2013
Redwood Children’s Services, Inc.
DRAFT: 02-03-13
Compliance plan
Behavioral health services
The federal Medicaid Managed Care regulations require that mental health providers have
Administrative and Management Procedures, including a mandatory compliance program,
designed to guard against fraud and abuse (Title 42, Code of Federal Regulations, Chapter 4,
Section 438.608: Program Integrity Requirements).
TABLE OF CONTENTS
INTRODUCTION .............................................................................................................................................................1
STANDARDS and PROCEDURES......................................................................................................................................2
COMPLIANCE MISSION STATEMENT ........................................................................................................................2
CONDUCT STANDARDS .............................................................................................................................................3
DOCUMENTATION OF COMPLIANCE EFFORTS .........................................................................................................3
CODE OF ETHICS should this be an Exhibit?? ...........................................................................................................4
RCS COMPLIANCE PROGRAM CODE OF ETHICS .......................................................................................................5
RCS COMPLIANCE PROGRAM CONTRACTOR CODE OF ETHICS ...............................................................................7
OVERSIGHT ....................................................................................................................................................................8
COMPLIANCE OFFICER (CO) ......................................................................................................................................8
THE RESPONSIBILITIES of the COmpliance officer include: ...................................................................................8
COMPLIANCE COMMITTEE .......................................................................................................................................9
THE RESPONSIBILITIES of the Compliance Committee include: ..........................................................................10
TRAINING and EDUCATION ..........................................................................................................................................11
RESOURCE MATERIALS ...........................................................................................................................................11
TYPES OF TRAINING ................................................................................................................................................12
General COmpliance Training ..............................................................................................................................12
JOB-SPECIFIC COMPLIANCE TRAINING ................................................................................................................12
DOCUMENTATION AND BILLING .................................................................................................................................12
CHARGE ENTRY/ADJUSTMENTS ...........................................................................................................................12
DOCUMENTATION OF TRAININGS/EDUCATION ....................................................................................................13
REPORTING AND FOLLOW-UP ................................................................................................................................13
FOR: GENERAL COMPLIANCE, DOCUMENTATION AND BILLING, AND INFORMATION SYSTEM CHARGE
ENTRY/ADJUSTMENTS TRAININGS ......................................................................................................................13
FOR: OTHER JOB-SPECIFIC TRAININGS.................................................................................................................13
COMMUNICATION ..................................................................................................................................................14
REPORTING VIOLATIONS OR SUSPECTED NON-COMPLIANCE...............................................................................14
REPORTING METHODS: .......................................................................................................................................14
CLARIFICATION ....................................................................................................................................................15
ENFORCEMENT and DISCIPLINE ..............................................................................................................................15
DISCIPLINE ...........................................................................................................................................................15
Notice of Intended Order for Disciplinary Action: .................................................................................................16
Notice of Disciplinary Action - Employee and Human Resource notification: .....................................................16
Answer to Notice: ................................................................................................................................................17
MONITORING and AUDITING PROCEDURES ................................................................................................................17
AUDIT SCOPE ...........................................................................................................................................................17
MONITORING TECHNIQUES/PROCESSES ................................................................................................................17
CLINICAL LICENSE VERIFICATION AND BACKGROUND CHECKS ...........................................................................18
RECORDS REVIEWS..................................................................................................................................................18
REPORTING ..........................................................................................................................................................19
BILLING COMMITTEE SCOPE AND RESPONSIBILITY ...............................................................................................19
BILLING Department ....................................................................................................................................................19
To accomplish these functions, the Billing Department will: ..............................................................................20
CLAIM DEVELOPMENT AND SUBMISSION (ALL PAYERS) .......................................................................................20
MEDI-CAL .................................................................................................................................................................21
Billing, Payments, Adjustments, Refunds/Overpayments ...................................................................................21
Review and Reporting ..........................................................................................................................................21
INSURANCE AND PRIVATE PAY/UMDAP ................................................................................................................21
Insurance Billing ..................................................................................................................................................21
Private Pay/ UMDAP (UNiveral Method of determining ability to pay) Billing ...................................................22
Adjustments.........................................................................................................................................................22
Refunds/Overpayments..........................................................................................................................................22
COST REPORT ...............................................................................................................................................................22
REVIEW AND REPORTING .......................................................................................................................................23
ORGANIZATIONAL COMPLIANCE .................................................................................................................................23
MONITORING AND AUDITING PROCEDURES...............................................................................................................23
CORRECTIVE ACTION ...............................................................................................................................................23
INVESTIGATION AND FOLLOW-UP..........................................................................................................................23
OVERPAYMENTS .....................................................................................................................................................24
VOLUNTARY DISCLOSURE ............................................................................................................................................24
EXHIBITS FOR CORRECTIVE ACTION ............................................................................................................................25
MAINTENANCE and RETENTION of COMPLIANCE RECORDS .......................................................................................28
TYPES OF RECORDS TO BE RETAINED .....................................................................................................................28
MAINTENANCE AND RETENTION............................................................................................................................28
EXHIBIT: MAINTENANCE AND RETENTION OF COMPLIANCE RECORDS Policy/Procedure .........................................29
EMPLOYEE ACKNOWLEDGEMENT AND AGREEMENT ............................................................................................32
CONTRACTOR ACKNOWLEDGEMENT AND AGREEMENT ...........................................................................33
INTRODUCTION
The federal Medicaid Managed Care Regulations require that mental health providers have
Administrative and Management procedures, including a Mandatory Compliance Program
designed to guard against fraud and abuse (Title 42, Code of Federal Regulations, Chapter 4,
Section 438.608: Program Integrity Requirements). The policies and procedures must include the
following seven specific requirements:
 Written policies, procedures, and standards of conduct that articulate the commitment to
comply with all applicable federal and state standards.
 The designation of a Compliance Officer and a Compliance Committee that is accountable
to Senior Management.
 Effective training and education for the Compliance Officer and RCS employees.
 Effective lines of communication between the Compliance Officer and RCS employees.
 Enforcement of standards through well-publicized disciplinary guidelines.
 Provision for internal monitoring and auditing.
 Provision for prompt response to detected offenses and for development of corrective
action initiatives relating to RCS contracts with the Counties.
The focus of the Compliance Program is to ensure that each RCS employee conducts his or her
work with the highest standards of ethics and integrity. The Compliance Program also assists RCS
employees in taking proactive steps to minimize the risks associated with the increasing efforts of
Federal and State authorities to address fraud in mental health services. This program will
provide the means to correct problems before they rise to the level of an enforcement issue.
The goals and objectives of the Compliance Program are:
 Maintenance of a working environment that promotes ethical values, exemplary behavior
and compliance with the letter and spirit of all applicable laws.
 Development of a program that encourages employees and contractors to demonstrate
the highest ethical standards in performing their daily tasks.
 Adherence to the RCS Code of Ethics and RCS Code of Conduct.
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 Development of a disclosure system (Hotline, email or postal mail) that requires RCS to
respond to reports by employees or others of a suspected violation of law or the principles
of the Compliance Program.
 Identification of those situations in which applicable laws, regulations, rules and standards
may not have been followed and facilitation of the correction of any such practices.
 Implementation of procedures to assure future compliance with all laws and regulations of
the Medicaid programs and all other applicable laws.
 Training and communication that ensures employees and contractors understand and
comply with all applicable laws, regulations, rules, and standards.
 Adherence to established policies for appropriate screening of prospective employees and
contractors to reduce the likelihood that violations will occur.
 Assurance that documents are retained and kept secure for the appropriate length of time
as required by applicable regulation.
 Adherence to established disciplinary policies that are prompt, effective and consistent,
and will discipline employees based on the severity of the violation, not on the basis of
their position or tenure with RCS.
 Assurance that government inspections proceed in a smooth and professional manner, and
that all requests and concerns are addressed promptly and appropriately.
The term “staff” used throughout this handbook refers to full and part time employees,
volunteers, board members, interns, contractors and other agents acting on behalf of BHS.
Although contractors are not technically “staff”, the provisions of this handbook apply to them.
The entire Compliance Program is described herein and includes references to policies and
procedures, forms and worksheets. On any compliance issue, absent any formal policy or
procedure, the language contained in this Compliance Program will serve as the guideline for
adherence purposes.
STANDARDS AND PROCEDURES
COMPLIANCE MISSION STATEMENT
Redwood Children’s Services Inc., (RCS) will comply with all applicable regulations, laws, rules or
guidelines governing the provision of mental health services. All employees and contractors, who
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provide and receive payment for mental health services, are expected to conduct themselves
honestly, fairly, and with a high degree of integrity. In addition, this program has been instituted
as a means of preventing fraud, abuse and false billings to any third-party payer. Strict adherence
to the Compliance Program is expected of all employees, volunteers and contractors.
CONDUCT STANDARDS
To ensure that RCS’s commitment to compliance is shared by its employees, RCS will adhere to
RCS Code of Ethics, RCS Code of Conduct, the RCS Employee Manual, County Mental Health Plans
and this Compliance Program.
To ensure that contractors also share in this commitment each contractor who provides and
receives payment for mental health services will be required to comply with this Code as a
condition of contractual arrangement with RCS.
All RCS employees and contractors will perform their duties in a manner that they reasonably
believe to be in the best interest of RCS and the clients we serve. They must maintain a high level
of integrity in their conduct and avoid any conduct that could reasonably be expected to reflect
adversely upon the integrity of RCS and the services we provide.
RCS will provide training on this Compliance Program to all applicable employees and contractors;
therefore, they are expected to adhere to it. To acknowledge receipt of training and information
on the Compliance Program, staff will sign the Acknowledgment and Agreement form; Copies of
these forms will be retained in the employee’s personnel file or the contractor’s credentialing file
and as part of the Compliance Program’s training documentation.
DOCUMENTATION OF COMPLIANCE EFFORTS
Compliance efforts will be documented to protect the integrity of the compliance process and
confirm the effectiveness of the program. In addition to the Code of Conduct, additional
compliance Policy and Procedures (P&P) have been developed and are included herein. All P&Ps
will be updated as needed and, at a minimum, will be reviewed on an annual basis. Other P&Ps
may be developed as needed. Within 30 days after the effective date of any new/revised P&P,
the P&P shall be distributed to all individuals whose job duties and functions relate to the
new/revised Policy and Procedure.
Besides formal P&Ps, other documentation requirements will vary depending on the area of
review or emphasis, but will include, at a minimum, items such as:
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Evidence of employee training
Reports from the RCS compliance hotline
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Results from any investigation
Modifications to the Compliance Program
Self-disclosure
Written notifications to contractors
Results of auditing and monitoring efforts
Documented compliance efforts will be retained in accordance with policy, and/or applicable
record retention rules or guidelines.
CODE OF ETHICS SHOULD THIS BE AN EXHIBIT??
RCS’ Code of Ethics seeks to ensure that the conduct of all RCS staff is ethical, professional,
responsible and productive. Such conduct is an essential component for providing high quality
Behavioral Health Services. Place loyalty to the highest moral principles and ethical business
practice above personal need.
•
NEVER discriminate unfairly by the dispensing of special favors, gratuities or privileges
to anyone, whether for remuneration or not; and never accept, for one's self or family,
favors or benefits under circumstances which might be construed by reasonable
persons as influencing the performance duties. Any doubts about the propriety of
accepting a particular gratuity should be resolved by the refusal of the gratuity.
•
UPHOLD the laws and legal regulations of the Federal, State and County governments,
and all licensure requirements and never be a party to their evasion.
•
GIVE a full day's labor for a full day's pay; giving to the performance of one's duties
one's earnest effort and best thought.
•
SEEK to find and employ more efficient and economical ways of getting tasks
accomplished.
•
ACCEPT no money, commissions or thing of value of any kind in exchange for or as
quid pro quo for services other than the regular RCS salary.
•
ENGAGE in no business either directly or indirectly, which is inconsistent with the
conscientious performance of one's RCS duties.
•
NEVER use any confidential information received in the performance of one's duties as
a means for making private profit.
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•
EXPOSE corruption wherever discovered. Promptly report any activity which may
violate the Policies and Procedures of RCS or any applicable law, regulation, rule or
guideline.
•
TREAT all individuals encountered in the performance of one's duties in a respectful
and professional manner.
RCS COMPLIANCE PROGRAM CODE OF ETHICS POLICY/PROCEDURE
RCS is committed to full compliance with all applicable laws, regulations, rules, and guidelines
that apply to the operations and services. At the core of this commitment are RCS employees and
the manner in which they conduct themselves. To assure that RCS’s commitment is shared by its
employees; RCS has established this Code of Conduct of which each employee will be required to
certify his or her compliance.
PURPOSE: To provide specific conduct standards prescribed by the Compliance Program. These
are maintained in addition to the Code of Ethics already in effect (see employee manual).
PROCEDURE:
1. A copy of this Code of Conduct shall be provided to all employees at the time of their initial
and annual general compliance training or whenever revised.
2. Upon initial receipt and review of this Code of Conduct, employees shall certify their intention
to abide by it by signing the Employee Acknowledgement and Agreement form. These signed
forms will be retained by the Human Resource Department. See attachment.
3. The Human Resource Manager will track the certifications made by employees and report to
the Compliance Officer and the Directors of Behavioral Health Services (BHS) on a quarterly basis.
4. The Code of Conduct will be prominently displayed throughout all BHS facilities and sites.
CODE OF CONDUCT:
This Code of Conduct is not intended to be an exhaustive list of all standards by which employees
are to be governed. Rather, it is intended to convey to employees the commitment to the high
standards that RCS has set for each of its employees.
In addition to the Code of Conduct listed in the RCS Employee Handbook, BHS employees shall:
1. Be responsible for reviewing and understanding Compliance Program Policies and Procedures
including the possible consequences for failure to comply or failure to report such noncompliance.
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2. Conduct themselves honestly, fairly, and with a high degree of integrity in their professional
dealings related to their employment with RCS and avoid any conduct that could reasonably
be expected to reflect adversely upon the integrity of RCS and the services it provides.
3. Comply with all applicable laws, regulations, rules, and guidelines and RCS Compliance
Program Policies and Procedures.
4. Practice good faith in transactions occurring during the course of business and never use or
exploit professional relationships or confidential information for personal purposes.
5. Preserve patient confidentiality unless there is appropriate, written permission to disclose
information, except when required by law.
6. Promptly report any activity, which they believe, may violate the policies and procedures of
the County, the Compliance Program, or any other applicable law, regulation, rule or
guideline, in accordance with the reporting procedures set forth in RCS policies and
procedures.
7. Immediately notify their Supervisor if they are assigned a client who is an acquaintance,
friend or relative, or if the employee has a professional relationship with the person other
than the RCS working relationship. The Supervisor will determine if there is a need to assign
the client to another employee.
8. Immediately notify their Supervisor if there is a Supervisor/employee relationship between
themselves and a relative, spouse or significant other.
9. Comply with not only the letter of Policies and Procedures, but also with the spirit of those
Policies and Procedures as well as other rules adopted by RCS. When in doubt about what
constitutes compliance performance, employees should consult with their supervisor.
10. Protect and retain records and documents as required by professional standards,
governmental regulations and organizational policies.
11. Ensure that claims are prepared and submitted accurately and timely and are consistent with
all applicable laws, regulations, rules and guidelines.
12. Clients and the public at large have a right to expect that services will be rendered in a
professional manner consistent with the ethical guidelines set forth above, as well as
commonly accepted standards for moral and ethical behavior.
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RCS COMPLIANCE PROGRAM CONTRACTOR CODE OF ETHICS POLICY/PROCEDURE
Redwood Children’s Services, Inc. (RCS) is firmly committed to full compliance with all applicable
laws, regulations, rules and guidelines that apply to the provision and payment of mental health
services. RCS contractors and the manner in which they conduct themselves are a vital part of
this commitment.
RCS has established this Contractor Code of Conduct and Ethics with which contractor and its
employees and subcontractors shall comply. Contractor shall require its employees and
subcontractors to attend a compliance training that will be provided by RCS. After completion of
this training, each employee and subcontractor must sign the Contractor Acknowledgment and
Agreement form and return this form to the Compliance Officer or designee. See Attachment.
Contractor and its employees and subcontractors will:
1. Comply with all applicable laws, regulations, rules or guidelines when providing and billing
for mental health services.
2. Conduct themselves honestly, fairly, courteously and with a high degree of integrity in
professional dealings related to your contract with RCS and avoid any conduct that could
reasonably be expected to reflect adversely upon the integrity of RCS.
3. Treat RCS employees, consumers and other RCS contractors fairly and with respect.
4. NOT engage in any activity in violation of the RCS Compliance Program, nor engage in any
other conduct which violates any applicable law, regulation, rule or guideline.
5. Take precautions to ensure that claims are prepared and submitted accurately, timely and
are consistent with all applicable laws, regulations, rules or guidelines.
6. Ensure that no false, fraudulent, inaccurate or fictitious claims for payment or
reimbursement of any kind are submitted.
7. Bill only for eligible services actually rendered and fully documented. Use billing codes
that accurately describe the services provided.
8. Act promptly to investigate and correct problems if errors in claims or billings are
discovered.
9. Promptly report to the RCS Compliance Officer, any activity that they believe may violate
the standards of the Compliance Program, or any other applicable law, regulation, rule or
guideline.
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10. Promptly report to the RCS Compliance Officer any suspected violation(s) of this Code of
Conduct and Ethics by RCS employees or other RCS contractors.
11. Consult with the RCS Compliance Officer if you have any questions or are uncertain of any
Compliance Program standard or any other applicable law, regulation, rule or guideline.
OVERSIGHT
COMPLIANCE OFFICER (CO)
The CO or designee has the authority and responsibility for the development, operation,
implementation, oversight and refinement of the Compliance Program. This involves developing
standards, coordinating compliance training and education, conducting or arranging internal
audits, identifying compliance issues and trends, investigating and resolving compliance
complaints and promoting an awareness and understanding of the positive ethical and moral
practices consistent with the mission and values of RCS and those required by all applicable laws,
regulations, rules or guidelines.
The CO or designee has the authority to review any and all documents and other information that
may be relevant to compliance activities, including, but not limited to:
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Consumer records
Billing records
Contracts with other parties

Results of internal and external
audits
The CO or designee has the full authority to stop any work process that may be the cause of or
contributing to noncompliance until the process has been reviewed and/or corrected, if
needed.
RCS has established the following minimum requirements for the person holding the position of
CO:
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Has not been found to be in violation of any laws or policy of RCS
Possesses values and principles which are representative of RCS
Understands and accepts the principles to be achieved with the Compliance Program
RCS Compliance Officer is: LYNN SALLEE, Financial Director
THE RESPONSIBILITIES OF THE COMPLIANCE OFFICER INCLUDE:
 Oversee and monitor the implementation of the Compliance Program.
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 Report on a regular basis to the Directors on the progress of implementation (see
Organization Chart for Compliance) Do we have Org Chart for Compliance??? Is that the
chart with the blue squares
 Chair the Compliance Committee.
 Establish and maintain a document control system for all reports and operations of the
Compliance Committee including minutes of meetings, audit and monitoring reports,
corrective actions, disciplinary actions, investigations, disclosures, training and
education, government inspections.
 Develop, coordinate and participate in an education and training program that focuses
on the elements of the Compliance Program and seeks to ensure that all appropriate
employees and contractors are knowledgeable of and comply with the Compliance
Program as well as all applicable laws, regulations, rules or guidelines; assess the need
for additional training and education
 Monitor and keep current with all applicable laws, regulations, rules, guidelines and RCS
processes.
 Assist those that provide and bill for mental health services, in coordinating internal
compliance monitoring activities
 Develop a system that enables employees and contractors to report suspected
violations without fear of retaliation. Ensure that this system is publicized and that
allegations of non-compliance are investigated and responded to promptly
 Investigate matters related to compliance and coordinate internal and external
investigations. Assist in the development of corrective action
 Periodic review of the effectiveness of the Compliance Program and implement
improvements or modifications on an ongoing basis to meet the changes in the
organization’s risks and needs.
COMPLIANCE COMMITTEE
A Compliance Committee has been established to provide organizational support, create
awareness of the Compliance Program, advise the CO, and assist in the implementation of the
Compliance Program. The CO will serve as chairperson of the Compliance Committee.
The Compliance Committee will be comprised of the following members:
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Compliance Officer
BHS Director or designee
Operations Manager
Quality Improvement Manager
Assistant Director
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RCS Executive Director
Administrative Director
Human Resource Manager
HIPAA Privacy Officer or
designee
As appropriate, other staff will be invited to join the committee meeting when it is addressing
specific issues, but they will not serve as members.
THE RESPONSIBILITIES OF THE COMPLIANCE COMMITTEE INCLUDE:
 Analyze RCS’s regulatory environment and legal requirements with which it must
comply and identify specific risk areas.
 Assess existing policies and procedures that address these risk areas for possible
incorporation into the Compliance Program.
 Work with appropriate departments, programs, and contractors to ensure adherence to
established conduct standards and practices and other policies and procedures that
promote allegiance to the Compliance Program.
 Recommend and monitor the development of internal systems and controls to achieve
RCS’s standards, policies, and procedures as part of its daily operations.
 Develop and monitor communication methods and training programs to ensure that
employees and contractors receive proper information about the Compliance Program,
including their duties under it.
 Determine appropriate strategies and approaches to promote compliance and detection
of any potential violations.
 Develop a system to solicit, evaluate, and respond to complaints and suspected cases of
noncompliance.
 Monitor internal and external audits and investigations to identify troublesome issues
and deficient areas in the organization and develop and implement corrective and
preventive action.
 Address other functions as the compliance concept becomes part of the overall
operating structure and daily routine.
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 Develop and work with special task groups assigned to focus on identified risk areas, to
develop standards, and to formulate appropriate policies and procedures for
compliance with ethical and legal standards.
 Assign duties to individuals to ensure implementation of the Compliance Program and
maintain a current listing of the assignment of these duties The committee will meet, at
a minimum, on a quarterly basis or more often as needed.
EXHIBIT:
• Organization Chart for Compliance (Blue box “BHS Complaint”)
TRAINING AND EDUCATION
Education and Training is an important part of any Compliance Program. As federal and state
regulations and RCS standards change, it is essential that RCS employees and contractors are
sufficiently trained and re-trained to keep abreast of these changes. All RCS employees and
contractors will receive general compliance training. Job-specific training will be provided as
appropriate or as needed based on job classification or job duties/functions.
RESOURCE MATERIALS
RCS has developed and will provide the following resource materials to employees or
contractors:
•
Documentation and Billing Policies and Procedures - Provides guidance on
documentation and billing standards in order to comply with applicable laws,
regulations, rules, and RCS standards. It also provides information on the Compliance
Program. These Policies and Procedures will be revised as applicable regulations and
RCS standards change. This handbook will be provided to all RCS direct service and
clinical management staff.
•
Medi-Cal Provider Updates – These are for the RCS service providers who provide and
bill for mental health services. This is County or State information that is sent to RCS and
will highlight any changes in regulations, provides guidance on billing and
documentation, and provides information that is applicable to mental health providers
or billers.
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•
In addition to these resources, all RCS supervisory staff and contractors will receive a
copy of the Compliance Program and will make this available to their staff. This can also
be accessed via the RCS website at www.RCS4Kids.org
TYPES OF TRAINING
GENERAL COMPLIANCE TRAINING
All RCS employees and contractors will be provided this training within 90 days of approval of
the Compliance Program and annually thereafter. New hires and new contractors will receive
this training within 30 days of hire and annually thereafter. All mental health service providers
will receive the RCS and MHP Code of Ethics to read and sign at the time of hire.
The curriculum is approved by the Compliance Committee and will be reviewed annually. It will
be updated as needed to reflect changes in federal healthcare program requirements, for any
issues discovered during internal audits or for any other relevant information.
JOB-SPECIFIC COMPLIANCE TRAINING
Some job classifications require specific training to ensure compliance with federal and state
regulations and RCS standards. These trainings include, but are not limited to: Documentation
and Billing, Charge Entry/Adjustments, and Financial Office Processes and Procedures.
DOCUMENTATION AND BILLING
All existing RCS direct service and clinical management staff (Managers and Clinical Supervisors)
will attend this training within 90 days of approval of the Compliance Program and annually
thereafter. New hires will attend this training within 30 days of hire and annually thereafter.
The curriculum is developed by the Compliance Committee along with a licensed staff. BHS will
also provide training to RCS contractors within 30 days of contract implementation and when
requested by the contractor.
CHARGE ENTRY/ADJUSTMENTS
All existing BHS Managers, Clinical Supervisors, and Information System Billing Coordinators and
Analysts will be provided this training within 90 days of approval of the Compliance Program
and annually thereafter. New hires will be trained within 30 days of hire and annually
thereafter. On an as needed basis, additional training will be provided when there are changes
to the Information System that will affect billing.
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The curriculum is developed by the Financial Director and BHS Operations Manager. They will
be responsible for initial and annual training of their appropriate clerical staff on specific billing
and Information System Processes and Procedures.
Applicable billing staff will be trained on coding and billing of mental health services. The Billing
Coordinator and Operations Manager will maintain current reference tools to assist staff in
coding and billing functions, e.g., ICD-9/10, CPT/CPT Assistant, and other reference manuals or
materials as needed.
DOCUMENTATION OF TRAININGS/EDUCATION
All compliance and other applicable training or education will be documented and forwarded to
the Human Resource Department and a report will be generated for the Compliance Officer on
a quarterly basis. Documentation should include:
• Training date
• Topic
• Compliance related material covered (provide syllabus if available)
• Name of trainer(s)
• Participant names and signatures
All documentation will be maintained as outlined in the policies provided in Maintenance and
Retention of Compliance Records.
REPORTING AND FOLLOW-UP
GENERAL COMPLIANCE, DOCUMENTATION AND BILLING, AND INFORMATION SYSTEM
CHARGE ENTRY/ADJUSTMENTS TRAININGS
The Human Resource Department will provide quarterly reports to the Compliance Committee
on the number of existing staff and new hires (within the quarter) who have/have not attended
these required trainings.
OTHER JOB-SPECIFIC TRAININGS
The Human Resource Department will provide an Annual Report to the Compliance Committee
on training activities conducted throughout the year. They will also submit all training
documentation that must be retained by the Compliance Committee.
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The CO and Compliance Committee will review these Education Activity Reports as well as
reports of other education activity provided in specific departments to assure all staff receives
Compliance Training as required and needed. They may direct follow-ups with Managers and
Supervisors to assure training is conducted and reaching all targeted staff.
COMMUNICATION
An effective line of communication between the CO and RCS employees and contractors is
critical for the adherence to and effectiveness of the Compliance Program. Communication may
consist of or be in the form of formal trainings, posters, e-mail, intranet/internet or other
appropriate means including, but not limited to, the following:
•
Establish and maintain a web page. All appropriate documents, forms and P&Ps will be
available for access by employees and contractors.
•
Compliance standards will be communicated regularly and timely; establish initial and
annual training for appropriate RCS employees and contractors.
•
Behavioral Health Services and program areas providing Behavioral Health Services will
prominently post the following information: Code of Ethics, Compliance Program Code
of Conduct, Non-Compliance Reporting Process, and information on the Hotline.
REPORTING VIOLATIONS OR SUSPECTED NON-COMPLIANCE
All RCS employees and contractors are expected to report any activity that may violate the
Compliance Program’s Mission and/or Standards, and any applicable law, regulation, rule or
guideline.
RCS prohibits retaliation against any person making a report. Any employee engaging in any
form of retaliation will be subject to disciplinary action.
Employees and contractors may report anonymously using any of the three reporting methods
described below. The goal of all reporting methods is to provide opportunities for the
Identification, Investigation, Correction and Prevention of inappropriate activities.
REPORTING METHODS:
 TELEPHONE: The Compliance Hotline (707-467-2010 ext.102) is available Monday
through Friday, 8 a.m. to 5 p.m. The Hotline will be maintained by QA staff. All calls will
remain confidential and private and every caller has the option to remain anonymous by
calling after hours (the phone number will not be identified or traced).
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 EMAIL: If the caller wishes to remain anonymous, he/she should leave a private email
address. Using this email, the caller will be contacted for additional information if
needed. QA will email or call back within 20 days to report the status of their report.
This is also an opportunity for the caller to provide more information if needed by the
investigation staff.
 MAIL: Addressed to:
 RCS QA Manager, P.O. Box 422, Ukiah, CA 95482
Documentation will include the process and results of the investigation;
corrective action taken, if any; and follow-up performed.
CLARIFICATION
With ongoing changes in federal and state regulations it is expected that employees may be
uncertain of or have questions about practice and procedures. It is also expected that
employees will need clarification on Compliance Standards and Procedures. Questions should
be directed to the CO by telephone (707-964-4770) or e-mail (SalleeL@rcs4kids.org). These
requests will be documented and presented for review by the Compliance Committee to
determine if there are specific departments, areas or programs that should be reviewed for
possible non-compliance and/or additional trainings.
ENFORCEMENT AND DISCIPLINE
RCS is committed to a fair and reasonable but unwavering enforcement of these Compliance
Standards. RCS will communicate the standards of enforcement and discipline, clearly stating
that it is without prejudice, bias, or other non-standard conduct. On a case by case basis, after a
thorough investigation is completed, if it is determined that any employee knowingly
committed a violation, the employee will be subject to appropriate disciplinary action.
DISCIPLINE
All employment at Redwood Children’s Services (“RCS” or “Agency”) is at-will. In other words,
employees, as well as RCS, are free to end the employment relationship at any time, with or
without notice, with or without cause, for any reason not prohibited by law. This at-will
relationship can be modified only if such modification is in writing and the written modification
is signed by the Executive Director.
Disciplinary action will be carried out as appropriate. Disciplinary actions may include:
15
Oral Reprimand: A formal discussion with an employee about performance or conduct
problems. This action preferably is summarized by the Supervisor or Director and a copy given
to the employee.
Written Reprimand: A written document presented to an employee regarding performance or
conduct problems. A copy must be provided to the employee with a copy filed in the
employee’s personnel folder. The employee shall be permitted to file a written response, the
original being directed to the Supervisor and a copy filed in the employee's personnel file.
Disciplinary Suspension: An involuntary absence without pay for a period up to and including
30 working days.
Disciplinary Demotion: Reduction from a position class to a position in another class having a
lower salary range allocation.
Dismissal: Discharge - termination
NOTICE OF INTENDED ORDER FOR DISCIPLINARY ACTION
Prior to the effective time of any disciplinary action, a verbal notice of intended order for
disciplinary action will be discussed with the employee. The notice will have information
supporting the allegations against the employee.
The notice will inform the employee of the type of disciplinary action intended to be taken and
will notify employee of his/her right, if he/she chooses, to deny the charges or explain conduct
orally or in writing, or both, within 24 hours from the time of the verbal notice.
The notice will also advise the employee that if he/she fails to reply to the Supervisor or
Director within the 24 hour period, or if the denial is deemed by the Director to be untrue, or if
the reasons given as to why the notice should not be served upon are deemed by the
Supervisor or Director to be insufficient excuse for this conduct as set forth in the proposed
notice, the formal notice for disciplinary action will be signed and the employee may be
suspended or terminated at that time.
NOTICE OF DISCIPLINARY ACTION - EMPLOYEE AND HUMAN RESOURCE NOTIFICATION:
If an employee is disciplined by dismissal, demotion, suspension, or administrative salary
reduction, a written notice for disciplinary action will be prepared by the Compliance Officer
and/or HR Supervisor. Serving a Notice for disciplinary action or any notice required to be given
to an employee will be deemed sufficient and complete when delivered in person to the
employee to whom it is directed or when it is deposited in the United States mail, postage
prepaid, and addressed to the last known address of the employee.
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ANSWER TO NOTICE:
Within five working days of Notice, the employee may file with the Human Resources a written
answer to the charges denying the allegations he/she does not believe to be true and briefly
stating the foundations for his belief or otherwise explaining the conduct. A copy of the answer
with proof of service must be served by the employee on the Manager of Human Resources.
Service will be deemed sufficient and complete when delivered in person to the HR Supervisor
or Compliance Officer or when it is deposited in the United States mail, certified return
receipt, postage prepaid.
MONITORING AND AUDITING PROCEDURES
To ensure the Compliance Program is effective and that RCS’s performance is compliant with all
applicable laws, regulations, rules, and guidelines, RCS will monitor activities that are subject to
regulatory requirements, and routinely report findings to the Compliance Committee and the
Directors. BHS QA/QIC staff will perform audits to investigate indications of non-compliance
revealed by monitoring activities, the Hotline and other reporting or detection means.
Collectively, these audits and reviews, conducted with the support of management, will also
help ensure compliance with the Policies and Procedures of RCS and the Compliance Program.
AUDIT SCOPE
At a minimum, audits will be conducted in these areas to measure RCS’s compliance with laws
governing:
•
•
•
•
•
Hotline/other Communication Systems
Background Checks (OIG & EPLS)
Clinical Records Reviews
Financial/Billing Office Functions
Cost Reporting
Additional audits will be conducted to investigate specific concerns identified within RCS and
those that may be identified by a contractor, or other outside agency, including federal or state
agencies.
MONITORING TECHNIQUES/PROCESSES
These may include, but not be limited to, the following:
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•
•
•
•
•
Site visits
Improvised audits and investigations
Examination of RCS’s grievance logs
Reviewing written materials and/or documentation prepared by the different program
areas within RCS
Reports from ongoing monitoring efforts, including reports of suspected
noncompliance, will be maintained by the CO and reviewed with the Compliance
Committee and the Directors of RCS.
CLINICAL LICENSE VERIFICATION AND BACKGROUND CHECKS
RCS Human Resource Manager must check the credential and approve all prospective RCS
employees or contractors, in the disciplines listed below, before they may provide and bill for
mental health services or contract with RCS:







Psychologist (licensed and waivered)
Clinical Social Worker (licensed and associates)
Marriage and Family Therapist (licensed and interns)
Licensed Psychiatric Technician
Rehabilitation Specialist
Human Service Worker
TBS Provider
This credentialing approval process includes a verification of the individual’s professional
license and a background check. The background check is performed on RCS employees before
hire. The background check consists of a query of all of the following sources:




Medi-Cal Suspended and Ineligible Provider List (this is also checked on a monthly
basis by the QA/QI Department)
Office of Inspector General List of Excluded Individuals/Entities (LEIE)
Verifications of credentials through College Transcripts, Licensing Boards (all current
and previous licenses will be reviewed), etc.
Department of Justice (DOJ), FBI and Child Abuse Index
The credentialing process is performed in accordance with RCS’ Policy and Procedure: License
and Background Verification.
RECORDS REVIEWS
Quality Assurance staff will conduct records review of contracted individual and organizational
providers to review compliance with documentation and billing standards. These Record
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Reviews will be performed in accordance with RCS Policy and Procedure: Provider Medi-Cal
Records Review.
REPORTING
On a quarterly basis, the QA Coordinator will brief the CO or designee, on the results of these
reviews. In the event that a provider is not compliant with either documentation or billing
standards, a written report will be prepared and submitted to the Compliance Committee
summarizing the results of the review and any action taken.
BILLING COMMITTEE SCOPE AND RESPONSIBILITY
The Billing Committee is responsible for reviewing and approving any changes that may affect
the billing/claiming of mental health services. This includes, but is not limited to, reviewing and
approving:
•
•
•
•
•
New Billing Codes.
Changes to the Information System that is maintained by BHS, such as a change in
licensure, etc.
New cost centers and, if applicable, any service codes allowed to be used by new cost
centers.
Modifications to the Information System that may affect the billing system, including,
but not limited to: coding, service charges, billing, claim production or the client ledger.
Appeals and failure to pay.
The Billing Committee includes: Financial Director, Billing staff, Operations Manager and a
Clinical Person, when needed.
BILLING DEPARTMENT
The Billing Department is responsible for the accurate and timely:
•
•
•
•
•
Billing and/or rebilling of all billable mental health services to the appropriate payer(s).
Posting of payments
Adjustments and deletions, as approved by the Clinical Director.
Sending Appeals as needed and reporting non-payments
Processing of refunds to the appropriate payer(s).
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TO ACCOMPLISH THESE FUNCTIONS, THE BILLING DEPARTMENT WILL:
 Follow recognized guidelines for accurate coding approved by CMS or other applicable
regulatory body.
 Use current billing codes, including, as appropriate, those established or approved by
CMS, the DHCS, and all other applicable government entities or third-party payers.
 Provide Medi-Cal, and other third-party payers with appropriate information to pay
claims.
 Examine payment and denial documents received on accounts for accuracy of
information provided. Report any discrepancies to the Financial Director.
 Maintain current reference tools necessary to assist Billing staff in performing accurate
coding and billing functions. Examples of reference tools include: ICD-9/10-CM, CPT/
CPT Assistant, and HCPCS reference manuals.
 Provide annual training or more often as needed. Training will include, but will not be
limited to:
o Changes in billing/coding regulations
o EOB claim denials
o Other adjustments or deletions to billed/claimed services
o Any other changes that might affect billing/coding
 Document all training/education provided to staff (documentation will include subject
matter of the training as well as those in attendance). Applicable P&Ps will also be
updated as needed.
 Report billing errors that are discovered, through any means, to the appropriate
Supervisor and the CO. An action plan will be developed and implemented to correct
and prevent future errors.
CLAIM DEVELOPMENT AND SUBMISSION (ALL PAYERS)
All RCS staff will only bill for the correct patient, service, and time, using the correct coding based on
usual and legally accepted billing standards. The following general policies reinforce current federal and
state statutes and regulations regarding the proper development and submission of claims to third-party
payers:
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•
No claim will be submitted to a third-party payer or patient for items or services not actually
provided. Any questionable charge will be investigated by the Compliance Officer, Clinical
Director and Operations Manager.
•
All Services claimed must be supported by proper documentation in the clinical record.
MEDI-CAL
BILLING, PAYMENTS, ADJUSTMENTS, REFUNDS/OVERPAYMENTS
Medi-Cal services are processed and claimed according to the timeline in the Contract between
each County and RCS. Normally, billing is to take place prior to the 10th day of the month
following services. Error reports generated from the Information System are reviewed by the
Billing Department, Operations Manager and the Clinical Director who then makes corrections
or adjustments as needed before the claim is submitted.
When Electronic Billing is Available: After claims are processed, (Electronic Claims Records)
ECRs are provided to allow one opportunity to review or correct claims before they are denied.
ECRs are processed by BO billing staff who may work with RCS programs to correct claim errors.
Any claim on the ECR not responded to within 30 days will be denied with no opportunity for
appeal.
The Financial Department also reviews the Aged Trial Balance report each month for any
outstanding Medi-Cal balances that are older than 45 days for possible adjustments or rebilling
within the allowed billing limits.
REVIEW AND REPORTING
The Billing Department is required to perform utilization and eligibility reviews. Deletions or
adjustments discovered through these reviews or any other means will be summarized and
reported to the Compliance Officer and Clinical Director on a monthly basis, by the 12 th of the
month following services.
INSURANCE AND PRIVATE PAY/UMDAP
INSURANCE BILLING
Insurance Billing is done on a monthly basis. All insurance information should be obtained from
clients on the first visit by the provider. Payments and denials are received via U.S. mail and
distributed to staff for posting. Payments will be posted within five (5) days of receipt. Within
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one (1) week, denials will be posted or additional information provided to the insurance
company.
PRIVATE PAY/ UMDAP (UNIVERAL METHOD OF DETERMINING ABILITY TO PAY) BILLING
Private Pay statements are printed and mailed by the 5th of the month following services.
Claims are to be reviewed by billing staff for accuracy prior to mailing. If a balance is transferred
to private pay during the month a demand statement will be printed and mailed to the client
immediately. Billing staff will post payments within two (2) days of receipt.
ADJUSTMENTS
Adjustments must be approved and signed by the Clinical Director. Adjustments include, but
are not limited to: Administrative write-offs/fee waiver, Out of billing limitations, other
coverage, UMDAP revisions and UR Adjustments.
REFUNDS/OVERPAYMENTS
Refunds may result due to a UR, audit, deletion of service, or overpayment. Refunds are made
to the County Auditor-Controller’s office as they occur or the County may choose to deduct the
amount from the next check. This should be noted in writing and on the Electronic Account.
COST REPORTING
RCS is a legal entity that is required to submit an annual Cost Report which identifies expenses,
funding sources, and other statistics all related to mental health activity. The purpose of the
cost report is to:



Compute the cost per unit
Determine the estimated net Medi-Cal entitlement from the Federal Financial
Participation
Establish the basis for the year-end cost settlement
The method of Cost Reporting is outlined in the Cost and Financial Reporting System (CFRS)
Manual. Cost Reporting is identifying allowable costs that are properly classified and supported
with appropriate documentation for audit purposes. Cost reporting also requires the proper use
of acceptable cost allocation methods.
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REVIEW AND REPORTING
On an annual basis Accounting will provide to the Compliance Committee, a summary report on
the preliminary cost settlement for the current fiscal year.
ORGANIZATIONAL COMPLIANCE
The Compliance Committee will review the results of internal audits as well as review other
material on compliance with federal and state standards. As issues arise, the Compliance
Committee will determine how best to address the specific issue and the most effective means
to ensure that these are effectively addressed.
MONITORING AND AUDITING PROCEDURES
CORRECTIVE ACTION
Upon report or reasonable indication of suspected noncompliance, the CO or designee will
promptly investigate the conduct in question to determine whether a material violation of
applicable law, regulation, rule, guideline, program instruction or the requirements of the
Compliance Program have occurred.
Detected but uncorrected misconduct can seriously endanger the mission, reputation and legal
status of RCS. These compliance standards will assure that detected misconduct is promptly
investigated and corrective action is carried out promptly and responsibly.
INVESTIGATION AND FOLLOW-UP
The CO or designee is responsible for promptly investigating every report or discovery of
suspected non-compliance. Accordingly, appropriate corrective action, if needed, must be
carried out promptly, fairly and responsibly. Investigations will be performed as outlined in the
Compliance Program Policy and Procedure: Process for Investigating Non-Compliance (provided
at the end of this section).
Within a reasonable amount of time after the completion of an investigation, a follow-up
audit/review will be performed. The CO or designee will review the circumstances that formed
the basis of the investigation to determine whether similar problems have emerged or whether
modifications of the Compliance Program are necessary to prevent and detect other violations.
If needed, further action will be taken as appropriate.
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OVERPAYMENTS
For each overpayment discovered or identified through any means, the Billing Department will:
•
•
•
Notify the payer and repay any amount owed within 30 days.
Review the circumstances which created the overpayment and correct the problem (as
appropriate) within 60 days.
Perform a follow-up to ensure that the problem is not occurring and that other similar
problems have not emerged.
Overpayments discovered through internal audit procedures require documentation that a
request has been made to the Billing Department to reverse the charges. Failure to report or
repay an overpayment within a reasonable amount of time could be interpreted as an
intentional attempt to conceal the overpayment from the government, so overpayments must
be processed promptly.
VOLUNTARY DISCLOSURE
It is a felony when a person has “knowledge of the occurrence of any event affecting (a) his
initial or continued right to any such benefit or payment, or (b) the initial or continued right to
any such benefit of payment of any other individual on whose benefit he has applied for or is
receiving such benefit or payment, conceals or fails to disclose such event” (42 U.S.C. § 1320a7b (a)(3).
If, after thorough investigation of a reported violation or suspected non-compliance, the CO or
the Compliance Committee with consultation from Counsel determines that the misconduct
may violate criminal, civil, or administrative law, they should act promptly to disclose
misconduct to the appropriate authorities. When appropriate, the CO or designee will report to
the appropriate governmental authority the existence of misconduct no more than sixty (60)
days after determining that there is credible evidence of a violation.
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EXHIBIT: NON-COMPLIANCE INVESTIGATION
RCS Compliance Program Policy and Procedure
Subject: Process for Investigating Non-Compliance
Effective Date: January 1, 2013
POLICY: The Compliance Officer or designee is responsible for promptly investigating every
report or discovery of suspected non-compliance. When the investigation is completed, a
detailed report will be submitted to the Compliance Committee.
PURPOSE: To establish a process that will assure that reported or detected misconduct is
promptly investigated and appropriate corrective action is carried out promptly, fairly, and
responsibly. Detected but uncorrected misconduct can endanger the mission, reputation and
legal status of RCS.
PROCEDURE:
1. Alleged violations may be detected through one of several means:
• Hotline
• E-mail
• Postal Mail
• Employee or Contractor reporting
• Monitoring of routine reports or processes
• Ad hoc audits and self-assessments
2. When an alleged violation has been detected, the Compliance Officer (CO) or designee
will initiate an investigation within ten (10) working days of the detection.
3. The alleged violation, the investigation and corrective action, if any, will be documented
on the Compliance Investigation Worksheet (see attachment). Every worksheet/report
will be logged in the Compliance Investigation Log that is maintained by the CO or
designee.
4. Depending on the nature of the alleged violation, the investigation may include:
•
•
•
Interviews of employees or other person(s) as needed. RCS staff may be subject to
disciplinary measures for failure to cooperate with any investigation.
Review of relevant records or documents.
Research of regulations, contracts or other information as appropriate
25
•
Access to other relevant documentation or assistance of any person(s), inside or
outside of the organization, as deemed necessary to complete the investigation.
5. During an investigation, if the CO or designee believes the integrity of the investigation
may be at stake because of the presence of employees under investigation, those
individuals may be removed from their current work activity until the investigation is
completed (unless an internal or government-led undercover operations known to the
organization is in effect.)
6. Records of the investigation, including the completed Compliance Investigation
Worksheet, will contain documentation of the alleged violation, a description of the
investigative process, copies of interview notes and key documents, a log of the
witnesses interviewed and all documents reviewed, and the results of the investigation
(any corrective action implemented or any disciplinary action taken.)
7. The CO or designee will take or direct appropriate corrective action:
1. If disciplinary action is needed, the CO or designee, Clinical Director and Human
Resources will determine the appropriate measure(s) to be taken.
2. If the investigation determines that an overpayment was made to RCS, any excess
reimbursement will be immediately refunded to the appropriate payer or settled
through the Medi-Cal cost report at the end of the fiscal year. RCS will make full
disclosure of suspected overpayments, document efforts to remedy the situation,
refund the overpayment, and develop or revise procedures to ensure that the error
does not occur in the future. Examples of overpayments to RCS include:
•
•
•
•
•
paid twice for the same service, either by the same payer or a combination of
payers;
paid for services that were planned but not actually provided;
paid for services that were not a covered benefit;
overpayment resulting from an error, either by RCS or the payer; or
paid for services that are lockouts or were included in the per diem rate.
3. If it is determined that the deviation was caused by fraud, improper procedures,
misunderstanding of rules, or system problems, the CO or designee and the Compliance
Committee will direct or assist RCS to take prompt steps to correct the problem(s).
4. The CO or designee will submit a written and verbal report of any investigation to the
Compliance Committee.
5. Within a reasonable amount of time after the completion of an investigation, a followup audit will be performed. The CO or designee will review the circumstances that
26
formed the basis of the investigation to determine whether similar problems have
emerged or whether modifications of the Compliance Program are necessary to prevent
and detect other violations. If needed, further action will be taken as appropriate.
6. 10. Documents or other evidence relevant to the investigation will be maintained for at
least six (6) years from the date the information was created or used, whichever is later.
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MAINTENANCE AND RETENTION OF COMPLIANCE RECORDS
The Compliance Officer will retain records necessary to protect the integrity of the compliance
process, confirm the effectiveness of the Compliance Program, and to provide evidence of
RCS’s compliance efforts.
TYPES OF RECORDS TO BE RETAINED
The CO will retain all records that substantially affect the obligations of the Compliance
Program. Examples of records to be retained include, but are not limited to, the following:
•
•
•
•
•
•
•
•
•
Documentation of compliance training
Compliance policies and procedures
Meeting records (agenda, minutes, etc.)
Records from reports of violations, including hotline calls, including the nature and
results of any investigation that was conducted
Documentation of corrective action, including disciplinary action taken and policy
improvements introduced in response to an investigation
Modifications to the Compliance Program
Documentation of any self-disclosures
Written notifications to contractors
Results of RCS’s auditing and monitoring efforts
MAINTENANCE AND RETENTION
Records will be maintained and/or destroyed in accordance with the Compliance Program’s
P&P: Maintenance and Retention of Compliance Records (provided at the end of this section).
Specific documents or information which include: claims processing data, BO records, audit
documentation, and Compliance Committee minutes will be maintained for at least six (6) years
from the date these documents were created.
Documentation related to the investigation of a particular violation will be reviewed on a biannual basis to determine when these records will be kept or should be destroyed to ensure
confidentiality of all involved particularly those who reported the violation.
The CO or designee will purge records on a bi-annual basis to avoid any appearance that the CO
deliberately destroyed records in anticipation of an outside review or discovery. Through
annual reviews, the CO will ensure that record maintenance procedures are being followed.
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Before the record of any investigation is destroyed, there should be a written record of each
investigation including the dates and results of the investigation.
In the event that the CO receives notice regarding the initiation of an external investigation,
immediate steps must be taken to prevent the destruction of any relevant documents pending
further notice that the investigation or litigation has been concluded.
EXHIBIT: MAINTENANCE AND RETENTION OF COMPLIANCE RECORDS
POLICY/PROCEDURE
RCS Compliance Program Policy and Procedure
Subject: Maintenance and Retention of Compliance Records
Effective Date: January 1, 2013
POLICY: Redwood Children’s Services (RCS) will document its compliance efforts to:
•
•
Provide evidence of RCS’s efforts to comply with applicable laws, regulations, rules,
guidelines, and Compliance Program or RCS requirements;
Protect the integrity of the compliance process; confirm the effectiveness of the
Compliance Program.
The Compliance Officer (CO) or designee will maintain and/or dispose of compliance related
documents and records in accordance with applicable laws, statutes, regulations, or existing
RCS Records Retention Schedules (RRS) or Policies and Procedures. Additional records and
documents may be maintained or disposed of as necessary to support the Compliance Program.
PURPOSE: The Compliance Office receives and generates a substantial volume of records,
documents and other information, in both electronic and hardcopy format. Certain records and
documents must be maintained for given periods of time specified by applicable laws,
regulations or by contractual obligations. Other records should either be retained or destroyed
according to a standard policy.
PROCEDURE:
1. The Compliance Office will retain records that may substantively affect the obligations of
RCS. Records maintained in the Compliance Office will include, but not be limited to, the
following:
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









Documentation of compliance training
Reports and investigations of violations, including Hotline reports
Compliance policies and procedures, memoranda and other communications
Meeting records (agendas, minutes, etc.)
Reports to Compliance Committee, Governing Board, etc.
Documentation of corrective actions and their resolution, including any disciplinary
actions taken.
Results of auditing and monitoring activities
Modifications to the Compliance Program
Written notifications to contractors
Documentation of any self-disclosures
2. Records will be secured to protect the privacy and confidentiality of employees, clients,
contractors, as well as RCS proprietary information. Hardcopy records will be maintained in
a secure area and within locked cabinets; electronic records will be password protected.
Access to compliance records will be controlled by the CO.
3. All records with information received by or generated by the CO or the hotline will be
maintained, at a minimum, until the related matter is resolved.
4. For records related to any investigation:


These will be destroyed no earlier than three months after satisfactory resolution of all
issues pertaining to the specific incident has occurred and the CO has performed a
follow-up review to determine if similar problems have emerged.
Otherwise, they shall be destroyed on a bi-annual basis unless applicable laws,
regulation or RCS policies require longer retention.
5. All miscellaneous records or compliance information contained in correspondence,
calendars, notepads, personal files, telephone message pads, and similar materials will be
part of the bi-annual review for determination of record maintenance or destruction.
6. All other records will be maintained for the minimum period required by applicable laws,
regulations or in accordance with the RRS and applicable policies and procedures.
7. A log system will be maintained to document the destruction of records. Before any record
of any investigation is destroyed, there should be a written summary of the investigation,
including the dates and results of the investigation.
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8. The CO, through periodic audits, will ensure that file retention policies and procedures are
being followed.
•
•
Files will be periodically reviewed to determine whether it is appropriate to purge at
that time, or defer to a later date.
There should be a written record of each review indicating the date it was made and
results of the review, prior to any file being destroyed.
9. Upon receipt of notice regarding the initiation of an investigation or the service of legal
process, the CO will take immediate steps to cease the destruction of any relevant documents
pending further notice that the investigation or litigation has concluded.
Compliance org chart will be included as well
Attachment MHP Code of Conduct and MHP Code of Ethics – as though need signed as well
Do we also want to include the sheet from Mendo County Compliance Plan - “Medical
Necessity for Specialty Mental Health Services that are the ……”
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RCS Compliance Program
EMPLOYEE ACKNOWLEDGEMENT AND AGREEMENT
I hereby acknowledge that I have received, read and understand the Redwood Children’s
Services Code of Ethics and the Compliance Program Code of Conduct. I hereby acknowledge
that I have received training and information on the Compliance Program and understand the
contents thereof. I agree to abide by the Code of Ethics, the Code of Conduct, and all
Compliance Program requirements as they apply to my job responsibilities.
I understand and accept my responsibilities under this agreement. I further understand that any
violation of the Code of Ethics, the Code of Conduct or the Compliance Program is a violation of
RCS policy can result in disciplinary action, up to and including termination of my employment.
I further understand that RCS will report me to the appropriate Federal or State agency. This
was on the contractor agreement
Name (print): _________________________________
Job Title: _________________________________
Signature: _________________________________
Date: ____/____/_____
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RCS Compliance Program
CONTRACTOR ACKNOWLEDGEMENT AND AGREEMENT
I hereby acknowledge that I have received, read and understand the Contractor Code of
Conduct and Ethics. I hereby acknowledge that I have received training and information on the
RCS Compliance Program and understand the contents thereof. I further agree to abide by the
Contractor Code of Conduct and Ethics, and all Compliance Program requirements as they apply
to my responsibilities as a mental health contractor for RCS.
I understand and accept my responsibilities under this agreement. I further understand that
any violation of the Contractor Code of Conduct and Ethics or the Compliance Program is a
violation of RCS policy and may also be a violation of applicable laws, regulations, rules or
guidelines.
I further understand that violation of the Contractor Code of Conduct and Ethics or the
Compliance Program may result in termination of my agreement with RCS.
I further understand that RCS will report me to the appropriate Federal or State agency.
Contractor Name (print):_________________________________________
Signature:_________________________________ Date: ____/____/_____
For Group or Organizational Providers:
Group/Org.Name (print):_____________________________________________
Employee Name: ________________________________
Title: _________________________________
Signature: _________________________________ Date: ____/____/_____
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