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Scope and purposes
The MHS Board of Directors established the Corporate Compliance Program in May, 2005. The scope of the program is broad, and includes all administrative, clinical, business, marketing, and financial activities. The program emphasizes "(1) prevention of wrongdoing – 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."
Staffing
The Executive Director has overall responsibility for the program. The ED designates a Corporate Compliance Officer (CCO), and a Compliance Committee to administer the program. The CCO conducts reviews of risk areas, and submits a report each year to the ED and the Board. Committee members share responsibility for the Compliance Hotline, help educate employees about the program, help the CCO conduct reviews, and work to develop and implement standards of conduct and operational policies and procedures.
Reporting mechanisms and responsibility
A Corporate Compliance Hotline has been established – the number is 216-274-3319. Calling this number gives you the opportunity to leave a message of unlimited length. You may report your concerns in privacy, and leave as little or as much information as you choose. Another reporting mechanism for employees of MHS is the agency intranet. Reports may also be made by phone, email, or in writing to Committee members (names presented below), the CCO, or an employee’s supervisor. All MHS employees have the affirmative responsibility to report conduct they believe to be unethical or illegal. The identity of an employee making a report is disclosed only as needed.
Process
All reports are directed to the Corporate Compliance Officer, who initiates an investigation. The report and results of the investigation are presented to the Committee, and the Committee takes corrective action when needed, and follows up to make sure that the action taken was, in fact, corrective.
Discipline
Employees who have engaged in conduct that violates MHS policies or that is illegal are referred to Human Resources and the employee’s supervisor. Failure to report improper or illegal conduct, and providing materially false information, are also grounds for disciplinary action.
MHS’ right to legal representatation
Employees who are asked for information outside the scope of normal business practices by a representative of any government agency seek and follow the guidance of the CCO or Executive Director before responding to any requests. This practice protects the rights and interests of clients, staff members, and MHS. Employees who receive a request for information by an attorney, or who receive a court notice, subpoena, or search warrant immediately seek and follow the directives of the Director of Quality Assurance and their supervisor before taking any action.
Accuracy and integrity of reports and records
Employees never destroy or alter agency documents in response to or in anticipation of an investigation. Employees never lie or make misleading statements to agency or government investigators. Employees never encourage anyone to withhold information, provide incomplete information, or provide false information to agency or government investigators.
Training
All employees are to attend periodic Corporate Compliance Training programs. Adherence to the provisions of the Compliance Program will be a factor in each employee’s annual performance evaluation. All training is documented in the Compliance Education Activity logbook. Additional information and/or training will be provided to those requesting it. An annual assessment of employee knowledge of the program is conducted in coordination with the agency’s Department of Human Resources.
Annual conflict of interest certification
Senior supervisory personnel and employees with management responsibilities shall report at least annually, and at other times when needed, "any interest or affiliation which conflicts, may conflict, or may appear to conflict with the discharge of his or her duties..." A Conflict of Interest Certification Form is submitted at least annually to the Corporate Compliance Officer.
Code of conduct
Employees are bound by an agency Code of Conduct. The Code emphasizes honesty, full disclosure, observance of the law, accurate and complete documentation, fair billing practices, truth and fairness in marketing, maintenance of professional relationships, avoidance of dual relationships, notification about secondary employment and avoidance of outside employment that presents a conflict of interest, and reporting abuse and neglect.
Protection of nonprofit status
MHS protects its tax-exempt status. All transactions and compensation must be at fair market value, unless approved by outside Counsel. Employees must not, during work hours or in their capacity as a representative of MHS, engage in lobbying nor directly or indirectly campaign for or in opposition to any candidate for public office. MHS facilities must only be used for activities that promote the fulfillment of its mission.
Avoidance of undue influence in healthcare decisions
Employees never offer or exchange money or anything of value in return for accepting or making referrals of clients, or to induce someone to use an MHS service.
Avoidance of anticompetitive practices
Employees never enter into anticompetitive agreements. MHS never enters into anticompetitive agreements with a competitor or potential competitor.
Ensuring provider eligibility
MHS does not knowingly employ or contract with, regardless of compensation, any individual or entity listed by a federal agency as excluded, debarred, suspended, or otherwise ineligible to participate in health care programs. MHS makes reasonable inquiries in order to adhere to this policy.
Protection of those reporting compliance concerns
Employees, especially supervisors and managers, are strictly prohibited from engaging in any act of retaliation, retribution, or harassment directed against an employee who reports a compliance concern. Any such act will be subject to corrective action, up to and including termination.
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