the center for family support, inc

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Policy and Procedure: Corporate Compliance Topic: Employee, Board Member and Independent Contractor Compliance Training SCOPE OF POLICY This policy applies to all employees, including trainees, volunteers, consultants, independent vendors and contractors or subcontractors as well as The Board of Directors.

STATEMENT OF PURPOSE The development and implementation of regular, effective education and training seminars for employees is an integral part of The Center for Family Support’s corporate compliance program. Compliance education and training is divided into two general components. First, all employees must receive an introduction to the corporate compliance program as part of new employee orientation. Board members receive this introduction as part of their initial phase-in to Board responsibilities. Independent contractors will be briefed as part of the negotiation of contracts. Second, employees whose work is linked to identified risk areas should receive compliance education pertaining to their function and responsibilities. Members of the Board will also receive such training which will include training on the corporate compliance policies and procedures, conflicts of interest and their fiduciary responsibilities related to corporate compliance. All employees and Board Members will thereafter receive training on an annual basis.

STATEMENT OF POLICY All employees, including new hires, will receive training related to the organization’s overall compliance program. Employees in identified risk areas and members of the Board of Directors will receive more detailed education related to their function and responsibilities. They will all attend training updates on an annual basis, at a minimum each year thereafter. Independent contractors will be briefed on the compliance plan as it pertains to the contract under negotiation. Attendance at training sessions is mandatory and is a condition of continued employment or contractual relationships.

IMPLEMENTATION OF POLICY 1. The Corporate Compliance Officer is responsible for developing the compliance education curriculum and monitoring and ensuring that compliance training and orientation meet the policy standards on this subject.

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2. Compliance training will include an explanation of the structure and operation of the corporate compliance program and inform all attendees and employees as to the identity of the Corporate Compliance Officer. 3. Compliance training, at a minimum, will include information on the following aspects of the compliance program: A. An Overview of Corporate Compliance and Related Laws and Regulations a. Health Insurance Portability & Accountability Act (HIPAA) of 1996 for Privacy and Security Issues b. Balanced Budget Act (BBA) of 1997 c. False Claims Act (FCA) – Federal & State Laws d. Deficit Reduction Act (DRA) of 2006 B. An Overview of the CFS Corporate Compliance Plan Components, Policies and Procedures a. Code of Conduct & Conflict of Interest policy and other related written guidance; b. Qui Tam / Whistleblower Actions/Provisions, Policy and Process c. Methods of Reporting Concerns; Open Door Policy; communication channels, including the contact information for the CFS Corporate Compliance Officer, CFS Director of Human Resources, Executive Director, Assistant Executive Director and the established Corporate Compliance / Whistleblower hotline and internet complaint site to report concerns anonymously; d. Non-Retaliation Policy for Reporting (suspected or actual noncompliance) C. Methods of Compliance Oversight & Enforcement Standards a. Internal Audits, Plans of Corrective Actions and Follow-Up Activities b. Corporate Compliance Committee c. Initial Staff Training and Continuous Education d. Consequences for Non-Compliance (and failing to report known noncompliance) E.

Duties of the Corporate Compliance Officer

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Documentation Requirements for Billable Services Rendered a. Service Planning & Delivery Documentation of Medically Necessary Services: b. Provided By Qualified Personnel c. Properly Authorized, Allowable by Law and Based on Diagnosis d. Goal Driven, Measurable and Meaningful to the Individual e. Properly Documented in a Contemporaneous Manner

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G. Employee Responsibilities; a. Organizational expectations for reporting problems and concerns; and 4. Comprehensive education materials have been developed to facilitate the compliance sessions and ensure that a consistent message is delivered to all employees, Board Members and contractors. Education protocols and materials are standardized, so as to evidence that everyone attending a seminar receives the same instruction. 5. As part of his or her initial orientation, each employee shall receive training during new employee orientation. Board Members shall receive training at the First Board meeting subsequent to the commencement of their respective Board affiliation. Independent contractors must participate in training prior to initiation of any contractual agreement. Each employee, Board Member and contractor will receive an introduction to CFS’s corporate compliance program and objectives, and a written copy of the Code of Conduct & Conflict of Interest policy, corporate compliance plan and compliance policies. Each new employee, Board Member or contractor will sign an acknowledgement that they are aware of and will abide by the Corporate Compliance Program and Code of Conduct & Conflict of Interest policy. 6. All existing employees and Board Members will receive an initial training session and then receive training minimally annually thereafter year to include a review of the existing Corporate Compliance Program, the Code of Conduct & Conflict of Interest Policy, and any updates or changes to applicable policies and procedures. The session will also focus on any changes in federal and/or state & local laws and regulations. 7. All education and training relating to the Corporate Compliance Program will be verified by attendance and a signed acknowledgement of receipt of training. The Corporate Compliance Officer will submit these documents for employees to the Human Resources Department who will maintain a file of attendance forms for all training sessions in each employee’s personnel file. The Corporate Compliance Officer will submit these documents for Board Members to the Executive Director who will maintain a file of attendance forms for all training sessions in each Board Member’s file. The Corporate Compliance Officer will submit these documents for independent contractors to the Assistant Executive Director who oversees financial operations who will maintain a file of attendance forms for all training sessions in each contractor’s file. 8. Employees, independent contractors and Board Members will be provided with the opportunity to seek clarification or more information on any aspect of the corporate compliance program. Trainers who are not able to answer specific questions will arrange for follow-up to be conducted by the Corporate Compliance Officer.

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9. Only properly trained individuals will be used to provide compliance education and training seminars. Compliance program trainers must be knowledgeable of the (a) compliance program; (b) applicable federal laws and regulations; (c) requirements of the Federal Sentencing Guidelines; (d) relevant organization policies/procedures; (e) operations of the compliance program; and (f) content of the Code of Conduct & Conflict of Interest Policy. 10. The Corporate Compliance Officer is responsible for coordinating with management to ensure that specialized compliance education occurs in identified risk areas. 11. The Executive Director is responsible to ensure that the agency Corporate Compliance Officer has sufficient opportunities to attend and receive ongoing education regarding any law amendments or additions in the realm of corporate compliance. 12. The Corporate Compliance Officer is also responsible for submitting periodic reports to the Corporate Compliance Committee and Board of Directors on all education seminars related to the compliance program.

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CENTER FOR FAMILY SUPPORT, INC. ATTESTATION OF CORPORATE COMPLIANCE TRAINING Date Training Conducted: _________________________________________________ Name of QA/Corporate Compliance Trainer: _________________________________ Signature of Trainer: _____________________________________________________ Topics Covered in Training Included: 1. An Overview of Corporate Compliance and Related Laws and Regulations: a. Health Insurance Portability & Accountability Act (HIPAA) of 1996 for Privacy and Security Issues b. Balanced Budget Act (BBA) of 1997 c. False Claims Act (FCA) – Federal & State Laws d. Deficit Reduction Act (DRA) of 2006 2. An Overview of the CFS Corporate Compliance Plan Components, Policies and Procedures a. Revisit Compliance Plan, Test for Effectiveness and Revisions 3. Qui Tam / Whistleblower Actions, Policy and Process a. Methods of Reporting Concerns; Open Door Policy b. Anonymous Hotline System c. Non-Retaliation Policy for Reporting (suspected or actual non-compliance) d. Contact Information for:  Corporate Compliance Officer / Director of Quality Assurance  Director of Human Resources  Executive Staff 4. Methods of Compliance Oversight & Enforcement Standards a. Internal Audits, Plans of Corrective Actions and Follow-Up Activities b. Corporate Compliance Committee c. Initial Staff Training and Continuous Education d. Consequences for Non-Compliance (and failing to report known non-compliance) 5. Duties of the Corporate Compliance Officer 6. Corporate Compliance Committee Process 7. Agency Code of Conduct & Conflict of Interest Policy (explained and distributed) 8. Service Planning & Delivery of Medically Necessary Services: a. Provided By Qualified Personnel b. Properly Authorized, Allowable by Law and Based on Diagnosis c. Goal Driven, Measurable and Meaningful to the Individual d. Properly Documented in a Contemporaneous Manner 9. Employee Responsibilities The undersigned individual acknowledges that he/she did receive training today on the above listed topics along with materials that included a synopsis of the agency Corporate Compliance Plan & employee responsibilities. The undersigned also received a copy of the agency conflict of interest policy, the agency code of conduct, and reporting and contact information in order to report any suspected or actual noncompliance issues. The undersigned person understands that he/she must comply with all laws, agency policies and this compliance plan, must report any instances of possible violations and that failure to report and/or comply with such may result in disciplinary action, up to and including termination.

_______________________________ (Printed name of Trainee)

________________________________ _______________ (Signature of Trainee)

(Date)