from the consequences of their own misconduct by reporting the issue, although self-reporting may be taken into account in determining the appropriate course of action.
Conflict of Interest Policy:
All employees, officers, directors and agents who work for our organization, including auditors, accountants, and consultants retained by us, have an obligation to conduct business within guidelines that prohibit actual or potential conflicts of interest. This policy is established to ensure that child care and business activities are conducted in an objective manner and are not motivated by the desire for personal or financial gain.
1. Employees and those acting on behalf of us are required to disclose any actual or potential conflicts of interest and seek guidance on how to handle such situations.
Conflict of Interest:
Any situation in which financial or other personal considerations may compromise or appear to compromise: (1) the business judgment of any employee or other party engaged by us; (2) the delivery of service; or; (3) the ability of an employee to do his or her job. An actual or potential conflict of interest occurs when an individual is in a position to influence a decision that may result in a personal gain for that person at the expense of our best interest or of our stakeholders.
The confidentiality of information is of the utmost importance to the organization. Accordingly, all employees, directors, officers and agents of NYTPS are responsible for ensuring the confidentiality of all personal identifiable information in all early intervention/school records, as defined above, consistent with the provision of FERPA and other applicable provisions of law governing the confidentiality of records.
We are committed to the establishment of a culture that promotes prevention, detection and resolution of instances of conduct that do not conform to federal and state laws and regulations, as well as the Code of Conduct and Ethics. In furtherance of this we established a problem resolution process and a strict non-retaliation can undermine the problem resolution process and result in a failure of communication channels in the organization. This policy has been developed to underscore these principles.
1. It is our policy to prohibit the firing, threatening or otherwise harming of any person of the basis of the employee's reporting a problem or his or her participation in an investigation of violations of rules or corporate responsibility laws.
2. People who report problems and concerns regarding questionable accounting, internal accounting controls, or auditing to the hotline established by the CEO may do so without fear of retaliation or retribution.
3. People who bring organization problems or criminal conduct to their supervisors, others in management, or federal authorities are entitled to protections and remedies.
This policy is consistent with the provisions of sections 740 and 741 of New York State Labor Law. An employee, officer, director or agent of NYTPS who has been the subject of a retaliatory personnel action may initiate such legal actions and proceedings and request such relief to the extent provided in sections 740 and 741 of the New York State Labor Law.
Auditing and Monitoring Policy:
This policy focuses on the ongoing auditing and monitoring of accounting controls, systems and procedures. Management will review and certify internal accounting controls are in place and sufficient to gather the information needed to evaluate and reflect in the financial statements. A sound system of internal controls is required to enable reliance upon financial systems.
Given the nature of our business, we have identified the following compliance risk areas which we currently monitor and perform internal audits:
Billing & Payments
Quality of services
Other risk areas that may be identified
We shall conduct, internal audits to effectively identify non-compliance according to an audit plan which is:
developed at least annually, and revised as necessary
assessed compliance data from the previous year (audits, statistics, etc.), to identify high risk areas for the coming year (trend tracking)
identifies corrective action plan that requires auditing to confirm compliance; and
includes measurements, timetable and individuals responsible for addressing each risk area.
Such audit findings shall be analyzed to identify non-compliance and identification of trends and other appropriate metrics identified in advance of internal and external audits.
NYTPS is committed to conducting all of its affairs in accordance with applicable federal and state laws ad regulations.
Training & Education:
The effectiveness of the Plan will be enhanced by the provision of training to all employees and affected individuals to assure accurate, reliable and consistent information which will lead to improved compliance.
All employees, officers, directors and agents of NYTPS will receive training on policies and procedures and specifically, the Plan, as well as the expectations with respect to compliance with the Plan, at the time of hire or at such other time as such individual commences activities on behalf of or for the benefit of NYTPS.
Training provided in furtherance of the Plan shall be provided by qualified individuals and will contain the following components:
Training shall be mandatory and carry sanctions for failure to attend.
Training materials shall be annually evaluated, consider relevant audits and investigations, include a variety of teaching methods, and be provided in different languages (where necessary).
Training information shall be distributed through several means, including, but not limited to, newsletters, notices, posters, and intranet sites and may occur at regular staff meetings.
Training and education will be centered on changes in applicable laws, regulations and policies.
Training will address identified or potential weaknesses in current operations, including the development and implementation of corrective action plans when necessary.
Training will explain the importance of complying with applicable laws, rules and regulations.
Training shall include legal requirements relating to the False Claim Act and related laws.
Training shall include review of disciplinary policies which encourage good faith participation in compliance program.