FY 2013 Corporate Compliance & Rights Protection Training. Reasons For a Compliance Plan. To prevent unwanted events from happening - intentionally and unintentionally. To help the organization learn about these unwanted events first.
& Rights Protection Training
1. Written standards of conduct for all employees, contractors and volunteers that promote a clear commitment to compliance.
2. The appointment of high level individuals in the organization to oversee the compliance effort.
3. Due care taken by the organization to not delegate responsibility or authority to those who may engage in illegal activity.
4. Effective training and education programs for all employees and volunteers.
5. Monitoring and reporting systems to uncover potential problems and to encourage the reporting of potential problems
by employees without fear of retaliation.
6. Disciplinary systems for non-compliant employees - and their managers- that are consistently enforced at all levels of the organization.
7. Reasonable steps taken to respond appropriately to detected offenses and to
DO NOT MAKE THE EASY
MISTAKE OF FAXING
(this is a CPA Office in Alvin!)
Considerations: Seriousness, Circumstances,
Work Record, Length between violations
Possible Actions: Required Training, Written
Reprimand, Probation, Demotion, Reassignment,
Termination, Disclosures as required by Law
Confirmed Cases of Abuse, Neglect or Exploitation:
Reported in CANRS
May be reported to the Employee
Misconduct Registry, effective September 1,
2010. (Senate Bill 806, 81st Legislature)
Compliance Detected Offenses:May Include a
Corrective Action Plan
Reassignment may occur during an
investigationAction Taken in Detected Compliance Offenses and Other Confirmed Cases of Misconduct (including abuse neglect and exploitation)
1. Statement of Purpose
2. Ethical Standards
3. Leadership Responsibilities
4. Conflict of Interest/Outside
Business and Financial
5. Gifts and Favors
7. Accounting and
Receiving paid consultation by Contractor
Received > 10% of your Gross Income for the previous year from Contractor
Are a Member of Contractor’s Board of Trustees/Directors
Have Ownership > 10% of voting stock of shares of the Contractor
Have Ownership of > 10% / $5000 of the Fair Market Value of the ContractorThe Board of Trustees and Center Employees MAY NOT have a CONFLICT OF INTEREST with Contracts Management(Code of Conduct # 4)
8. Corporate Resources
9. Political Activities
11. Employee Relations
12. Customer Focus / Client
13. Controlled Substances
14. Reporting Misconduct
15. Risk Reporting
You have breached confidentiality if you disclose information to a third party who is not involved in furthering care or does not have a legitimate need to know.
the consumer is dead, USPS informs us not an accurate
address, contact from an insurance fraud investigator
Harassment could be related to race, creed, color, sex, sexual orientation, national origin, ancestry, citizenship status, marital status, pregnancy, age, medical condition, handicap and/or disability
Harassment does include offensive remarks or jokes, other verbal, graphic, physical conduct and/or threats of physical aggression (note: as part of our commitment to safety, we have a No Weapons Policy)
If you feel a staff, consumer, vendor or supplier is harassing you, report the harassment immediately to a supervisor. If the supervisor is involved or you feel they can not or will not address the issue, contact the Chief Operations Officer, HR Director, or Center Attorney. Regardless of who you report to, the complaint will be immediately forwarded to the Center Attorney who will initiate an investigation within 5 business days.
The Center can only resolve an issue of harassment if we know about it. Therefore, it is your responsibility to bring these kinds of problems to our attention so that we can take the necessary steps
to correct the problem or issue at hand
If you have any questions as to what constitutes harassment do not hesitate to contact the Center Attorney or refer to the No Harassment Policy.No Harassment Sexual or Otherwise(Code of Conduct , # 11)
Simple teasing, off-handed comments, and isolated incidents of harassment, unless very serious, will generally not constitute actionable harassment in a court of law. However, it may lead to disciplinary action, up to and including termination depending upon the circumstances of the situation.
Sexual harassment is actionable under Title VII only if it is so “severe and persistent” as to alter the conditions of the person’s employment and create an abusive working environment
The four elements which will be used to make this determination are:
Director, Legal Affairs Director, HR Manager, or the
Rights and Compliance Officer. EXCEPTION:
Investigations involving Connect Transit and its
services shall be investigated by Asset Management
and/or Facility and Transportation Services staff.
allegations, employee misconduct, and/or consumer-
staff do not have the authority to initiate investigations
against fellow staff, contractors, or consumers.
Investigating does include and is not limited to
photographing, monitoring and documenting activity,
reading internal and external mail, and recording
conversations without the other persons knowledge
and consent. Staff involved in unauthorized
investigative tactics will be subject to disciplinary
action up to and including termination.
alter documents; lie; or make misleading statements to
authorized Center staff conducting the investigation. Staff
who violate this requirement shall be terminated. Full
cooperation is required and includes providing complete
timely and thorough information promptly.
Implied Sexual and Sexual in Nature Contacts (i.e., physical act, telephonic and electronic)
No Living Arrangement Agreements
No loans or storing/holding of Consumer Funds/Money
Staff may accept no monetary gifts. Policy does allow acceptance of gifts of <$50.00. Recovery programs can not accepts gifts, monetary or otherwise
Consumers can not do chores (i.e. picking up trash or cleaning restrooms) for cigarettes or other privileges; this is a violation of the Department of Labor
Caution: Telephone communications should be limited to Center Business due to misinterpretations of others.
Caution: If a consumer/client has a business and you would like to bid for his services or have him do some work for you do realize that there may be some ramifications for such action. The relationship may appear to have some form
Caution: Avoid the appearance of inappropriate behavior.
Learn your Job Understand expectations
and focus on doing your job well.
Communication Don’t take your anger or
frustration out on persons served or their families. Do your part to help foster positive relationships with co-workers and keep morale high.
Stress Management Manage your stress levels.
Personal Problem Management Leave personal problems outside of the workplace. If you are having difficulty with this, speak to your supervisor. Seek help if you need it!
Multiple scratches, cuts, bruises,
Unusual patterns of injuries
Inadequate or illogical explanation
Serious injuries: sprains, breaks,
Reports of confinement
Reluctance to participate in physical
Passive, withdrawn behavior with
Lack of food or malnourishment
Lack of water or dehydration
Unsanitary living conditions
Untreated health problems
hygiene / clothes
purchased for staff
ALL staff have the responsibility to report.
Immediately (within 1 hour) make a report to DFPS via the reporting website:
Complete an Incident Report within 24 hours and fax to RPO if the alleged perpetrator is a Center staff or contract staff
Employees and Consumers are
protected from retaliation when
reporting.Reporting Allegations of Suspected Abuse, Neglect or Exploitation
Substance Use Recovery ServicesReporting Allegations of Suspected Abuse, Neglect or Exploitation When the Alleged Perpetrator is a center staff or contract staff
If the client also has a Mental Health ,
diagnosis follow guidelines for reporting to
DFPS on previous slide
If the AP is not a Center staff or contract
staff, report to proper authorities
DO NOT notify the alleged perpetrator of the impending investigation.
DO NOT conduct a mini-investigation.
DO NOT discuss incident with others (with the possible exception of your supervisor).
DO preserve the safety of the person and arrange for emotional support or medical care as appropriate
DO protect any evidence (i.e.. ake pictures, secure the record, etc.)
DO cooperate with DFPS investigators
The “Interpretive Guidance on Laws Pertaining to Privacy of Mental Health and Mental Retardation Records for the MHMR Service Delivery System” pursuant to the TAC Protected Health Information, Chapter 414, Subchapter A, states:
§When Authorization is not Required to Use or Disclose Protected Health Information that Relates to MHMR Services
(b) When required or authorized by law
(3) A component may disclose PHI to the Department of Family and Protective Services) when necessary to report or cooperate in the investigation of suspected child abuse or neglect.
However, the PHI of a parent
or other person responsible for the care of the child who is the subject of the report or investigation may only be disclosed pursuant to a court order.
DFPS receives a report (website or
APS initiates an investigation
RPO notifies ED, Review Committee, Supervisor
APS mails completed investigative report to RPO upon completion
Copy of report given to ED, Review Committee and (if confirmed), to staff; Case reviewed
Request for Review forwarded to Assistant Commis-sioner of APS
Disagree with findings
Agree with findings
to the RPO & treatment team
(email or phone)
The death of a former service recipient should also be reported to the RPO upon discovery
however, an incident report is not needed .
Injuries(client or staff) Report immediately to
(if not part of approved Behavior Plan)
must be submitted to
the RPO within 24
1) abuse/ neglect/
exploitation/ other rights
issues (when staff is the
2) deaths (active clients)
3) incidents involving
workman’s comp (also
fax to Ricki at Admin!)
All other reports must
be submitted to the
RPO within 48 hours
follow-up to incident
1) Fax to RPO in League
City: 281-338-2460 /
Send original to RPO
2) Submit electronically
Do not keep a
copy or put a copy
in the record