“Life without limits for people with disabilities”

CORPORATE COMPLIANCE PLAN

Maintaining, Upholding and Enforcing our Commitment to Compliance

United Cerebral Palsy of Central Pennsylvania, Inc. ● 925 Linda Lane, Camp Hill PA 17011

MESSAGE FROM THE COMPLIANCE OFFICER, MIA WOODS

UCP Central PA has a long standing history of fair and ethical business practices. The agency’s main goal is to improve the lives of the consumers receiving services from our agency. In my role as the Corporate Compliance Officer, I am committed to continuing this legacy. This Compliance Plan is designed to equipall members of the UCP Central PA community ( Board of Directors, Staff, Management, business associates , etc. ) with a guide and point of reference for appropriate legal and regulatory practices associated with our business and the services we provide.

Although my role makes me the primarily responsible for the Compliance program, each and every one of you are also a vital part of making it successful. I need you to utilize this plan and the other available tools (compliance hotline and email) to ensure that UCP’s culture of compliance remains strong. Remember that I am here to assist, provide guidance and to support everyone in the efforts of “doing the right thing” for the consumers and the agency.

A manual of the full UCP Compliance Program is available for review. If you have questions concerning this plan or the full Compliance program please feel free to contact me at 717-737-3477 ext.150 or at .

THE COMPLIANCE PLAN

This Compliance Plan is intended to help prevent and detect non-compliant behavior and activity. The ongoing benefits of this Compliance Plan is that it;

  1. Establishes and maintains an effective system of compliance monitoring and reporting,
  2. Provides assurance to the Board of Directors and the Chief Executive Officer that the organization is addressing all instances of non-compliant conduct,
  3. Reduces the likelihood of violations of laws, regulations, and requirements,
  4. Improve internal communication and employee feedback to the Management Team,
  5. Establishes a structure to educate and disseminate legal and policy changes quickly and
  6. Improves the speed and quality of responses to audits, investigations, and other compliance situations that occur.

The following is an outline of the expected outcomes of the successful implementation and maintenance of this Compliance Plan:

  1. Development and implementation of compliance standards and policies
  2. Identification of areas of potential compliance risks
  3. Ongoing evaluation and monitoring of compliance practices
  4. Completion of an effective reporting and investigative process
  5. Maintenance of an anonymous compliance hotline and email for employees
  6. Development of effective employee compliance training programs

ORGANIZATIONAL STRUCTURE OF THE COMPLIANCE PLAN

This Compliance Plan demands the active participation of all levels of the organization’s workforce, including the Board of Directors. The following describes the responsibilities related to the Corporate Compliance Program:

  1. Board of Directors – This Compliance Plan has been approved by the Board of Directors. The Board of Directors has the ultimate responsibility for oversight of the Corporate Compliance Program, as outlined in this Compliance Plan.
  2. Chief Executive Officer – The Chief Executive Officer is responsible to ensure that the Corporate Compliance Program is carried out according to this Plan.
  3. Corporate Compliance Officer and Compliance Committer- The Corporate Compliance Officer shall oversee all day to day activities of the Corporate Compliance Program, as outlined in this Plan, with the assistance of the Compliance Committee.
  4. External Consultants – External consultants may be used to assist the Corporate Compliance Officer and to enhance the quality of this Compliance Plan.

RESPONSIBILITIES OF EMPLOYEES

The effectiveness of this Compliance Plan depends on each employee’s efforts to bring all compliance questions and issues to the attention of his/her Supervisor, the Corporate Compliance Officer, or a member of UCP’s Management Team. If an employee is unsure as to whether a particular situation raises a compliance issue, he/she should always report it. UCP employees are responsible for:

  1. Understand and abide by UCP Policies – Each employee is expected to be knowledgeable about, and abide by, UCP Policies.
  2. Compliance Training – Each Employee will receive training on this Compliance plan. It is each employee’s responsibility to ask all questions he/she may have about this Compliance plan.
  3. Report Actual or Suspected Compliance Issues – Each employee must report all actual or suspected compliance issues to their Supervisor, directly to the Corporate Compliance Officer by use of the compliance “hotline” or to a member of the Management Team.

RESPONSIBILITIES OF MANAGEMENT

All level of management have the responsibility to set forth UCP’s standards for compliance. Supervisors serve as the primary example for, and the primary source of information to, the organization’s employees. A Supervisors and Management staff are responsible for:

  1. Understand, Abide by, and Enforce Compliance Policies – Supervisors are responsible to follow this Compliance Plan and to ensure that the employees they manage also follow this Plan.
  2. Compliance Training – Supervisors must formally, and informally, communicate the importance of compliance to every employee and actively promote adherence to this Compliance Plan. Mere distribution of the compliance literature is unacceptable.
  3. Report Compliance Issues – All Supervisors must see to it that any actual or potential compliance issues are reported to the Corporate Compliance officer.
  4. Accountability – Supervisors are equally accountable for their own actions as well as the actions of the employees they supervise.

RESPONSIBILITIES OF INDEPENDENT SUBCONTRACTORS

It is expected that each contractor will review, understand and abide by the standards and procedures outlined in this Compliance Plan and the Business Associate Agreement.

REPSONSIBILITIES OF THE CORPORATE COMPLIANCE OFFICER

The Corporate Compliance Officer, to support, oversee and manage the day to day operation of this Compliance Plan. The following outlines the main responsibilities of the Corporate Compliance Officer;

  1. Development and Implementation of Compliance Policies – The Compliance Officer shall be responsible for the development, implementation, and maintenance of effective compliance policies, procedures, and practices.
  2. Development and Implementation of Audit and Monitoring Programs – The Corporate Compliance Officer shall develop and implement an Internal Audit Program.
  3. Dissemination of Information - The Corporate Compliance Officer shall establish and oversee procedures to ensure that every employee fully understands this Compliance Plan.
  4. Oversee All Compliance Training Programs – The Corporate Compliance Officer shall oversee and coordinate all compliance training.
  5. Establish a means for reporting of fraud, waste and abuse/general compliance concerns – A Compliance Hotline and email.

COMPLIANCE STANDARDS

The Compliance standards outlined below reflects general standards that apply to all UCP operations. This general list is not exhaustive of all prohibited conduct or ethical situations. If unsure as to whether a particular situation raises a compliance issue, employees should always err on the side of caution by reporting it to a Supervisor, a member of the Management Team, or to the Corporate Compliance Officer. Remember...

WHEN IN DOUBT, POINT IT OUT!

UCP shall maintain full compliance with all internal policies and all applicable laws, regulations, and statutes, and all Federal, and State health care program requirements. The following issues have been addressed in UCP’s Policy Manuals:

Billing and Claims Submission – UCP shall charge, bill, document, and submit claims for reimbursement in the manner required by all applicable laws, regulations and statutes.

Conflict of Interest - UCP shall enforce its policies related to maintaining relationships that are free from conflict-of-interest.

Market Competition/Anti-Trust – UCP shall comply with all laws and regulations pertaining to “antitrust” issues.

Kickbacks and Gifts – Officers and employees may not accept a payment, gift, or other inducement in return for purchasing goods or services, providing referrals, or for participating in other business transactions

Confidentiality – UCP shall comply with all federal and state laws related to maintaining the confidentiality of health care and business records.

Response to Investigations – UCP shall cooperate with all investigations, subpoenas, search warrants, and other similar documents and action to the full extent required by law.

Non Retribution and Non –Retaliation – UCP will not tolerate any action which is intended to intimidate, threaten , coerce, discriminate against, or take any other retaliatory action against any UCP employee for exercising his/her right(s) in good faith to report non–compliance as detailed in the Compliance Plan.

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