Corporate Compliance Plan

INTRODUCTION

At all levels of our organization, Cape Fear Group Homes, Inc. (CFGH) is committed to providing high quality care and services in a manner that is in the best interest of our Program Participants and in compliance with all Federal and State laws and regulations.

We are dedicated to assisting individuals, utilizing a person-centered philosophy, to become fully participating members of the community through goal development and skill acquisition. CFGH’s Corporate Compliance Plan exists to formalize this philosophy with a focus on the prevention and detection of law violations, waste, fraud, abuse, and other wrongdoings.

CFGH maintains and promotes an effective Compliance Program through the following elements:

• Code of Conduct
• Reporting
• Quality Assurance/ Quality Improvement Program
• Human Resources
• Executive Team
• Screening and Evaluation of Employees
• Security of Records
• Education and Training
• Referrals
• Marketing
• Use of Social Media
• Investigation and Remedial Measures
• Internal Audit and Monitoring Systems
• Fiscal Management
• Employee Responsibility to Compliance
• Corrective Action Related to Corporate Compliance

CODE OF CONDUCT

CFGH’ Code of Conduct is intended as a basis for ethical decision making in the conduct of day-to-day professional work as well as the overall business function and serves to supplement the mission, core values, and policies of CFGH.

CFGH employees are expected to know and adhere to the Code of Conduct. Failure to do so may result in disciplinary action, including termination of employment.

Board Members, Volunteers, Contractors, Consultants and all others performing professional work or services for CFGH are expected to know and adhere to the Code of Conduct in conjunction with their work for us. Failure to do so may result in termination of their relationship with CFGH.

• Quality of Services: Program Participants will receive high quality service, to the best of an employee’s ability. Program Participants will be provided with information that is accurate, objective, relevant, timely and understandable. Employees will use sound judgment in the performance of their duties and will seek information when those duties are unclear. Employees will promote ethical behavior as a responsible partner among peers in the work environment. Employees will focus on job responsibilities and will refrain from engaging in non-work related activities such as personal phone calls, texting, reading, napping and TV or personal computer use unless permitted to do so by the Program Director.
• Respect and Dignity: Program Participants and Employees will be treated with respect and dignity without prejudice to race, color, religion, national origin, gender, sexual orientation, age, disability or other legally protected status.
• Confidentiality: Confidentiality standards for Protected Health Information (PHI) will be followed per HIPAA and State guidelines. Information entrusted to employees by CFGH will be kept confidential except when authorized or otherwise legally obligated to disclose.  Employee records and sensitive agency information will be kept confidential and shared only on a need-to-know basis.
• Integrity: Employees will be honest and ethical in conduct in all aspects of employment, including verbal and written communication, documentation, financial matters, time worked and mileage reported. Employees will honestly communicate work restrictions and changes in eligibility to perform job responsibilities, including but not limited to medical restrictions, driving violations and criminal charges obtained after hire. Additionally, employees will demonstrate the highest standard of integrity in communication with fellow employees, Program Participants, Program Directors and all others associated with CFGH.
• Attendance: Employees will be punctual and will arrive to work prepared, both physically and mentally to complete job responsibilities to the highest level of ability. Employees will follow CFGH policies and seek instruction from their Program Directors on how to call out sick or use vacation leave.
• Professionalism: Employees will conduct themselves in all settings, including social media, in a manner that represents themselves and CFGH in the highest of esteem and respect. When concerns or problems arise, employees will address their concerns directly with the other individual involved and when necessary, their Direct Supervisor. Employees will refrain from arguing, expressing anger, communicating in a threatening manner with or gossiping about Program Participants, their families, co-workers and all others associated with CFGH.
• Conflicts of Interest: Employees will openly disclose actual or apparent conflicts of interest between personal & professional relationships. Examples include but are not limited to referrals, preferential treatment of an individual or entity due to a personal relationship with someone in the company, use of confidential information for one’s own advantage, or employment by more than one organization resulting in competing interests.
  • Conflicts of interest apply to the company as a whole. Examples include but are not limited to acceptance of gifts or money from a vendor who does or is trying to secure business with the organization or a board member who also serves on the board of a competitor organization.
• Boundaries in Relationships:
  • With Participants: CFGH employees are expected to maintain professional boundaries and are not permitted to have dual relationships with their direct Participants. Examples of a dual relationship include instances when a Participant is or becomes a friend, family member, significant other, employee or business associate outside of services.
  • Between Employees: Supervisors, Board Members, Consultants, and Family Members of Program Participants will not be involved in the employment process, supervision or review of an employee related by blood, marriage, or residence. Related individuals will not be placed in the same area or department or have access to the other related individual’s personnel records.
• Regulations: Employees will comply with all applicable laws, rules, regulations, codes and agency policies and procedures when representing CFGH.
• Documentation: To the best of ability, employees will submit accurate documentation and follow billing and reporting procedures, both operational and financial, with the knowledge that falsification of documentation is considered fraud and participation in or observation of such practices may result in criminal prosecution. Discovered errors will be reported immediately. Record retention and disposal will be managed in accord with CFGH Policies and Procedures as well as all regulatory and legal requirements. As applicable, employees will sign and date documentation.
• Witness of legal documents: CFGH employees may sign as a witness on approved CFGH forms. Examples include consent forms for Program Participants at intake and witness statements for an event or incident that occurred with a Participant, and/or on CFGH premises, etc.
  • Employees may not sign as a witness to represent CFGH on any non-CFGH legal document without written permission from the Executive Director. Examples include Guardianship paperwork, powers of attorney and advance directives.
• Company Assets: Employees will protect and ensure the proper use of company assets, including but not limited to credit, cash, equipment, Employee records, Program Participant records and electronic passwords.
• Soliciting and Accepting of Gifts/ Money (excluding approved corporate fundraising):
  • Soliciting: Employees will not solicit money, loans, gratuities, gifts, or any other products or services either directly or indirectly from other employees, Program Participants, Guardians or any other entity associated with CFGH, for personal purposes.
  • Accepting: Employees will not accept money, loans, gratuities, gifts, or any other products or services of unusual value either directly or indirectly from other employees, Program Participants, Guardians or any other entity associated with CFGH, for personal purposes. Employees will immediately report any gift received, regardless of value, to their Supervisor for Direction.
    • Any value over $25 would be considered unusual. Gifts of unusual value will be returned to their donors, if possible, or disposed of in another appropriate manner, with the return or disposal thoroughly documented.
    • Receipt of gifts from Program Participants is discouraged. Exceptions must be approved by the Executive Director.
  • Gifting:
    • Additionally, it is improper for CFGH employees to sell or gift cash, gift cards or items of value or any other goods or services to Program Participants. This includes the purchase of meals and/ or other necessities. Exceptions must be approved by the Executive Director.
  • Additionally, employees, agents and officers or subrecipient shall not solicit or accept gratuities, favors or anything of monetary value from contractors, potential contractors or parties to sub agreements.
  • Fundraising:
    • Personal: Personal fundraising for causes unrelated to CFGH must be approved by the Executive Director prior to any solicitation.
    • Corporate: Corporate fundraising for CFGH must be approved by the Executive Director prior to any solicitation and must follow the fundraising policies.
  • Safeguarding of Property: All personnel are expected to treat the personal property of Participants, employees and other visitors as well as the property of CFGH with respect and security to the best of their ability. Employees will safeguard their keys and passcodes to CFGH buildings and will ensure they follow the lock-up procedures in place when leaving a building or group home. Neglect, damage or misappropriation of property may result in staff correction or termination.
    • Vocational Services Participants: CFVS Participants are responsible for their own personal property whether they are receiving services in one of our offices or in the community.
    • Group Home Participants: CFGH Participants are responsible for their own personal property but may need assistance from staff in keeping track of their possessions. Staff will make every effort to protect participant’s personal clothing and possessions from loss or damage. Full restitution of their property will be made if it is damaged by another Participant.
  • Contractual Agreements: Cape Fear Group Homes contracts with various professionals (hereafter consultants) in the community in order to provide services from various disciplines to meet the needs of Program Participants.
    • Consultants will provide staff training and information specific to Program Participant need.
    • Consultants who must be licensed or registered to practice in their respective fields in the community at large must also be licensed or registered to be on contract at Cape Fear Group Homes, Inc.  Proof of licensing and/or registration in a consultant’s field must be provided to the Cape Fear Group Homes, Inc. Administrative Office prior to any contract being issued.
    • Cape Fear Group Homes has a standard contract format.  Each completed contract identifies the specific duties of each consultant which shall be reviewed annually.  Contracts for services will be renewed annually, based upon the performance of the consultant.
    • The NC Personnel Health Care Registry and E-verify are contacted prior to CFGH entering into a contractual agreement. CFGH will disqualify candidates when abuse or neglect are substantiated on the registry. Candidates not legally eligible to work in the United States will not be offered a contract.
    • The Office of the Inspector General Exclusion list is checked monthly to ensure current consultants are not on the list. Discovery that a consultant is on the list will result in dissolvement of their contract.
  • Business: All business functions of CFGH will be conducted ethically, responsibly, and with a high level of integrity to build and maintain trust in relationships with stakeholders on every level. For example, this includes but is not limited to ensuring bills and fees are paid on time, ensuring funds are spent responsibly, ensuring employees receive competitive pay and comprehensive benefits, and ensuring participants receive an appropriate quality and quantity of services. 

REPORTING

• Cape Fear Group Homes, Inc. employees, volunteers and consultants are expected to report any actual or suspected violations of the Corporate Compliance Plan, CFGH Policies and Procedures, and/or State and Federal laws and regulations.
• A Qualified Professional and Group Home Manager are available to Intermediate Care Facility (ICF) employees to discuss questions, concerns and take reports regarding compliance.
• Regional and Assistant Directors are available to Supported Employment (SE) employees to discuss questions, concerns and take reports regarding compliance.
• The Executive Director, HR Director and Quality Assurance/ Quality Improvement Coordinator are available to all employees to discuss questions, concerns and take reports regarding compliance.
• Reports may be made anonymously through the Quality Assurance Hotline.
• Report of a compliance violation benefits CFGH. CFGH takes a no-reprisal approach, meaning an employee who makes an honest report of an actual or seemingly actual compliance violation will not be subject to any retaliation, penalties, discrimination, confrontation, or any other type of consequences for making the report.
• Reports will be followed up on within 48 business hours of receipt or sooner depending on the severity and nature of the report. A decision will be rendered within 72 hours of the report whenever possible. Unless reported anonymously, the reporter will be notified that their report was received. The reporter may or may not be notified of a resulting investigation and/or results of the investigation, depending on circumstances such as other employee involvement or confidentiality of Participants and their records.
• Any investigation that results from a report will be documented with the allegation addressed, appropriate authorities and entities notified, and appropriate action taken. The investigation will be completed as soon as possible but in no more than five business days from the time the report was received.

QUALITY ASSURANCE/ QUALITY IMPROVEMENT (QA/QI) Program

• The QA/QI Coordinator is responsible for ensuring employee access to the Corporate Compliance Plan and investigating suspected violations of the plan.
• Compliance issues and concerns of the QA/QI Coordinator are brought to the attention of the appropriate Director and will monitored on an ongoing basis until resolved.
• The QA/QI Committee meets quarterly to review QA/QI goals, issues related to compliance and areas needing improvement. Minutes of the meeting are documented.
• A QA Hotline and Email account are available to all employees who have questions, issues, and concerns. This service may be utilized by all CFGH employees, free of consequence to employment.
  • Phone calls may be made anonymously. When requested, the QA/QI Coordinator will return calls and emails in a timely manner. 

HUMAN RESOURCES

• The Executive Director is responsible for appointing the Human Resource Specialist.
• The Human Resource Specialist is responsible for receiving all applications for employment and in following procedure in screening and evaluating prospective employees.
• The Human Resource Specialist receives employee timecards prepares payroll disbursement.
• The Human Resource Specialist oversees all Workers’ Compensation Claims. 

EXECUTIVE TEAM

• The Executive Team is comprised of the Executive Director, Program Directors, Office Manager, Human Resource Specialist, Quality Assurance/ Improvement Coordinator, the LPN and any other positions designated by the Executive Director.
• The Executive Team is led by the Executive Director.
• Professional responsibilities of this team include attendance of Executive Team meetings, reporting concerns that could affect program or business function to the team and addressing action items or concerns following team meetings in a timely manner.
• Each member of the Executive Team is expected to report knowledgably and honestly related to their area of professional responsibility.
• An organizational chart is maintained, indicating specific roles within CFGH. Job descriptions outline professional responsibilities for these roles.

SCREENING AND EVALUATION OF EMPLOYEES

• Applications for employment are submitted to Human Resources for initial screening. Candidates of sufficient interest for vacant positions are interviewed by Program Directors (and Managers as applicable) with Executive Director input.
• Internal applicants are given preference for vacant positions. When an internal candidate is not chosen, CFGH will advertise as needed to the general public.
• A criminal background check is conducted prior to hire. An applicant with a felony conviction and/or a misdemeanor conviction for assault, abuse or neglect are not eligible for employment.
• The NC Personnel Health Care Registry and E-verify are contacted prior to an offer of employment being made. CFGH will disqualify candidates when abuse or neglect are substantiated on the registry. Candidates not legally eligible to work in the United States will not be offered employment.
• Pre-employment drug screening will be conducted for all staff in all classifications. A positive test for banned substances could preclude an offer of employment.
• A job performance evaluation is conducted at the end of an employee’s 90-day probation period (unless extended) and is based on the employee’s job description. Thereafter, evaluations are conducted annually. Employees who transition into other positions may receive another 90-day evaluation based on their most current job description.
• The Office of the Inspector General Exclusion list is checked monthly to ensure current employees are not on the list. Discovery that a staff member is on the list will result in termination of employment. 

SECURITY OF RECORDS

• All records are the property of CFGH, Inc. and are not to be removed from the facility except by authorization of the Executive Director, his/her designee or by court order.
• In the event, approval is obtained to remove a record from its location; the record must travel in a locked container and in the custody of designated employee.
• CFGH, Inc. has the right to deny the release of any confidential information unless there is a legitimate need to know the information.
• Records will be placed in a location that can be locked and secured from theft.
• When necessary, and if safe to do so, records will be placed higher and/or moved to a safer location during or pending the threat of an emergency or natural disaster. 

EDUCATION AND TRAINING

• CFGH’ Corporate Compliance Plan will be included in the new hire packet for all locations. Employees will keep a copy of the plan and will sign a statement of their willingness to follow the standards within the plan.
• Education and training on corporate compliance will be completed at hire and annually for all employees.
• Education and training as applicable to job descriptions will be completed at hire and as needed for all employees.
• Education and training on specific Policies and Procedures as applicable to job descriptions will be completed at hire and as needed for all employees. The Policies and Procedures Manual in its entirety will be available to all CFGH employees.
• Documentation of training will be kept in personnel files and/or electronically tracked.
• Employees are responsible for completing all aspects of training and for taking initiative to seek answers to questions.
• CFGH’ Corporate Compliance Plan is on the company website and is posted in all offices. Paper copies are available upon request for all stakeholders.

REFERRALS

• CFGH will not receive or make referrals in exchange for any remunerations (including but not limited to cash, free rent, free or discounted entertainment or meals, marketing, excessive compensation for consultancies, etc…), unless excepted under federal the “safe harbor” regulations.
• Improper or fraudulent influence over an external auditor is prohibited.

MARKETING

• Marketing related decisions must be approved by the Executive Director.
• The Operations Analyst is primarily responsible for developing and implementing marketing tools.
• The Operations Analyst heads the Marketing Committee which exists to develop marketing strategies, furthering community education on CFGH services and opportunities.

USE OF SOCIAL MEDIA

• The use of social media to directly represent CFGH must be approved by the Executive Director and implemented by the Executive Director or designee. Changes made to existing social media must receive prior approval from the Executive Director.
  • Employees may share or forward existing social media. Examples include articles posted on Facebook or the website, fundraising event information, etc.
  • Employees may not use the CFGH name or logo without the express written consent of the CFGH Executive Director or designee.
• If an employee identifies themselves as a CFGH employee on social media, they must take appropriate measures to assure others realize they are not speaking for CFGH.
• Employees will not publish any photographs taken at CFGH, to include pictures of program participants.
• Employees will not reveal any confidential information, trade secrets, or intellectual property of CFGH, obtained during employment, including information relating to finances, marketing, program participants, operational methods, plans and policies.
• Employees will not make comments that suggest that they, or other employees, have engaged, or are engaging in, any violation of law or CFGH policy.
• CFGH reserves the right to monitor and access any information or data that is viewed, created, sent, received or stored using CFGH’ equipment or electronic systems, including electronic communication, internet usage, hard drives and other stored, transmitted or received information.

 USE OF TECHNOLOGY

• Hardware, software, internet, email, cell phones and all other forms of technology or systems owned and/or provided by CFGH are to be used primarily for business purposes. CFGH reserves the right to monitor and access any information or data that is viewed, created, sent, received or stored using CFGH’ equipment or electronic systems, including electronic communication, internet usage, hard drives and other stored, transmitted or received information. Technology Systems may not be used for the purpose of defamation, harassment, discrimination, etc.
  • Use of CFGH technology systems is restricted to authorized persons.
  • A user agreement will be signed by employees when they are assigned or check out an electronic device.
  • In the event a device is lost or stolen, the employee assigned that device must immediately report the incident at the time of discovery to their Supervisor. The employee must not discuss the incident with other personnel, Participants, donors, law enforcement, or anyone else until they have received explicit instructions to do so from the Executive Director or designee.
  • All electronic devices used to access or create CFGH documentation or other content are required to contain virus protection and must also be protected by a password or code. This includes personal devices.
    • Data not containing PHI or other sensitive information may be stored on or transferred with minimal security using email, external storage such as a flash drive or a personal device. Data that contains PHI or other sensitive information must be secured at all times and email containing PHI or sensitive information must be encrypted.
  • Any actual or suspected breach of hardware, software, internet, email, cell phone and all other forms of technology or systems owned or provided by CFGH will be immediately reported to the employees Supervisor.
• Exploration and use of the Internet pertaining to non-work related items should not interfere with productivity and must be done during approved break periods, or before or after work hours.
  • Use of CFGH internet or any other CFGH asset to access offensive sites, sites that would be deemed inappropriate to view at work, or sites that could reasonably transmit a virus are prohibited and subject to corrective action.
• Use of a current staff member’s account or access to their files without their consent is prohibited without prior approval of the Executive Director.
  • Account passwords must be protected. If a computer is lost or stolen, or if an ID or password are suspected to be stolen, employees will report immediately to their Supervisor or designated IT personnel.
  • An account password may be changed by the HR Specialist when an employee forgets their password or their password expires.
  • An account password may be changed by the HR Specialist for the purpose of viewing emails and/or content created or stored by an employee, during an investigation, suspension or extended leave. When possible, the employee will be informed that their password has been changed.
• CFGH reserves the right to suspend individual user accounts for violation of CFGH polices.
• User privileges may be suspended during an investigation and pending investigation results.
• User privileges will be de-activated at the termination of employment.
• Hardware belonging to CFGH may only be disposed of by the Office Manager or designee.

INVESTIGATION AND REMEDIAL MEASURES

Any employee who violates or knowingly fails to report any violation of the Corporate Compliance Plan, company policy or applicable laws/ regulations is subject to appropriate disciplinary action, up to and including termination. Allegations of employee misconduct will be investigated swiftly, thoroughly, and fairly by the Executive Director or designee. The identity of a reporter will be kept confidential to the greatest extent possible while the investigation is conducted. The discipline utilized will depend on the nature, frequency and severity of the violation. There may be instances when additional training is appropriate in lieu of disciplinary action as determined by the Executive Director or designee.

INTERNAL AUDIT AND MONITORING SYSTEMS

• The Board of Directors meets quarterly to establish and oversee the implementation of all policies and procedures.
• The Executive Director meets quarterly with the Operations Analyst and QA/QI Coordinator to review the Risk Management and Strategic Plans.
• The Corporate Compliance Plan is reviewed annually and updated as needed by the Executive Director or designee.
• Policies and Procedures are reviewed annually and updated as needed by the Executive Director or designee.
• The Human Rights Committee meets quarterly to ensure the proper treatment of all Program Participants and to ensure due process is followed in implementing a treatment program for ICF Program Participants.
• CFGH’ Intermediate Care Facilities are audited annually by government entities such as The Department of Health and Human Services and Life and Safety. CFVS may be audited by Vocational Rehabilitation. A plan will be written and implemented to correct deficiencies identified by these entities. Documentation of correction will be stored in the main office and/or program location.
• Program observations in each location are conducted quarterly at a minimum and as often as needed by the QA/QI Coordinator and Program Directors.
• Chart reviews for ICFs are conducted quarterly by the QA/QI Coordinator and Qualified Professional.
• Chart reviews for Supported Employment programs are conducted quarterly, at random, by the QA/QI Coordinator. 

FISCAL MANAGEMENT

• The Treasurer and/or Executive Director shall be responsible for ensuring proper handling of all revenues and expenses and accurate record-keeping of all finances.
• The Executive Director shall prepare budgets and budget revisions for each fiscal year to be reviewed and approved by the Finance Committee and submitted to the Board of Directors.
• All checks will be signed by the Executive Director.
• All transactions must be approved by the Executive Director.
• Transactions will be recorded by the Office Manager and posted to the appropriate Ledgers and Cost Centers.
• Monthly Financial Statements shall be forwarded to the Treasurer and each member of the finance committee for review.
• The Human Resource Specialist will prepare the payroll disbursements.
• Only the Accountant, Human Resource Specialist, Executive Director, and the Board Treasurer shall have access to the payroll records, which remain locked.  Each employee may review his own record under supervision at a scheduled time.
• The Executive Director may purchase up to $2,500.00 in capital expenditures. Excess of $2,500.00 shall be approved by the Board of Directors or its’ designee.
• An annual inventory will be taken to reconcile the property count to property records. 

EMPLOYEE RESPONSIBILTY TO COMPLIANCE

• Attend and complete required trainings.
• Read, understand, and adhere to CFGH’ Corporate Compliance Plan, Code of Ethics, and Policies and Procedures.
• Abide by State and Federal laws and regulations in relation to employment and Program Participants served.
• Be alert to any situation that could violate CFGH’ Compliance Plan, Policies and Procedures, and/or State and Federal laws and regulations.
• Promptly report any situation that violates or seemingly violates CFGH’ Compliance Plan, Policies and Procedures, and/or State and Federal laws and regulations.
• Ask questions, seek answers.

CORRECTIVE ACTION RELATED TO CORPORATE COMPLIANCE

Employees will adhere to the Corporate Compliance Plan and the Code of Ethics herein. Failure to do so may result in corrective action up to and including termination.

 

 

Rev. 11-13-17, 1-7-18, 7-1-18, 5-26-20, 6-8-20, 6-30-21, 2-16-23, 10-18-23