Corporate Compliance Plan

Spaulding Support Services

Corporate Compliance Plan

Approved by Board of Directors 3-14-12

Updated and approved 10-8-13

I. Organization Overview

Spaulding Support Services has many years of experience assisting individualswith developmental disabilities living in OnondagaCounty. Our comprehensive programs fall under four main categories of service:

Habilitation Services

Service Coordination Services

Respite Services

Support Services

II. Mission Statement

Our agency is committed to supporting people with developmental disabilities and their families by providing services related to each individual’s unique and evolving life circumstances.

III. Philosophy Statement

We recognize that all people are inherently valuable and are entitled to supports and services that promote their well-being.

IV. Values Statement

We strive to provide supports and services that are based on these values:

DignityTo interact with the people we support respectfully and to honortheir choices, values and privacy.

CommunityTo support people’s involvement, presence and acceptance in the community.

RelationshipsTo support the people we serve with maintaining and developing their relationships.

CollaborationTo work with individuals and advocates in fostering a collaborative approach to supports and services.

EmpowermentTo support the people we serve in making informed decisions andadvocating for themselves.

IntegrityTo promote ethical standards and conduct by the agency and our employees.

V. Corporate Compliance Overview

Spaulding Support Services has established a CorporateCompliance Plan tailored to the agency’s principle lines of business. We are dedicated tomanaging and operating its programs in keeping with the highest of business, ethical and moral principles. Each employee, member of the Board of Directors, Standing Committee Members, consultant, andvolunteer contributes to achieving these principals by conducting business activities for theagency with integrity and high ethical standards. Supervisors and managers also contributeto achieving these principles by exercising good leadership and being a good example increating and promoting a workplace environment in which compliance and ethical businessconduct is expected. Spaulding Support Services has adopted the followingdefinition of Corporate Compliance:

“A Corporate Compliance plan is a system which isdesigned to detect and prevent violations of law, as well asthe likelihood of unethical activity by agency employees,volunteers, contractors, officers and directors.”

Spaulding Support Services will transact its business incompliance with the laws of the jurisdiction in which it does business, including local, stateand federal jurisdictions. As a not-for-profit agency, Spaulding Support Services will conduct business in compliance with all IRSregulations governing tax-exempt organizations and will refrain from any private interests, andbenefit issues. Instances where questions arise concerning interpretation or applications oflaws and regulations should be referred to the Executive Director or Corporate ComplianceOfficer. Applicable laws include, but are not limited to anti-kickback statutes, labor laws,tax code and regulations, antitrust laws, copyright laws, false claims laws, rights ofindividuals receiving services and environmental laws.As used in this Corporate Compliance Plan, the following definitions apply:

A.Spaulding Support ServicesRepresentatives:employees, agents, board members, committee members, volunteers, contractors, andothers working for or on behalf of Spaulding Support Services.

B.Agency:Spaulding P.R.A.Y. Residence Corporation d/b/a Spaulding Support Services.

VI. Code of Business Conduct & Ethics

A. Overview

The Code of Ethics provides Spaulding Support Services employees, agents, members of the Board ofDirectors, Standing Committee Members, consultants, and volunteers with information necessary to adhere tothe high ethical principles the agency lives by. Spaulding Support Services is accountable for compliance not only with theCode of Business Conduct & Ethics, but also with all laws and regulationsapplicable to our activities, and other policies and procedures prepared by ouragency and oversight bodies.

B. Honesty and Integrity

Honesty and Integrity are what this Code of Ethics is allabout; they define our relationships with people receiving services, outsideagencies, business partners, and each other. By maintaining the highest levelof corporate integrity through open, honest and fair dealings, we earn trust forour services and ourselves from everyone with whom we come in contact.

C. Standards of Conduct

Spaulding Support Services representativesare expected to comply with the following standards:

1.Business Principles

a. Maintain the Confidentiality of Agency Records.

The agency is responsible and accountable for the integrity andprotection of its business information. All agency records anddocuments (in any form or media) are the sole property of theagency and thereby considered confidential by their nature, exceptas provided by law or regulation. All agency information (i.e.policies, procedures, strategic or business plans, administrativememos, financial documents, etc.), whether in electronic orwritten format, is confidential and may not be released or sharedwith others outside the agency without proper prior authorization.No Spaulding Support Services representatives shall disclose to othersany confidential information obtained during the course ofemployment, work (paid or unpaid) or receipt of reports, whichhave not been published or disclosed, to the public. Documentsand electronic media containing sensitive information on peoplereceiving services, staff, consultants, volunteers, board membersand other representatives of the agency must be carefully handledand properly secured. Once an agency representative terminatesthe relationship with the agency, they have no right to access oruse agency information.If any Spaulding Support Services representative observes or becomesaware of a breach of this policy including misuse of confidentialinformation, or an unauthorized or unrecognized individual usinga computer terminal in an area familiar to you, immediatelycontact a supervisor.

b. Protect Agency Assets

It is the obligation of all agency representatives to protect theassets of the agency. Agency property, such as office supplies,office equipment, vehicles, and property may not be used forpersonal reasons.Any misuse or misappropriations of agency funds, information,equipment, facilities or other assets may be considered criminalbehavior and can bring severe employment and legalconsequences. Agency funds include, but are not limited to bankaccounts, credit and debit cards, and business accounts.

c. Maintain the Corporate Image

The agency’s reputation and identity are among its most valuableassets. All agency representatives are expected to conductthemselves in a manner that reflects positively on the agency’simage and identity, both internal and external. No one should actin a way that adversely affects the reputation or image of theagency with employees, volunteers, people receiving services orwith the community at large.Each agency representative should endeavor to deal fairly withthe people receiving services, consultants, suppliers, competitorsand other employees. No one should take advantage of anyoneelse through manipulation, concealment, abuse of privilegedinformation, misrepresentation of material facts, or other unfairdealingpractice.While the agency cannot control what its representatives doduring non-working hours, it is important to understand thatinformation posted online is public and comments made aboutthe agency or agency representatives that are defamatory orviolate agency policy (i.e. confidentially, conflict of interest,harassment) can result in disciplinary action, no matter whetherthe employee wrote it from work or outside of work.

d. Have Job Accountability

Each agency representative is responsible for knowing andexecuting the responsibilities of his or her job. This means theindividual is held accountable for the quality of the work he orshe produces. In addition, management is responsible forensuring that they have provided their employees with thenecessary information to do their jobs.

e. Avoid Conflicts of Interests

Each agency representative has a primary business responsibilityto the agency and is expected to avoid any activity that mayinterfere or have the appearance of interfering with theirperformance. A conflict of interest exists if an agencyrepresentative’s outside business or other interests may affectadversely, or have the potential to affect adversely, his or hermotivation, objectivity, loyalty or performance. In addition, apotential conflict of interest occurs when an individual’s personalor private interests might lead an independent observer toreasonably question whether the individual’s professional actionsor decisions are influenced by significant personal interest,financial or otherwise.Agency Representatives shall not participate in the selection,award or administration of a contract supported by Federal, Stateor other government funds if a real or apparent conflict of interestwould be involved. Such a conflict would arise when theemployee, officer, or agent, any member of his or her immediatefamily, his or her partner, or when the agency employs or is aboutto employ any of the parties indicated herein, has a financial orother interest in the firm selected for an award.Some additional situations in which agency representatives mightencounter that would be considered a conflict of interests are:

• Having a relationship with a person receivingservices outside of the workplace and/or employment by aperson receiving services and/or the family member of aperson receiving services;
• Directly supervising a family member as acontractor, supplier or employee of the agency;
• Romantic relationships between a supervisor and asubordinate. Supervisor is defined as “a person who hasauthority, direct or indirect, over another by virtue of theirjob classification. Subordinate is defined as “a personwho is answerable to another person based on their jobclassification.” While the supervisor is ultimately heldresponsible for ensuring that this type of relationship doesnot occur, it does not absolve the subordinate of anywrongdoing.
• Using agency assets, including agency time, name,information, equipment or facilities, for personal use;
• Misuse of information obtained by an agencyrepresentative during the course of his or heremployment;
• Soliciting personal cash or non-cash gifts of anyamount or value from any person or business that has arelationship with the Agency;
• Accepting personal cash gifts of any amount fromany person or business that has a relationship with theAgency;
• Financial transactions between people receivingservices and/or their family members/responsibleparties;
• Outside employment that interferes with theemployees job responsibilities and/or is in conflict withagency interests.
• Use of information created by or for the agency forpersonal gain or use by others outside the agency withoutprior permission.

All agency representatives including Board Members, Employees, Standing Committee Members, and Volunteers, as identified in the agency“Conflict of Interest Policy & Procedure” are required tocomplete the Agency “Conflict of InterestDisclosure Form” upon the beginningof the relationship with the agency and when a new conflict arises or is eliminatedthereafter.The above situations identified as “conflicts of interests” are notall inclusive. Agency representatives are expected to exercisegood judgment and be mindful of how their personalrelationships and outside activities may be affecting theworkplace. Agency representatives may also find themselves in asituation where they do not feel like they can be objective in theirdecision making due to their personal relationship or beliefs.Should an agency representative feel that they are not able to beobjective in making a business related decision they shouldvoluntarily abstain/refrain from participating in the decisionmaking process. Furthermore, if any matter exists that might be aconflict of interest or creates the appearance of a conflict ofinterest, agency representatives are required to consult theirsupervisor, Compliance Officer or Human ResourcesRepresentative to assess whether a problem exists.

f. Display Caution when Offered Gratuities

In the course of performing their jobs, agency representativesmay be offered gratuities, which usually are intended as gesturesof goodwill or appreciation. These include gifts, entertainment,gift cards, meals and beverages, tickets to sporting or culturalevents, services or other similar favors. Agency representativesmay not accept, individually or as part of a group, anything thatcould reasonably be thought to have more than a nominalintrinsic value (nominal intrinsic value: e.g. promotional oradvertising pens, pencils, notepads, calendars, greeting cards,trinkets, baked goods or other similar gifts of limited value).Gifts, gratuities, or attendance at events exceeding nominalintrinsic, typically greater than $50.00, should be refused orreturned unless the Corporate Compliance Officer approves ofacceptance as part of a business need or special occasion i.e.holiday gift basket during holidays to be shared amongstrepresentatives.Even nominal gifts can be inappropriate if used in a way whichcreates the impression that a certain vendor or person is receivingor attempting to obtain preferential treatment. Therefore theacceptance of any gift, regardless of its value, must be done sowith caution and when in doubt needs to be reported to a supervisorin order to determine whether the gift may or may not beaccepted to avoid a conflict of interest.Acceptance or participation in a business meal situation isappropriate when based on a business need and such diningoccurs in conjunction with business discussions.These guidelines cannot cover every situation that may arise;employees should discuss with their supervisor or ComplianceOfficer any situation involving gratuities they are uncertainabout.

g. Adhere to the Agency Media Communication Policy

It is the agency’s policy to provide open, accurate, and consistentcommunication with the public. To maintain the consistency andaccuracy of the information, agency spokespersons aredesignated to respond to all inquiries. Only these designatedspokespersons are authorized and responsible for releasinginformation at the appropriate time and for guarding against theinadvertent disclosure of confidential information. All inquiriesregarding the Media Communication Policy should be directed tothe Executive Director.Social network sites, such as Facebook and My Space, also fallunder the umbrella of “media.” If you are not a designatedspokesperson for the agency then any comments you make aboutagency activities on these sites could, depending on the content,be a violation of the Agency Media and Confidentiality Policy.Representatives of the agency need to take responsibility for whatthey write, and exercise good judgment and common sense. It isalso important that agency representatives who identifythemselves on these sites as having an affiliation withSpaulding Support Services do not give readers the impression that theircomments represent agency opinion.

2. Quality of Care

a. Adhere to Individual’s Rights and Responsibilities

By regulation, all individuals receiving services havecertain rights and responsibilities. It is expected that all agencyrepresentatives adhere to the provisions set forth in theseregulations. In particular, agency representatives shall notengage in any activities that constitute abuse of persons receivingservices as defined in the regulations of the Commissioner ofOPWDD. Failure to exercise one’s duty to intercede or to reportany activity, which may be considered abuse, will constituteabuse.

b. Follow Individual’s Service Plan

Agency employees are expected to comply with each person’sservice plan and communicate any changes in the plan to thenecessary parties in accordance with regulatory requirements andprogram policies and procedures.It is not acceptable for people receiving services to carry out theduties of employees unless such tasks are described in their planof services by their program planning team and for the purpose ofincreasing their skills.

c. Maintain Appropriate Interactions with Individuals

Agency representatives must maintain professional relationshipswith people receiving services. There shall be no personalfinancial transactions between agency representatives and peoplereceiving services or their family/responsible party. Financialtransactions, which may be construed as exploitation or result ingreater benefit to the agency representative than the personreceiving services will be considered abuse.The receipt of any personal gift by any agency representativefrom any person receiving services or their familymember/responsible party is discouraged and needs to beavoided. Depending on the circumstances, a gift of nominal valuemay be allowed. An example of such a gift might be baked goodsor a dollar store trinket. Any gift must be disclosed to thesupervisor to determine whether the gift may or may not beaccepted to avoid a conflict of interest.Agency representatives may not accept cash gifts fromindividuals receiving services under any circumstances.However, cash donations from a family member/responsibleparty to the agency may be accepted. Should a familymember/responsible party be interested in donating to the agencythey should contact the Executive Director.All agency representatives are expected to maintain aprofessional demeanor with people receiving services. It is alsoexpected that agency representatives shall model appropriate andacceptable behavior while in the presence of people receivingservices.

d. Safeguard Individuals Privacy

Agency representatives shall treat all clinical, program information as confidential, and utilize such information in aprofessional manner at all times. Access to information onpeople receiving services must be limited to the extent permittedby the agency policies and procedure pursuant to state and federallaw. In addition, information pertaining to HIV/Aidsis subject to additional regulatory requirements and should not bereleased without the proper authorization to do so. AnySpaulding Support Services representative who engages in unauthorizeddisclosure, access to, or misuse of information in violation of theprivacy rights of people receiving services, or others may besubject to disciplinary action in addition to civil or criminalsanctions. Any Spaulding Support Services representative whobecomes aware of such unauthorized disclosure shouldimmediately report this to their supervisor or CorporateCompliance Officer.

3. Medical Practices

a. Follow Regulations Regarding Control of Medications

It is the agency policy that all Spaulding Support Servicesrepresentatives shall be diligent in discharging their obligationsregarding prescription drugs and controlled substances inaccordance with applicable laws, regulations and agency policiesand procedures.The agency is legally responsible for the proper distribution,handling of and prevention of unauthorized access topharmaceutical products. The diversion of any prescription drugor controlled substance, including a drug sample, in any amountfor any reason to an unauthorized individual or entity isforbidden. Spaulding Support Services representatives may not use drugs stored inagency programs intended for the use of people receivingservices.

4. Legal Obligations & Compliance

a. To Maintain a Safe and Healthful Workplace

The agency has a commitment to maintain a safe and healthfulworkplace for agency representatives and people receivingservices. As part of this commitment, the agency maintainsreasonable safety rules, practices and procedures for all agencyrepresentatives. At the same time, the agency expects agencyrepresentatives to be efficient and productive in performing theirjob assignments. The agency provides a safe and healthy work environment byadhering to the laws, regulations and commonly accepted safepractices in accordance with federal and state laws regardingoccupational and environmental safety.Laws and policies regarding hazardous materials, pollutants andmedical waste must be strictly followed by all Spaulding Support Services representatives.