COMPLIANCE PROGRAM PLAN Reviewed/revised 6/15/21 COMPLIANCE PROGRAM PLAN TABLE OF CONTENTS I. Compliance Program Plan Introduction……………………………………………………………… Page 3 II. Written Policy and Procedures …………………………………………………………………………. Page 4             Compliance Policy Compliance Committee Policy Conflict of Interest and Internal Investigations Code of Ethical Conduct Compliance Training Business Confidentiality Non-Bargaining Unit Employee Disciplinary Action Monitoring and Audit Policy Investigation of Compliance Issues Exclusion Screening False Claim Act Prevention Policy Whistleblower Policy III. Designation of Compliance Officer……………………………….………………………………..  Accountability to the CEO and Board of Directors Page 5 IV. Training and Education………………………………………………..………………………………  New Employee Training  Board of Directors Training  Contractors Training Page 6 V. Communication Lines to the Compliance Department…………………….…………..  Access to the Compliance Officer  24 Hour Hotline/Confidential and Anonymous  Compliance email Page 7-8 VI. Enforcement of Compliance Program Plan & Encouragement of……………………….. Page 9 Good Faith Participation VII. System for Routine Identification of Compliance Risk Areas……………………………… Page 10-11 VIII. Responding to and Remediating Compliance Issues………………………………………….. Page 12 IX. Non-Intimidation and Non-Retaliation………………………………….………..…………………. Page 13 X. Revision Tracking………………………………………………………………………………………………… Page 14 Compliance Program Plan Revision 3 Page 2 of 14 CDS Monarch Compliance Program Plan CDS Monarch (CDSM) is committed to maintaining an effective Compliance Program to assure compliance with all applicable laws and regulations. CDSM maintains a high level of professional and business standards to provide a work environment where high standards of ethical and legal behavior are recognized and practiced. The Board of Directors of CDSM is responsible for overseeing the effectiveness of the Compliance Program. The Compliance Program Plan reflects CDSM’s mission of providing highquality services to individuals with intellectual and developmental disabilities. The Compliance Program Plan establishes a foundation for accountability, quality, efficiency, and safety. CDSM maintains and promotes an effective Compliance Program through the following elements: Compliance Program Plan - Written Policies and Procedures Compliance Program Oversite Training and Education Communication Lines to the Compliance Department Enforcement of Compliance Program Plan and Encouragement of Good Faith Participation System for Routine Identification of Compliance Risk Areas Responding to and Remediating Compliance Issues Non-Intimidation and Non-Retaliation – Whistleblower Protections SCOPE: CDSM complies with the following laws including but not limited to:  42 C.F.R. §§422.503(b)(4)(vi) and 423.504(b)(4)(vi)  42 C.F.R. §423.501  New York State Social Services §363-d  18NYCRR Part 521  Federal false Claims Act (FCA) (31 U.S.C. §et seq.)  Section 6402 of the Patient Protection and Affordable Care Act (PPACA)  New York State Labor Law Sections 740 (and 741 as guide) (Whistleblower laws)  New York State False Claims Act (State Finance Law)  Health Insurance Portability and Accountability Act of 1996 (HIPAA) Compliance Program Plan Revision 3 Page 3 of 14 Compliance Program Plan - Written Policies and Procedures The Compliance Program Plan is formally promulgated as policy. Additional compliance related policy and procedures have been developed to provide guidance and direction for staff. Collectively these documents establish standards and procedures that must be followed. Compliance Policy Compliance Committee Policy Conflict of Interest and Internal Investigations Code of Ethical Conduct Compliance Training Business Confidentiality Non-Bargaining Unit Employee Disciplinary Action Monitoring and Audit Policy Investigation of Compliance Issues Exclusion Screening False Claim Act Prevention Policy Whistleblower Protections Compliance Program Plan Revision 3 Page 4 of 14 Designation of Compliance Officer The Vice President of Compliance and Quality Improvement is the designated Compliance Officer for CDSM. The Compliance Officer is responsible for the development, implementation, and monitoring of the agency’s Compliance Program. REPORTING RELATIONSHIP: The CDSM Compliance Officer reports to the President/CEO. Additionally, the Compliance Officer has direct communicati