Compliance Program

I.  Mission of Corporate Compliance

Introduction 

To realize Vancouver Home Health Care Agency LLC’s vision of continuing its positive influence in the community, improving health status, providing better access and establishing cost-effective quality home health care, Vancouver Home Health Care Agency LLC holds its employees to the highest ethical and quality standards. In striving to achieve this goal, Vancouver Home Health Care Agency LLC has set out to implement a Corporate Compliance Program, and an Office of Corporate Compliance to assist in carrying out the program. 

Mission 

The mission of the Corporate Compliance Officer is to strive to protect and promote our integrity and enhance our ability to achieve our business and strategic objectives in a manner consistent with the Mission and Values of Vancouver Home Health Care Agency LLC. The mission of the Compliance Officer is to assist and advise employees and affiliated professionals to help ensure Vancouver Home Health Care Agency LLC is compliant with applicable Federal, State and local laws. In this capacity the compliance office is committed to providing clear guidelines to train and educate employees and affiliated professionals regarding applicable laws, regulations, policies and procedures as they pertain to compliance.

·       The Corporate Compliance Officer will promote a culture that encourages employees and affiliated affiliate professionals to conduct activities with integrity and in compliance with laws, regulations and Vancouver Home Health Care Agency LLC policies and procedures; and, to report instances of non-compliance to the Corporate Compliance Department.

·       To educate officers, directors, employees, and affiliate professionals of Vancouver Home Health Care Agency LLC concerning the legal risks of certain business practices.

·       To encourage Vancouver Home Health Care Agency LLC managers to seek appropriate counsel regarding business practices and to conduct those activities within the requirements of the law and ethical standards of conduct for Vancouver Home Health Care Agency LLC employees; and, to secure compliance with the Federal Sentencing Guidelines. 

Vision 

Corporate Compliance is a partnership with management, to help identify areas of regulatory risk and to help mitigate risk of non-compliance. This partnership enhances management’s ability to achieve organizational goals and objectives in a manner consistent with the Values of Vancouver Home Health Care Agency LLC. As employees, we will be dedicated to Vancouver Home Health Care Agency LLC and will act in a diligent, loyal and prudent manner to ensure high standards of creative leadership and fiscal responsibility; to collaborate and network with others who share our values in the provision of health related services; advocate on behalf of issues of conscience and human need; and contribute to the preservation and strength of professional home care. The Governing Board of Vancouver Home Health Care Agency LLC provides strategic direction. The Compliance Advisory Committee consists of members of senior management.

This Committee will have the responsibility of assisting the Compliance Officer in the implementation of the Compliance Program. The Committee shall provide support and feedback for the development of priorities for the Compliance Program and the implementation of the Compliance Program at Vancouver Home Health Care Agency LLC. In addition, the Committee shall establish priorities for educational programs to be provided as part of the Compliance Program and to help identify necessary human and financial resources required for the effective implementation of the Compliance Program. 

The Compliance Program shall include monitoring and auditing systems designed to detect ethical or legal violations and a reporting system whereby employees may report suspected violations of standards for ethical and legal conduct. Internal Audit staff shall, in consultation and collaboration with the Corporate Compliance Officer, coordinate appropriate internal audits and surveys to verify adherence to and awareness of Vancouver Home Health Care Agency LLC’s ethics and compliance policies and procedures. 

The Corporate Compliance Officer shall report to the Administrator regarding the Compliance Program on an ongoing basis, report the activities of the Compliance Program to the Corporate Compliance Committee at least annually, and report legal and ethics compliance as required.

II. Policy

PURPOSE 

The purposes of the Compliance Program are: 

1.  To educate officers, directors, employees, and affiliated professionals of Vancouver Home Health Care Agency LLC concerning the legal risks of certain business practices; 

2.  To encourage Vancouver Home Health Care Agency LLC managers to seek appropriate counsel regarding business practices and to conduct those activities within the requirements of the law and ethical standards of conduct for Vancouver Home Health Care Agency LLC employees; and, 

3.  To secure compliance with the Federal and State Guidelines. 

In furtherance of Vancouver Home Health Care Agency LLC’s Mission and Values, management will exercise appropriate due diligence to prevent and detect unlawful and/or unethical conduct by its employees and agents. To these ends, Vancouver Home Health Care Agency LLC’s Compliance Program is hereby established. 

POLICY 

Vancouver Home Health Care Agency LLC is committed to establishing and observing high standards and ethical conduct in its business and operational practices. This policy establishes a corporate compliance program, and policies and procedures, which conform to the standards, set forth in the Federal & State Guidelines. The Compliance Program shall be a Vancouver Home Health Care Agency LLC system wide program, structured to encourage collaborative participation at all levels of the Vancouver Home Health Care Agency LLC system. The Compliance Program shall focus on the detection and prevention of violations of federal, state and local laws. The Compliance Program shall foster an environment in which employees and affiliated professionals comply with all relevant laws and regulations and report any concerns about business practices as set forth under this policy. 

PROCEDURES 

A. Compliance Program Positions 

1.  Vancouver Home Health Care Agency, LLC.  Governing Body 

Vancouver Home Health Care Agency LLC Governing Body will provide strategic direction to the Corporate Compliance Program, and be responsible for approving the Corporate Compliance Risk Assessment and Plan. The Corporate Compliance Officer will update and report progress to the Committee at its regular meetings. 

2.  Corporate Compliance Officer 

Vancouver Home Health Care Agency LLC Corporate Compliance Officer shall be an employee who is delegated authority for day-to-day operation of the Compliance Program. The Corporate Compliance Officer shall report directly to the Administrator. 

3.  Corporate Compliance Advisory Committee 

A Corporate Compliance Advisory Committee shall be created and will consist of members of senior management. This Committee will have the responsibility of assisting the Compliance Officer in the implementation of the Compliance Program. The Committee shall provide support and feedback for the development of priorities for the Compliance Program and the implementation of the Compliance Program at Vancouver Home Health Care Agency LLC.  In addition, the Committee shall establish priorities for educational programs to be provided as part of the Compliance Program and to help identify necessary human and financial resources required for the effective implementation of the Compliance Program. 

B.   Elements of the Compliance Program 

1.  Corporate Compliance Officer 

The Corporate Compliance Officer will be responsible for the development, operation and oversight of the Compliance Program. 

2.  Employee Code of Conduct 

Vancouver Home Health Care Agency LLC shall establish a Code of Conduct, which shall govern the proper conduct of Vancouver Home Health Care Agency LLC employees and shall require all directors, officers, employees and affiliated professionals to comply with the ethical and legal standards outlined in this Compliance Program. 

3.  Evaluation of Business Practices 

In order to evaluate Vancouver Home Health Care Agency LLC business practices, the Corporate Compliance Officer shall: 

(a) Ensure that Vancouver Home Health Care Agency LLC business practices are monitored to ensure compliance with Vancouver Home Health Care Agency LLC’s policies and procedures and Compliance Program. 

(b) Ensure consistency in the application of Vancouver Home Health Care Agency LLC policies and procedures with the requirements of the Compliance Program, and implement appropriate corrective action. 

(c) Ensure that reasonable steps are taken to respond appropriately to ethics and/or legal compliance violations, to prevent further similar violations, and to recommend appropriate and consistent discipline for violators. 

(d) Oversee, as appropriate, investigations of ethics and/or legal Compliance Policy violations to ensure consistency in the enforcement of Vancouver Home Health Care Agency LLC’s policies. 

4.  Effective Reporting and Investigative Processes 

Under the general direction of the Corporate Compliance Officer, Vancouver Home Health Care Agency LLC shall implement processes to provide education and guidance on Vancouver Home Health Care Agency LLC’s ethics and legal compliance policies and procedures and for the reporting and investigation of business issues. 

(a) Each employee shall have responsibility to notify his or her supervisor in a timely manner, of any violations or suspected violations of the standards for ethics and legal conduct. In the alternative, an employee may follow the reporting procedure under section 5 (b) hereof. Employees will be informed that in some instances, the mere failure to report a suspected violation may itself be a basis for disciplinary action against an employee. 

(b) Employees will not be subject to reprisal for reporting, in good faith, actions that they feel violate the law or established standards. Any employee engaging in any act of reprisal for any good faith reporting shall be subject to discipline and or discharge. 

5.  Effective Communications and Training Programs to Alert Employees of Their Responsibilities 

The Corporate Compliance Officer shall have general responsibility to oversee the development and implementation of employee communications and training programs to ensure compliance with the Compliance Program. The communication and training programs shall include the following areas: 

(a) New employee orientation (to include coverage of ethics and legal compliance issues); 

(b) Annual review of ethics and legal compliance issues in departments at substantial risk and Specific business practices; and, 

(c) The identification of resources to provide effective compliance educational programs. 

(d) Employees shall be informed that strict compliance with both the Vancouver Home Health Care Agency LLC Code of Conduct and the requirements of the Compliance Plan is a condition of employment, and that: 

(i) The promotion of and adherence to compliance with the Code of Conduct and the requirements of the Compliance Plan are elements of evaluating supervisors and managers; and, 

(ii) Vancouver Home Health Care Agency LLC has a policy concerning the non-employment or retention of employees who are sanctioned for a violation of either the Code of Conduct, or the requirements of the Compliance Plan. 

6.  Monitoring Compliance with Compliance Policy 

(a) The Compliance Program shall include monitoring and auditing systems designed to detect ethical or legal violations and a reporting system whereby employees may report suspected violations of standards for ethical and legal conduct. 

(b) Internal Audit shall: 

(1) Identify audits required to verify adherence to, and awareness of, ethics and compliance policies.

(2) Review the results of periodic surveys to test awareness of Vancouver Home Health Care Agency LLC’s ethics and legal compliance policies and procedures. 

(3) Conduct Special audits as necessary to verify adherence to Vancouver Home Health Care Agency LLC’s ethics and compliance policies and procedures. These audits may include (a) on-site visits, (b) interviews with personnel, (c) reviews of written materials and documentation, and (d) trend analysis studies. 

(4) Monitor compliance with the terms of settlement agreements having systemwide implications, including settlement of government investigations, or major litigation. 

8.  Keeping the Vancouver Home Health Care Agency LLC Informed Concerning Compliance with Ethical and Legal Standards 

The Corporate Compliance Officer shall: 

(a) Report to the Administrator regarding the Compliance Program on an ongoing basis. 

(b) Report the activities of the Compliance Program to the Vancouver Home Health Care Agency LLC Governing Board at least annually. 

III. Code of Conduct

PURPOSE 

This policy shall set forth standards by which employees and affiliated professionals of Vancouver Home Health Care Agency LLC and its affiliates will conduct themselves in order to protect and promote organization wide integrity and to enhance the ability of Vancouver Home Health Care Agency LLC and its affiliates to achieve its business and strategic objectives in a manner consistent with the Mission and Values of Vancouver Home Health Care Agency LLC. 

SCOPE 

Vancouver Home Health Care Agency, LLC.

POLICY 

This policy articulates for employees and affiliated professionals of Vancouver Home Health Care Agency LLC the ethical framework within which Vancouver Home Health Care Agency LLC operates and places employees on notice that they will be held accountable for abiding by the articulated standards set forth in the Code of Conduct concerning applicable laws and ethical standards of business behavior for Vancouver Home Health Care Agency LLC and its affiliates. 

PROCEDURE 

This policy specifically relates to the Corporate Compliance Code of Conduct and is maintained in addition to other standard Codes of Conduct already in effect. In keeping with the Mission and Values of Vancouver Home Health Care Agency LLC, directors/trustees, officers, managers, employees, professional affiliates, contractors, volunteers, students and others are expected to comply with the following guidelines. Instances of non-compliance shall be promptly reported, and appropriate corrective actions shall be immediately taken. 

Vancouver Home Health Care Agency LLC employees and affiliated professionals shall: 

·       Deal openly and honestly with fellow employees, customers, contractors, government entities and others.   

·       Maintain high standards of business and ethical conduct in accordance with applicable federal, state, and local laws and regulations including fraud, waste and abuse.

·       Adhere to both the spirit and letter of applicable federal, state and local laws and regulations. 

·       Practice good faith in transactions occurring during the course of business.

·       Conduct business dealings in a manner such that the Organization shall be the beneficiary of such dealings.

·       Preserve patient confidentiality unless there is written permission to divulge information, except as required by law.

·       Refuse any illegal offers, solicitations, payments, or other remuneration to induce referrals of the people we serve for an item of service reimbursable by a third party.

·       Disclose financial interests/affiliations with outside entities to the Board of Trustees as required by the Conflict of Interest Statement.

·       Hold vendors to the same Code of Conduct as part of their dealings with Vancouver Home Health Care Agency LLC.

·       Notify his or her supervisor or, in the alternative, the Compliance Officer of instances of non-compliance.

·       Ensure compliance requirements regarding coding and billing are monitored and enforced. 

·       Use supplies and services in a manner that avoids waste.

·       Protect and retain records and documents as required by professional standards, governmental regulations and organizational policies.

·       Exercise discretion in the coding and billing of services, regardless of payor source. 

All directors, officers, managers, employees, professional affiliates, contractors, volunteers, students and others are informed of this Code of Conduct and sign an Affirmation Statement indicating their adherence to the Code of Conduct. However, this Code of Conduct does not replace sound ethical and professional judgment.

For any inquiries or to exercise your rights, please reach out to our office using the provided contact information.

Vancouver Home Health Care Agency,LLC.
8885 SW Canyon Rd. Suite 123
Portland, OR 97225-3455
Email Us at info@vhhca.com 

“At Vancouver Home Health Care Agency, our commitment is rooted in caring and compassion, ensuring that your well-being remains at the heart of what we do”