| Corporate Compliance |
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Table of Contents
Corporate Compliance Policy .
Standards of Conduct – Code of Conduct .
Standards of Conduct – Corporate Compliance Program Policies and Procedures.
Standards of Conduct – Departmental Policies and Procedures.
Compliance Officer and Compliance Committee .
Training and Education .
Reporting Concerns of Questionable Conduct .
Confidential Report of Concern .
Confidential Report of Concern Form.
Disciplinary Guidelines .
Monitoring Activities .
Investigations .
Training Certification .
Employee Training Certification.
Board Member Training Certification.
Contractor Training Certification.
CORPORATE COMPLIANCE POLICY
Comprehensive Systems, Inc. is dedicated to the delivery of services in an environment
characterized by strict conformance with the highest standards of accountability for
administrative, business and financial management.
The leadership of Comprehensive Systems, Inc. is aware of and fully committed to the
organization clearly establishing expectations regarding employee behavior, i.e., to act in a
way that always respects laws and regulations and in a manner that will protect the
organization’s assets from fraud, waste, and abuse. The development and implementation of
policies and procedures and other corporate compliance measures will help ensure regular
monitoring and conformance with all legal and regulatory requirements.
On April 27, 2006, the Board of Directors of Comprehensive Systems, Inc. passed a
resolution directing and authorizing the C.E.O. to take all actions necessary to immediately
and fully develop and implement a corporate compliance program for the company.
Effective also on this date, the Board passed an additional resolution designating and
appointing the Corporate Compliance Officer for Comprehensive Systems, Inc. The C.C.
O. will have direct access to the C.E.O., legal counsel and the Board of Directors as
necessary. In addition to development, implementation, and monitoring of the corporate
compliance program, the C.C.O. shall be responsible for establishing and chairing the
Compliance Committee and submitting periodic reports on the committee’s activities and
other corporate compliance activities as required.
STANDARDS of CONDUCT
Code of Conduct
Comprehensive Systems, Inc. has adopted a code of conduct, setting forth the legal and
ethical standards of the organization, to be followed throughout the organization for the
purpose of reducing unlawful or unethical conduct in the workplace. Each year, all
employees of Comprehensive Systems, Inc. will receive and review the code of conduct.
Each will be required to sign a written acknowledgment that he/she has received, read, and
will abide by the organization's code of conduct. The signed acknowledgment will be
maintained in the individual’s personnel file. (The Comprehensive Systems, Inc.’s Code of
Conduct is included in both the General Handbook for Non-Administrative Employees and in
the Administrative/Professional Employee Handbook. It is also available upon request.)
STANDARDS of CONDUCT
Corporate Compliance Program
Policies and Procedures
Comprehensive Systems, Inc. has adopted policies and procedures implementing the
corporate compliance program. All employees of Comprehensive Systems, Inc. will receive
training on the policies and procedures of the corporate compliance program and will be
required to sign a written acknowledgment that they have received, read and will abide by
the policies and procedures outlined in this program. The policies and procedures
implementing the corporate compliance program follow in this document.
STANDARDS of CONDUCT
Departmental Policies and Procedures
Neither the corporate compliance program nor the code of conduct covers all of the detailed
policies and procedures adopted by Comprehensive Systems, Inc. to achieve compliance in
each area of its operations. Policies and procedures pertaining to specific areas of the
organization's operations will be reviewed and, where necessary, amended or created to
ensure clarity of and adherence to legal and ethical requirements governing that particular
area. Employees affected by these policies will receive training on the policies and
procedures specific to their job responsibilities. Departmental policies and procedures are
located in each of the respective departments. Questions concerning the location of a
particular policy or procedure, or concerning a policy's meaning, should be directed to the
department supervisor.
COMPLIANCE OFFICER and
COMPLIANCE COMMITTEE
Role of the Compliance Officer
The Board of Directors has designated a corporate compliance officer for Comprehensive
Systems, Inc. The corporate compliance officer has the authority and responsibility for
overseeing the development, implementation and maintenance of Comprehensive Systems,
Inc.'s corporate compliance program. Ethical and legal behavior, including adherence to all
of Comprehensive Systems, Inc.'s policies and procedures, is not the sole responsibility of
the corporate compliance officer. All employees play a critical role in the organization's
commitment to ethical and legal compliance and to the success of the corporate compliance
program.
Employees who suspect or know of any violations, or potential violations, of the code of
conduct, the corporate compliance program policies and procedures, departmental policies
or procedures, or the laws and regulations governing Comprehensive Systems, Inc. are
expected to report those violations to their supervisor. Employees, who are not comfortable
reporting suspected, known or potential violations to their supervisor, should report those
violations directly to the corporate compliance officer, to any other member of the
compliance committee, or to the director of personnel services.
Complaints, deemed to be of a personnel nature, will be investigated by personnel services
following the grievance/complaints procedure outlined in either the General Handbook for
Non-Administrative Employees or the Administrative/Professional Employee Handbook.
Complaints, that are of a non-personnel nature, will be investigated following the procedure
in the Corporate Compliance Program.
Role of the Compliance Committee
The compliance committee is responsible for implementing the activities of the corporate
compliance program under the direction of the compliance officer. The members of the
compliance committee will provide advice on how to achieve the goals and objectives of the
corporate compliance program. Committee members are expected to display integrity,
confidentiality and professional judgment. The compliance committee will consist of four
core members but may also include ad hoc members as needed. The four core members of
the compliance committee are:
Chief Compliance Officer
Legal Counsel
Administrative Officer
Chief Operating Officer
TRAINING and EDUCATION
Compliance Training
The compliance officer is responsible for ensuring that members of the organization receive
training on the ethical and legal principles set forth in the code of conduct, and on the
policies and procedures governing the corporate compliance program which includes
training on Section 6032 of the Deficit Reduction Act of 2005 and the False Claims Act. A
minimum of one hour of compliance training will be provided to new employees within sixty
days of employment as part of the orientation training. A minimum of one hour of
compliance training will be provided to all employees annually. Members of the board of
directors and contractors for Comprehensive Systems, Inc. will also receive a minimum of
one hour of compliance training on an annual basis.
Specialized Training
Managers are responsible for ensuring that training on the policies and procedures pertaining
to specific areas of the organization's operations is provided to all employees affected by the
policies. Employees will receive a minimum of one hour of in-service training per year on
the policies and procedures specific to their job responsibilities. In-depth training is provided
so employees know how to monitor documentation in order to detect and/or prevent
improper payments from Medicaid.
REPORTING CONCERNS of QUESTIONABLE CONDUCT
Employees who suspect or know of any violations, or potential violations, of the code of
conduct, the corporate compliance program policies and procedures, departmental policies
or procedures, or the laws and regulations governing Comprehensive Systems, Inc. that are
of a non-personnel nature are expected to report those violations utilizing the procedures
established in the corporate compliance program. The first step of reporting should be to
their supervisor. However, if an employee is not comfortable discussing a concern with his
or her supervisor, or the employee is not satisfied with his or her supervisor's response, the
employee is expected to take the next step. The concern should then be reported to the
compliance officer or to another member of the compliance committee.
All reports of a compliance violation will be taken seriously and will be promptly investigated
under the direction of the compliance officer. To ensure that the compliance officer has all
the information necessary to thoroughly investigate a report, Comprehensive Systems, Inc.
strongly encourages direct communication of the concern by an employee to his or her
supervisor, to the compliance officer, or to another member of the compliance committee.
It should be noted that complaints deemed of a personnel nature, will be referred to
personnel services. Following an investigation of a reported concern, the compliance
officer or designee will report back the outcome of the investigation to the employee who
made the report.
Comprehensive Systems, Inc. has designed a system to help protect the identity of an
employee who reports a compliance concern. Every reasonable effort will be made to keep
a reporting employee's identity confidential, but complete protection of privacy will not
always be possible. It must be understood that there are no absolute guarantees regarding
confidentiality once a corporate compliance “report” is submitted. In addition, there are
some circumstances under which Comprehensive Systems, Inc. may be required by law to
disclose a reporting employee's identity, such as under a subpoena to produce records or
give testimony. Employees may also give permission to Comprehensive Systems, Inc. to
reveal their identity.
No disciplinary action or retaliation will be taken against an employee who makes a good
faith report of a compliance violation. Anyone who retaliates against an employee for
reporting a compliance violation will be subject to disciplinary action, up to and including
termination. Employees are expected to report any suspected or known violations of the
Comprehensive Systems, Inc. confidentiality and non-retaliation policies to the compliance
officer.
To further promote reporting of compliance violations, Comprehensive Systems, Inc. has
established an anonymous reporting system that permits employees and contractors to
report concerns on an anonymous basis. This system has been established for those
persons who, for whatever reason, are not comfortable taking their concern to their
supervisor, to the compliance officer or to a member of the compliance committee. Just as
any other report, a concern reported through the anonymous reporting system will be
investigated under the direction of the compliance officer. Because the report was made
anonymously, the compliance officer will not be able to report back the outcome of the
investigation to the employee who made the report.
An anonymous report can be made by completing a Confidential Report of Concern Form
and mailing it to the compliance officer at the designated address. If a report is made
anonymously in writing, it must be sufficiently detailed to provide a factual basis for the
allegations in order to allow an appropriate investigation. It must be noted that effective
investigation and appropriate resolution of reported concerns are made more difficult by
anonymous reports. The possibility exists that an investigation may not be able to be
completed due to the anonymity of the report. Employees are urged to identify themselves
when making any report.
The above notwithstanding, the filing of a false or intentionally inaccurate Confidential
Report of Concern through the anonymous reporting system shall be considered a serious
offense. The anonymous reporting system is not intended to provide an opportunity for
employees or contractors to get other employees "in trouble", but rather is intended solely as
a methodology for the reporting of the violations set forth above. The filing of an
intentionally false or misleading report could subject an employee to disciplinary action.
CONFIDENTIAL REPORT of CONCERN
The purpose of this form is to report the facts pertaining to any known or suspected
violation of the code of conduct, the corporate compliance program policies and
procedures, departmental policies and procedures, or the laws and regulations governing
Comprehensive Systems, Inc. Although we ask you to provide your name, it is not
necessary for you to do so if you wish to make an anonymous report. An anonymous
report can be made by completing this form and mailing it to the compliance officer at
Comprehensive Systems, Inc. at the following address: P.O. Box 1186, Mason City,
Iowa 50402. The form may also be sent through inter-facility mail to the compliance
officer.
If you do not want to give your name, you may call the compliance officer after one week
of submitting this report to inquire about the outcome of the investigation. If you do not
call, the compliance officer will not be able to report back the outcome of the investigation
arising out of your report.
If you wish to identify yourself in this report, Comprehensive Systems, Inc. will make
every effort to keep your identity confidential. Only the compliance officer, and others
designated by the compliance officer to conduct investigations, will have access to your
initial report. It must be understood that there are no absolute guarantees regarding
confidentiality once a corporate compliance “report” is submitted. There are some
circumstances under which Comprehensive Systems, Inc. may be required by law to
disclose a reporting employee’s identity. In addition, employees may also give
Comprehensive Systems, Inc. permission to reveal their identity.
Please include all the factual details of the suspected violation, however big or small, to
ensure the compliance officer has all the information necessary to conduct a thorough
investigation. Please attach additional pages as needed. The information you provide should
include names, dates, times, places and a detailed description of the occurrence that led you
to believe a violation of the principles of the corporate compliance program occurred.
Please include a copy or a description of any documents that support your concerns.
The Confidential Report of Concern form is on the following page. It can also be found on
the company website at www.comprehensivesystems.org. Click on the Corporate
Compliance link.
Confidential Report of Concern Form
Date of this report:
Name of person making this report (optional):
Description of the suspected violation/s:
Detailed description of the occurrence/s resulting in the suspected violation (Include names,
dates, times and places. Add additional pages if necessary)
Name/s of person/s involved in the occurrence and an explanation of their role:
Name/s of other person/s having knowledge of the occurrence:
Department/s involved in the occurrence:
Date/s of the occurrence:
How did you learn about the occurrence?
Have you previously reported this concern to your supervisor, to the compliance officer or
to any other member of the compliance committee? YES NO
If you answered "YES" to the previous question, please provide the following information:
(a) The name/s of the person/s to whom you made an earlier report:
(b) Whether the report was verbal or written:
(c) The date of the earlier report:
(d) The actions taken as a result of your earlier report:
Please attach or describe any documents that support your concern (include a description of
the documents, the identity of the person/s who wrote the documents, the dates of the
documents, and the location of the documents)
DISCIPLINARY GUIDELINES
Members of the organization will be subject to disciplinary action for failure to comply with
the legal and ethical standards adopted by Comprehensive Systems, Inc. Strict adherence to
the organization's policies and procedures is a condition of employment. Violations of the
code of conduct, the corporate compliance program policies and procedures or
departmental policies and procedures will result in disciplinary action, up to and including
termination, as determined on a case-by-case basis.
Comprehensive Systems, Inc. generally follows progressive disciplinary steps in
determining the disciplinary action or sanctions to be applied against an employee for
violation of the organization's policies and procedures. The range of disciplinary action
includes oral or written warnings, suspension from employment and termination of
employment. These progressive disciplinary steps are used by Comprehensive Systems,
Inc. as a guideline, and should not be construed as prohibiting Comprehensive Systems,
Inc. from taking other disciplinary action that it feels, in its sole discretion and judgment, is
appropriate under the circumstances. Comprehensive Systems, Inc. reserves the right to
terminate an employee at any time, for any lawful reason, with or without warning.
Although disciplinary actions may vary according to the nature and severity of the violation,
disciplinary actions will be consistently applied and enforced against all levels of employees
who commit similar violations under similar circumstances. In general, Comprehensive
Systems, Inc. personnel will be subject to disciplinary action for violating the policies and
procedures referenced in this program, failing to report a violation of the policies and
procedures referenced in this program, failing to cooperate during an investigation of a
suspected violation, and failing to take reasonable steps to detect and correct a violation
within an employee's area of responsibility.
An employee's legal and ethical conduct contributes to the success of the corporate
compliance program, as well as to the success of the employee's job performance. An
employee's adherence to the organization's policies and procedures, including the employee's
responsibility to report known or suspected violations, will be assessed and recognized as a
part of the employee's performance evaluation.
MONITORING ACTIVITIES
One of the ways to evaluate the success of the corporate compliance program is to
routinely review and assess the activities and operations of the organization. Comprehensive
Systems, Inc. will routinely monitor various activities within the organization to ensure that
employees, contractors and other persons acting on behalf of Comprehensive Systems, Inc.
are adhering to the organization's policies and procedures. Monitoring activities will be
conducted under the direction of the compliance officer and may involve interviews with
personnel and review of pertinent records.
INVESTIGATIONS
The compliance officer will ensure that a prompt and confidential investigation is conducted
in response to a reported concern or other detected violation of the code of conduct, the
corporate compliance program policies and procedures, departmental policies and
procedures or the laws and regulations governing Comprehensive Systems, Inc. All
employees are expected to cooperate fully in an investigation. Failure of an employee to
cooperate in any investigation may lead to disciplinary action. Retaliation against any
employee who cooperates in an investigation is strictly prohibited and will lead to
disciplinary action, up to and including termination. Investigations will be conducted as
follows:
If the report of concern or a violation is expressed informally (verbally) at the time of the
occurrence by the person who observed the activity in question, or through a subsequent
communication with the individual’s supervisor, the supervisor shall meet with the individual
to discuss and review the allegation. The supervisor will take notes of the discussion and
pass those notes on to the compliance officer. If possible, informal allegations will be
resolved within five (5) business days from when the allegations were made. Such
resolution shall be reported to the compliance officer.
If the allegation comes through the formal process of a Confidential Report of Concern, the
compliance officer will be responsible for conducting the appropriate investigation as
follows:
a. Review the Confidential Report of Concern and determine what, if any, additional
information is required.
b. Within 5 days of receipt of the Confidential Report of Concern, meet with the
supervisor of the employee involved to determine the scope of the investigation.
c. Interview the employee involved and review any documents relevant to the allegation.
d. Within 10 business days of receipt of the Confidential Report of Concern, prepare a
written report of the investigation and present the report to the Compliance Committee.
After reviewing the report of the investigation, the Compliance Committee will either make a
recommendation for additional investigation, or submit the compliance officer’s report to
the Chief Executive Officer along with a recommendation as to whether the report should
be determined to be founded or unfounded.
e. Any founded allegations will be documented in the employee’s personnel file along
with a record of any disciplinary actions taken as the result of the investigation.
f. Any unfounded allegations will be reviewed and discussed, if possible, with the
reporting employee and the individual against whom the allegation was made. All
documentation regarding unfounded allegations will be destroyed.
TRAINING CERTIFICATION
Employees and members of the board of directors will certify that they have received, read,
and been trained in Comprehensive Systems, Inc.’s Corporate Compliance Program. Each
will attest to comply with the policies and procedures of the corporate compliance program
and understand that a violation of its standards may lead to disciplinary action, up to and
including termination of employment and/or appointment to the board of directors.
When an employee has fulfilled the above requirements, a certificate designating this
completion will be signed by the employee and the trainer, and it will be kept in the
employee’s personnel file.
When a member of the board of directors or a contractor for Comprehensive Systems has
fulfilled the above requirements, a certificate designating this completion will be signed by
the board member or the contractor and the corporate compliance officer, and it will be
kept in the corporate compliance officer’s files.
Employee - Comprehensive Systems, Inc.
Corporate Compliance Training Certification
I certify that I have received, read, and been trained in the Comprehensive Systems, Inc.
Corporate Compliance Program. I will comply with the policies and procedures of the
corporate compliance program and understand that a violation of its standards may lead to
disciplinary action, up to and including termination of my employment.
I understand that this signed document will be filed in my personnel record.