AMADOR COUNTY MENTAL HEALTH
POLICY AND PROCEDURE
Compliance Program
POLICY:
It is the policy of Amador County Mental Health (ACMH) to comply with federal and
state laws and regulations, and to promote and enforce adherence to this policy. One of
the means ACMH will use to promote and gain adherence to this policy is the
development and maintenance of a Compliance Program.
This policy establishes a Compliance Program, standards, and policies and procedures,
which promote adherence to state and federal laws and regulations.
PURPOSE:
The Compliance Program is designed, and will be implemented and enforced in order to
promote ACMH’s understanding of and adherence to state and federal statutes and
regulations that are applicable to ACMH business, as well as to detect, respond to, and
prevent violations of those requirements. The program’s design incorporates the seven
elements that represent industry standard for scope of a compliance program:
1. Standards and procedures
2. High level of oversight and delegation of authority
3. Employee training
4. Communication
5. Auditing & monitoring
6. Enforcement & discipline
7. Corrective actions & prevention
The Compliance Program will address the following goals and objectives:
1. Maintenance of a working environment that promotes ethical values, exemplary
behavior and compliance with the letter and spirit of all applicable laws
2. Development of a Program that encourages employees, affiliated professionals and
contractors to demonstrate the highest ethical standards in performing their daily
tasks
3. Establishment of a Code of Conduct.
4. Development of a disclosure system (Hotline) that requires ACMH to respond to
reports by employees or others of a suspected violation of law or the principals of the
Program.
5. Identification of those situations in which the laws, rules and standards of state and/or
federal programs or other applicable laws may have not been followed, and
facilitation of the correction of any such practices.
6. Implementation of procedures to assure future compliance with all laws and
regulations of the Medicare and Medicaid programs and all other applicable laws.
7. Training and communication that assures employees, affiliated professionals and
contractors understand and comply with all state and federal laws and regulations,
and will endeavor to reduce the likelihood that violations will occur through
appropriate screening of potential employees and agents of ACMH.
8. Assurance that documents are retained and kept secure, as required by state and
federal regulation, for the appropriate length of time.
9. Establishment of disciplinary policies that are prompt, effective and consistent, and
will discipline employees based on the severity of the violation, and not on the basis
of their position or tenure with ACMH.
10. Assurance that government inspections proceed in a smooth and professional manner,
and that all requests and concerns are addressed promptly and appropriately.
PROCEDURE:
1. Compliance Program Authority
a) Executive Oversight
The Compliance Oversight Committee, with general oversight responsibility for
the ACMH, will provide strategic direction to the Compliance Program, as well as
be responsible for approving the Compliance Program. The Compliance Officer
will communicate status and progress to the Compliance Oversight Committee
during its regular meetings.
b) Compliance Officer
The ACMH Compliance Officer is delegated authority for development and dayto-day operation of the Compliance Program. The Compliance Officer shall
report directly to the MHP Director and will have a working relationship with
County Counsel. The Compliance Officer will update the Oversight Committee
on status and progress of the Compliance Program during its regular meetings.
c) Compliance Committee
The Compliance Committee will assist the Compliance Officer in the
development, implementation and ongoing refinement of the Compliance
Program.
d) County Counsel
The Compliance Officer will collaborate with the County Counsel, in the
development and implementation of the Compliance Program. The County
Counsel shall be responsible for:
i)
ii)
iii)
Providing legal counsel and support to the Compliance Officer
Actively participating in the training and educational sessions regarding
legal elements of the Compliance Program; and,
As requested, investigating complaints and issues that are raised during
the monitoring of compliance activities.
e) Organizational Chart
Agency
Oversight Committee
MHP Director
Compliance Officer
Compliance Committee
Compliance
Subcommittees/
Work Groups
Ad Hoc Corrective
Action Teams
2. Elements of the Compliance Program
a) Compliance Officer and Compliance Committee
The Compliance Officer, with the assistance and support of the Compliance
Committee, will be responsible for the development, operation and general
management of the Compliance Program.
b) Code of Conduct
ACMH will establish a Code of Conduct, which will govern the proper conduct of
ACMH employees and will require all employees, affiliated professionals, and
contractors to comply with the ethical and legal standards outlined in the
Compliance Program.
c) Compliance Standards
The Compliance Program will establish standards, including policies and
procedures, to facilitate adherence to applicable laws and regulations.
i)
ii)
iii)
The Compliance Officer, in collaboration with the Compliance
Committee, will be responsible to identify those areas where there is a
substantial risk for non-compliant conduct.
The Compliance Officer will ensure the development of compliance
standards by responsible functional areas.
The compliance with these standards will be a component of position
descriptions and performance evaluations.
d) Effective Reporting and Investigative Processes
A responsibility of the Compliance Officer will be implementation of processes
for the reporting and investigation of potentially non-compliant practices and
conduct.
i)
ii)
iii)
Each employee will be responsible to notify his or her supervisor in a
timely manner, of any violations or suspected violations of the standards
for ethics and legal conduct. As an alternative, an employee may follow
the reporting procedure under section d) ii) below. Employees will be
informed that in some instances, the mere failure to report a suspected
violation may itself be basis for disciplinary action against an employee.
A written procedure will be developed and a telephone line (Hotline)
made available to all employees who wish to report actual or perceived
violations of law or applicable ACMH policies and procedures.
Employees will not be subject to reprisal for reporting, in good faith,
action that they feel violates the law or established standards. Any
employee engaging in any action of reprisal for any good faith reporting
shall be subject to discipline and/or discharge.
e) Effective Communications and Training Programs to Alert Employees of Their
Responsibilities
The Compliance Officer has the general responsibility to oversee the development
and implementation of employee communications and training programs to
achieve compliance with Compliance Program. The communication and training
programs shall include the following areas:
i)
ii)
iii)
iv)
Identification of resources to provide effective compliance training and
educational programs;
New employee orientation (to include coverage of ethics and legal
compliance issues);
Department-specific training and educational programs in identified highrisk areas; and,
Annual review of ethics and legal compliance issues in departs at
substantial.
Employees shall be informed that strict compliance with both the ACMH Code of
Conduct and the requirements of the Compliance Program is a condition of
employment, and that:
v)
vi)
The promotion of and adherence to compliance with the Code of Conduct
and the requirements of the Compliance Program are elements of
performance evaluations; and,
ACMH has a policy concerning the non-employment or retention of
employees who are sanctioned for a violation of either the Code of
Conduct, or the requirements of the Compliance Program.
f) Monitoring Compliance with Compliance Program Standards and Policies
i)
ii)
The Compliance Program will include monitoring and auditing systems
designed to detect ethical or legal violations and a reporting system
whereby employees may report suspected violations of standards for
ethical and legal conduct.
The Compliance Officer and Compliance Committee shall:
(a) Identify audits required to verify adherence to, and awareness of,
ethics and compliance policies throughout ACMH as audits are carried
out;
(b) Review the results of periodic surveys to test awareness of ACMH’s
ethics and legal compliance policies and procedures;
(c) Conduct special audits as necessary to verify adherence to ACMH’s
ethics and compliance policies and procedures. These audits may
include 1) on-site visits, 2) interviews with personnel, 3) reviews of
written materials and documentation, and 4) trend analysis studies.
g) Evaluation of the Program
The Compliance Committee must monitor the Program on an on-going basis.
Through monitoring, the Compliance Officer and Compliance Committee will
assure that the Program is evolving to meet the needs of ACMH. Monitoring
should include:
i)
ii)
iii)
Obtaining employee feedback on how the Compliance Program can be
more effective;
Identify any areas where compliance efforts break down or pursuit of the
seven elements is insufficient or inadequate; and,
Based on outcomes of i) and ii), modify the Compliance Program to
incorporate changes in laws or regulations or ACMH’s businesses;
On at least an annual basis, the Compliance Committee will conduct a formal
evaluation that demonstrates to the Oversight Committee that:
i)
ii)
iii)
iv)
v)
vi)
vii)
viii)
The Code of Conduct, policy statements and other written compliance
communications were distributed to all targeted employees;
All vendors or independent contractors have received compliance
communications pertinent to them;
All scheduled training has occurred;
Auditing and monitoring has taken place for all targeted risk areas;
Violations or other problems identified in the audit process have been
addressed appropriately;
Employees are being encouraged to report violations without fear of
retaliation;
The disciplinary process has been functioning as intended; and,
The Compliance Program has been reviewed for possible improvements,
both when violations or near misses have occurred and on a routine basis
based on changing government standards or industry practices.
ADOPTED 3-2-04 FW ________ SP _________