TARRY HOUSE, INC.

 

Subject:  Corporate Compliance Program

 

Procedure Number:  M.L. 02

Site: All Sites

 

Issued By: Executive Director

Effective:  01/21/02

Approved By: The Board of Trustees

Revised:  05/04/02; 5/18/05

Reference Policy:

Reviewed: 12/30/02; 12/30/04; 5/18/05; 2/28/08

 

Standards Reference:

CARF: Section 1. I

ODMH: 5122-30

 

 

I.                   Purpose

 

To establish and publish the official policy of Tarry House, Inc. regarding the organizations corporate compliance program and plan.

 

 

II.                 Policy

 

Tarry House, Inc. is dedicated to the delivery of behavioral health care in an environment characterized by strict conformance with the highest standards of accountability for administration, clinical, business, marketing and financial management.  Tarry House’s leadership is fully committed to the need to prevent and detect fraud, fiscal mismanagement and misappropriation of funds and therefore, to the development of a formal corporate compliance program to insure on-going monitoring and conformance with all legal and regulatory requirements.  Further, the organization is committed to the establishment, implementation and maintenance of a corporate compliance program that emphasizes (1) prevention of wrong doing – whether intentional or unintentional, (2) immediate reporting and investigation of questionable activities and practices without consequences to the reporting party and (3) timely correction of any situation which puts the organization, its leadership or staff, funding sources or consumers at risk.

 

III.               Procedure

 

By formal resolution, the Board of Trustees has delegated overall responsibility for the Corporate Compliance Program to the Executive Director.  The Executive Director will formally designate, subject to Board approval a Corporate Compliance Officer, to monitor the organizations corporate compliance program and provide periodic and regular reports to the Board of Directors on matters pertaining to the program.

 

The Corporate Compliance Officer (CCO) shall (1) chair the organization’s corporate compliance efforts and serve as the organization’s primary point of contact for all corporate compliance issues, including scheduling meetings, reporting on such efforts and making recommendations to the Executive Director and Board of Trustees as required; (2) develop, implement and monitor on a regular and consistent basis the organizations corporate compliance plan, including all internal and external monitoring, auditing, investigative and reporting processes, procedures and system; (3) prepare, submit and present periodic reports to the Executive Director and/or Board of Trustees as may be required to provide clear communication to the organization’s formal corporate compliance plan with the Executive Director and the Board of Trustees.

 

At least once per year the Corporate Compliance Officer will initiate a Compensation Review Committee meeting of assigned members of the Board of Trustees.  The compensation review process will review the compensation benefits of all key staff members, those staff members who have the potential to exercise “substantial control of the organization’s policies, procedures and operations.” Results of the compensation review process will be maintained by the Executive Director who will, in consultation with the Board of Trustees, determine the appropriate remedial action, if any.

 

The Corporate Compliance Officer shall submit an annual report to the Board of Trustees.  Annual reports will, include at a minimum; (1) a summary of all allegations, investigations, and/or complaints processed in the proceeding 12 months in conjunction with the corporate compliance program; (2) a complete description of all corrective actions taken; (3) any recommendations for changes to the organization’s policies and/or procedures.

 

In the performance of his/her duties, the CCO shall have direct and unimpeded access to the Executive Director, the Board of Trustees and the organization’s accounting firm and/or legal counsel for matters pertaining to corporate compliance.

 

As part of corporate compliance plan development, the CCO shall schedule, coordinate and monitor regular and periodic reviews of risk areas by competent persons external to the organization.  Such reviews will be conducted as a way to ensure ongoing conformance with billing, accounting and collection regulations imposed by the federal government and other “third party” funding sources.  More critically, these reviews will augment the organizations annual audit of its accounting system and provide an additional internal measure to ensure conformance with billing policies and practices that will withstand the scrutiny of any regulatory audit or examination.

 

REPORTING PROTOCOL:

 

The Corporate Compliance Officer (CCO) shall report any perceived or reported compliance issues to the President of the Board.  Any issue should be raised as soon as the Corporate Compliance Officer discovers or is made aware of it.  The Board President, in turn, shall work with the CCO, as well as any other person deemed necessary by the President to address the issue, including an investigation of the issue.  Upon termination of the investigation, the CCO shall prepare a written report that sets forth the issued raised, the relevant facts obtained through the investigation, pertinent rules or standards and the recommended action.  The written report shall be provided to the President as soon as, but no later than 30 days after the issue has been raised, unless the President sets a different deadline for the report.  Upon receipt of the report, the President shall distribute the report to the entire Board membership for review and discussion.  The Board shall meet and confer on the issue(s) raised by the report and take final action relating to such issue(s) as soon as practical.  The Board of Trustees, or its designated representative, shall ensure that its final action on the issue(s) is a matter of record and should take such final action no later than 60 days after the issue is raised, unless a longer period of time is warranted under the circumstances.

 

 

 

 

___________________________                                                       ____________________

   Executive Director                                                                                Date