The Road to Organizational Excellence

1. EAGLE ACCREDITATION The Road to Organizational Excellence

2. Presenter Information Matt Obert, MSW, LCSW • Director of Quality Assurance and Facilities Quincy, Illinois mobert@chaddock.org Debi Armstrong, MS, LCPC • Vice President of Quality and Information Systems Normal, Illinois darmstrong@thebabyfold.org

3. Most Common Challenges • QUALITY IMPROVEMENT and SERVICE EXCELLENCE • CORPORATE COMPLIANCE • RISK MANAGEMENT • TECHNOLOGY SECURITY and DISASTER RECOVERY

4. INTEGRITY: “Doing the right thing even when nobody is looking”

5. EAGLE Principle 5.4. Legal and Ethical Compliance How does your organization: • Establish and implement compliance standards and procedures? • Effectively communicate the compliance standards, procedures and performance expectations to employees, volunteers, governing body members, agents and vendors? • Deploy auditing and monitoring systems within the organization? • Decide areas of potential risk on which to focus? • Evaluate and improve the organization’s compliance program?

6. EAGLE Expectations • Effectively operate a corporate compliance program • Focus on key areas of risk • Senior executive is responsible and accountable • Within that program are: • Published compliance standards and procedures • Minimize the potential for wrongful conduct • Effectively communicated to all stakeholders • Reasonable steps to ensure compliance • Monitoring and auditing systems • Publicized means of reporting • No retribution or retaliation for “good faith” reporting

7. EAGLE Expectations continued • Consistently enforce its compliance standards through appropriate disciplinary actions • Take reasonable steps to appropriately respond to detected non-compliance, to include actions to prevent recurrence • Ensure its governing body regularly reviews and modifies as necessary the compliance program

8. EAGLE Accredited Organizations:We “Do The Right Thing” • Provide the highest quality services possible • Adhere to ethical and legal practices • Provide services with honesty and integrity • Report questionable activities or practices • Protect reporters from retaliation or consequences • Promote ongoing education and communication

9. Why a Corporate Compliance Plan? • EAGLE and COA accreditation requirement • Medicaid compliance requirement • Manage risk to agency, clients, employees • Audits and fraud investigations • HIPAA security audits • Sets ethical and legal expectations • Provides a compliance framework

10. A Corporate Compliance Plan helps to ensure: • Ethical conduct and practice • Compliance with laws and regulations • Compliance with licensing and accreditation • Quality of services • Positive external reports and audits • Accurate and complete documentation • Confidentiality and security of information • Immediate reporting of wrong doing • Timely correction of issues

11. Elements of the Corporate Compliance Plan • Based on Values and Ethics • Board and Employee Responsibilities • Relevant Policies and Procedures • Auditing and Monitoring Functions • Training and Education • Reporting and Investigation Processes • Consequences for Misconduct • Corrective Action • Regulatory Access

12. Values and Ethics • Agency Mission and Values • Agency Code of Ethics • Codes of Conduct/Professional Behavior • State contractor Code of Ethics, e.g. DCFS Code of Ethics for Child Welfare Professionals • Professional Licensure Codes of Ethics

13. Expectation of All Employees • Remain compliant with all laws and regulations • Conduct themselves ethically and avoid even the appearance of impropriety • Submit honest and accurate records, both client and organizational • Adhere to organizational values

14. Administrative Responsibilities • Board of Directors • Chief Executive Officer • Supervisors and Management • Corporate Compliance Committee • Corporate Compliance Officer

15. Specify Policies and Procedures • Employee Handbook • Accreditation Standards • Licensing and Regulatory Standards • Agency Policy and Procedures • Medicaid Policy and Procedures • Department Procedure Manuals • Program Procedure Manuals

16. Auditing and Monitoring Functions • Financial Processes and Contracts • Third Party Billing • Standing Committees • Quality Improvement Processes • Employee/Intern/Direct Service Volunteer Screening • External Reviews and Audits • Accreditation Processes

17. Training and Education • Mandatory training for all employees • Incorporate into Orientation Process • Periodic training when changes occur • Ongoing training on laws and standards • Acknowledge receipt of the plan • Test to ensure competency

18. Corporate Compliance Reports • What to report • Fraud including Medicaid billing fraud • Embezzlement/kickback/bribery • Breaches of client confidentiality • Unethical client relationships • Falsifying documentation • Violations of client rights • Criminal acts, e.g. theft, cyber crime • Steering referrals

19. Ethical Billing Ethical Billing Standards False Claims Act Violations • Bill only services personally delivered • Deliver services that are medically necessary • Complete required documentation • Use correct service codes • Report billing irregularities to Corporate Compliance Officer • Submit claim for services not provided • Submit claim for more units than were provided • Submit claim for services paid by another source • Submit claim for services not medically necessary • Submit claim for services falsely coded at a higher rate

20. Other types of reporting • Harassment • Sexual Misconduct • Retaliation • Discrimination • Employee Grievances • Employee Complaints

21. Methods of Reporting • Report to Corporate Compliance Officer • By phone/email/in writing or face to face • Can be anonymous report • Mail to or deliver to CCO mailbox • Agency sanctioned reporting methods • Establish who to report to if CCO or CEO are involved in report

22. Elements of Reporting Processes • Expectation of employees to report illegal or unethical activities • Expectation to report suspected misconduct: do not need “proof” • Expectation to report immediately • Protection from retaliation or consequences if made in good faith • Reporter not exonerated if involved

23. Investigations • Diligence and discretion in investigation • Consultation with legal counsel or other expert as needed • Resolved in a fair and timely manner • Corrective action as warranted • Disciplinary action as warranted up to and including termination

24. Identify Regulatory Access Agency Policy and Procedure Laws, Regulations, Standards • Policy and Procedure Manuals • Employee Handbook • Copy of program and department level manuals • Electronic versions • Location of hard copies • Website links to specific laws • Website links to Accreditation Standards • Website links to Regulatory bodies and corresponding rules • Consult with supervisor or management

25. Consequences of Misconduct Consequences should fit the degree of unethical or illegal misconduct. • Disciplinary methods vary as to how they are established by the agency: • Mandatory retraining • Verbal warning • Written warning • Suspension pending investigation • Suspension without pay • Involuntary or Voluntary Termination • Reporting to professional licensing board • Reporting to law enforcement

26. Corrective Action and Remediation • Establish new methods of oversight or monitoring • Mandatory training requirements • Close loopholes with new processes • Increased supervision • Modify or initiate documentation methods

27. Reporting Corporate Compliance Activities • Quarterly review by leadership as part of Quality or Risk Management Processes • Report critical or significant findings to board on an immediate or quarterly basis • Comprehensive annual report to leadership and the Board of Directors • What to include?

28. Reviewing and Improving the Plan • Formally review the plan at least annually • Determine if new monitoring or auditing processes are needed • Changes in laws, regulations, or standards should be communicated to employees • Determine any training needs in specific areas • Modify reporting and investigation processes based on experiences

29. QUESTIONS?