Table of Contents Mission Statement .............................................................................................. 2 Core Values and Benchmarks .............................................................................. 3 How Do We Preserve Core Values & Purpose...................................................... 4 Strategic Integrated Plan .................................................................................... 5 Technology Accelerators ..................................................................................... 6 Expectations of Internal & External Stakeholder ................................................. 7 MCE Goal Planning 2015 ................................................................................... 11 MCE 2015 Organizational Goals ........................................................................ 18 Technology Plan 2014 ....................................................................................... 23 Corporate Compliance Policy and Plan .............................................................. 27 Accessibility Plan 2013-2104 Status Report ....................................................... 52 Accessibility Plan 2014-2015 ............................................................................. 55 MCE 2014 Program Goals Progress Report ........................................................ 59 2014 Organizational Goals Progress Report ...................................................... 64 2012-2013 Outcomes Management Report....................................................... 65 Terminology Key ............................................................................................... 73 1 MAGIC CITY ENTERPRISES MISSION STATEMENT “Supporting individuals with disabilities to live successfully.” 2 What Are Our Core Values and Purpose? 1. 2. 3. 4. 5. 6. 7. 8. 9. Health, well being & safety: Promote optimal health, safety, and well being for everyone. Achieve Personal Growth: Support the growth of all involved with MCE. Stability: Provide stability to facilitate a feeling of security for stakeholders. Continuing Quality Improvement: Provide timely, efficient and effective education and training. Stellar Reputation: Maintain a positive reputation as the premiere service provider. Celebrate All Successes: Celebrate large and small, individual, group, and organizational successes. Teamwork: Everyone work together at MCE for a common purpose. Excellent Support through Education and Learning. Full Community Participation. eamwork ealth, well being and safety xcellent support through education and learning Full community participation chieve personal growth elebrate All successes ontinuing quality improvement tability tellar Repuation MCE BENCHMARKS 1. Health, Well-Being, and Safety are our Top Priority 2. Participant Satisfaction - 5 Star Service 3. Teamwork 4. No one person is more important than anyone else 3 How Do We Preserve Our Core Values and Purpose? 1. Therap 2. Commitment to persons served and job before ego 3. To be proactive 4. Organization wide input for solutions from all stakeholders 5. Education for all staff to improve practicing our core values 6. Change our behaviors to meet our goals and not our goals to meet behaviors 7. Continue to be open, honest and forthcoming 8 Support all employees to do their best, and maintain a great work ethic 9. Incorporate our values and mission in our daily performance at a high standard 10. Through staff training 11. Incorporate team building everyday 12. MCE Code of Ethics 4 STRATEGIC INTEGRATED PLAN INFORMATION MEASUREMENT & MANAGEMENT AND PERFORMANCE IMPROVEMENT The following information was considered during the development of this plan document: 1. Expectations of persons served 2. Expectations of other internal and external stakeholders 3. The competitive environment 4. Financial opportunities and threats 5. Our capabilities 6. The service needs of Cheyenne and the surrounding communities 7. Demographics of Cheyenne and the surrounding communities 8. Our relationships with external stakeholders 9. The regulatory environment 10.The legislative environment The following data was collected and is included in this plan document: 1. Needs and expectations of the persons served 2. Needs and expectations of other internal and external stakeholders 3. MCE’s business needs Data from the following areas was utilized in setting the goals, objectives and performance indicators which are found in this plan document: 1. Financial information 2. Accessibility surveys, reviews, and plan 3. Resource allocation 4. DDD site survey, satisfaction surveys, CARF survey, NISH evaluation 5. Risk analysis and plan 6. Board of Directors 7. Human resources 8. Technology analysis and plan 9. Environmental health and safety documents and inspection reports 10. Trends in the field of disabilities 11. Wyoming’s service delivery system The following areas were analyzed for performance related to goals and are included in this plan document: 1. Business functions 2. Effectiveness of services 5 3. 4. 5. 6. Efficiency of services Service access Satisfaction of and feedback from persons served Satisfaction of and feedback from other internal and external stakeholders This goal plan reflects the following in regards to areas analyzed: 1. Areas needing performance improvement have been identified. 2. Action plans have been established to address the improvements needed 3. Actions taken to improve performance have been outlined. The following documents have been utilized in the development of this plan document. 1. Management reports from the various program areas 2. 2013 strategic plan document 3. FY 2013 Budgets 4. FY 2013 Outcomes Management Report 5. 2013 Accessibility Plan 6. 2013 Technology and Systems Plan 7. Health and Safety documentation and reports 8. Individual Plans of Care for persons receiving services 9. Progress reports and notes for persons receiving services 10. Satisfaction information for persons receiving services and other internal and external stakeholders 11. Demographic information on persons referred for, receiving and/or discharged from services 12. Follow-up documentation on persons who have left MCE’s services Technology Accelerators 1. Continue to work towards fully utilizing THERAP and use to bill through web portal for effectiveness and efficiency 2. Five to ten minute videos for staff training- computerized training 3. Continue to update and utilize our MCE website for effectiveness and efficiency 4. Increased assistive technology for participants for effectiveness 5. Continue to increase the use of ADP for efficiency 6. Networking to off site locations 7. Upgrade security for effectiveness 8. Increase mobile technology 9. Increased use of social media for increased public exposure Adapting the Business Strategy 1. Incorporate diversification of services and revenue 2. To be politically active/astute 6 3. Implement changes in the way we serve participants in Residential and Day Habilitation services 4. Become entrepreneurial in seeking and bidding on lucrative contracts 5. Research alternative ways to cut costs and get input from employees EXPECTATIONS OF INTERNAL & EXTERNAL STAKEHOLDERS Be Gracious and Attentive to the needs of all Stakeholders INTERNAL: GUARDIANS AND FAMILIES EXPECT: Live as individuals as much as possible and success in life MCE needs to adapt to changes beyond old fashioned model Put more participants (people) in apartments Need to stay relevant Assist and support participants/people with their desire to be more independent Few less stringent contracts with not as many background checks Develop relevance Live quality lives as independently as possible, help integrate into the community Stabilize with waiver changes Make decisions about who MCE can and cannot serve Clear communication about who MCE can and cannot serve Be current in DD Field-competitive employment, independent living Continue to be a quality program that MCE has always been EXPECTATIONS FROM PARTICIPANTS: More outings Increased security measures Assistance in communicating with family People they can trust Someone to help them Dreams to achieve Safe housing Health and safety for participants Support o In making good decisions o In day-to-day decisions o With food, medications, etc. Consistency Training Transportation Environment Community exposure 7 Community Involvement Money Protection against exploitation Funding and Support Dignity and Respect Opportunity for more independence and awareness of community opportunities Staff understanding Information about opportunities, employment, housing and daily needs Choices Empathetic understanding Sense of worth Good health care A Hug Advocate Knowledge, education and respect of rights EXPECTATIONS FROM EMPLOYEES: Nice working environment Support-education To feel appreciated To feel what I do is important-Sense of purpose what they are doing is important not menial Money-Better Wages Job security Communication Being heard about concerns and something is being done about it if possible Respected in what they say and do Provided good up to date information Recognition Resources available to do the job Reliable working company transportation Support-self worth-want to feel like we value their opinions and ideas To have an authority figure a “phone call away” Management follow through Responsibility: Co-equal authority to accomplish that responsibility Opportunity to problem solve-vent Benefits Assurance (real) that leadership is doing all it can to make MCE successful-share how Opportunity for advancement EXPECTATIONS FROM BOARD OF DIRECTORS More Public Relations o Need a Public Relations Specialist 8 New clients Strengthen employment Strengthen residential Individual competitive supported employment-huge impact on commerce E-Recycling Exit Interviews when employees resign Sophisticated jobs, real life, dignity, inclusion, education and growth in Cheyenne for our participants Get back Warren Air Force Base Recycling Contract Reinvent MCE o Offer new versions of current services o Offer new services to the community A good quality of life in the community for MCE participants Opportunities for clients and participants to work, focus on job opportunities More communication with the public Be better at educating our legislatures o Continual education of legislatures and community Educate the general population on how smart our clients our Ability to have properly paid staff Continue to strive to have the best run facility in the state Greater stability and confidence Add sources of revenue, i.e., a senior center CEO: Be creative and bring the best ideas to us A business plan More job opportunities Creation of a Brain Injury Program EXTERNAL EXPECTATIONS FROM OTHER STAKEHOLDERS: Strong commitment and service to participants Assist clients with opportunities Resources to assist participants Stability for participants, employees and organization Goals met-participants, employees and organization Continually work on maintaining as normal a life as possible for participants Continually work on keeping a good staff o Higher competitive wages o Good positive working environment o Staff Recognition/Well Developed Recognition Programs o Clear communication and timely communication Best quality of life on an everyday basis with the fewest of issues as possible for the participants Expand service opportunities for participants and staff Promote volunteer opportunities in the community 9 More efficient communication process for participants and staff Educate and communicate with the community on who and what MCE is o What is our vision and mission Supplemental steady revenue income so not so dependent on waiver revenue o Continually seek out outside sources of income Secure funding Opportunities for participants to improve themselves o Community inclusion o Community awareness o Meaningful well paying employment Continual work on participant needs, wants, talents and desires. Base programs around a bright future Promote “Employment First!” Increase Support Living Operate existing contracts efficiently and cooperatively High quality trained employees Vision led employees Happy, safe and healthy participants Participant Independence Trust in MCE Recognize how MCE benefits others Political clout Support participants to get out of poverty Strive for full community participation MCE needs to be a role model Transparency Maintain the highest level of professionalism Adherence to all laws and regulations MCE needs to continue to “do what we say we’ll do”. Be reliable and accountable o Responsiveness to requests Treat all people in the community with respect and dignity o “Treat people as people” Money/Politics-do more with less Get permission from Guardians Don’t make waves-unwritten social expectations State expectations to demonstrate increased quality and increased quantity 10 MCE Goal Planning 2015 The 2014 – 2015 Goal Planning session began with a review of our Mission Statement and Core Values. Our Benchmarks and Core Values and Purpose assist us in staying focused on our goals. Economic and financial challenges are constant and we continue to find new ways to overcome them to succeed. Strong Leadership and Managing people are key in obtaining business and participant success. Session 1: Strengths 1. Staff, participants, Board of Directors have pride and believe in MCE Program 2. Huge commitment to participants, their quality of life and full participation in the community with dignity, help them feel successful in life 3. Treat participants with kindness and patience, respect their dignity and individual preferences 4. Strong/fantastic staff 5. Security and protection for the company 6. Staff takes pride in their contributions to participant success 7. Staff has a good sense of participants strengths and limitations 8. Staff really care about participants/strive to do their best to achieve participant success 9. Currently good and effective communication with participants parents/guardians 10. Good organizational skills, consistency with participants and staff/guardians 11. Trust MCE to continually work with participants to grow to become more independent 12. Board of Directors has an excellent history of longevity and willingness to learn the business 13. Positive reputation of quality service around the state 14. Most comprehensive services 15. Possesses Professionalism 16. Integrity 17. Education and Experience of Leadership 18. Ethical 19. Adaptable 20. Training Ground for other, local providers 21. Positive Reputation and History 22. Longevity 23. Positive Role Models for/In the Community 24. Influential/Expertise 25. Proactive with Legislative Changes 26. Focus on our Clients (Personal Centered) 27. Provide Opportunities for Staff Advancement 28. Training Program 29. Broad Community Support 11 30. Employment Services 31. HUD Housing 32. Diversity of Assets 33. Relationship with Community Businesses 34. Federal and State Contracts 35. Fund Raising and Awareness Events 36. Dedicated Employees Create Opportunities for Community Integration 37. Innovative and Expanding 38. React Quickly to Financial Challenges 39. Ethical, Practices Integrity 40. Diversity of Assets 41. Transparent 42. Highest Level of CARF Accreditation Since 1982 43. Good Mix of Professionalism on Boards - Variety of Services (Most Comprehensive) 44. Therapeutic Services 45. Often Chosen for Pilot Projects 46. Events 47. Presence in the Community 48. Name Recognition 49. Eco Recycling Opportunities 1. Integration between home/departments: Residential Support/Supported Living/Independent Families/Day Services 2. Flexibility - Taking People in on emergency bases 3. More volunteer sites that work into employment 4. Provide resources for the elderly 5. Group homes based on age/abilities 6. Volunteer/Donations 7. Outreach to the wounded vets/Acquired Brain Injury/Non DD 8. Employment Training a. Basic Living Skills Training 9. Keeping in contact/finding family members 10. Communicating with other agencies a. Setting up Joint Activities with other agencies 11. Transportation a. Out of town functions b. Work c. Events d. Special Olympics e. Etc. 12. Getting on the same page as Wyoming Community Service Providers 13. Elections 14. Unnecessary space-Renting out or selling houses 15. Expanding because of employment changes from Waiver 12 16. Bring in new people off waiting list 17. Help participants deal with change 18. Help participants strive to live more independently 19. Assist participants in getting better jobs in the community a. Expand individual competitive employment to where this becomes the norm 20. Create more unique type outings for the participants 21. Create better communication between MCE and the community a. Foster an atmosphere that there are differences but yet we are all the same 22. Stabilize and grow after waiver cuts a. Identify growth areas 23. Create a positive staff force a. Pay competitive wages b. Do not overwhelm c. Empathy toward staff issues d. Create an outlet for staff to vent/leave feedback etc. e. Create a more interactive type staff meeting i. Allow staff to have their own meeting without supervisors, managers and administrators to allow them to truly express their thoughts and concerns f. Allow staff to be more part of the “change”-forecasting 24. Continue to be more creative: “Think outside the box” 25. Opportunity to start over “rebuild” MCE from the ground up a. Close what we have to close (not working) b. Stabilize and gradually build back up c. Smaller group programs but best of MCE-new version 26. Reduce wait lists 27. Develop clarity-we can or can’t serve 28. Increase services 29. Keep competitive clients 30. E-Recycling-leverage other recycling needs 31. Warren Air Force Base Recycling 32. Look for more job opportunities for other disabled individuals (Non-MCE disabled) in the community 33. TBI Programming 34. Stay current with DD changes in competitive employment and independent living 35. Restructure in response to financial threats (look for additional revenue sources, i.e. contracts) 36. Improve employee recruiting: a. Involve participants, families and guardians in the interview practice. b. Shadow prior to hiring c. Employee contracts 37. Develop a plan for each department to handle the upcoming changes Threats 1. Financial (Waiver, Contracts, Overtime, Competitive Market) 13 2. Regulatory Agencies 3. Competition 4. Poor Communication (Due to changes, administrative, staffing, inconsistency) 5. Economy 6. Living in the “Unknown” 7. Being in "Survival Mode" 8. Legislature 9. Reputation “stained” by certain events and unhappy former employees 10. Insurance Costs 11. Repercussions of breaking contracts 12. Participants fearful of where they will be, what they will have (same programming?) – this is causing levels of anxiety and sadness among them 13. Possibility of no Day Habilitation in the future a. Loss of revenue b. This will create a smaller company with fewer programs c. What will happen to Day Habilitation participants if Day Hab. closes (Where will they go)? 14. Information Available to community (Response to competition) 15. Communication with Legislature 16. Communication with Behavioral Health Division 17. Figure out how to allocate and stretch funds and cut expenses 18. Better recognition programs (in response to reputation threat) 19. Cut down overtime 20. Transition Meetings 21. MCE may also have to look at closing other programs besides Day Hab 22. Lack of pre-vocational classes or activities with adequate supplies to support those capable of working increases the chance of failure 23. Lack of a structured Public Relations Team can be detrimental to MCE educating our internal community as well as the external community we interact with a. Current lack of regular constant communication and education of our legislatures and community 24. Lack of routinely planned activities to keep participants staying busy in a positive manner 25. Must expand independent living to stay relevant in the field Areas to Improve 1. Reliant on Waiver 2. Poor Communication-Positions-who to contact when you need something. Especially about changes 3. More "Warm and Fuzzy" than "Numbers" type of people 4. MCE Management and Staff seem to have more “Cliques” instead of teams 5. Time constraints: especially procrastination 6. Multiple and ongoing changes 7. Staff Turnover/High level of unskilled staff 8. Burnout level of staff is increasing-losing good people 14 9. Staff fearful of not having job security a. Will MCE be closing its doors b. Fear coupled with they don’t feel important is causing them to leave 10. Poor internal communication a. Communication level between Management and Staff weak b. Staff wants communication/information earlier c. Staff feels that they are not part of the decision making process-want their opinions and ideas to considered when decisions are being made regarding issues that affect them or resources that they need d. “Let us know ahead of time what is going on” before it actually happens e. Staff feels that they do not get help if there is an issue-just immediate reprimanded 11. High training costs 12. Multiple and ongoing changes in the state 13. Committees that don't function efficiently 14. Lack of accountability for follow up 15. Non-competitive wages 16. Over-regulations/and being completely controlled by regulations 17. Geographically Challenged 18. Can't predict the future 19. Too Many Meetings that are to long 20. Divergent foci People don’t really understand about disabilities 21. Gossip, rumors and eavesdropping 22. Fear of change 23. Underutilization of properties, IBAs, and resources 24. Unskilled/untrained/uncertified staff 25. Transportation inefficiency 26. Lack of marketing and public relations 27. Stigma about "entitlements" 28. Too reactive Areas to Focus for Improvement 1. 2. 3. 4. Effective communication regarding upcoming changes Address increased stress levels at all stages related to change Team building and reducing compartmentalization Implement training and development program for new and future supervisors and managers 5. Implement staff appreciation program 6. Develop marketing team to improve public education of MCE 7. Develop additional fundraising opportunities Core Competencies 15 4 Benchmarks for Service. Rapport with participants-they feel at home with MCE. Quality of training and services for participants. Variety of available services. Homes feel like a home. Family environment. Multiple activities and events. Community oriented. Positive history of serving in the community! Participants feel they have a voice, choices and rights. They have the ability to express as they see fit. 10. Employment opportunities. 11. Participant oriented. 1. 2. 3. 4. 5. 6. 7. 8. 9. Identifying Issues and Assessing Environments” The Competitive Environment 1. Inconsistent regulation of competition - rules don't apply evenly between small and large providers 2. Dishonest and unethical competition is not regulated and not defined well in the regulations 3. Must compete for quality staff 4. Confusion in the community between programs 5. Flooded market 6. Competing for state/fed funding (i.e.: legislature, other agencies, etc) Regulatory Environment 1. 2. 3. 4. 5. 6. 7. Staff-participant ratios Case Management separation CMS Fraud and Abuse Audits Ever changing HUD Requirements Social Security regulations are confusing Unpredictable continuous changes in waivers Health Care Reform Legislative Environment 1. Wyoming Legislature is very conservative 16 2. Concerned of economic future 3. Misconception of community interaction and group homes 4. Want to keep adding to the "Rainy Day Fund" 5. The new State Medicaid Reform Law 6. Federal emphasis on employment of people with disabilities WHAT ARE OUR SERVICE CAPABILITIES AND CAPACITY? Expand on Service Capabilities 1. Unlimited in Supported Living 2. Capacity to provide Individualized Community Employment services 3. Reinstate Children’s Services 4. Expanding Apartment Services 5. No expansion of PT, OT, ST 6. Possible aging/elderly care in homes 7. Possible DFS funded youth in homes 17 2015 MCE Organizational Goals 1. Communication regarding waiver changes and residential changes next 2 months: By October 1, 2014 a. Staff preferences will be considered first but not always possible b. Individual participant meetings to clarify waiver changes/opportunities c. DD world uncertainty; We will provide you the most information, the best that we can, given the information we have d. We want people to keep their jobs. Layoffs will be accomplished through attrition as much as possible e. MCE will stay open f. MCE has history, we have and will continue to weather the storm g. Will make IPC minutes available to transitions meetings and to residential staff 2. Timely Information: Clarify client changes 1st-Methodical movement of clients and staff schedules: Completed and ongoing by October 1, 2014 a. Give people time to change personal lives b. Inform before rumors start c. More definition of schedules, particularly Day Hab/Residential d. Distribute information to staff before action is taken e. Reducing multiple staff in home f. Turnover/transition/attrition/layoffs 3. Open additional home: By October 1, 2014 4. Effective ongoing management/staff communication: Measure by October 1, 2014 then every 6 months through June 30, 2016. Final goal date is July 1, 2016 a. Email updates b. Need clarification/perhaps with increased staff feedback c. Organizational charts i. Distribute during orientation ii. Be available online d. Define roles of administrative staff i. Who does what? ii. Define for whom? iii. Who do we go to for answers-questions-online? e. Design meetings to be more organized f. Tell Staff what they can count on and what may change and why 5. Establish Participant/Staff/Case Manager Accessibility: By June 30, 2015 with a follow-up survey and measure of improvement a. Establish new relationships with new case managers b. Send case managers a questionnaire i. Ask case managers what type of contact they prefer ii. How often they prefer iii. With whom 18 c. Define staff roles with case managers d. Build better communication with case managers outside the organization through bi-monthly meetings 6. Smooth transition to new waiver for participants including communication to them and their teams including supporting their decisions, use examples: By January 1, 2015 a. CEO, Laura McKinney is speaking individually with participants as transition plans are reviewed b. Reinforce individual choice in moves. Prepare ahead individually c. Maximize opportunities for participants to make choice changes d. Establish dinner exchanges with clients and staff to increase comfort level, also movies and physical activities e. Integrate participants and staff on shopping dates/church outings in small groups f. Help decorate new rooms g. Share transitions plans h. Identify natural external supports in transitions for participants i. Psychology department supporting transition j. Separation of Staff We/Them k. Combining programs i. Continue progression Residential and Day Hab l. Making decisions together m. Encourage staff to work out own conflict n. Teambuilding i. Introduce staff in their team role ii. Team development activities 7. Develop more staff engagement and involvement: By July 1, 2016 a. Redirect Staff Council b. Gather information about preferences c. Utilize feedback about preferences d. Ask for more feedback e. Staff meetings/neutral sites f. Identify direct care leader 8. Develop Stress Management for Staff and Participants: By May 1, 2015 a. Stress management and refresher courses b. Stress management tips on THERAP c. Stress management group-transfer learning from d. Remind each other of stress level and survival mode everyone has been in (all staff) e. Try not to be judgmental 9. Staff Appreciation Program: By January 1, 2015 a. Slow small steps 19 b. Use staff meeting format to encourage staff to appreciate other staff (modeling or direct format) c. Develop a kudos/appreciation system to increase appreciation for staff d. Tell people you appreciate them/use their name e. Bonus system with PR follow up f. Use THERAP for appreciation reinforcement g. Refer to exceptional employees to Laura for her recognition (company-wide) i. Needs to be something concrete 10. Develop training and development program for Managers/Supervisors: By June 30, 2015 a. Clarify expectations of supervisors b. Validate staff other ways c. Teach problem solving skills d. Ask questions with no wrong answers e. Don’t ask if you know f. Don’t be judgmental when skills seem low g. Identify communication needs with single staff homes 11. Transitioning staff to new duties/assignments as determined by waiver changes: By January 1, 2015 a. Choose home/staff combinations b. Transition dinners, movies, physical activities c. “Establishing” dynamic teams d. Ensure information to staff in homes e. Staff team up and transition to more independent home with supervisor f. Evaluate possibility of establishing training house engaging participants g. Identify communication needs with single staff homes h. Help staff work alone i. Chore lists to staff working alone ii. Reinforce accessibility iii. Staff choice/input of which home/individual as much as possible 12. Educate employees on the history, stability and organizational culture of Magic City: By January 1, 2016 a. Teach foundation and history in orientation and refresher courses b. Utilize participant stories-then and now! c. Display history with pictures/collages d. On this date in history-hang in homes e. Scavenger hunt for information f. Better history on MCE website g. Emphasize the variety of services MCE offers, i.e., License plates h. Things might not look the same but we are still here i. CARF History j. Chamber of Commerce Award k. Full participant in the community l. Variety of contracts, AFB and other services 20 m. Give tours n. A community of values o. Marketing Team 13. Educate employees so they can educate and inform candidates and current legislatures to help them vote: Candidates by October 31, 2014 and Legislature by December 31, 2014 a. Voting education for participants and employees i. Keep them informed ii. Use THERAP b. Provide phone list and scripts for employees who are interested in talking to candidates, community members and family members c. Provide links for letters for employees that may be sent or modified and sent to community members or candidates 14. Develop a marketing/public relations team to included Board Members that will develop a marketing plan for MCE: By June 30, 2015 a. Include Board Participation b. Utilize newspaper, television, radio, social media and recycling sign on truck as marketing resources c. Additional marketing resources available include LCCC, local high schools, marketing classes and business classes d. Skit/Participant-“A day in the life…” e. Positive contributions of participants-working volunteering 15. Develop Business Opportunities (business franchise, contracts): By Jul 31, 2015 a. Keep Production Director informed b. Stay in contact with new businesses c. Many opportunities-if not contracts-possible employment for clients-recycling etc. d. Stay in contact with old business i. May have experienced a change ii. New ownership iii. New model of business/arena e. E-Waste i. Accesses for utility/sales f. New business opportunities i. Franchises 16. Recruit new participants for employment. Increase by 10: By June 30, 2015 a. Establish relationships b. Already certified ready to go c. Marketing d. Mega Conference e. Use customized examples f. Letters to case managers state wide g. Check into School District #1/Special Education 21 17. Develop additional Supported Living or independent living settings 5 participants By July 30, 2015 a. Provide independent living b. Rent from provider c. Increased integrated community participation 18. Research feasibility and community need to expanding services to include people with ABI and disabled vets: By April 15, 2015 Note: Barb to work on employment services section a. Customized employment ready to go b. ABI Training or just employment services c. Vets-Employment d. DVR employment e. More research 19. Identify and utilize volunteer services, at least 2 additional and 4 potential: By July 1, 2015 a. Presentation/Outreach b. To Service Clubs-Rotary Lions c. Churches d. Civic League e. XJWC f. AARP g. Sr. Companions h. Newspapers i. Sr. Citizens j. Expand MCE Auxiliary Structure for volunteers i. Mailing-Thor R. ii. IPC Meetings-Kristen V. 20. Develop additional fundraising opportunities utilizing MCE Fundraising Plan: By July 1, 2017 22 Magic City Enterprises Technology Plan 2014 - 2015 Information Management: The MCE Network & Security Coordinator meets with the Administration Team periodically to review and update aspects of the computer systems, and project needs. A budget is prepared accordingly for IT related services for the following fiscal year. Any non-budgeted expense items that may be needed are taken to the CEO for approval. Networks: MCE has been able to establish a system for Remote Access to the server and network that is secure. The current server and network setup is in good condition and is being maintained regularly. No foreseen costs or systems should be needed in the upcoming year. Hardware: Older computers are being replaced as needed. This is a continuing procedure. MCE has received business donations of IT equipment such as computers, printers, and notebooks. The needed costs of replacement hardware are estimated to be $900 for the upcoming year. This includes additional RAM for computers and monitors if no donations occur. Software: Software and license agreements are under the supervision of the Network & Security Coordinator. Original disks, media, and license agreements are maintained in the “Computer Room” at 1780 and on Microsoft Volume Licensing. The Network & Security Coordinator is responsible for establishing and maintaining systems which assure the security, license compliance, coordination of purchases, and issuance of hardware, software, and assistive equipment (when needed). 31 workstations will need updated from Microsoft Windows XP to Microsoft Windows 7 Enterprise by October 2014 due to security updates not being supported by Microsoft for XP. MCE currently has enough licenses for Microsoft Windows 7 Enterprise to accomplish this task. Printers & Copiers: MCE will take every precaution to remove/erase hard drives that contain confidential information when a copier or printer is replaced. The copiers and most printers are maintained by Lewan Technology. Lewan is under contract and also provides reduced prices for toner and ink. MCE currently has a backup copier that cannot be maintained by Lewan in case of emergency. No needed changes foreseen. Confidentiality: MCE has taken every precaution necessary to inform staff of the importance of maintaining the highest level of confidentiality. The HIPAA rules apply to all participant and business information contained within the IT equipment (computers). All systems are password protected and employees are instructed to safeguard MCE information and take proper care of MCE equipment. Employees are instructed to “not expose” 23 Computer Information to others while their computer is being used. A notebook Computer Confidentiality Agreement is entered into for staff that may be assigned one. Network Security: The Main Server Network is secured through a SonicWall. The SonicWall was recently updated and services are paid for through 2016. The SonicWall assures that outside intrusion is not possible and that users on the network are only allowed to view or utilize trusted sites and email. The Network & Security Coordinator receives weekly updates for attempted hacks, suggested changes to the SonicWall, and listings of un-trusted sites attempted by users on the network. The SonicWall along with Vipre Antivirus keep the network as safe as possible against malware, viruses, Trojans, and Spyware. All confirmed threats are checked on and fixed by the Network & Security Coordinator. Remote workstations and network workstations are secured by Vipre Antivirus and GFI Max. GFI Max is a reporting software that allows access remotely to each workstation. The Network & Security Coordinator reviews a weekly log as to any threats or reported problems on each workstation. 9 workstations in the Group Homes are secured with Sonar. Sonar only allows users to access sites that have been chosen by MCE to be work needed. All other attempts to access sites not on the chosen list are sent to the Network & Security Coordinator by Sonar. All of the above software and system is used to keep assets safe and HIPAA compliancy at a high standard. Location Security: MCE utilizes numerous security cameras on main campus at 1780 & 1750 Westland. Assess camera security needs by May 2015 for Deming, 1704 Westland and/or additional to main campus. Deming 1780, 1750, 1720, & 1704 Westland have monitored security alarms that notify the Cheyenne Police Department of intrusion. Continue with services. 1780, 1750, 1710, & 1704 Westland have electronic access door locks. This is maintained by Network & Security Coordinator. Continue to maintain. All other areas and locations are secured by Key locks. Keys are issued to each employee as needed and a copy of the agreement is kept in their personnel file. System is maintained by Network & Security Coordinator. Vehicle Security: MCE vehicles that are used for transport of participants are secured with a GPS tracking system. This system is monitored through FleetMatics and allows MCE to provide detailed reports of how a vehicle is being used, where the vehicle currently is, and flags safety concerns such as speeding or harsh driving. This system is monitored by the Network & Security Coordinator. MCE’s mechanic also receives information on maintenance of the vehicle and needed tasks. Safety concerns are emailed to the Department Manager in which the vehicle is listed by the software. Keys for the vehicles are assigned to the department manager and a listing is maintained by the Network & Security Coordinator. A Key Issue form is kept on all keys assigned in their personnel file. Use of Gas Cards: Each vehicle has an assigned gas card. Access to utilize the cards is given by the Network & Security Coordinator. All users must have Manager 24 permission to obtain a pin #. Internet/Remote Location/Wireless Security: MCE maintains a high level of security on all systems to prevent viruses, fraud, and unauthorized access. This includes utilizing 256 bit WPA2 Encryption for the wireless connections, utilizing a 13 character, secure password, which only IT staff have access. The Domain Server will provide additional security by providing a managed domain system for our computers, as well as requiring authentication to the network. Internet access for most locations is being provided by Charter communications. Deming, ECO, & Greenview utilize a DSL connection through Century Link. Assess needs and changes to internet access by Oct 2014. This will include any need or discontinuation of service at the Greenview apartments. Backup Procedures: Nightly back ups are run to external hard drives for data redundancy and disaster recovery. A copy of the backup is located at the Deming site weekly. Assistive Technology: It is the philosophy of MCE to encourage professional and program staff to work with WIND and other organizations that provide assistive technology for individuals with developmental disabilities. This can include computer software, hardware, and specific mechanical/electrical devices to assist individuals in their daily living and work. Requests for funding or assistance can be made to the Program Coordinator and C.E.O. during the year and can also be included in the department’s presentation for our Annual Goal Plan. Disaster Recovery Preparedness: A Copy of the Network and Server backup is stored weekly at the Deming location. This area of Deming is monitored by a security alarm. No additional redundancy is needed for the level of security or importance of these documents. MHP IT Support Technicians have administrative access to MCE’s servers for support as needed. Critical documents and replacement documents can be secured from county, city, state, and federal record archives. Virus Protection: The network is protected by both a hardware firewall, software antivirus and other programs deemed appropriate to protect our systems and data. MCE maintains a policy which forbids employees from bringing files from home if the media has been used on a non-MCE computer or a personal computer that has been on the internet. Any files that need to put on a computer on the internal network must be checked for viruses by the Network & Security Coordinator and approved by the CEO. Staff are required to read the MCE Personnel Manual for current updates in policies and procedures related to use and access to MCE computers and networks. Administration considers computers and any information or files used on computers or our networks to be MCE’s property and subject to our policies concerning their usage and access, in particular HIPAA confidentiality requirements. 25 THERAP: THERAP is a Web-Based Documentation and Communication Software System for Providers Supporting People with Developmental Disabilities. This program has the capability to restrict access among personnel and has helped us be more efficient with our documentation and communication between all staff, professional services, guardians and parents. A comprehensive data entry billing system is being used on THERAP for the billing of all service areas. User access and limitations are controlled by the Network & Security Coordinator. Electronic Mail: Microsoft Exchange is the e-mail system being used for all offices and homes, for internal and internet use. Website & Social Media: MCE currently has a Hosted Website that is maintained and updated by the Network & Security Coordinator. All information and images is approved by the CEO and participant’s team if needed. Facebook, Twitter, & Google accounts are also maintained by the Network & Security Coordinator. Information to be posted is approved by the CEO and team members as needed. – Create a marketing campaign through social media to obtain more traffic and users accessing MCE information. This will create a source for new clientele and reach for advocacy. $150 will be needed for this project. Due December 2014. Phones: Main campus phone system is maintained by Network & Security Coordinator. Major upgrades or line changes is done by Capitol Communications. Continue as normal no foreseen costs. Cell phones and 2 Hotspots are maintained by Network & Security Coordinator. These are serviced through Verizon Wireless and will need some upgrades this year. MCE currently has 4 phone upgrades available as needed. Assess the need for a Smartphone option for Network & Security Coordinator. This is a need when MCE experiences a power failure and could help in other needs as well. Assess by Jan 2015. Plan for FY 2014: MCE has changed to an employed Network & Security Coordinator in 2013. MHP is now working as a backup PRN. All computer support is managed by the Network & Security Coordinator. MCE will continue to upgrade computers and software as needed. Department managers will review computer and assistive technology needs with the department staff and submit software, hardware, and equipment requests at the Annual MCE Goal Planning meeting or as needed throughout the year. 26 MAGIC CITY ENTERPRISES, INC CORPORATE COMPLIANCE POLICY AND PLAN Pursuant to Section 60.32. of the Federal Deficit Reduction Act of 2005, P.L. 109-171 (S 1932) (February, 2006: Magic City Enterprises, Inc. employees and participants are required to report any concerns regarding waste, fraud, abuse, and other wrong doing concerning federal rules and funding. The Quality Assurance Manager is the designated Corporate Compliance Officer. All concerns and complaints should be submitted directly to the Quality Assurance Manager, who will review these and report any substantiated concerns to the Magic City Enterprises CEO, and Board of Directors and appropriate federal/state authorities within 2 weeks of receiving the report. Any allegations which name or allude to the involvement of the CEO or CFO will be reported directly to the Magic City Enterprises Board of Directors. Magic City Enterprises, Inc. will protect employees reporting corporate compliance issues from retaliation by those accursed or by any Magic City Enterprises management staff. Substantiated retaliation will result in personnel action or termination, as determined by the Magic City Enterprises CEO and Board of Directors. Intentionally false reports or accusations of compliance violation issued by an employee will result in personnel action or termination, as determined by the Magic City Enterprises CEO and Board of Directors. Reports made confidentially should be put in a sealed envelope and addressed as follows: “Personal Business, Quality Assurance Manager” and either put directly in their mailbox or given to the Administrative Specialist at 1780 Westland Road. Confidential notices will be restricted to the Quality Assurance Manager, Administrative Specialist or other Magic City Enterprises staff on a “need to know” basis only, at all times respecting the reporting employees confidence as much as possible during the investigation and resolution. After informing the CEO and Board of Directors about the compliance issue and providing supporting evidence, the Quality Assurance Manager is authorized to independently notify appropriate legal and contract authorities. Implementation of this Compliance Program guidance may not entirely eliminate fraud and abuse from the agency’s programs. It is the responsibility of the organization to mold the 27 concepts contained within the program guidance to its individual culture, and institute a program that monitors the individual elements so as to assure ongoing program effectiveness. Contractors: Any time that a business, government agency or other outside entity is doing business with Magic City Enterprises though a contractual agreement, Magic City Enterprises’ personnel who negotiate and/or manage the contract shall inform the vendor of the Compliance Program. We have always been and remain committed to our responsibility to conduct our business affairs with integrity based on sound ethical and moral standards. We will hold our employees, contracted practitioners, and vendors to these same standards. Magic City Enterprises, Inc. is committed to maintaining and measuring the effectiveness of our Compliance Policies and standards through monitoring and auditing systems reasonably designed to detect noncompliance by its employees and agents. We shall require the performance of regular, periodic compliance audits by internal and/or external auditors who have expertise in federal and state health care statutes, regulations, and health care program requirements. RESPONSIBILITY All employees, contracted practitioners, volunteers, interns, members of the Board of Directors and vendors shall acknowledge that it is their responsibility to report any instances of suspected or known noncompliance to their immediate supervisor, the Chief Executive Officer or the Compliance Officer. Reports may be made anonymously without fear of retaliation or retribution. Failure to report known noncompliance or making reports which are not in good faith will be grounds for disciplinary action, up to and including termination. Reports related to harassment or other workplace-oriented issues will be referred to the Quality Assurance Manager or CEO. POLICIES AND PROCEDURES Magic City Enterprises, Inc. will communicate its compliance standards and policies through required training initiatives to all employees, contracted practitioners, volunteers, members of the board and vendors. We are committed to these efforts through distribution of this Compliance Plan and our Code of Ethics. ENFORCEMENT This Compliance Plan will be consistently enforced through appropriate disciplinary mechanisms including, if appropriate, discipline of individuals responsible for failure to detect and/or report noncompliance. 28 RESPONSE Detected noncompliance, through any mechanism, i.e. compliance auditing procedures, confidential reporting, will be responded to in an expedient manner. We are dedicated to the resolution of such matters and will take all reasonable steps to prevent further similar violations, including any necessary modifications to the Compliance Plan. DUE DILIGENCE Magic City Enterprises, Inc. will, at all times, exercise due diligence with regard to background, exclusion and professional license investigations for all prospective employees, contractors, vendors, and members of the Board of Directors. Code of Ethics and Mission The Code of Conduct was approved by Magic City Enterprises Inc.’s s Board of Directors and is a formal statement of MCE’s commitment to the standards and rules of ethical conduct. Magic City Enterprises, Inc. is committed to preventing the occurrence of unethical or unlawful behavior, stopping such behavior as soon as possible after discovery, and to discipline employees who violate the Code of Ethics, including employees who neglect to report a violation. All employees must comply with this Code of Ethics, immediately report any alleged violations of wrongdoing, and assist management and compliance personnel in investigating allegations of wrongdoing. While the standards addressed in the Code of Ethics are intended to guide employees in the course of their day-to-day responsibilities, they do not replace any other program policies and procedures. There may be instances that are not addressed by the Code of Ethics or existing policies and procedures. Employees must seek direction from their supervisor, or any management staff or the Corporate Compliance Officer in these instances. 29 Magic City Enterprises’ Mission and Core Values I. “Supporting individuals with disabilities to live successfully.” The principles and values of the mission which stress well being, quality service, and equality: Health, Well Being, and Safety: Promote optimal health, safety, and well being for everyone. Achieve Personal Growth: Support the growth of all involved with MCE. Stability: Provide stability to facilitate a feeling of security for stakeholders. Continuous Quality Improvement: Provide timely, efficient and effective and training. Stellar Reputation: Maintain a positive reputation as the premiere service provider. Celebrate All Successes: Celebrate large and small, individual, group, and organizational successes. Teamwork: Everyone work together at MCE for a common purpose. Excellent Support through Education and Learning. Full Community Participation. EXPECTATIONS Magic City Enterprises, Inc. ensures that all aspects of consumer care and business conduct are performed in compliance with our mission statement, core values, policies, and procedures, professional standards, and applicable governmental laws, rules, and regulations and other payer standards. Magic City Enterprises, Inc. expects every person who provides services to our consumers to adhere to the highest ethical standards and to promote ethical behavior. Any person whose behavior is found to violate ethical standards will be disciplined appropriately. 30 Employees may not engage in any conduct that conflicts – or is perceived to conflict – with the best interest of Magic City Enterprises, Inc. Employees must disclose any circumstances where the employee or his or her immediate family member is an employee, consultant, owner, contractor or investor in any entity that (i) engages in any business or maintains any relationship with Magic City, Inc.; (ii) provides to, or receives from, Magic City Enterprises, Inc. any consumer referrals; or (iii) competes with Magic City Enterprises, Inc. Employees may not, without permission of the CEO, accept, solicit, or offer anything of value from anyone doing business with Magic City Enterprises, Inc. Employees are expected to maintain complete, accurate, and contemporaneous records as required by Magic City Enterprises, Inc. The term “records” includes all documents, both written and electronic, that relates to the provision of MCE. services or provides support for the billing of MCE services. o Records must reflect the actual service provided. o Any records to be appropriately altered must reflect the date of the alteration, the name, signature and title of the person altering the document and the reason for the alteration if not apparent. o No person shall ever sign the name of another person to any document. o Signature stamps shall not be used. o Backdating and predating documents is unacceptable and will lead to disciplinary action, up to and including termination. When any person knows or reasonably suspects that the expectations above have not been met, this must be reported to either the immediate supervisor, the Compliance Officer or the Chief Executive Officer, so each situation may be appropriately dealt with. The Corporate Compliance Officer may be reached at (307) 637-8869 ext. 268. Violations may also be reported to the Manager On Call at (307) 286-2424. 31 MAGIC CITY ENTERPRISES BOARD MEMBERS “CODE OF ETHICS” MCE board members shall recognize that as members of the MCE board they are fulfilling a position of trust, responsibility, and authority. In honoring the high responsibility which his/her membership demands, the board member: 1. Shall remember that the first and greatest concern must be the mission of MCE; 2. Shall bring about desired changes through legal and ethical procedures; 3. Shall uphold all laws, by-laws of MCE and mission described by the Articles of Incorporation, as amended; 4. Shall hold confidential all matters pertaining to MCE issues, which if disclosed, may needlessly injure individuals or organizations, and shall respect the confidentiality of information that is privileged under applicable law or executive session; 5. Shall recognize that decisions must be made by the Board as a whole, make no personal promise, or take private action which could compromise the Board, and recognize that authority rests only with the Board in official meetings; 6. Shall endeavor to make policy decision only after full discussion at official Board meetings; 7. Shall tender all decisions based on the available facts and refuse to surrender that judgment to individuals or special interest groups; 8. Shall refuse to participate in irregular meetings such as “secret” meetings, which are not official and in which all members do not have the opportunity to attend; 9. Shall encourage the free expression of opinion by all Board members and seek systematic communications between the Board, consumers, staff, and of the community; 10. Shall make certain the Board remains responsive to the community and shall communicate to the Board members and the President at appropriate times expressions of public reaction to Board policies and MCE programs; 11. Shall avoid being placed in a position of conflict of interest and refrain from using the Board position for personal or partisan gain; 32 12. Shall attend all regularly scheduled Board meetings insofar as possible and become informed concerning the issues to be considered at those meetings; 13. Shall understand and accept that the basic function of the Board is to make policy and not to administrate, and to learn to discriminate between the two functions; 14. Shall refer all complaints to the proper administrative office and discuss them at a regular meeting after failure of administrative solution; 15. Shall refrain from voting on any matter or letting any contracts in which the Board member or his/her immediate family or business associates stand to gain a pecuniary benefit; 16. Shall not knowingly make false or malicious statements about MCE employees, consumers, or parents. BOARD OF DIRECTOR’S CODE OF ETHICS Business and Financial Practices & Marketing Activities 1. Shall conduct regular reviews of financial reports at Board Meetings and secure annual audits of Magic City Enterprises by external CPA’s. 2. Shall annually review financial policies of Magic City Enterprises and maintain and submit current authorized officers, directors, and staff signature cards to the appropriate financial institutions. 3. Shall recruit consumers and expand services according to guidelines and policies of contracting state agencies. 4. Shall compete with other businesses fairly and positively for contracts. 5. Shall not convey or repeat information concerning people or organizations, which is knowingly untrue, inaccurate, defamatory, or exaggerated. (These Business and Financial Practices & Marketing Activities Code of Ethics are part of and attached to the Magic City Enterprises Board Members Code of Ethics. _________________________________________________ Name Date 33 MAGIC CITY ENTERPRISES CODE OF ETHICS FOR ALL STAFF MEMBERS As MCE staff I agree to know and adhere to the mission and values of Magic City Enterprises. I will be accountable for my actions, provide real choice to our participants and show compassion for our participants and all with whom I work. I will strive to provide superior services. I also agree to adhere to the following: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Focus first on the participant and understand that my role will require flexibility, creativity and commitment. Honor the personality, choices, preferences, culture and gifts of the participants I support. Protect the health, safety and emotional well being of participants by assisting them in preventing illness and avoiding unsafe activities. I will work with the individual and their team to identify areas of risk and create safeguards specific to these concerns. Always promote the human rights of all participants and recognize and report those who may victimize, exploit, abuse, neglect or harm participants. Protect the privacy and confidentiality of the participants I support at all times during and following my employment with Magic City Enterprises. Help the participants I support to understand and express their rights and responsibilities. Assist participants in speaking for themselves and represent those who cannot speak for themselves by advocating for their preferences and best interests. Respect and recognize cultural context (e.g. religion, sexual orientation, ethnicity, socio-economic class, etc.) of the participants supported by me while separating my own personal beliefs and expectations which may influence participants and their personal preferences. If I am unable to separate my own beliefs/preferences in a given situation, I will actively remove myself from the situation. Recognize the importance of relationships and proactively facilitate relationships between the participants I support, their family and friends while providing opportunities and supports that help them to be viewed with respect and as integral members of the community Refrain from expressing negative views, harsh judgments, and stereotyping of people who are close to the participants I support. Work in partnership with the participant’s team to support him/her in living a self-directed life while understanding the guardianship of the person I support and work in partnership with legal representatives to assure that the individual’s preferences and interests are honored. Develop relationships that are respectful, based on mutual trust, and that maintain professional boundaries. Respect and acknowledge other members of the participant’s team and follow written plans developed by and for the participant. 34 14. 15. 16. 17. 18. 19. Never solicit participants who are currently receiving services from another provider. Maintain competency in my profession through learning and ongoing communication with others. Practice responsible work habits and assume responsibility and accountability for my decisions and actions. Recognize the value and importance of modeling positive behaviors to coworkers, participants and the community at large. Actively seek advice and guidance on ethical issues from others as needed when making decisions. Always represent Magic City Enterprises and our participants in a positive, Conflict of Interest Employees, and members of the Board of Directors must not allow any outside financial interest, or competing personal interest to influence their decisions or actions taken on behalf of Magic City Enterprises, Inc. Employees, and members of the Board of Directors must avoid any situation where a conflict of interest exists or might appear between their personal interests and those of Magic City Enterprises, Inc. The appearance of a conflict of interest may be as serious as an actual conflict of interest. Employees shall not engage in placing business with any firm in which there is a family relationship that may constitute a conflict of interest. Advance disclosure and Board of Directors’ approval are required in such a situation. Guidelines for employees: It is a conflict of interest for you to personally take for yourself, opportunities that are discovered through the use of Magic City Enterprises, Inc. property, information or position with MCE, to use MCE property or information for personal gain; or to compete with Magic City Enterprises, Inc. There are many types of situations where potential conflicts may arise. You must promptly report any actual or potential conflicts of interest to your immediate supervisor or directly to the Corporate Compliance Officer. Use of Organization Funds and Resources Magic City Enterprises, Inc.’s assets are to only be used for the benefit of MCE, Inc. and the people we serve. Assets include not only funds, equipment, inventory, and office supplies; but also concepts, business plans and strategies, information about people served, financial information, computer property rights, and other business information about MCE. You may not use Magic City Enterprises, Inc. assets for personal gain or give them to any other persons or entities, except in the ordinary course of business as part of an approved transaction. All employees, consultants and vendors are personally responsible and accountable for the proper expenditure of funds and for the proper 35 use of company property. All employees must obtain CEO authorization prior to committing or spending Magic City Enterprises’ funds. Any improper financial gain to the employee through misconduct involving misuse of Magic City Enterprises’ or a consumer's property is prohibited, including the outright theft of property or embezzlement of money. Medical waste or other hazardous materials shall be disposed of properly. Employees may not use Magic City Enterprises or a consumer's resources for personal or improper purposes, or permit others to do so. Surplus, obsolete or junked property shall be disposed of in accordance with MCE's procedures. Unauthorized disposal of property is a misuse of assets. Confidentiality During your employment, you may acquire confidential information about Magic City Enterprises, Inc., its staff, and people we serve that must be handled in strict confidence and not discussed with outsiders. The protection of confidential business, staff and consumer information is very important. Employees shall not use or reveal any confidential information concerning MCE or use, for personal gain, confidential information obtained as an employee of MCE Employees should be honest and forthright in any representations made to consumers, vendors, payers, other employees or agents, and the community. All reports or other information required to be provided to any federal, state or local government agency authorized to receive such information, shall be accurate, complete, and filed on time. Business Dealings between Magic City Enterprises, Inc. and Employees Magic City Enterprises, Inc. will not be inappropriately influenced with goods or services from any business in which you or your immediate family members have a substantial interest. Property and resources of Magic City Enterprises, Inc. should only be used for the benefit of MCE. or the people we serve. Maintenance of Records Employees must record and report all agency, consumer and financial information fully, accurately and honestly. 36 Records include, but are not limited to records of the people we serve, documentation of services, accounting books or records, financial statements, timesheets or records, expense reports, vouchers, bills, payroll, claims payment records, correspondence, and any other method of communication. Employees must not omit or conceal any relevant information. Guidelines for employees: Many of Magic City Enterprises, Inc.’s forms are legal documents used to prove that a service was provided, to bill for a service to a consumer, to record a job task, or to record specific happenings. You must document accurately and honestly, and only for those services that you provided or those events you were involved in. Falsification of Records You must not make any false entries in any of Magic City Enterprises, Inc.’s records or in any public record for any reason. You may not alter any permanent entries in Magic City Enterprises, Inc.’s records. You may only approve payments or receipts on behalf of Magic City Enterprises, Inc. that are described in documents supporting the transaction. “Slush funds” or similar off-book accounts, where there is no accounting for receipts or expenditures on the agency books, are strictly prohibited. You may not create or participate in the creation of any records that are intended to mislead or to conceal anything that is improper. Expense Records You must always charge expenses accurately and to the appropriate cost center or account, regardless of the financial status of the program, project or contract, or the budget status of a particular account or line item. Retention of Records The retention, disposal or destruction of records of or pertaining to Magic City Enterprises, Inc. must always comply with legal and regulatory requirements and MCE policy. You may not destroy records pertaining to litigation or government investigations or audit without express written approval of the CEO. Protection of Confidential Information Magic City Enterprises, Inc. has developed policies and procedures to assure that the confidentiality of MCE information and information about the people we serve is 37 protected and released only with the appropriate authorization or for lawful reasons, in addition to purposes of treatment, payment, and operations. All employees are required to comply with Jawonio, Inc. policies on Confidentiality and the Health Insurance Portability & Accountability Act policies as well as HIPAA Security Compliance Policies. If you have any questions concerning confidential information or Magic City Enterprises, Inc.’s policies, contact your immediate supervisor or manager. . Guidelines for employees and contractors: You must treat all records and information as confidential. You may not release confidential information without the proper authorization. Confidential information includes not only information about the people that we serve and their families, but also non-public information about Magic City Enterprises, Inc. that maybe of use to MCE.’s competitors or harmful to MCE. or its customers if released. You must protect Magic City Enterprises, Inc.’s information and avoid discussing or disclosing MCE information, purposefully or inadvertently (through casual conversation), to any unauthorized person inside or outside MCE. Furthermore, staff may not share confidential information with anyone, except where required for a legitimate business purpose. Magic City Enterprises, Inc. information may not be removed from facility property without permission from a supervisor or manager with proper authority over the information. Ask your supervisor if you are not sure whether certain information is confidential. Termination of Employment You may not use any confidential information gained from your employment with Magic City Enterprises, Inc. for your or another company’s benefit. You may not take copies of any reports, documents or any other property belonging to MCE when you leave your employment at MCE. Upon termination of employment with Magic City Enterprises, Inc., you must return all MCE property including, but not limited to, copies of documents, notes, and other records containing confidential information; computer drives; ID badges; keys and credit cards. Information Security You are responsible for properly using information stored and produced by all of Magic City Enterprises, Inc.’s computer systems. 38 Computers, Internet access, email, or other office communications systems are intended for business-related purposes only and not for uses that may be disruptive, offensive, harassing or harmful to others. Do not share your system user name or password with another person or allow another to access the computer with your password. All employees are required to comply with Magic City Enterprises, Inc.’s Information Technology and Health Insurance Portability and Accountability Act security policies. If you have any questions concerning information security, contact your immediate supervisor or manager, the Security Officer or the Privacy Officer. Fair Dealing Conducting business with providers, contractors, suppliers, people we serve, and competitors may pose ethical problems. Employees are expected to deal fairly with providers, contractors, people we serve, and competitors. The Code of Ethics and the following guidelines are intended to help you make appropriate, responsible and correct decisions in these and all matters: Kickbacks and Rebate Kickbacks and rebates in cash, credit or other form are prohibited. They are not only unethical, but in many cases, illegal. Gifts and Gratuities and Entertainment You may not solicit money, gifts, gratitude or any other personal benefits or favors of any kind from providers, contractors, producers, accounts, or people we serve and their families. You must not offer or accept entertainment that is not a reasonable addition to a business relationship but is primarily intended to gain favor or to influence a business decision. Occasional non-cash gifts from providers, contractors, producers, accounts, that are limited to reasonable meal expenditures or entertainment or that are of nominal value, although not expressly prohibited, are discouraged. Any gifts from people we serve are prohibited. Occasional nominal non-cash gifts from families or guardians of persons served are acceptable but must be disclosed to your immediate supervisor or manager. You should report any potential conflicts of interest concerning yourself or your family members to the Corporate Compliance Officer. Agreements with Contractors and Vendors 39 Magic City Enterprises, Inc. must assure that any agreements with contractors and vendors clearly and accurately describe the services to be performed or items to be purchased. Performance standards, and the applicable compensation, if any, must be reasonable in amount, not be excessive in terms of industry practice and must equal the value of the services rendered. Improper Use of Funds or Assets Use of Magic City Enterprises, Inc.’s funds or assets for any improper purpose is strictly prohibited. If you are aware of or have reason to believe that funds or assets are being improperly used, you must report this immediately to your supervisor or the Compliance Officer. Federal and State Programs Magic City Enterprises, Inc. is committed to complying with the laws and regulations that govern the federal and state programs that it administers. Policies and procedures, the Compliance Program, and the Code of Ethics are developed to provide guidance in your day-to-day work. You must abide by the policies and procedures and the standards set by MCE. Governmental Investigations There may be times that Magic City Enterprises, Inc. is asked to cooperate with an investigation by a federal or state governmental agency, or to respond to a request for information. A request may be formally addressed to MCE or an individual within the agency. Employees must report any requests for information or cooperation with an investigation to the CEO. Employment Environment Magic City Enterprises, Inc. is committed to creating a safe and professional workplace where employees and others are treated with respect. Discrimination against any person in recruitment, hiring, training, compensation, assignment of work, promotion, retention, discipline or any other aspect of personnel administration because of race, sex, age, religion, national origin, color, marital status, disability, religion, political affiliation, or other protected characteristics. Business integrity, teamwork, trust and respect are some of MCE.’s most important values. Unlawful discrimination or harassment of any sort violates these values. Quality care can only be delivered through the use of qualified, competent staff. MCE will contribute to an employees’ competence by making available continuing jobrelated education and training (within the limits of its resources). Applicants and employees shall be afforded equal employment and advancement opportunities, pursuant to MCE’s policies. 40 Work and safety rules were created to protect us all. Employees are expected to comply with those rules. As defined further in its policies, MCE strives to maintain a working environment free from all forms of harassment or intimidation. By way of example, unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature are serious violations of the standards of conduct and will not be condoned or permitted. MCE promotes a drug and alcohol free workplace in accordance with its policies. MCE will not permit any action of retaliation or reprisal to be taken against an employee who reports a violation of law, regulation, standard, procedure, or policy. Guidelines for Employees: All employees are required to support Magic City Enterprises, Inc.’s commitment to a safe and professional work environment and to demonstrate appropriate behavior in the workplace. All employees are prohibited from joking about another employee’s race, sex, age, religion, national origin, color, marital status, disability, political affiliation, or other protected characteristics. All employees must exhibit and promote respect, integrity, trust, and teamwork in the workplace and must comply with this policy prohibiting discrimination and harassment in all facets of Magic City Enterprises, Inc.’s work. Employees are expected to conform to the standards of their respective professions and exercise sound judgment in the performance of their duties. Any differences of opinion in professional judgment should be referred to appropriate management levels for resolution in accordance with standard grievance procedures. All employees are prohibited from considering someone’s race, color, religion, sex, national origin, age, disability, or other protected characteristic in making decisions about hiring, placement, assignment of duties, training, promotion, termination, compensation, benefits and other work terms. Sexual harassment is prohibited. Sexual harassment includes any form of unwelcome sexual advance, request for sexual favors or other verbal or physical conduct of a sexual or sex-based nature. You are responsible for understanding MCE’s policy prohibiting discrimination and sexual harassment. You should consult with any manager or the Organizational Development Manager you have questions about your right to a workplace free from unlawful harassment or discrimination or if you have questions about your duty to avoid discrimination. 41 The Role of the Corporate Compliance Officer CORPORATE COMPLIANCE OFFICER The Board of Directors of Magic City Enterprises, Inc. designates Barbara Schutkowski-Fortish, Quality Assurance Manager as the Corporate Compliance Officer (CCO). The Corporate Compliance Officer has direct lines of communication to the Chief Executive Officer and the Board of Directors. The Corporate Compliance Officer is the "core" of the Corporate Compliance Program. Questions, complaints, concerns and suggestions are received from numerous sources, including staff, participants, advocates, stakeholders, and community members. The Corporate Compliance Committee acts as a resource for information and coordination of compliance activities, in all programs from the various programs within the organizational structure. Under the auspices of the Corporate Compliance Officer, this committee receives and evaluates information regarding all services; they monitor overall process operations to attain desired outcomes. The Corporate Compliance Officer is charged with the responsibility of fulfilling the organization's mission to provide the highest quality, cost effective care. JOB DUTIES The Corporate Compliance Officer is directly obligated to serve the best interests of Magic City Enterprises, Inc., participants and employees. Responsibilities of the Corporate Compliance Officer include, but are not limited to: Overseeing and monitoring the implementation of the compliance program. Directing Magic City Enterprises, Inc. internal audits established to monitor effectiveness of compliance standards. Providing guidance to management, program personnel and individual departments regarding the compliance program and governmental laws, rules and regulations. Updating, periodically, the Compliance Plan as changes occur within Magic City Enterprises, Inc., and/or in the law and regulations or governmental and third party payers. Overseeing efforts to communicate awareness of the existence and contents of the Compliance Plan. Overseeing the coordination, development, and delivery of the educational and training program. Actively seeking up-to-date material and releases regarding regulatory compliance. 42 Maintaining a reporting system and responding to concerns, complaints and questions related to the Compliance Plan. Acting as a resourceful leader regarding regulatory compliance issues. Investigating and acting on issues related to compliance and facilitating the self disclosure process. Coordinating internal investigations and implementing corrective action. The Structure, Duties and Role of the Compliance Committee REPORTING STRUCTURE AND PURPOSE A Corporate Compliance Committee, under the supervision of the Corporate Compliance Officer, has been appointed by the Chief Executive Officer to administer the program. The committee should include appropriate organization personnel relative to administrative, financial and other departments. The committee’s purposes include: Analyzing specific risk areas and existing policies and procedures that address these risk areas for possible incorporation into the compliance program; Working with appropriate departments to develop standards of conduct and policies and procedures to promote compliance with legal and ethical requirements; Recommending and monitoring the development of internal systems and controls to carry out the agency’s standards, policies and procedures; Developing a system to solicit, evaluate, and respond to complaints and problems; and Monitoring internal and external audits for the purpose of identifying potential noncompliant issues, and implementing corrective and preventive action. Function The Corporate Compliance Officer reports directly to the Chief Executive Officer and the Board of Directors. The Corporate Compliance Committee is comprised of representatives from designated departments and directly reports to their respective supervisors regarding their general work responsibilities, with the exception of corporate compliance issues. These issues are under the supervision of the Corporate Compliance Officer. Specifically, the roles of the Compliance Committee include: Analyzing the environment where MCE does business, including legal requirements with which it must comply. 43 Reviewing and assessing existing policies and procedures that address these risk areas for possible incorporation into the Compliance Plan. Working with departments to develop standards and policies and procedures that address specific risk areas and encourage compliance according to legal and ethical requirements. Advising and monitoring appropriate services relative to compliance matters. Developing internal systems and controls to carry out compliance standards and policies. Monitoring internal and external audits to identify potential non-compliant issues. Implementing corrective and preventive action plans. Developing a process to solicit, evaluate and respond to complaints and problems. Reporting Paths The Corporate Compliance Officer reports directly to the Chief Executive Officer and the Board of Directors. The Corporate Compliance Committee is comprised of representatives from designated departments and directly reports to their respective supervisors regarding their general work responsibilities, with the exception of corporate compliance issues. These issues are under the supervision of the Compliance Officer. Delegation of Substantial Discretionary Authority REQUIREMENT Any employee or prospective employee who holds, or intends to hold, a position with substantial discretionary authority for Magic City Enterprises, Inc. is required to disclose any name changes, and any involvement in non-compliant activities including health care related crimes. In addition, Magic City Enterprises, Inc. performs reasonable inquiries into the background of such applicants, contractors, vendors and Members of the Board of Directors. The following organizations may be queried with respect to potential employees, contractors, vendors and Members of the Board of Directors: a) General services administration: list of parties excluded from federal programs. The URL address is http://epls.gov/epls/servlet/EPLSSearchMain/2. b) List of Excluded Individuals/Entities (LEIE) (OIG) http://www.oig.hhs.gov/fraud/ exclusions/exclusions/about.asp c) List of Parties Excluded From Federal Procurement and Non-procurement Programs 44 http://www.epls.gov d) Restricted, Terminated www.OMIG.state.ny.us or d) Wyoming’s Medicaid exclusion list. Excluded Individuals or Entities www.exclusions.oig.hhs.gov Education and Training EXPECTATIONS Education and training are critical elements of the Compliance Plan. Every employee and agent is expected to be familiar and knowledgeable about Magic City Enterprises, Inc.’s Compliance Plan and have a solid working knowledge of his or her responsibilities under the plan. Compliance policies and standards will be communicated to all employees through required participation in training programs. TRAINING TOPICS – GENERAL All employees shall participate in training on the topics identified below: Government and private payer reimbursement principles; Government initiatives; History and background of Corporate Compliance; General prohibitions on paying or receiving remuneration to induce referrals and the importance of fair market value; Prohibition against submitting a claim for services when documentation of the service does not exist to the extent required; Prohibitions against signing for the work of another employee; Prohibitions against alterations to medical records and appropriate methods of alteration; Proper documentation of services rendered; and Duty to report misconduct. TRAINING TOPICS - TARGETED In addition to the above, targeted training will be provided to all managers and any other employees whose job responsibilities include activities related to compliance topics. 45 Managers shall assist the Corporate Compliance Officer in identifying areas that require specific training. INTAKE As part of their intake, each employee and contractor shall receive a written copy of the Compliance Plan, policies and specific standards of conduct that affect their position. ATTENDANCE All education and training relating to the Compliance Plan will be verified by attendance and a signed acknowledgement of receipt of the Compliance Plan and standards. Attendance at compliance training sessions is mandatory and is a condition of continued employment. Effective Confidential Communication EXPECTATIONS Open lines of communication between the Corporate Compliance Officer and every employee subject to this Plan are essential to the success of our Compliance Program. Every employee has an obligation to refuse to participate in any wrongful course of action and to report the actions according to the procedure listed below. REPORTING PROCEDURE If an employee witnesses, learns of, or is asked to participate in potential non-compliant activities, in violation of this Compliance Plan, he or she should contact the Corporate Compliance Officer, his or her immediate supervisor or the Chief Executive Officer. Reports may be made in person or by calling (637) 637-8869, ext. 268, mailing information to Barbara Schutkowski-Fortish, Quality Assurance Manager at Magic City Enterprises, Inc., 1780 Westland Rd., Cheyenne, Wyoming, 82001. Upon receipt of a question or concern, any supervisor, or manager shall document the issue at hand and report it to the Corporate Compliance Officer. Any questions or concerns relating to potential non-compliance by the Corporate Compliance Officer should be reported immediately to the Chief Executive Officer. The Corporate Compliance Officer or designee shall record the information necessary to conduct an appropriate investigation of all complaints. If the employee was seeking information concerning the Code of Ethics or its application, the Corporate Compliance Officer or Organizational Development Manager shall record the facts of the call, the nature of the information sought and responds as appropriate. Magic City Enterprises, Inc. shall, as 46 much as is possible, protect the anonymity of the employee who reports any complaint or question. PROTECTIONS The identity of reporters will be safeguarded to the fullest extent possible and will be protected against retribution. Report of any suspected violation of this Plan by following the above shall not result in any retribution. Any threat of reprisal against a person who acts in good faith pursuant to his or her responsibilities under the Plan is acting against Magic City Enterprises, Inc.’s compliance policy. Discipline, up to and including termination of employment will result if such reprisal is proven. GUIDANCE Any employee and agent may seek guidance with respect to the Compliance Plan or Code of Ethics at any time by following the reporting mechanisms outlined above. Enforcement of Compliance Standards BACKGROUND INVESTIGATIONS For all employees who have authority to make decisions that may involve compliance issues, Magic City Enterprises, Inc. will conduct a reasonable and prudent background investigation, including a reference check, as part of every employment application. DISCIPLINARY ACTION - GENERAL Employees who fail to comply with Magic City Enterprises, Inc.’s compliance policy and standards, or who have engaged in conduct that has the potential of impairing MCE.’s status as a reliable, honest, and trustworthy service provider will be subject to disciplinary action, up to and including termination. Any discipline will be appropriately documented in the employee’s personnel file, along with a written statement of reason(s) for imposing such discipline. The Corporate Compliance Officer shall maintain a record of all disciplinary actions involving the Compliance Plan and report at least annually to the Board of Directors regarding such actions. PERFORMANCE EVALUATION - SUPERVISORY Magic City Enterprises Compliance Program requires that the promotion of, and adherence to, the elements of the Compliance Program be a factor in evaluating the performance of MCE employees. They will be periodically trained in new compliance policies and procedures. In addition, all managers and supervisors will: 47 a. Discuss with all supervised employees the compliance policies and legal requirements applicable to their function. b. Inform all supervised personnel that strict compliance with these policies and requirements is a condition of employment. c. Disclose to all supervised personnel that MCE will take disciplinary action up to and including termination or revocation of privileges for violation of these policies and requirements. DISCIPLINARY ACTION - SUPERVISORY Supervisory personnel may receive disciplinary action for failure to adequately instruct their subordinates, or for failing to detect noncompliance with applicable policies and legal requirements, where reasonable diligence on the part of the supervisor would have led to the earlier discovery of any problems or violations and would have provided MCE with the opportunity to correct them. Auditing and Monitoring of Compliance Activities INTERNAL AUDITS Ongoing evaluation is critical in detecting non-compliance and will help ensure the success of Magic City Enterprises, Inc.’s Compliance Program. An ongoing auditing and monitoring system, implemented by the Corporate Compliance Officer, in consultation with the Compliance Committee, is an integral component of our auditing and monitoring systems. This ongoing evaluation shall include the following: Compliance audits of compliance policies and standards; and Review of documentation and billing relating to claims made to federal, state, and private payers for reimbursement, performed internally or by an external consultant as determined by the Corporate Compliance Officer and Compliance Committee. The audits and reviews examine MCE’s compliance with specific rules and policies through on-site visits, personnel interviews, general questionnaires (submitted to employees), and participant record The Corporate Compliance Committee reviews auditing, assessment, and monitoring activities designed to detect and prevent ethical or legal violations. The Corporate Compliance Officer conducts assessments (audits) that help to ensure that MCE's practices are evaluated for consistency in application of policies and procedures and the implementation of appropriate corrective action(s) have been taken. Each audit, assessment or monitoring process is designed and implemented to program needs and provides for a complete representation of the integrity of procedures across agency and program regulations. 48 The Corporate Compliance Officer and the Corporate Compliance Committee will recommend and facilitate auditing and monitoring of the identified risk areas related to compliance with laws and regulations, as well as MCE policies, procedures, and standards of conduct. (Risk areas may be identified through the regular course of business, external alerts, or internal reporting channels). The audits and reviews conducted by management will examine Magic City Enterprises, Inc.’s compliance with specific rules and policies through on-site visits, personnel interviews, general questionnaires (submitted to employees), clinical record reviews to support claims for reimbursement, and documentation reviews. Potential risks are assessed by the Compliance Committee, based on information received through seminars and training sessions, the agency’s independent auditors, and member (trade) organizations relative to current audit activities both nationally and statewide. The Program Director will conduct and/or oversee compliance reviews with guidance and assistance from the Corporate Compliance Officer. A randomly selected number of consumer records are reviewed to ensure compliance with regulations relative to documentation and reimbursement. The Corporate Compliance Officer will determine the sample size and sample criteria prior to each audit. All review tools will be standardized for each program and approved by the Corporate Compliance Officer. Department managers will address any weaknesses identified by the audit process. The Program Director will validate any corrective measures through review and when audit results reveal areas needing additional information or education of employees and/or providers, the Corporate Compliance Officer will determine whether these areas should be incorporated into the training and education program. The compliance audit, in some cases, may generate a repayment with an appropriate explanation to the payer. PLAN INTEGRITY Additional steps to ensure the integrity of the Compliance Plan will include: Annual review of all records of communications and reports by all employees or contractors kept in accordance with this Plan. The Corporate Compliance Officer will be notified immediately in the event of any visits, audits, investigations or surveys by any federal or state agency or authority, and shall immediately receive a photocopy of any correspondence from any regulatory agency charged with licensing/certifying Magic City Enterprises, Inc. and/or administering a federally or state-funded program. Establishment of a process detailing ongoing notification by the Corporate Compliance Officer to all appropriate personnel of any changes in laws, regulations or policies as well as appropriate training to assure continuous compliance. 49 Detection and Response VIOLATION DETECTION The Corporate Compliance Officer, Chief Executive Officer and the Compliance Committee shall determine whether there is any basis to suspect that a violation of the Compliance Plan has occurred. If advice is sought from a governmental agency, the request, and any written or oral response, shall be fully documented. REPORTING Magic City Enterprises, Inc.’s Mandatory Reporting Policy Any employee who suspects that another employee (including a supervisory or managerial employee) has violated the Code of Ethics, Compliance Guidelines, policies, procedures, or any applicable state or federal law, should immediately report his/her suspicion to the Corporate Compliance Officer, the Quality Assurance Manager, the department manager, or the employee's direct supervisor. All reports of suspected violations will be treated confidentially. Magic City Enterprises, Inc. will promptly and thoroughly investigate any suspected violation in as confidential manner as possible, and take appropriate disciplinary action if warranted. No employee who reports a suspected violation of the Code of Ethics, Compliance Guidelines or who participates in an investigation of an alleged violation will suffer any retaliation or reprisal for such report or participation. It is important to the integrity of our operation that all claims of suspected violations be thoroughly reviewed and investigated so that appropriate action can be taken as necessary. At the conclusion of an investigation, the investigator shall issue a report to the Corporate Compliance Officer, Chief Executive Officer, and Compliance Committee summarizing his or her findings, conclusions and recommendations and will render an opinion as to whether a violation of the law has occurred. The Corporate Compliance Officer shall report to the Compliance Committee regarding each investigation conducted. RECTIFICATION Overpayments/Errors If Magic City Enterprises, Inc. identifies that an overpayment was received from any third party payer, It is the policy of Magic City Enterprises Inc. to ensure compliance with all disclosure requirements set forth by federal or state regulatory agencies that have oversight 50 of Magic City Enterprise, Inc. programs. Magic City Enterprises, Inc. is committed to disclosing inappropriate payments as early in the discovery process as possible. When deciding whether to disclose, Magic City Enterprises, Inc. shall consider the precise issue, the amount involved any patterns or trends that the problem may demonstrate, the period of noncompliance, and the circumstances that led to the noncompliance. Generally, issues that are identified as appropriate for disclosure include but are not limited to (1) substantial routine errors, (2) systematic errors, (3) patterns of errors, and (4) potential violations of fraud and abuse laws. Magic City Enterprises, Inc. shall conduct an investigation to distinguish between “patterns of errors” that should be disclosed and “simple, more routine occurrences of overpayment.” When a situation has been deemed to warrant disclosure, such disclosure and repayment shall be made to the government agency that has oversight of the program where the situation has occurred (Division of Medicaid, Division of Behavioral Health, Department of Health, Division of Vocational Rehabilitation, Department of Workforce Services, etc.). The repayment of simple, more routine occurrences of overpayment shall be handled through typical methods of resolution, which may include voiding or adjusting the amounts of claims. Systems shall also be put in place to prevent such overpayments in the future. Response & Prevention After an offense has been detected, the organization will take all reasonable steps to respond appropriately to the offense and to prevent further similar offenses – including any necessary modifications to its programs to prevent and detect violations of the law. In addition, we seek to: 1. Maintain and enhance quality of care; 2. Demonstrate sincere, ongoing efforts to comply with all applicable laws; 3. Revise and clarify policies and procedures to enhance compliance; 4. Enhance communications with governmental entities with respect to compliance activities; 5. Empower all responsible parties to prevent, detect, respond to, report and resolve conduct that does not conform to applicable laws, regulations. 6. Establish mechanisms for employees to raise questions and concerns about compliance issues and ensure those concerns are appropriately addressed. RECORD KEEPING Regardless of whether a report is made to a governmental agency, the Corporate Compliance Officer shall maintain a record of the investigation, including copies of all pertinent documentation. This record will be considered confidential and privileged and will not be released without the approval of the Chief Executive Officer or Board of Directors. 51 MAGIC CITY ENTERPRISES, INC. ACCESSIBILITY PLAN 2013- 2014 (Status Report) Architectural Goals 1. Contact SWRS to get approval/funding to modify the fire door on the north side of HUB to make it wheelchair accessible. 4/14 Administration: Completed November, 2013 2. Obtain funding for and install an automatic door opener on the east inside door of 1780. 4/14 Administration and maintenance: Completed October, 2013 3. Assess how to make the bathrooms in all MCE Facilities wheelchair accessible. 4/14 Maintenance: Not Completed 4. Renovate the main bathroom at Hamilton to make it wheelchair accessible. 6/14 Maintenance: Drop 5. Install door bell/buzzer on the entrance doors of 1710 and 1720. 4/14 Maintenance: Not Done 6. Install automatic door openers at the Deming Building. 4/14 Maintenance: Drop 7. Write a letter to the Mayor’s Council on the Handicapped identifying and requesting correction of accessibility issues identified in the Accessibility Survey, specifically sidewalks near the hospital are not wide enough for wheelchairs, need audible signals at stop lights, need more handicap parking spaces in the community, need for expanded transit services and noting that some businesses and public areas are not wheelchair accessible. 4/14 Administration: Continue 8. Assess doors in all buildings used by participants, employees and visitors who use wheelchairs to assure accessibility of thresholds. 4/14 Maintenance: Not Completed 9. Write a letter to Terry Bison Ranch requesting that they assess the doorway by the handicapped bathroom for safety and accessibility. 4/14 Administration: Continue Environmental Goals 1. Assess possible solutions to draft down the hallway at HUB caused by the vestibule. 4/14 Maintenance: Drop 2. Implement recommendations from the Safety Committee to assure ice does not build up on the parking lot. 4/14 Maintenance: Continue 3. Investigate options for constructing shade areas at Ridge, South 4 th, Cleveland and Wills. 4/14 Maintenance, Residential Habilitation Program: Continue 52 4. Install fans in restrooms at 1750 Westland. 4/14 Maintenance: Completed November, 2013 5. Add shade to the patio at 1750 Westland. 4/14 Administration, Maintenance: Not Done 6. Assess parking lots at the Westland Complex and the needs of employees and visitors to assure that adequate handicapped parking spaces are assigned and available. 4/14 Administration, Maintenance: Completed January, 2014 Communication Goals 1. Develop staff position or agreement to provide ongoing sign language training for employees. 4/14 Administration, Training: Drop 2. Investigate the use of an overhead communication system for the Westland Complex. 4/14 Administration: Continue 3. Expand staff training opportunities to include understanding the cognitive processes of persons with developmental disabilities. 4/14 Training: Continue 4. Purchase large print telephone books and make them available for participants. 4/14 Administration: Drop-get online Financial Goals 1. Continue advocacy for adequate funding to provide services to participants. 4/14 Board of Directors, Administration, Management: Continue 2. Develop a system for participants to access MCE activity funds. 4/14 Accounting, Day Services Program, Residential Program, Supported Living: Continue 3. Send a formal communication to Wyoming’s Congressional contingent regarding Social Security disincentives to employment, including resource limits. 4/14 Administration: Completed December, 2013 4. Implement a debit card system for participants in the representative payee program. 4/14 Accounting: Completed November, 2013 Employment Goals 1. Assure appropriate job match for participants when developing employment/jobs. 4/14 Community Employment: Completed April, 2014 2. Continue to educate employers and the public regarding the employment value of participants. 4/14 Board of Directors, Administration, Community Employment, managers: Continue 53 Transportation Goals 1. Continue training participants to use public transit. 4/14 Day Services Program, Residential Program, Supported Living: Completed March, 2014 2. Continue to work with the Cheyenne Transit Program to advocate for additional routes in order to reduce wait and ride times. 4/14 Administration, Day Services: Continue Attitudinal Goals 1. Continue public awareness of the contributions and abilities of persons with developmental disabilities. 4/14 Board of Directors, Administration, managers: Complete-Continue 2. Increase the opportunities for staff training on participant choice. 4/14 Training, Day Services Program, Residential Program, Supported Living: Continue Integration Goals 1. Develop additional opportunities for participants to be a part of community sponsored activities. 4/14 Day Services Program, Residential Program, Supported Living: Continue 2. Access alternative ways to meet staff ratios to allow for dispersed community activities. 4/14 Day Services Program, Residential Program, Supported Living: Completed April, 2014 54 MAGIC CITY ENTERPRISES, INC. ACCESSIBILITY PLAN 2014 - 2015 Architectural barriers in service area and community: 1. Contact SWRS for approval/funding to modify fire door on N. side of Hub for wheelchair accessibility. Administration 5/2015 2. Add concrete pad for a turnaround or move nursing to more accessible office 1710 Westland. Maintenance 5/2015 3. Assess all MCE bathrooms to make them accessible. Install auto doors if participants are to continue to receive services in 1710 and 1720. Administration/Maintenance. 5/15 4. Write a letter to the Mayors council for People with Disabilities identifying and requested correction of accessibility issues identified in the Accessibility Survey. Handicapped parking, audible traffic signals, extended transit hours and noting businesses that are not wheelchair accessible. Laura and Barbara 12/14 5. Write a letter to Terry Bison Ranch asking they assess the doorway by the handicapped bathroom in their establishment. Administration 1/15 6. Assess Repairs of concrete in the patio area 1750. Administration, Maintenance 11/14 7. Assess all doors and thresholds to assure accessibility of wheelchairs in MCE buildings. Maintenance continue 1/15 8. Restripe parking lot for additional and wider parking. Administration/ Maintenance 5/15 9. Close the door off to the hall way from O.T. room so not to block hall, use as a fire exit only. Administration, O.T. 7/14 Environmental Barriers: 1. Obtain funds to purchase more chairs for the areas. Administration/ Fundraiser 12/14 2. Trade out the tables and try a different set up for the lunch and main area to accommodate wheelchairs in 1720. Sup. Employment 7/14 55 3. Investigate options for a shaded area in Patio area at 1750 Westland, Ridge, S.4 th, Cleveland and Wills. Maintenance, Residential and Day Program continue 4/15 Communication Goals: 1. Investigate the use of overhead communication system for the Westland Complex. Administration 1/15 2. Expand staff training to include expanding the cognitive processes of persons with developmental disabilities and uses of adaptive equipment specific to participant. Adaptive Equipment Specialist, Training program 12/14 3. Have information for all staff to training on all participants’ mode of communication. Program area supervisors 10/14 Financial Goals 1. Identify those participants that do not have resources to purchase necessities for themselves Family members, Supervisors, Case managers, Accounting 4/15 2. Advocacy for adequate funding to provide services to participants. Board of Directors, Administration and Management 1/15 3. Encourage involvement of Legislation, organizations and communities through awareness events. Board of Directors, Administration, Management 4/15 4. Develop a system for participants to access MCE activity funds. Accounting, Managers 1/15 5. Send a formal communication to Wyoming’s Congressional leaders regarding Social Security disincentives to employment including resource limits. Administration 4/15 6. Continue being active in voting and educating the families and public how the waiver cuts affects services. Board of Directors, Administration, Management 4/15 Employment Goals: 1. Bringing more awareness to local employers the abilities people have to offer the workforce through Customized employment. Employment Coordinator 4/15 2. Concerns of Waiver funding can Education to the public, voting for members who back persons with disabilities will help with. Administration 4/15 3. Continue to educate employers and the public regarding the employment value of participants. Board of Directors, Administration, Community Employment and Managers 4/15 56 Transportation Goals: 1. Contact City Transit about routes, stops and extending hours and holiday service. Administration/Day and Supported Living Services 1/15 2. Assure there are seatbelt extensions available to staff and participants that need them. Mechanic/ DCP Staff 9/14 3. Arrange for gravel or de-icier to be put on parking lots in the winter. Maintenance /Staff 10/14 4. Provide travel training on the use of City Transit, Taxi Cabs, family, friends and co workers. Continue Sup Employment, Residential, Sup. Living, Day Services 1/15 Attitudinal Goals 1. Educate the public on people with disabilities. Board of Directors, Administration, Managers, 4/15 2. Voting for members who advocate for people with disabilities, supporting local advocate groups spread the word to your friends, neighbors and communities how important voting is. Administration, managers, supervisors, all participants. 4/15 3. Educating the public to be aware of persons with disabilities, role model while in the community. All MCE staff and participants 4/15 4. Change political attitudes through education, awareness, staff meetings and events such as the Disabilities awareness walk. Managers, Administration 4/15 5. Proactive approach to Medicaid and its benefits to our population through community awareness and education, understanding legislation and bills. Administration, Managers 4/15 6. Offer training on offering choices to participants. Training Department, Supported Living, Residential and Day services. 1/15 Goals for consumers receiving services: 1. Training to Staff to advocate for the participants and report to supervisors. Training, Day, Residential, Contracts and Supported Living 1/15 2. Use of communication notebooks, signs on training staff to communicate with non verbal consumers. Training Department, Day Services, Residential, and Sup. Living 1/15 57 3. Address transportation needs in each department area. All program area Managers , supervisors , 1/15 4. Offer information and education on Services provided at MCE to families and community. Administration, Auxiliary, Public announcements. 1/15 Ask consumers if they feel there are barriers and describe: 1. Assess extending ramp at Ridge, this is on the needs list, continue – Maintenance 4/15 2. Assess the ECO area to set up a turnaround for unloading product. Maintenance, Contracts, Administration 1/15 Technology Needs: 1. Install a computer in the 3 day service areas for participants to learn computer skills. Aaron 1/15 2. Replace laptop in day services. Tech Aaron 1/15 Integration Goals: 1. Develop opportunities for participants to access attractions not available in our community, such as a zoo, water parks and museums. Administration, Residential and Day Managers 4/15 58 MCE Program Goals and Needs 2014 COMMUNITY EMPLOYMENT 1. Expand Contracts 4/2014: Continue 2. Have two additional individuals self employed 7/2013: Continue 3. Increase the number of individual community job placements by 6 3/2014: Completed AREA NEEDS 1. 2. 3. 4. 5. Accessible restrooms at 1704 Painting at 1704 Better chairs for workers on Zotz contract Man gate at 1704 New carpeting at 1704 RESIDENTIAL 1. Develop an in home and participant training system for new staff and refreshers for Residential staff 10/2013: July 2013 2. Transition Greenview to a more independent staff support model 3/2014: Continue 3. Develop a plan to react to waiver changes 1/2014: Continue-have plan AREA NEEDS 1. 2. 3. 4. 5. 6. 7. Covered patio at the Ridge home Improve ramp off the patio at the Ridge home Updated kitchen cabinets and counter tops at Hamilton and Sycamore homes Shaun downstairs bathroom needs to be remodeled Hamilton bathroom floor needs remodeled Shade structure for patio at South Fourth, Wills, and Cleveland homes Independence home needs new windows OCCUPATIONAL THERAPY 1. Develop a benchmark based handbook for MCE staff and participants by 1/2014 2. Design and obtain a wooden memorial plaque for MCE family members who have Passed away 9/2013 3. Becoming a Medicaid provider 1/2013: Not Achievable 4. Daily THERAP billing 8/2013: July 2013 59 DAY HAB 1. Develop a consistent volunteer program 12/2013: November 2013 2. Implement and refine three focused areas of day services 12/2013: September 2013 3. Re-design transportation to improve efficiency 10/2013: Continuing October 2013 AREA NEEDS 1. 2. 3. 4. 5. 6. New tables and chairs New bathroom floors New carpet Men’s bathroom remodeled Better ventilation system for day service bathrooms Picnic tables for outdoor area SUPPORTED LIVING 1. Develop an informational slide show for MCE Supported Living services 10/2013: Done-Continue based on training 2. Develop a contingency plan to serve participants in Support Living on short notice 12/2013: Continue AREA NEEDS 1. Improved copier 2. Sinks in bathroom ACCOUNTING 1. 2. 3. 4. 5. Develop efficient money request system 11/2013: Done Implement debit cards for MCE payee recipients 6/2013: Done Certify employees in certain areas of expertise 12/2013: Drop Alternative personnel in Accounting trained in financials 3/2014: Continue Expand THERAP utilization to include Case Management, Psychology, and Occupational Therapy 10/2013: Done 6. Implement electronic billing and accounts receivable via direct Deposit 3/2014: Continue AREA NEEDS None 60 CONTRACTING GSA 1. Additional training for participants on floor machines 4/2014: November 2103 2. Train more participants on tractor 12/2013: November 2013 3. Training more participants on waxing post office floor 4/2014: December 2103 AREA NEEDS 1. Buffer/scrubber 2. Six janitorial Rubbermaid carts ECO 1. Expand PR for recycling 4/2014: Continue 2. Implement E-Waste program 8/2014: Continue AREA NEEDS 1. 2. 3. 4. 5. 6. New forklift Additional outside covered storage for cardboard North side awnings enclosed Security system for E-recycling Bailer for E-recycling Calibrated scale COMMISSARY 1. Train a participant to perform order writing duties 10/2013: October 2013 2. Train a participant to clean the meat room 3/2014: November 2013 AREA NEEDS 1. Reacher and Picker LOWE’S 1. Maintain and expand the Lowe’s contract 5/2013: June 2103 2. Develop a program for participants to work independently 3/2014: Drop AREA NEEDS None 61 ZOTZ AND LICENSE PLATES AREA NEEDS 1. New chairs MAINTENANCE AREA NEEDS None STAFF DEVELOPMENT 1. Expand technology in human resources 3/2014: Continue AREA NEEDS None STAFF TRAINING 1. Develop the 10 minute videos for training 3/2014: Continue AREA NEEDS 1. Updated training materials 2. New computers for staff training 3. Printer NURSING 1. Complete daily billing through THERAP 8/2013: August 2013 2. Develop internal procedures specific to the Health Care Services office 10/2013: Drop 3. Develop consistent system for utilization of nursing units 10/2013: Continue AREA NEEDS 1. Sick room 62 PSYCH 1. Complete daily billing through THERAP 9/2013: Completed AREA NEEDS 1. None CASE MANAGEMENT 1. Transition to a conflict free Case Management system that minimizes negative impact to employees and participants 1/2014: Continue 2. Monthly THERAP billing 9/2013: September 2013 AREA NEEDS 1. None ADMINISTRATION & SUPPORT SERVICES AREA NEEDS 1. New projector 2. New camera for presentation 3. New carpet and paint at 1780 Westland 63 2014 MCE Organizational Goals 1. Implementation of an Employee Retention Plan identifying with the younger generation of Employees March 2014: Completed July 2013 2. Make MCE services information available to other communities for participants looking to live in Cheyenne October 2014: Continue 3. Implement Employee Wellness Program January 2014: June 2013 4. Continue efforts to secure funding for integrated child cares services January 2014: Continue 5. Develop a succession plan for the MCE Board and upper management: Continue 6. Research and attain one more government or private industry contract: Continue 7. Develop a business or franchise operated by participants April 2015, Continue 8. Work with inter-corps board to purchase or build a CoApt April 2014: Drop 9. Develop a comprehensive safety program with a purpose of reducing workers’ Comp costs/claims March 2014: Continue 10. Adapt our business model to successfully utilize changed waiver funding April 2014: Continue 11. IPC’s available to read online October 2013: Completed 64 65 Magic City Enterprises, Inc. (MCE) was established by the Cheyenne Kiwanis Foundation in 1971 with the mission of providing opportunities for people with developmental disabilities. Remaining true to this mission for over 40 years, MCE has developed a diverse set of services to meet the needs of adults and children with developmental disabilities in Cheyenne and the surrounding areas. The following is MCE’s 2012-2013 outcomes for goals set to improve the quality of services, provide data for evidence based management decisions, and to present a report card to MCE’s stakeholders. MCE Demographics Currently in MCE Admissions, 12 individuals are waiting for funding from the DDD Home and Community-based Waiver. 10 reside in the Cheyenne area. disability type on waiting list mild id downs syndrome moderate id pervasive developmental disorder Characteristics of Participants on wait list at Magic City Enterprises, July 2012June 2013 Currently on the waiting list there are twelve people waiting to be served. Among these individuals are seven males and five females. There is one Hispanic individual and 11 Caucasians. Ages range from seven individuals between the ages of 20-29; two individuals between the ages of 10-19; and two individuals between the ages of 40-49. With the hopes of a funded waiting list MCE will be looking to attracting newly funded people the their diverse programming. 66 Characteristics of Participants at Magic City Enterprises, July 2012-June 2013 During the months of July 2012 through June 2013, MCE served 217 different participants, some of whom received multiple services from MCE. This number differs from the number served at any given time, as it is a cumulative figure for the year. This year’s total number of participants served increased by 4 individuals from last year. There were 162 total Home and Community-based participants. 55 participants who were served by MCE did not receive Waiver funding. These participants were funded by the Department of Vocational Rehabilitation (DVR), private pay, or direct Medicaid/Medicare funding for MCE services provided. Between the months of July 2012 through June 2013, of the 217 participants served, 138 were male and 79 were female. Between the months of July 2012 through June 2013, participants ranged in age from child to senior. MCE served 2 participants under the age of 10 years old; 3 participants between 10 and 19 years of age; 46 participants between the ages of 20-29 years of age; 42 participants between the ages of 30-39; 58 participants between the ages of 40-49; 48 participants between the ages of 50-59 and 18 participants served who are 60 years of age and older. Age of Participants Under 10 years old 10-19 years old 40-49 years old 50-59 years old 20-29 years old over 60 years old 1% 2% 8% 21% 22% 19% 27% 67 30-39 years old MCE served in the months of July 2012 through June 2013, 176 Caucasian participants, 11 AfricanAmerican participants; 2 Asian participants, 28 Hispanic participants and 0 Native American participants. Ethnicity of Participants Caucasian Hispanic African-American Native American Asian 1% 5% 13% 81% MCE served in the months of July 2012 through June 2013 MCE met the needs of many individuals with a variety of disabilities. Although many people served had multiple disabilities, a measurement of the primary diagnosis is documented as 13 individuals with severe ID; 39 with moderate ID; 116 with mild ID; 32 with mental illness; 9 with autism; 5 with Asperger’s Syndrome; 1 with acquired brain injuries; and 2 with physical disabilities. type of disability type of disability 116 39 32 13 severe ID moderate ID 9 mild ID mental illness autism 68 5 1 Asperger's acquired brain injury 2 physical disability Data Analysis Data is gathered by MCE based on four domains in each department. Effectiveness asks the question, “How effective was MCE’s programming this past year for the participants served?” Also important to measure is the Efficiency of MCE’s departments whether providing employment or residential services. Departments working within provided resources is crucial for stability. Another important inquiry is, “What is MCE’s capacity, and how well does the agency provide access to those participants desiring services?” Lastly, Satisfaction is measured to improve the quality of services based on feedback from participants and their families. Effectiveness Each program area measured one effectiveness goal. Results are as follows: Eco-Recycling: Goal: To increase participant knowledge of daily tasks by 5%. Result: Goal was met. There was a participant increase from 90% to 100%. GSA: Goal: Improve skills using machine by 5% Result: Goal was not met. There was a participant decrease from 93% to 90%. Supported Living: Goal: Improve completion of IPC objectives by.25% from prior plan year. Result: Goal was met. IPC objectives overall average improved by 57.20%. Residential Goal: To have at least one healthy meal choice 90% of the time Result: Goal was met. The goal was achieved 91% of the time. Day Hab Goal: To have three volunteer sites for 3 months. Result: Goal was met. There were six volunteer sites for 3 months. Community Employment Goal: The goal was to have 55% of the participants earn $7.75 an hour or above. Result: Goal was met. There were 64% participants who earned $7.75 or more an hour. 69 Efficiency Each program area measured one efficiency goal. Results are as follows: Eco-Recycling: Goal: To increase awareness of equipment by 5%. Result: Goal was met. There was a 10% increase in equipment awareness. GSA: Goal: Increase understanding of cleaning products by 10%. Result: Goal was not met. The participant understanding was maintained remained at 85%. Supported Living: Goal: To achieve 95% utilization. Result: Goal was met. Utilization achievement rate was 100.32%. Residential Goal: Not to average more than 100 hours of overtime per month. Result: Goal was not met. The monthly average overtime was 381.6 hours. Day Hab Goal: To reach 80% of Utilization rate. Result: Goal was met. Utilization achievement average rate was 83%. Community Employment Goal: The goal was to minimize the time in average time in job development to 5 months. Result: Goal was not met. The average time in job development was 6 months. 70 Access Each program area measured one access goal. Results are as follows: Eco-Recycling: Goal: To increase interaction between participants and customers by 5%. Result: Goal not was met. There was a decrease from 95% to 90%. GSA: Goal: Decrease the number of deficiencies per month by ½. Result: Goal was not met. The number of deficiencies per month went from 3 to 5. Supported Living: Goal: To have 90% of the participants receive training on accessing community. Result: Goal not met. Training was given 6 to 12 months of the year to 100 % of the participants. Note: The training schedule/program was re-tooled to meet the participants needs thus the reason for the original goal not being met. Residential Goal: To be able provide service availability within 14 days of request. Result: Goal was met. There was a 100% success rate for each service request. Day Hab Goal: To follow community interaction schedule 100% of the time for 8 ½ months. Result: Goal was met. The community interaction schedule was for 9 ½ months. Community Employment Goal: To have active employment status with three months of referral. Result: Goal was met. There was 100% success rate. . 71 Satisfaction Each program area measured one Satisfaction goal. Results are as follows: Eco-Recycling: Participant satisfaction is 100% (2/2) GSA: There was no data given for this segment. Supported Living: Participant satisfaction is 100% (8/8) Residential Each year MCE is met with the many oversight agency requirements, budget restraints and changing needs of the participants served. With consideration of these challenges, Magic City Enterprises will continue to set goals to improve the quality of services through outcomes data collected. Participant satisfaction is 88% (15/17) Day Hab Participant satisfaction is 90% (18/20) Community Employment Participant satisfaction is 88% (14/16) NOTE: Satisfaction Percentage average from 2012 to 2013 remained the same at 93%. 72 TERMINOLOGY KEY In the order they appear in the Goal Plan document MCE………………………………Magic City Enterprises Therap…………………………An online documentation and communication software system DDD……………………………Wyoming Behavioral Health Division, Developmental Disabilities Programs CARF……………………………An international accreditation organization NISH……………………………National Industries for the Severely Handicapped, now Source America FY…………………………………Fiscal Year ADP………………………………Automated Data Processing, a payroll processing service DD……………………………….Developmental Disabilities E-Recycling……………………Electronics Recycling CEO………………………………Chief Executive Officer HUD……………………………..U.S. Department of Housing and Urban Development TBI………………………………..Traumatic Brain Injury Day Hab………………………..Day Habilitation IBAs……………………………….Individual Budget Amounts Fed…………………………………Federal CMS………………………………..U. S. Center for Medicaid and Medicare Services PT……………………………………Physical Therapy OT…………………………………..Occupational Therapy ST……………………………………Speech Therapy DFS………………………………….Wyoming Department of Family Services IPC…………………………………..Individual Plan of Care PR……………………………………Public Relations AFB………………………………….F.E. Warren Air Force Base LCCC……………………………….Laramie County Community College E-Waste………………………….Electronics Waste 73 Mega Conference……………An annual conference on developmental disability issues School District #1……………Laramie County School District #1 ABI…………………………………Acquired Brain Injury Vets……………………………….Veterans DVR………………………………..Wyoming Division of Vocational Rehabilitation XJWC………………………………Ex Junior Women’s Club Sr……………………………………Senior IT……………………………………Internet Technology HIPAA…………………………….Health Insurance Portability and Accountability Act WIND……………………………..Wyoming Institute on Disabilities MHP……………………………….McGee, Hearne and Paiz, L.L.C. PRN…………………………………As needed CPAs………………………………..Certified Public Accountants SWRS……………………………….A corporation which supports Magic City Enterprises HUB…………………………………Day services area Sup. Living………………………Supported Living 1704……………………………….1704 Westland Dr. Zotz…………………………………A company that contracts with MCE to perform packaging services Inter-Corps……………………..Various corporations that are related to and support Magic City Enterprises CoApt……………………………..Cooperative Apartments for participants of Magic City Enterprises Worker’s Comp……………….Worker’s Compensation ID……………………………………Intellectual Disability GSA…………………………………U. S. Government Services Administration 74