Highlands at Brighton and Highlands Living Center Corporate Compliance Plan

The Highlands at Brighton and The Highlands Living Center, as affiliates of the University of Rochester Medical Center, recognize the efficiencies of aligning with one another on a Corporate Compliance Program, and have adopted this Corporate Compliance Plan and related policies and procedures to govern each of their Corporate Compliance Programs.

The purpose of the Corporate Compliance Program of Highlands at Brighton and Highlands Living Center (individually and collectively referred to as LTC) is to adopt, implement and maintain an effective Compliance Program (referred to as "Program") together with LTC's Code of Ethical Conduct and Compliance Policies and Procedures. LTC's Compliance Plan is supported by the University of Rochester Medical Center's (URMC) Corporate Compliance Plan and available resources.

This Compliance Plan outlines and demonstrates LTC's commitment to comply with all applicable federal and New York State laws, rules, regulations and standards (referred to as "regulations") through the implementation of the following required Program elements, requirements and guidelines1:

1. Written policies, procedures, and Code of Ethical Conduct describing compliance expectations that are available, accessible, and applicable to all Affected Individuals2;
2. Designation of an individual to serve as its compliance officer who is the focal point for the program and is responsible for the day-to-day program operation;
3. Designation of a compliance committee responsible to coordinate with the compliance officer to ensure LTC is conducting its business in an ethical and responsible manner, consistent with its program;
4. Creation and maintenance of an effective compliance education and training program for its compliance officer and all affected individuals;
5. Maintenance of effective lines of communication, ensuring confidentiality for its affected individuals;Procedures for the enforcement of written disciplinary standards addressing potential program violations and encouraging good faith participation in the program by all affected individuals;
6. An effective system for the routine monitoring and identification of compliance risks; and,
7. Procedures and systems for promptly responding to compliance issues as they are raised including the investigation of potential issues as identified in the course of internal auditing and monitoring and the day-to-day program operation.

Policies, Procedures and Code of Ethical Conduct

LTC's Compliance policies, procedures and Code of Ethical Conduct provide the framework and structure for an effective compliance program. Our written documents communicate compliance mandates and expectations of all Affected Individuals. They promote adherence to our legal and ethical obligations and are reasonably designed and implement to prevent, detect and correct non-compliance with government program requirements including fraud, waste and abuse most likely to occur within our program risk areas and organizational experience.

Our Compliance Program documents are applicable and disseminated to all Applicable Individuals and are incorporated into all Compliance Training and Education as outlined in the Annual LTC Compliance Training Plan. The LTC Compliance Committee approves all written documents associated with the Program and ensures review and revision, if needed, on an annual basis.

Compliance Committee and Compliance Officer

The LTC Compliance and Privacy Officer ("Compliance Officer") is responsible for carrying out the day-to-day activities of the LTC Program and reports directly and is accountable to the LTC Chief Executive Officer/President and the LTC Board of Directors. In addition, as an employee of the URMC Office of Compliance and Integrity (OIC), the Compliance Officer directly reports to the URMC Chief Compliance Officer and URMC Chief Privacy Officer.

Education and Training Program

LTC has established and developed an effective compliance education and training program ("education") for its compliance officer and affected individuals. Education includes all aspects of the Compliance Program, LTC program risks and best practices for coding and billing where applicable. Education occurs promptly upon hire and no less frequently than annually for All Affected Individuals.

Each education program conducted reinforces the fact that strict compliance with LTC's Compliance Program is a condition of employment or doing business with LTC.

Refer to LTC's 'Compliance Education and Training Program Policy'.

Lines of Communication

LTC has established and implemented accessible effective lines of communication ("communication") that ensure reporter confidentiality and/or anonymity, if chosen, for all Affected Individuals.

Communication allows for Program questions to be asked or violations reported. Access to the LTC Compliance Officer is publicized within Program documents, LTC Compliance Training and Education, and via the URMC OIC website.

The confidentiality of persons reporting compliance issues shall be maintained unless the matter is:

• Subject to a disciplinary proceeding, or,
• Referred to or under investigation by law enforcement, Health and Human Services Office of Inspector General, the New York State Attorney General's Medicaid Fraud Control Unit, or the New York State Office of the Medicaid Inspector General; or,
• Required to be disclosed during a legal proceeding.

Any person making a disclosure shall be protected under LTC's policy for non-intimidation and non-retaliation.

Refer to LTC's 'Lines of Communication Policy'.

Disciplinary Standards

LTC has established written disciplinary standards and implemented procedures for the enforcement of those disciplinary standards to address potential violations and encourage good faith participation in the Program by all Affected Individuals.

LTC's Disciplinary Standards Policy is disseminated and accessible to Affected Individuals and included in new employee and annual mandatory education.

Disciplinary standards shall be fairly and consistently enforced and applied to all levels of personnel. Refer to LTC's 'Disciplinary Standards for Compliance Violations Policy'

Auditing and Monitoring

LTC has established and implemented an effective system for the routine monitoring and identification of compliance risks. This system includes internal monitoring and audits and, as appropriate, external audits, to evaluate LTC's compliance with the requirements of Medicare, Medicaid Managed Care Organizations (MMCOs), New York State Medicaid and overall effectiveness of the Program.

Results of internal and external audits (including governmental) are reviewed by the Compliance Committee for risk areas needing additional attention via policy/procedure revision, education and training or additional internal monitoring/auditing.

Refer to LTC's 'Auditing and Monitoring Policy'. Annual Program Review

The LTC Program will be reviewed on an annual basis by the Committee. As part of this review, the Committee will determine Program effectiveness and the need for revisions. Review process, design, implementation and results are documented including revisions and/or corrective action. Review results are shared with the Board of Directors.

Excluded Providers

LTC confirms the identity and determines exclusion status of Affected Individuals prior to hire or doing business with LTC and, afterwards, on a monthly basis.

Refer to LTC's 'Exclusion Checking Policy'.

Responding to Compliance Issues

LTC has established and implemented procedures and systems for promptly responding to compliance issues. Issues will be thoroughly investigated and risks mitigated via applicable plans of correction.

Investigations of compliance issues are documented including any disciplinary action taken and corrective action implemented.

Refer to LTC's 'Responding to Potential Violations of LTC's Compliance Program Policy'.

Obligations of Affected Individuals

Acknowledgement and Application

1. Affected Individuals have duties and responsibilities under the LTC Program, Code of Ethical Conduct, applicable policies and procedures, and contract terms, if applicable. Failure to perform according to those duties and responsibilities may subject Affected Individuals to Sanctions as detailed in the Program, Code of Ethical Conduct, applicable policies and procedures and contract terms, if applicable.
2. Acknowledgement Statement: Each employee/Affected Individual must complete and sign an acknowledgement statement, at the beginning of employment/contract or relationship with LTC, stating that the employee/Affected Individual has received, read, and understands the Code of Ethical Conduct and acknowledges their commitment to comply with the Code of Ethical Conduct as an employee. Each acknowledgement statement shall form a part of each employee's personnel file. The Code of Ethical Conduct will be distributed following any revisions, and the employee will be asked to confirm that they have received, read, and understand it by executing another acknowledgement statement.

Assessment of Employee/Affected Individual Performance under Program

1. Violation of Applicable Law or Regulation: If an employee/Affected Individual violates any law or regulation in the course of their employment/contract or relationship with LTC, the employee/Affected Individual may be subject to sanctions.
2. Other Violation of the Program: In addition to direct participation in an illegal act, employees/Affected Individuals may be subject to disciplinary actions for failure to adhere to the principles and policies set forth in this Program. Examples of actions or omissions that may subject an employee to discipline on this basis include, but are not limited to the following:
3. A breach of the policy.
4. Failure to report a suspected or actual violation of law or a breach of the policy.
5. Failure to make, or falsification of, any certification required under the Program.
6. Lack of attention or diligence on the part of supervisory personnel that directly or indirectly leads to a violation of law.
7. Direct or indirect retaliation against an employee/Affected Individual who reports a violation of the Compliance Plan or a breach of the Plan.
8. Possible Sanctions: The possible sanctions include, but are not limited to, termination of employment/contract, suspension, demotion, reduction in pay, reprimand, and/or retraining. Employees who engage in intentional or reckless violation of laws or regulations will be subject to more severe sanctions than accidental transgressors.

A. Non-employment or Retention of Sanctioned Individuals: LTC shall not knowingly employ any individual, or contract with any person or entity, who has been convicted of a criminal offense related to health care or who is listed by a Federal agency as debarred, excluded, or otherwise ineligible for participation in federally-funded or state health care programs. In addition, until resolution of such criminal charges or proposed debarment or exclusion, any individual who is charged with criminal offenses related to health care or proposed for exclusion or debarment shall be removed from direct responsibility for, or involvement in, documentation, coding, billing, or competitive practices. If resolution results in conviction, debarment, or exclusion of the individual, LTC shall terminate its employment of such individual or business relationship.

Compliance Investigations

LTC, along with its legal counsel where necessary, shall promptly respond to and investigate all allegations of wrongdoing of employees whether such allegations are received through the hotline or in any other manner.

LISTING OF STATUTORY AND REGULATORY AUTHORITIES

Federal Authorities

42 U.S.C. 1320a-7b(b),

42 U.S.C. 1359dd.

42 U.S.C. 1395nn.

New York State Authorities

Finance Law Article XIII - False Claims Act

Social Services Law Section 363-d – Provider Compliance Program18 NYCRR Part 521 - Fraud, Waste and Abuse Prevention Approved by LTC Compliance Committee: August 2023

1 NYCRR Title 18 SubPart 521-2, 'Compliance Programs'; and, the Department of Health and Human Services Office of Inspector General (HHS-OIG) 'Compliance Program Guidance for Nursing Facilities' 2000; and, 'Supplemental Compliance Program Guidance for Nursing Facilities', 2008.

2 Means all persons who are affected by the required provider's risk areas including the required provider's employees, the CEO, senior administrators, managers, contractors, agents, subcontractors, independent contractors, and governing body and corporate officers.