Developing a Corporate Compliance Program

1. Developing a Corporate Compliance Program Martha �Marti� Eagleton Director of Quality Improvement & Compliance United Methodist Children�s Home Worthington, Ohio

2. Objectives Understand the value and importance of implementing a voluntary corporate compliance program Understand the core elements of a corporate compliance program Understand how to develop a solid foundation for a corporate compliance program

3. Why bother? You send a strong message to stakeholders about your organization�s ethics and business practices It probably won�t be long before more of this is mandatory�

4. Voluntary versus Involuntary Sarbanes-Oxley (SOX) Deficit Reduction Act of 2005 COA Standards ETH RPM FIN

5. Key Components of SOX Focused primarily on the for-profit sector, but provisions for non-profits include policy development related to: Document destruction Whistle-blower protection Board independence Disclosure/certification of financial statements Separate audit committee Prohibition of insider transactions & conflicts of interest

6. Key Components of the DRA of 2005 Requires any provider who bills or pays out more than $5 million dollars annually (for the corporation) to have a compliance program as of January 1, 2007 as a �condition of payment� Employee, contractor and agents must receive �detailed� information about: Federal False Claims Act, Any state False Claims Acts and Any other administrative remedies for false claims under Federal law.

7. Key Components of COA ETH RPM FIN

8. OIG�s Recommended Process Implement a written plan Designate a compliance office and compliance committee Conduct effective training and education Maintain effective communication Perform internal monitoring and auditing Enforce standards through well-publicized disciplinary guidelines Respond promptly to detected offenses

9. 1. Implement a written plan What to include? Code of Conduct Day-to-day implementation Does an attorney need to draft the plan?

10. 2. Designate a compliance officer and compliance committee Selecting a compliance officer Internal vs. external Dedicated vs. dual roles Scope of role Organizing a compliance committee

11. 3. Conduct effective training and education How often do you expect your staff to complete training? How will you assess learning?

12. 3. Conduct effective training and education Every staff member should receive a copy of the Corporate Compliance Plan/Manual/Handbook which includes all relevant policies and procedures for the Corporate Compliance Program, Code of Conduct, etc. How to organize?

13. Keep in mind Policy strengthens practice

14. Policy Statements Anti-trust Tax Gifts/gratuities Referrals Environmental responsibility Misappropriation of information Confidentiality (client, personnel)

15. 4. Maintain effective communication What to report? Consider the �Suggested Questions for Directors� in OIG�s Corporate Responsibility and Corporate Compliance publication as a guide

16. 5. Perform internal monitoring and auditing Baseline audits What to review? Anything accreditation standards tell you to High risk/high volume Target areas where internal controls are not as strong Pay attention to trends in the news

17. 6. Enforce standards through disciplinary guidelines Be fair and consistent

18. 7. Respond promptly to detected offenses Develop a �Whistle Blower� policy Provisions for anonymous reporting Non-retaliation clause

19. 7. Respond promptly to detected offenses Ensure policy and procedure exist and are understood by staff, especially how and what to report The specific nature of the wrongful or inappropriate act (give as many details as possible); The name of person(s) who committed the act; The place where the person works; The date and time the act occurred; The place where the act occurred; The reason you believe the act is wrongful or inappropriate Close the loop following investigation

20. Some Additional Resources http://oig.hhs.gov/ http://www.boardsource.org/clientfiles/sarbanes-oxley.pdf

21. Marti Eagleton, Director of QI & Compliance United Methodist Children�s Home 1033 High Street Worthington, OH 43085 PHONE: (614) 885-5020, x576 FAX: (614) 885-4058 EMAIL: MEagleton@UMCHohio.org