Compliance & Ethics Program

It is IAHD’s policy to comply with all applicable federal, state and local laws and regulations and payer requirements. It is also IAHD’s policy to adhere to the Code of Conduct that is adopted by the Board of Directors, the Chief Executive Officer and the Compliance Committee. The “Code of Conduct” describes the behaviors and practices that are expected by those who work at, or for, IAHD. The Corporate Compliance Program operationalizes these expectations. It provides the practices, rules and laws related to each expectation, as well as a description of how an instance of failure to comply, both suspected and actual, is identified, managed, investigated and corrected. 

At the core of IAHD’s Compliance Program is the expectation that all employees, board members, vendors and associates follow all applicable laws, rules and regulations. All internal policies and protocols must also be adhered to by all parties. Transparency is paramount to our agency’s successes. IAHD respects the dignity of all persons and expects that others also demonstrate that level of respect toward others. This is accomplished by the following actions:

• Expecting honesty, trust and fair dealing in our relationships with others.
• Creating a professional atmosphere.
• IAHD has an intolerance of any actions which discriminate against anyone, or that diminishes their
  dignity.
• Fostering an environment in which inappropriate or unlawful behavior is addressed swiftly and
  effectively.

The New York State Office of the Medicaid Inspector General (“OMIG”) has also identified eight (8) discrete areas that mandatory compliance programs must address. These areas are defined under 18 NYCRR Section 521.3. IAHD’s Compliance Program outlines our commitment to these elements and our efforts to ensure compliance with each.

Compliance requires the commitment of everyone at IAHD

All employees, board members, vendors and associates are expected to bring any and all concerns to the attention of the Compliance Officer, their supervisor, or any member of the Compliance Committee, either directly and immediately upon learning of the potential problem or upon determining through their dealings with their co-employees or supervisors that their concerns have not been satisfactorily and completely addressed.

Reports of any compliance concerns may be made in person, in writing, over the telephone, or by email at the addresses and number designated (See contact information in “Compliance Officer section) Any written communications, relating to these issues, or to the Code of Conduct in general, should be marked “CONFIDENTIAL” and placed in a sealed envelope. Since a response to the reporting individual by the Compliance Officer is anticipated in virtually all instances, the reporting employee, board member, vendor or colleague should provide his or her name and work location when the report is made. However, reports may be made anonymously, if report is made in good faith. In this situation, the reporter must provide as much information as possible regarding the concern.

All reports and communications received will be deemed confidential and privileged. Upon receipt, the communication will be reviewed, and appropriate investigatory steps will be decided by the Compliance Officer, in conjunction with other appropriate individuals. The cooperation of the reporting individual may be sought during any investigation. Conversely, the failure to cooperate with IAHD will be considered unacceptable. Upon conclusion of the investigation, the Compliance Officer will make a recommendation to the appropriate parties for necessary follow-up action to be taken.

Questions about the procedures outlined above, or issues as they relate to the Compliance Program, may be directed (orally or in writing) to the Compliance Officer, who shall promptly and practicably provide an appropriate response.

To ensure that IAHD has in place a governing body that effectively discharges its oversight responsibilities, IAHD has undertaken the following steps:

1. Adopt a meaningful Conflict of Interest policy for governing body, Senior Leadership and others in supervisory or decision-making positions. Attestations signed annually.
2. Implement a compliance function that is connected to all management and governing body entities within the enterprise
3. Include the governing body in compliance program approval process
4. Include governing body in annual self-assessment and work plan process to include planning and tracking progress.
5. Regular reporting to the Board of Directors by the Compliance Officer and Board Compliance Liaison of any issues that may have arisen pertaining to any of the elements of the Compliance Program, any investigations conducted, and any corrective measures which may have been taken.
6. Annual training for the Board on the Corporate Compliance Program

IAHD has enacted a policy protecting all employees, board members or volunteers from retaliation or intimidation when reporting potential violation of laws, regulations or agency policy, if the report is made in good faith. These concerns may be reported directly to a supervisor or manager, the Compliance Officer, or anonymously using the Compliance hotline.

Any person reporting his/her own violation cannot utilize anonymous reporting to satisfy his/her obligation to report a Concern. Reports can be made to the Compliance Officer at any of the following:

• Telephone: 914-220-4383
• Anonymous Reporting Hotline: 914-220-4397
• Email: EMatthews@iahdny.org
• Anonymous Reporting Email: compliance@iahdny.org 

IAHD’s Whistleblower Policy can be found in the IAHD Employee Handbook.

In addition to rules and standards for corporate compliance, there are expectations and standards regulating other areas of IAHD operations. These expectations are outlined in the Code of Conduct as well as in the IAHD Employee Handbook.

IAHD Corporate Compliance Program

IAHD Compliance Reporting And Investigations Policy And Procedure

IAHD Corporate Compliance Policy

IAHD Medicaid Exclusion List Checks Policy

IAHD Whistleblower Policy

The Chief Quality Enhancement Officer is Elizabeth K. Matthews and is appointed the Compliance Officer for IAHD. This position has a direct line of communication to the Chief Executive Officer, Board of Directors and IAHD Counsel. The Compliance officer is responsible for investigating, or delegating the investigation of, any concerns or issues reported pertaining to inappropriate practices, in violation of statutes, regulations and/or IAHD policies. The Compliance officer is also responsible for ensuring all “affected individuals” receive training and information on how concerns may be reported.

The Compliance Officer may be contacted at:

• Direct Telephone: 914-220-4383
• Anonymous Reporting Hotline 914-220-4397
• Email: EMatthews@iahdny.org

The Compliance Officer is also responsible for, but not limited to, performing risk assessments to identify any areas of concern pertaining to compliance related matters, and to remedy any deficiencies detected.

Corporate Compliance Committee

The Compliance Officer also chairs IAHD’s Compliance Committee (the Committee). IAHD’s Committee membership has been formed at the direction of the Chief Executive Officer and IAHD’s Board of Directors.
Membership of the committee is made up of the following:

1. Chief Quality Enhancement Officer (Compliance Officer) - Chair
2. Chief Operating Officer
3. Chief Financial Officer
4. Chief Innovation Officer
5. Director(s) of Residential Services
6. Director of Adult Day Services
7. Director of Clinical Supports
8. Director of Human Resources
9. Director of Finance
10. Director of Facilities Management
11. Director of Workforce Development
12. Corporate Compliance Manager
13. Board of Directors Compliance Liaison

The Committee meets bi-monthly, but may meet more often, as needed. Contact information for all Compliance Committee members can be found by contacting the Chief Quality Enhancement Officer.

IAHD is committed to complying with all federal and state requirements for education and training Compliance training is conducted during orientation for all new employees and within three months of appointing new board members.

On an annual basis, all employees are trained on Corporate Compliance through our online learning management system, Relias, with pre and post testing to measure comprehension. Completion of training is a condition of continued employment. For those whose responsibilities will include billing, the appropriate supervisor will provide more targeted, detailed billing training.

Members of the Board of Directors and volunteers receive in person training on an annual basis, with a pre and post test to measure comprehension of the materials.

In addition to periodic training, the Compliance Officer will disseminate any relevant, or updated compliance information to relevant parties through monthly emails to all IAHD employees and board members. (aka
‘Compliance Tip of the Month.”) The purpose is also to reiterate all reporting requirements, roles and responsibilities. IAHD will also incorporate various events and contests in the month of November to coincide with National Corporate Compliance Week. 

All employees, board members, volunteers, vendors, consultants, contractors or other associates of IAHD may use the same methods of reporting any concerns or suspected violations that are available to IAHD employees.

All “affected individuals” may report in the following ways:

• Direct Telephone: 914-220-4383
• Anonymous Reporting Hotline 914-220-4397
• Email: EMatthews@iahdny.org
• Anonymous Reporting Email: compliance@iahdny.org

All reports and communications received will be deemed confidential and privileged. Upon receipt, the communication will be reviewed, and appropriate investigatory steps will be decided by the Compliance Officer, in conjunction with other appropriate individuals. The cooperation of the reporting individual may be sought during any investigation.

Conversely, the failure to cooperate with IAHD will be considered unacceptable. Upon conclusion of the investigation, the Compliance Officer will make a recommendation to the appropriate parties for necessary follow-up action to be taken.

Possible consequences of any evidence of non-compliance or false reporting may result in disciplinary action up to and including termination for employees, removal from the Board of Directors, or cancellation of agreements or contracts with vendors. Reports of intimidating, harassment or retaliation against any person(s) reporting a concern in good faith, will also be considered unacceptable and appropriate measures will be taken.

To assess compliance in our operations, IAHD conducts periodic audits internally. These audits are supervised by the Compliance Officer. Audits will include various departments and are designed to address payments, billing, training and other relevant compliance issues. All audit findings will be reviewed by the Committee and shared with Board of Directors.

The Compliance Officer, or designee, will conduct periodic audits in accordance with all laws and regulations. The Compliance Officer, or designee, shall investigate all complaints of non-compliance. Based upon the results of audits and investigations for any uncovered infraction, progressive discipline will be implemented.

Ongoing evaluation is critical in detecting non-compliance and will help ensure the success of IAHD’s Compliance Program. An ongoing auditing and monitoring system is an integral component of our auditing and monitoring systems.

When assessing payments made to IAHD for services rendered, the following steps are taken:

1. Track and analyze any overpayments, underpayments and denials (See “60-day Rule); determine if self-disclosure to OMIG is necessary or required. Tracking is shared with the Committee
2. Share results of accounts receivable internal audits with the Committee
3. Conduct tracer audit for payments to assess accuracy of billing and resulting payments
4. Determine if billing and payment weaknesses are being identified and corrected as necessary.

In addition, when an overpayment is identified, an analysis is generally conducted to determine the cause, and to address and correct any issues contributing to the overpayment. Corrective measures may be chosen as part of the Compliance Work Plan for ongoing oversight by the Committee to assure ongoing improvement.

All licensed health care professionals providing individual care services must be fully capable of providing clinical responsibilities, with the mandatory education, licensure, and experience to do so known as “credentialing.” Below are some of the ways IAHD is addressing this requirement:

1. Requiring copies of all licenses and credentialing upon hire
2. Pre employment background checks, including against the Medicaid Exclusion List
3. Periodically check accuracy and comprehensiveness of active credentialing
4. Check Medicaid Exclusion List monthly to ensure no current employees, board members, volunteers or vendors are included.

On a monthly basis, IAHD checks all employees, vendors, and Board Members against the General Services Administration (GSA) Excluded Parties List System (EPLS), OIG List of Excluded Individuals/Entities (LEIE), OIG Most Wanted, Specially Designated Nationals, Office of Foreign Assets Control (SDN-OFAC), and the NYS OMIG Exclusion list. These federal and state lists maintain information regarding entities debarred, suspended, proposed for debarment, excluded or disqualified under the non-procurement common rule, or otherwise declared ineligible from receiving federal or state contracts, certain subcontracts, and certain federal assistance and benefits. IAHD has contracted with Valenz, to conducted to monthly checks, and a review of these is conducted by the Compliance Officer, or designee. 

The Committee reviews auditing, assessment, and monitoring activities designed to detect and prevent ethical or legal violations. The Compliance Officer, or designee, conducts risk assessments that help to ensure that IAHD's practices are evaluated for consistency in application of policies and procedures and the implementation of appropriate corrective action(s) have been taken. Each audit, assessment or monitoring process is designed and implemented to program needs and provides for a complete representation of the integrity of procedures across organization and program regulations. Risk areas may be identified through the regular course of business, external alerts, or internal reporting channels.

When a determination is made that a compliance violation has occurred, the Compliance Officer will notify the CEO, if the violation involves an employee, the Board Chair if the violation involves a board member, and for independent contractors, the Director of the program or department currently contracting with the provider.

All concerns or reports of non-compliance brought to the Compliance Officer will be thoroughly investigated with in 30 days of the complaint. Results of the investigation will be shared with the Committee, as well as the appropriate administrative or program department involved in the alleged incident of non-compliance. Recommendations may be made as a result of the investigative findings, either by the investigator or the Committee. Corrective actions will be reviewed by the Committee.

For those who may have questions, or are in need of further information, pertaining the IAHD Compliance
Program, please use the below contact information.

Key Compliance Contacts

• Corporate Compliance Officer: Elizabeth K. Matthews, (914) 220-4383
• Chief Executive Officer: Omayra Andino, (914) 220-4333
• Anonymous Reporting Hotline: (914) 220-4397
• Anonymous Reporting Email: compliance@iahdny.org