Corporate Compliance Plan and Whistleblower Policy

SCOPE OF POLICY

Board of Directors and all of The Well Staff working in our Mental Health and Substance Abuse Residential and Outpatient Services

RESPONSIBILITY FOR COMPLIANCE

Board of Directors and Executive Director

POLICY

The Well is dedicated to the delivery of behavioral healthcare services in an environment characterized by strict conformance with the highest standards of accountability for administration, clinical, business, marketing, and financial management. The Well leadership is committed to the need to detect waste, fraud, abuse, fiscal mismanagement, and misappropriation of funds. Ongoing monitoring of ethical, legal, and regulatory requirements is part of The Well Corporate Compliance Program. Additionally included are advocacy efforts for the consumers and corporate citizenship. The Well Board of Directors is committed to the establishment, implementation, and maintenance of a corporate compliance program that emphasizes:

1. The prevention of wrong doing, whether intentional or unintentional.
2. Immediate reporting and investigation of questionable activities and practices without consequences to the reporting party.
3. Timely correction of any situation that puts the organization, its leadership or staff, funding sources, or consumers at risk.

The Whistleblower Policy is intended to encourage and enable employees and others to raise serious concerns within The Well prior to seeking resolution outside The Well. No director, officer, or employee who in good faith reports a violation of the Code shall suffer harassment, retaliation, or adverse employment consequence. An employee who retaliates against someone who has reported a violation in good faith is subject to discipline up to and including termination of employment.

PROCEDURE

1. The Executive Director is designated overall responsibility for The Well Corporate Compliance Program.
2. The Executive Director designates a Corporate Compliance Officer for The Well who is the Operations Officer, to monitor The Well Corporate Compliance Program and to make quarterly reports to the Board of Directors of matters relating to the compliance program.
3. The Corporate Compliance Officer (CCO) shall:
   1. Serve as the primary point of contact for corporate compliance issues, including scheduling meetings and making recommendations to the Board of Directors on such matters.
   2. The CCO will develop, implement, and monitor on a regular basis the plan, internal and external monitoring, auditing, investigative and reporting processes, procedures, and systems.
   3. Prepare, submit, and report quarterly reports to the Board of Directors, or as often as is required in order to provide clear communication to the Board to allow for administrative oversight of these activities.
   4. Oversee and report on advocacy and corporate citizenship efforts.
4. The CCO shall submit an annual report to the Executive Director and the Board of Directors to include a minimum of:
   1. A summary of all allegations, investigations, or complaints in the previous 12 months as relevant to the Corporate Compliance Plan.
   2. A description of the corrective action.
   3. Any recommendations to the Board for changes in policy and procedure.
5. In order to effectively perform her/his duties, the CCO shall have direct and unimpeded access to the Executive Director, Board of Directors, the agency’s accounting firm, and legal counsel for matters pertaining to corporate compliance.

Reporting Violations

Employees are expected to report immediately any concerns related to waste, fraud, abuse, fiscal mismanagement, and misappropriation of funds or ethical, legal, and regulatory requirements. Employees may go directly to their supervisor with these concerns, who will then report to the Corporate Compliance Officer or the employee may go first to the Corporate Compliance Officer. The Corporate Compliance Officer will notify the Executive Director of any reported violations immediately.

Accounting and Auditing Matters

The Board of Directors shall address all reported concerns or complaints regarding corporate accounting practices, internal controls, or auditing. The Executive Director shall immediately notify the Board of Directors of any such complaints and work with the board until the matter is resolved.

Fair Business Practices

The organization ensures that it avoids unfair business practices such as fee-splitting, kickbacks for referrals, business conflicts of interest, and self-dealing. The Well prohibits offering, paying, soliciting, or receiving anything of value to induce or reward referrals to the program.

Acting in Good Faith

Anyone filing a complaint concerning a violation or suspected violation must be acting in good faith and have reasonable grounds for believing the information disclosed indicated waste, fraud, abuse, fiscal mismanagement, and/or misappropriation of funds or is a violation of ethical, legal and/or regulatory requirements. Any allegations that prove not to be substantiated and which prove to have been made maliciously or knowingly to be false will be viewed as a serious disciplinary offense.

Confidentiality

Violations or suspected violations may be submitted on a confidential basis by the complainant or may be submitted anonymously. A report of violations or suspected violations will be kept confidential to the extent possible, consistent with the need to conduct an adequate investigation.

Handling of Reported Violations

The Corporate Compliance Officer will notify the sender and acknowledge receipt of the reported violation or suspected violation within five business days. All reports will be promptly investigated and appropriate corrective action will be taken within ten business days if warranted by the investigation.

Education

Personnel are trained on corporate compliance and ethical codes at the time of hire. Personnel are trained annually on corporate compliance and ethical codes through the Relias training program. Stakeholders are provided this information on The Well website.

Federally Funded Healthcare Programs

To comply with regulations governing Federally funded healthcare programs, prior to the hire of all new staff, the Human Resources Specialist will verify that personnel are not on the List of Excluded Individuals and Entities (LEIE). Verification will take place within 72 hours of the initial interview and prior to the hiring of all staff.