Compliance

Madison Cortland Chapter, NYSARC, Inc.
Corporate Compliance Plan
Plan Summary


Element 1 Compliance Standards and Procedures

“The organization must have established compliance standards and procedures to be followed by its employees and other agents that are reasonably capable of reducing the prospect of criminal conduct.” 

The Arc of Madison Cortland will develop and review, at least annually, a Compliance Code of Conduct, which will provide employees with guidance on requirements for employment conduct as established by The Arc of Madison Cortland and the regulations, laws and standards that are applicable to our work.  

All employees will be trained and provided with a copy of the Compliance Code of Conduct and Plan Summary, at initial compliance training. Employees will be asked to sign a statement acknowledging their receipt and understanding of the Compliance Code of Conduct and Compliance Plan. Employees will be trained on the Compliance Code of Conduct and Compliance Plan, and its applicability to their day-to-day work as employees and representatives of the organization, which will serve to reduce the prospect of criminal conduct.   

Element 2 Program Structure and Oversight Responsibilities

“Specific individual(s) within high level personnel in the organization must have been assigned overall responsibility to oversee compliance with such standards and resources.” 

The Arc of Madison Cortland is committed to the operation of an efficient and effective compliance program. The organization has therefore formalized an organizational structure including a Compliance Officer who will build the infrastructure for compliance, will assist management in monitoring, and will provide an objective point of view. The organizational structure will also include a Compliance Oversight Committee, and a Corporate Compliance Committee. These committees will assist the Compliance Officer in the development, implementation, oversight, and evaluation of the ethics and compliance program.  

Confidentiality

Staff assigned to compliance issues has access to confidential information. This includes clientele, employee, and business information that is sensitive and not available or known to the general public or other employees of the agency. This sensitive and confidential information must not be disclosed to unauthorized individuals. In addition, compliance program employees and committee members have a duty to take appropriate steps to secure and protect such information and to prevent any accidental disclosures.  


Element 3 Due Cares in Assignment of Responsibilities

“The organization must have used due care to delegate substantial discretionary authority to individuals whom the organization knew, or should have known through the exercise of the due diligence, had a propensity to engage in illegal activities.”

The Arc of Madison Cortland is committed to maintaining the integrity of our service, financial, and business operations. In order to do this it is important that we hire or contract with those individuals and organizations that have the same respect for law, regulation and standards that we do. Therefore, before hiring a new employee or independent contractor, the agency will conduct appropriate screening activities to make sure the individuals and organizations have not been sanctioned or excluded by a federal or state law enforcement agency, regulator, or licensing agency. 

Due care will be used in protecting the agency against any potential conflicts of interest. All members of the Board of Directors, Executive and Management staff will sign a statement disclosing any conflicts or potential conflicts. This will be done on an annual basis.  
  
Element 4 Education and Training

“The organization must have taken steps to communicate effectively its standards and procedures to all employees and other agents, e.g., by requiring participation in training programs or by disseminating publications that explain in a practical manner what is required.”

The Arc of Madison Cortland is committed to implementing an effective compliance program that will help to ensure that we deliver high quality services that are compliant with the regulations and laws that are applicable to our work. One of the key components of a compliance program is training. Employees will receive mandatory training on The Arc of Madison Cortland compliance program, including the Code of Conduct, within 90 days of their hire date and at least annually thereafter.  

Element 5 Monitoring and Auditing Systems

“The organization must have taken reasonable steps to achieve compliance with its standards, e.g., by utilizing monitoring and auditing systems reasonably designed to detect criminal conduct by its employees and other agents and by having in place and publicizing a reporting system whereby employees and other agents, could report criminal conduct by others within the organization without fear of retribution.”

It is the policy of The Arc of Madison Cortland to encourage an organizational culture in which all employees feel a duty to report behaviors or actions that they believe are not compliant with the laws and regulations that govern our work. Therefore, the effectiveness of our compliance program depends on the willingness of employees in all parts and at all levels of the agency to step forward, in good faith, with questions and concerns. We believe strongly that in all of these cases, resolution of the problem, behaviors or actions will result in better care for those people who receive our services. Therefore, each person reporting problems or concerns will be contributing positively to the overall quality of the services at The Arc of Madison Cortland. 

Ongoing monitoring and auditing of programs and services will be done on a regular and scheduled basis by both the programs and by Quality Management.  

Element 6 Disciplinary Action

“The standards must have been consistently enforced through appropriate disciplinary mechanisms, including, as appropriate, discipline of individuals responsible for the failure to detect an offense. Adequate discipline of individuals responsible for an offense is a necessary component of enforcement; however, the form of discipline that will be appropriate will be case specific.” 

Employees who fail to comply with the policies and standards or who engage in conduct that has the potential of impairing The Arc of Madison Cortland status as a reliable, honest and trustworthy healthcare provider will be subject to disciplinary action up to and including termination.

Element 7 Detection and Response, and Prevention

“After an offense has been detected, the organization must have taken all reasonable steps to respond appropriately to the offense and to prevent further similar offenses-including any necessary modifications to its program to prevent and detect violations of law. “

It is important for The Arc of Madison Cortland compliance program to detect and report instances of non-compliance on a timely basis. If a compliance problem is reported or detected internally, the agency, through its compliance program staff, will investigate to determine if credible evidence exists that a violation of law or regulation has occurred. If, after investigation or inquiry, the agency determines that credible evidence exists of violation of law or regulation, it will immediately implement a corrective action plan to correct the problem and to prevent its reoccurrence. It may also consult with legal counsel to determine if it is necessary to report the violation to law enforcement or to a regulatory agency, and will do so in a timely fashion, once a voluntary report is determined to be necessary.

Element 8 Non-Retaliation Policy

“Agencies must have a policy of non-intimidation and non-retaliation for good faith participation in the compliance program.”  

Our Code of Conduct states that we have our responsibility to maintain an environment where we can feel free to address concerns and report suspected noncompliance. Managers have a responsibility to promote this environment and educate our workforce, letting them know that we do not tolerate retaliation or retribution against anyone who in good faith reports illegal, unethical, or inappropriate activity that they are aware of at The Arc of Madison Cortland. Such retaliation will be subject to disciplinary action, up to and including dismissal.   


Element 1 COMPLIANCE STANDARDS AND PROCEDURES

Related Documents (see Appendix)

  • Compliance Code of Conduct  
  • The Arc of Madison Cortland Board of Directors Resolution #05-31-02
  • Compliance Program Maintenance

“The organization must have established compliance standards and procedures to be followed by its employees and other agents that are reasonably capable of reducing the prospect of criminal conduct.” 

The Chapter’s Compliance Standards are expressed in our Compliance Code of Conduct, Compliance Plan, and Procedures. Additional compliance guidance is contained in documents specific to our Departments (e.g., HCBS Waiver Services, Article 16 Clinic, Residential, Accounting).

These documents collectively establish compliance standards and procedures that must be followed by all The Arc of Madison Cortland associates. Understanding and following them will reduce the prospect of unethical, illegal, or criminal conduct and will protect The Arc of Madison Cortland and its associates.

All The Arc of Madison Cortland employees and Board members will receive a copy of the Code of Conduct and are responsible for reading this Code and seeking answers to any questions they may have regarding its content or intent.  

Revisions to the Corporate Compliance Program

The Chapter’s Corporate Compliance Program and its policies are intended to be flexible and readily adaptable to changes in regulatory requirements and the needs of the Chapter. The Program will be reviewed annually by the Corporate Compliance Committee and specific portions of the Program will be reviewed on an as-needed basis when prompt revisions are indicated. To facilitate appropriate revision to the Program, the Compliance Officer shall prepare an annual report for the Board of Directors, and the Executive Director, that describes the general compliance efforts that have been undertaken during the preceding year, and that identifies any changes that might be made to improve the Program.

Circumstances may necessitate more immediate changes or updates to the Compliance Program during the course of the year. These prompt changes may arise from amended laws changes. The Compliance Officer will draft such urgent changes or updates. Following comment and revision, the amended portion of the Compliance Program will be presented at the next scheduled meeting of the Corporate Compliance Committee for discussion.

Element 2 PROGRAM STRUCTURE AND OVERSIGHT RESPONSIBILITIES

Related Documents (see Appendix)

Program Structure and Oversight Responsibilities
a. The Role of the Compliance Officer
b. The Role of the Compliance Oversight Committee
c. The Role of the Corporate Compliance Committee
d. The Role of Management   

“Specific individual(s) within high level personnel in the organization must have been assigned overall responsibility to oversee compliance with such standards and resources.”

The Arc of Madison Cortland has assigned compliance oversight responsibilities to individuals at the Executive levels. These individuals occupy high levels within The Arc of Madison Cortland’s organizational structure and are empowered to implement the Compliance Plan, investigate compliance concerns, report compliance concerns directly to those in higher positions of authority up to, and including the Executive Director, President , and the Board of Directors. The Arc of Madison Cortland is committed to the operation of an effective compliance program.      

Element 3 DUE CARE IN ASSIGNMENT OF RESPONSIBILITIES   

Related Documents (see Appendix)

  • Credentialing of Professional Employees
  • Professional License/Certification Attestation
  • Policy Regarding Conflicts of Interest and Related Party Transactions
  • Conflicts of Interest and Related Party Transactions Acknowledgement
  • Criminal Background Checks - OPWDD
  • Criminal Background Checks - OMH
  • Employee Exclusion Check Policy/Procedure
  • Vendor/Contractor Exclusion Check Policy/Procedure
  • Employee Disclosures Procedure
  • Employee Disclosure Form
  • Child Abuse Policy

“The organization must have used due care to delegate substantial discretionary authority to individuals whom the organization knew, or should have known through the exercise of due diligence, had a propensity to engage in illegal activities.”

As a provider of health related services to people with disabilities, the organization must use due care not to delegate substantial discretionary authority to individuals whom the organization knows, or should have known through the exercise of due diligence, have propensity to engage in illegal activities that would result in exclusion or debarment from Federal Health Care programs.

The Arc of Madison Cortland uses due care to meet all regulatory standards not to employ and/or delegate substantial discretionary authority to individuals who have a propensity to engage in illegal activities regarding services to the disabled. This standard is applied to all new and existing employees, contractors and vendors.

New Employees

The Arc of Madison Cortland Human Resources conducts a pre-employment screening verification, based on regulatory and agency requirements as stated in the job description, for all new employees as part of the employment application process. This prescreening includes, but is not necessarily limited to educational qualifications and license verification as disclosed by the applicant and verification against appropriate federal and state excluded parties’ lists. 

As part of the job application process, all candidates must disclose criminal convictions, certify that he/she is not currently or has ever been debarred, excluded or ineligible from participation in the NYS Medicaid Program and/or a federal health care program. (See Form ‘Professional License/Certification Attestation’ appendix and Employee Application Insert- Attestation). The Arc of Madison Cortland policies prohibit the employment of individuals who are listed as debarred, excluded, or otherwise ineligible for participation in Federal health care programs (as defined in 43 USC 1320a & c).  

In addition, employees in selected classifications are required to pass a pre-employment drug screening examination, and/or screening done by the NYS Office of Child and Family Services and the Division of Criminal Justice Services. The Arc of Madison Cortland is prohibited from hiring or contracting with anyone that has been identified on the NYS Staff Exclusion List.

Existing Employees and Board Members

All existing professionally licensed employees are screened annually (if appropriate) to ensure that their professional licenses are active and accurate. In addition, employees will be screened to determine if they are currently under an investigation of the NYS Office of the Professions. Professional employees may be subjected to termination, if the aforementioned items are not found to be in order.

All existing employees and members of the Board of Directors will be checked monthly against the appropriate federal and state exclusion lists to assure that they have not been added to this database.

Vendors and Contractors

Any vendor or contractor wishing to enter into a contract with The Arc of Madison Cortland is required to certify in its contract that neither it nor any of its employees has been excluded from participation in federally sponsored health care programs. Each vendor/contractor shall be checked monthly by the Finance Department for potential exclusion against appropriate state and federal exclusion lists. 

Conflict of Interest

The Arc of Madison Cortland Board of Directors, Building Futures Foundation members, and upper management staff are required to sign a Conflict of Interest statement annually. They should avoid, or where impossible to avoid, should disclose outside business interests that could compromise their commitment to The Arc of Madison Cortland. 

Employee Disclosures

Employees are permitted to hold outside employment if it does not interfere with their attendance and/or job performance and does not represent a conflict of interest. Agency employees shall notify their supervisor using an Employee Disclosure Form. The supervisor shall then forward the form to the Human Resources Department. Employees on a Leave of Absence are not allowed to have employment elsewhere unless approved in writing by the Executive Director or designee.

Employees are required to complete a disclosure form when they have a relative working for, or receiving services from The Arc of Madison Cortland. Relative is defined as spouse, domestic partner, child, parent, sibling, grandparent, grandchild, uncle, aunt, first cousin or corresponding in-law or step-relation.
Criminal Background Checks

The Arc of Madison Cortland meets or exceeds the criminal background checks requirements as per NYS law(s). Employees, vendors, and contractors that must undergo a criminal history background check, by virtue of their job description, are obligated to inform their supervisor or the Director of Human Resources of any arrests or bars/exclusions that occur while employed within 48 hours of occurrence.

Element 4 EMPLOYEE EDUCATION AND TRAINING

Related Forms (see Appendix)

  • Compliance Education and Training
  • Acknowledgement Form, Employees
  • Acknowledgement Form, Board of Directors and Building Futures Foundation Board members

“The organization must have taken steps to communicate effectively its standards and procedures to all employees and other agents, e.g., by requiring participation in training programs or by disseminating publications that explain in a practical manner what is required.”

The Arc of Madison Cortland provides education and training programs in a variety of content areas for employees, the Board of Directors, and health care contractors. This education and training program communicates The Arc of Madison Cortland’s standards and procedures to enhance and maintain awareness of compliance policies and laws. Both initial and annual compliance education and training that is appropriate to the circumstances and duties of an employee’s job are provided. Education and training content areas shall include all areas of Corporate Compliance , as well as issues specific to a particular program, particular job, function, or activity (i.e. billing, information security).

All personnel and members of the Board of Directors, and Building Futures Foundation members shall participate in training on the topics identified below to which their responsibilities are relevant:
  • Government and private payer reimbursement principles,
  • Government initiatives,
  • History and background of Corporate Compliance,
  • Legal Authority,
  • General prohibitions on paying or receiving remuneration to induce referrals,
  • Prohibitions against submitting a claim for services when documentation of the service does not exist,
  • Prohibitions against signing for the work of another employee,
  • Prohibitions against alterations to individuals’ records, 
  • Prohibitions against performing medical or nursing therapies without a signed physician’s order, 
  • Proper documentation of services rendered, and 
  • Duty to report misconduct.

Managers shall assist the Compliance Officer in identifying areas that require specific training and are responsible for communication of the terms of the Compliance Plan to all independent contractors doing business with the agency. Managers are responsible for assuring that all health care related contractors abide by the terms of the Compliance Plan. Each employee and contractor shall receive a written summary of the compliance policies and specific standards of conduct that affect their position. They will also be informed of the location of the entire Compliance Plan and will have access to this document. 

All education and training relating to the compliance plan will be verified by attendance. A signed acknowledgement of initial training and receipt of compliance plan and standards (Form #994) will be kept in the employee’s personnel file.  

Attendance at annual compliance training sessions is mandatory and is a condition of continued employment.

Element 5 MONITORING AND AUDITING SYSTEMS (INCLUDING REPORTING)

Related Documents (see Appendix)

  • Internal Compliance Monitoring and Auditing
  • Compliance Line
  • Document Retention Policy
  • Electronic Storage of Paper Documentation Procedure
  • Files for Storage/Archive Instructions
  • Document /File Retrieval Procedure
  • Billing Adjustment Procedure & Form

“The organization must have taken reasonable steps to achieve compliance with its standards, e.g. by utilizing monitoring and auditing systems reasonably designed to detect criminal conduct by its employees and other agents and by having in place and publicizing a reporting system whereby employees and other agents, could report criminal conduct by others within the organization without fear of retribution.”

The Arc of Madison Cortland utilizes internal and external monitoring and auditing systems to detect unethical, non-compliant, or illegal conduct by The Arc of Madison Cortland associates.

Auditing Systems

The Arc of Madison Cortland engages in a system of ongoing monitoring and internal audits of its programmatic and business activities. The Compliance Officer determines annual priorities for internal audit and/or review. There are three general objectives that drive these reviews:

  • To assist the Chapter in performing risk analysis to determine compliance risk factors.
  • To assist the Chapter in implementing effective and efficient internal controls and process improvements that are responsive to the risk factors and that provide reasonable assurance of the Chapters’ compliance with laws and regulations.
  • To monitor compliance with the Chapter’s policies and procedures.
  • To improve overall quality of the services provided.

Any significant deficiencies in The Arc of Madison Cortland’s system of internal controls will be reported along with recommendations for process improvement and follow-up actions.

Individual departments are also responsible for quality assessment and improvement efforts and for monitoring procedures for compliance. Practices for the monitoring of departments are approved by, and results communicated to, the Compliance Officer to insure practicality and effectiveness.

Reporting Systems

Compliance issues/concerns may be presented initially to managers, the Compliance Officer or the Executive Director as appropriate.

The Arc of Madison Cortland employees who report compliance concerns in good faith will not be subject to retaliation or harassment as a result of the report. Concerns about possible retaliation or harassment stemming from a compliance report may be reported to the hotline, Compliance Officer, or Human Resources Manager.

The Compliance Officer will maintain a confidential log of compliance concerns that are reported. This log will record specific information about the concern and the person filing the initial report. Access to the confidential log is limited to the Compliance Oversight Committee and Quality Evaluators. A summary of the log and any investigations will be included in monthly board reports and in the annual compliance report to the Board of Directors.

Confidential Compliance Line (‘Hotline’)

The Arc of Madison Cortland’s Compliance Hotline permits compliance issues to be reported on an anonymous or confidential basis. The hotline is available 24 hours per day, seven days per week. Issues can be reported via a toll free number or by completing a web-based report. Reports to the Hotline may be made:

• Anonymously (the caller does not reveal his identity during the call)
• Confidentially (the caller reveals his/her identity but requests confidentiality)
• Identified (the caller reveals his/her identity and allows it to be used as needed)

All Hotline reports are directed to the Compliance Officer. Anonymous callers will be provided the opportunity to obtain a code number by leaving a call back number. The purpose of the call back number is to remain anonymous while still having the opportunity to call the compliance line at a later date to receive a follow up and/or resolution.

The Compliance Officer will maintain a log reflecting all compliance issues reported via the Hotline and the resolution of those reports.

 
Element 6 ENFORCEMENT AND DISCIPLINE

Related Documents (see Appendix)

  • Discipline & Incentive Program Policy
  • Enforcement and Discipline

“The standards must have been consistently enforced through appropriate disciplinary mechanisms, including, as appropriate, discipline of individuals responsible for the failure to detect an offense. Adequate discipline of individuals responsible for an offense is a necessary component of enforcement; however, the form of discipline that will be appropriate will be case specific.”

The Arc of Madison Cortland consistently enforces compliance with its standards through appropriate disciplinary mechanisms. Disciplinary procedures are weighted according to the compliance violation committed and the employee’s compliance history. 

All compliance-related disciplinary action shall be documented in an employee’s personnel record maintained by Human Resources. A copy will also remain with the Compliance Officer. While there are broad categories of disciplinary actions, each instance of compliance discipline will be case-specific.

Disciplinary action, up to and including dismissal, will occur for the following verified infractions:
  • Failure to report suspected problems
  • Participating in non-compliant behavior
  • Encouraging, directing, facilitating, or permitting either actively or passively non-compliant behavior
  • Retaliation against anyone who reports a compliance concern in good faith  

The Arc of Madison Cortland has established a “zero tolerance” for cases of verified fraud. Any employee or contractor determined to have committed fraud will be terminated.

Element 7 DETECTION, RESPONSE AND PREVENTION

Related Documents (see Appendix)

  • Response to Detected Offenses
  • Response to Warrants
  • Response to Subpoenas
  • Response to Government Audits or Inquiries
  • Detecting and Responding to Violations; Voluntary Disclosure Policy
  • Self-Disclosure Policy
  • NYS OMIG Self-disclosure Submission Guidelines
  • NYSARC, Inc. Board of Governors Resolution Requiring the Reporting of Significant Compliance Events

“After an offense has been detected, the organization must have taken all reasonable steps to respond appropriately to the offense and to prevent further similar offenses-including any necessary modifications to its program to prevent and detect violations of law.”

Response to Compliance Reports

The Arc of Madison Cortland continually monitors its compliance “atmosphere” with the intent of detecting, correcting, and preventing non-compliance behaviors. Through the process of its compliance reporting structure and the articulation of compliance-related roles and responsibilities at all levels, detection and correction of problems is expedited. The modalities for compliance reporting (which may be internal or via the Hotline; identified, confidential, or anonymous) encourage compliance concerns to be brought forward when The Arc of Madison Cortland employees have concerns. The Arc of Madison Cortland’s Compliance Officer and Compliance Oversight Committee may be involved in any or all stages of resolving a compliance report as appropriate. The collection of cumulative report information allows the Compliance Officer and Compliance Oversight Committee to detect potential areas of recurring problems and to institute measures to prevent future problems.

Our responses may include making prompt correction of overpayments, and notifying/self-disclosing to the appropriate governmental agencies.

All compliance matters where there is a substantial reason to believe that a Chapter director, officer, or executive manager has permitted or engaged in illegal activity must also be reported to NYSARC’s state office compliance staff.  

Prevention

Organization of the Compliance Program ensures that compliance issues may be forwarded to the Executive level. This allows systemic changes in policies and procedures to occur, thus reducing the prospect of future problems. In addition, The Arc of Madison Cortland’s compliance education, continuing education, and awareness programs, contribute to a culture of on-going awareness, detection, and prevention.   


Element 8 NON-RETALIATION POLICY

Related Documents (see Appendix)

  • False Claims Act
  • Reporting Compliance Concerns/Whistleblower/Anti-Retaliation Policy

“Agencies must have a policy of non-intimidation and non-retaliation for good faith participation in the compliance program.”  

The Chapter’s Code of Conduct specifically states our responsibility to ensure employees are treated with mutual respect. To this end, any employee who brings forth a compliance concern in good faith will have assurance of non-retaliation & non-intimidation. “Good faith” is defined as “a sincere belief or motive without any malice or the desire to defraud others”. 

Managers will treat all employee compliance concerns with a high degree of importance, and bring all issues to the Compliance Officer or designee in a timely fashion. Confidentiality will be protected to the degree possible.  

Specific areas of protected activity include (but are not limited to):

  • Reporting potential issues
  • Investigating issues
  • Self-evaluations, audits, and remedial actions
  • Reporting to appropriate officials as allowed by NYS Labor Law 740 & 741

TO REPORT A COMPLIANCE CONCERN, CONTACT:

Barbara McDermott, Corporate Compliance Officer 315-363-3389 Ext. 1003
or
Confidential Hotline: 1-800-401-8004 
or 
Reporting Compliance Concerns/Whistleblower/Anti-Retaliation Policy

Date of First Issue: January 2015 Revision Date(s): January 2017

I. POLICY

Strict adherence to The Arc of Madison Cortland’s Corporate Compliance Plan and Code of Conduct is vital. The Arc requires all employees, directors, officers and volunteers to promptly report any known or suspected violations of the Corporate Compliance Plan, Code of Conduct, policies and procedures or any of the laws, rules or regulations by which the Arc is governed. This Policy governs the procedure to be used by employees, directors, officers and volunteers to report compliance concerns and seeks to ensure that the Arc provides an environment that encourages individuals to report any suspected violations without fear of retaliation or retribution.

II. RESPONSIBLE PARTY

This Policy applies to all employees, directors, officers, and volunteers of The Arc of Madison Cortland. This policy must be distributed to all directors, officers, employees and volunteers who provide substantial services to The Arc. Distribution may be satisfied through posting of this policy to The Arc’s website or at the corporate offices in a conspicuous location available to employees and volunteers. The Board oversees implementation of and compliance with this policy.

III. PROCEDURE

Duty to Report

Employees, directors, officers, and volunteers are required to report any known or suspected violations of the Corporate Compliance Plan, Code of Conduct, policies and procedures or any of the laws, rules or regulations by which The Arc of Madison Cortland is governed to their supervisor, manager, the Corporate Compliance Officer or through The Arc of Madison Cortland’s Compliance Hotline.  

Reporting through the Arc of Madison Cortland’s Compliance Hotline

Employees, directors, officers, and volunteers may report their compliance concerns confidentially to The Arc of Madison Cortland’s Compliance Hotline. The Compliance Hotline telephone number is 1-800-401-8004. Hotline reports can also be submitted via website: http://www.lighthouse-services.com/madisoncortlandarc. Callers to the Compliance Hotline may make reports anonymously. No caller will be required to disclose his or her identity and no attempt will be made to trace the source of the call or identity of the caller when the caller requests anonymity.
If a caller has revealed his or her identity, confidentiality will be maintained to the extent practicable and allowed by law. Callers should be aware, however, that it may not be possible to preserve anonymity if they identify themselves, provide other information which identifies them, the investigation reveals their identity or they inform people that they have called the Compliance Hotline. Callers should also be aware that The Arc of Madison Cortland is legally required to report certain types of crimes or potential crimes and infractions to external governmental agencies.
The Compliance Hotline telephone number and website shall be visibly posted in a manner consistent with employee notification in locations frequented by The Arc employees, directors, officers, and volunteers.  
Confidentiality of Reports
The Arc of Madison Cortland will attempt to treat all reports made under this policy confidentially and to protect the identity of the individual who has made a report to the maximum extent possible consistent with fair and rigorous enforcement of the Corporate Compliance Program and Code of Conduct.
Tracking/Investigations of Reports
The web-based secure Case Management system associated with the Arc of Madison Cortland’s hotline will be the mechanism used to track all reports, including those that were submitted from sources other than the Hotline.  
The Compliance Officer or designee shall conduct an investigation in accordance with our compliance plan.
The Compliance Officer shall prepare a report to the Compliance Committee at least annually summarizing incidents reported, investigatory findings and any corrective actions taken.

The person who is subject of the whistleblower complaint may not be present or participate in board or committee deliberations or vote on the matter relating to the complaint (except that nothing prohibits the person from providing background information or answering questions before deliberations/voting begin).
Non-Retaliation/Non-Retribution

General Principles

The Arc of Madison Cortland will not impose any disciplinary or other action in retaliation, including intimidation, harassment, and discrimination, against individuals who make a report or complaint in good faith regarding any action or suspended action taken that the individual believes may violate the Arc of Madison Cortland’s Corporate Compliance Plan, Code of Conduct, its Compliance Policies, or any of the laws, rules or regulations by which we are governed. “Good faith” means the individual believes the potential violation actually occurred as he or she is reporting it.


All employees, directors, officers, and volunteers of The Arc of Madison Cortland are strictly prohibited from engaging in any act, conduct or behavior which results in, or is intended to result in, retaliation or retribution against any individual for reporting his or her concerns relating to a possible violation of The Arc’s Corporate Compliance Plan, Code of Conduct, its Compliance Policies or any of the laws, rules or regulations by which The Arc of Madison Cortland is governed.

The non-retribution/non-retaliation provisions of this Policy do not permit employees, directors, officers, or volunteers to avoid the consequences of their own wrongdoing by reporting such wrongdoing. Disciplinary actions taken against an employee, director, officer, or volunteer who reports his or her own wrongdoing will be a result of the wrongdoing itself, not the reporting of such wrongdoing and, therefore, are not to be considered retaliation or retribution. Self-reporting may, however, be taken into account in determining the appropriate disciplinary action to be taken.
Reporting Complaints

If an employee, director, officer, or volunteer believes in good faith that he or she has been retaliated against for initiating a report or complaint or for participating in any investigation related to such report or complaint, then The Arc employee, director, officer, or volunteer should report the retaliation to his or her supervisor, manager, the Corporate Compliance Officer or the Compliance Hotline as soon as possible. The report should provide a thorough account of the incident(s) and should include names, dates of specific events (if available), the names of any witnesses and the location or name of any document in support of the alleged retaliation.

The compliance officer or appropriate designee will conduct a thorough and objective investigation of the incident(s).  

Adverse actions in retaliation for an employee’s report or complaint may result in discipline, up to and including termination.

Discipline

Any disciplinary action for violation of the Corporate Compliance Plan, Code of Conduct, policies and procedures or any of the laws, rules or regulations by which The Arc of Madison Cortland is governed shall be imposed in accordance with The Arc’s Discipline and Incentive Program Policy.
In the event an employee makes a frivolous, malicious or knowingly false report or complaint under this Policy, the employee will be subject to appropriate discipline, up to and including termination.  
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