Compliance Plan

MEDICAID COMPLIANCE PLAN AND POLICIES 2024

To reach the Chief Compliance and Ethics Officer, Mark Kiss,

please call 718-863-3300 ext. 123, email mkiss@amazinghc.com, or call Amazing’s anonymous Compliance and Ethics Toll-Free Hotline

1-800-715-7021

INTRODUCTION AND STATEMENT

FROM THE GOVERNING AUTHORITY

Amazing Home Care Services, LLC ( “Amazing”), including its managing members (the “Governing Authority”), and the members of its senior management team, are committed to conducting themselves in accordance with the highest level of business and ethical standards and in compliance with all applicable federal and state laws and regulations, as well as health care program requirements, accepted industry practices, professional standards that apply to and impact Amazing in the provision of services, documentation, billing, and the day to day activities of Amazing and its employees and agents (collectively, “Regulations“)[1]. Amazing believes the best method to ensure consistency and compliance with applicable Regulations, and to avoid fraud, waste and abuse, is through the establishment and implementation of a robust and effective compliance program (the “Compliance Program” or the “Program“).

The Compliance Program consists of several core components that function in tandem to help effectively prevent, detect and deter wrongdoing and promote quality of care. The Program constitutes official company policy and anyone working at or associated with Amazing in any capacity – including, but not limited to, owners, operators, executives, officers, directors, governing body members, administrators, managers, employees, contractors, subcontractors, independent contractors, physicians, suppliers, vendors, agents, appointees, business associates, interns and volunteers (collectively, “Affected Individuals”)[2] – must abide by its guidelines as a prerequisite for any relationship with Amazing.[3] The components of the Compliance Program are designed to (a) prevent both inadvertent and intentional noncompliance with applicable Regulations; (b) promote the detection of noncompliance if it occurs; (c) discipline offenders when appropriate; and (d) educate Affected Individuals on the importance of compliance and Amazing’s compliance policies and procedures. The Compliance Program is designed to be an integral part of all aspects of Amazing’s operations, including billing; payments; ordered services; medical necessity; quality of care; governance; mandatory reporting; credentialing; contractor, subcontractor, agent or independent contractor oversight; and other risk areas identified by Amazing through its organizational experience (collectively, “Risk Areas“).

The Compliance Program is not intended to address isolated acts or incidents, for which the company has established channels and procedures. It is when there is a concern with or breakdown of these channels and procedures themselves that compliance steps in and works to improve or replace the system at issue. Utilizing the Compliance Program in this manner, across the entirety of operations, will allow Amazing to prevent, detect and resolve conduct that fails to conform with legal, moral or professional standards, as well as shortcomings in company processes. The Compliance Program is also designed to help Amazing proactively reduce or eliminate potential risk and anticipate potential weaknesses and inefficiencies in company systems. These benefits will, in turn, help ensure that Amazing complies with the law and thereby avoids criminal prosecution, civil liability and administrative sanctions, as well as fines, penalties and exclusion from participation in healthcare programs, that may be imposed against individuals and/or entities that fail to do so. Other valuable functions of an effective Compliance Program include: a platform through which Amazing can demonstrate its commitment to superior care and ethical values; a method for detecting issues early before they grow into larger problems; a tool to answer questions and respond to issues; a vehicle through which to disseminate information on laws, regulations and industry practices; and a mechanism to improve internal communications. Finally, this Compliance Program will help us achieve our mission by facilitating our pursuit of high quality, compassionate and cost-effective care and eliminating anything that may undermine or detract therefrom.

This Medicaid Compliance Plan and Policies (“Compliance Plan“) describes the components of the Compliance Program and the roles and responsibilities of Affected Individuals with respect to the Program. Each Affected Individual plays an important role in assisting Amazing achieve its mission of providing each properly certified and eligible patient with necessary care and/or services while following the law and maintaining an ethical culture. Amazing will designate an individual to serve as the Chief Compliance and Ethics Officer (“CCO“). The CCO, in conjunction with the Compliance and Ethics Committee (“CEC“) will be the focal point for Amazing’s Compliance Program and is responsible for the day-to-day operations of the Compliance Program. Every individual and company with an employment or service relationship with Amazing shall receive and review the Compliance Plan; internalize the principles it contains; and ultimately apply its precepts and spirit – using one’s good personal judgment – as appropriate, to the many scenarios that will arise while carrying out one’s responsibilities.[4]

Although this Compliance Plan may seem quite extensive, it is not – nor is it intended to be – an exhaustive compilation of applicable Regulations. Instead, it is meant to alert you to key legal and ethical issues that may arise and serve as an outline of morals, standards and guidelines that should be internalized by each Affected Individual so that its precepts and spirit can be prudently applied to Amazing’s unique conditions and utilized in the many different – and often unpredictable – situations you may face in carrying out your responsibilities. This versatility must pertain not only to the many circumstances to which the principles of the Compliance Program must be applied, but to the principles themselves, as the Compliance Plan and the overall Compliance Program must be periodically updated and modified to reflect changing laws, compliance risks, professional standards and on-the-ground developments.

Amazing acknowledges the potential challenges involved in fully understanding the directives set forth in this Compliance Plan and knowing how to apply them and their underlying tenets appropriately. You are therefore urged to seek guidance from supervisors, compliance personnel and/or the Compliance and Ethics Hotline for further instruction.

WRITTEN POLICIES AND PROCEDURES

Amazing maintains written policies and procedures that articulate Amazing’s (a) commitment and obligation to: comply with all Regulations applicable to Risk Areas; (b) describe compliance expectations as embodied in Standards of Conduct; (c) document and outline the implementation and ongoing operation of the Program; (d) provide guidance to Affected Individuals on dealing with potential compliance issues; (e) identify the methods and procedures for communicating compliance issues to the appropriate compliance personnel; (f) describe how potential compliance issues are investigated and resolved; and (g) describe the procedures for documenting the investigation of compliance issues and the resolution or outcome.

Copies of the Compliance Plan, and applicable policies and procedures, will be provided to all Affected Individuals upon commencement of employment (as part of the orientation process) or association with Amazing (for Contractors), and in the event they are subsequently modified. Copies of the Compliance Plan and other compliance materials shall be made available to patients, family members and visitors, including through information posted on Amazing’s website.

All policies and procedures that implement or impact components of this Compliance Plan or materially impact Risk Areas shall be reviewed and approved by (1) the CCO and the CEC, and (2) the Governing Authority.

The Compliance Plan.

The core elements of the Compliance Program and its functions, policies, and procedures are described in this Compliance Plan. The Compliance Plan is intended to reflect the commitment of Amazing and its Governing Authority to comply with all applicable Regulations, including 18 NYCCR Part 521-1 (“OMIG Compliance Regulations”). This Compliance Plan constitutes official company policy.

This Compliance Plan is applicable to Amazing’s contractors, agents, subcontractors, and independent contractors (collectively, “Contractors“) to the extent the services provided by such Contractors relate to one or more Risk Area(s). All such Contractors shall be provided with a copy of this Compliance Plan and any Amazing policies related to the Risk Area(s) relevant to the Contractor’s performance of its contractual obligations. All Contractors are required to acknowledge annually that they have received, read, understand, and agree to comply with this Compliance Plan. Contractors may satisfy this requirement by implementing a compliance plan within their own organization that satisfies the requirements of New York’s Social Services Law § 363-d, provided that Amazing shall have the right to audit the Contractor’s compliance plan operations and performance, and that the Contractor is required to timely notify Amazing of any instances of non-compliance, and any identified overpayments, that relate to or implicate the Contractor’s relationship with Amazing. These requirements shall be set forth in the written contract or agreement with such Contractor. Provisions relating to the foregoing shall be incorporated in new contracts, and shall be incorporated in existing contracts upon renewal or in the event of amendment.

This Compliance Plan and its policies and procedures will be reviewed by the CCO, CEC and the Governing Authority at least annually to determine (a) if such written policies and procedures have been implemented; (b) whether Affected Individuals are adhering to such policies and procedures; (c) whether such policies and procedures are effective; and (d) whether any updates to such policies and procedures are required. This Compliance Plan and Amazing’s policies and procedures shall be updated as needed upon completion of this review.

The Compliance Plan does not constitute an employment contract or any other type of contract, nor should it be interpreted as a promise of continued employment or any other relationship.

Standards of Conduct.

Amazing strives to maintain the highest level of professional and ethical standards in the conduct of its business, and places the highest importance upon its reputation for honesty, integrity and high ethical standards. These principles are embodied in formal Standards of Conduct adopted by the Governing Authority of Amazing. The Standards of Conduct is a constitution of sorts, providing a foundational framework of Amazing’s ideals and conveying a synopsis of the expectations that the company has for those who are employed by or interact with Amazing. The Standards of Conduct crystalize these ideals and expectations into paradigm principles, guidelines and internal controls. A copy of Amazing’s Standards of Conduct is attached hereto as Exhibit A.

The Standards of Conduct will be distributed to all Affected Individuals. Affected Individuals other than Contractors are required to certify, upon hiring and on an annual basis thereafter, that they have read, understand, and agree to adhere to the Standards of Conduct. Contractors subject to this Compliance Program are required to certify, upon execution of any contract or agreement with Amazing, that they either (1) have internal standards of conduct that protect against fraud, waste and abuse, with an emphasis on compliance, or (2) agree to adhere to Amazing’s Standards of Conduct in their performance of their contract with Amazing throughout its term.

The Standards of Conduct will be reviewed by the CCO, the CEC, and the Governing Authority, at least annually to determine (a) if the Standards of Conduct have been implemented; (b) whether Affected Individuals are adhering to the standards set forth therein; (c) whether such standards are effective; and (d) whether any updates to the Standards of Conduct are required. The Standards of Conduct shall be updated as needed upon review to ensure that Amazing maintains the highest possible standards of compliance. Any changes to the Standards of Conduct will be approved by the Governing Authority and distributed to Affected Individuals.

Operating Policies and Procedures Related to Billing and Payment Integrity.

Claims Submission, Billing and Payments Policies. It shall be the policy of Amazing to: (i) provide for sufficient and timely documentation of all services, including subcontracted services, prior to billing to ensure that only accurate and properly documented services are billed; (ii) submit claims only when appropriate documentation is maintained, appropriately organized in legible form, and available for audit and review; (iii) compensate billing department personnel and billing consultants only in a manner that does not offer any financial incentive to submit claims regardless of whether they meet applicable coverage criteria for reimbursement or accurately represent the services rendered; and (iv) establish and maintain a process for pre and post submission review of claims to ensure that claims submitted for reimbursement accurately represent medically necessary services actually provided, supported by sufficient documentation, and in conformity with any applicable coverage criteria for reimbursement (including without limitation 18 NYCRR Subchapter E, as applicable, and 10 NYCRR Part 766). In anticipation of claims being made to Medicaid, services should be evaluated for appropriateness and must be consistent with the patient’s plan of care.

Without limiting the foregoing, the following claims submission and billing guidelines shall be adhered to by Amazing and all Affected Individuals:

Adherence to Billing/Claims Submission Regulations. All Affected Individuals involved in billing and claims submission must adhere to all relevant billing and claims submission Regulations. Tainting the veracity of billing, coding or reimbursement documentation is absolutely prohibited.
Adherence to Insurance Regulations. Amazing shall abide by operative insurance Regulations, including, but not limited to, billing patients for applicable co-pay and deductible payments[5] and accepting the applicable Medicare and/or Medicaid payment for covered items and services as the complete payment, unless a valid exception applies.
Medical Necessity and Proper Authorization. Amazing shall bill only for medical assistance services that were medically necessary, as determined and ordered by an appropriate healthcare professional, based on patients’ specific clinical conditions and after having requisite assessments conducted.^[6] Claims shall only be submitted for services for which Amazing has documentation of authorization by a physician or other authorized clinician, as required by applicable law, and which are consistent with the patient’s treatment plan (10 NYCRR Part 766).
Plan of Care. Amazing must take all responsible steps to ensure that a plan of care is developed in accordance with the authorization. The plan of care must be dated and signed, and reviewed and updated as required by applicable law. (10 NYCRR Part 766.3).
Verified / Documented Services. Amazing shall bill only for medical assistance services that were actually provided as claimed to eligible patients. Proper, adequate, accurate and timely documentation to support coding and billings shall be maintained in accordance with Regulations and in as organized, legible and accessible form as practicable. All services for which reimbursement is sought must be performed and documented in accordance with New York State Department of Health (“DOH”) regulations (10 NYCRR § 766.12).

Amazing’s commitment to proper billing and reimbursement practices may compel quality assurance (“QA“) to employ the services of certain company personnel, the CEC and/or consultants or contractors, as appropriate, to audit, monitor and/or review procedures and systems for accuracy, legitimacy and effectiveness on behalf of QA. QA may also utilize the CEC and/or others for the collection and analysis of select billing and reimbursement data as part of Amazing’s ongoing efforts to uncover vulnerabilities and improve processes.[7]

Any inconsistencies in documentation or reports of impropriety with regard to claim development and submission will be investigated by the CCO. If errors or impropriety in claim development and submission are substantiated, necessary restitution will be made by Amazing and the individual or individuals responsible will face disciplinary action with consequences ranging from re-training to dismissal.

Reporting and Return of Overpayments. Amazing shall identify, investigate, report and return overpayments in accordance with applicable Requirements and the following overpayments policy. If an Affected Individual identifies or suspects the receipt of a potential overpayment or the misappropriation, conversion or wrongful retention of healthcare benefits and/or government funds he/she is required to report such knowledge or suspicion to the CCO, a CEC member and/or the Hotline immediately.[8]

Purpose.

To establish a process to report, return, and explain any overpayments of Medicaid funds within sixty (60) days of identification in accordance with Federal and State law. An overpayment includes any amount not authorized to be paid under the Medicaid program, whether paid as the result of inaccurate or improper cost reporting, improper claiming, unacceptable practices, fraud, or abuse. Overpayments may include, without limitation:

Duplicate payments
Payments for incorrect dates of service
Incorrect payment amounts
Incorrect Payer Responsibility/Coordination of Benefits (COB)
A simple billing error or mistake
A violation of the False Claims Act, Stark or Anti-Kickback Laws, or Civil Monetary Penalties Statute, or
Other reasons Amazing may not be entitled to payment.

Responsibility.

All Affected Individuals are required to promptly report potential or actual instances of non-compliance, including those that may give rise to overpayments, to the CCO as soon as the overpayment or potential overpayment is identified. The CCO is responsible for conducting or overseeing an appropriate investigation and ensuring compliance with this policy and all ACA (defined below) and OMIG overpayment reporting requirements (18 NYCRR Part 521-3).

Procedures.

All overpayments of Medicaid funds discovered by Amazing must be reported, returned, and explained in writing within sixty (60) days of the date they are identified as required by section 6402(a) of the Affordable Care Act of 2010 (“ACA“) and applicable Federal, state and local laws and regulations (see, e.g., OMIG Regulations at Part 521-3). Failure to exercise reasonable diligence in identifying an overpayment can result in an inference of knowledge and sanctions under Federal and State law. Failure to timely report and return any Medicaid overpayment can have severe consequences, including potential liability under the State and Federal False Claims Act, as well as the imposition of civil monetary penalties and exclusion from federal health care programs.

All potential Medicaid overpayments will be investigated by the CCO in conjunction with appropriate staff. If an overpayment is identified, the CCO will ensure that the overpayment is reported, returned, and explained to Medicaid in accordance with applicable self-disclosure processes or other permissible processes, within sixty (60) days of identification. The CCO shall confer with outside legal counsel prior to making a determination whether the overpayment requires self-disclosure.

All records related to Amazing’s compliance with this policy will be maintained by the CCO in compliance with Amazing’s records retention policy, but in no case for a period of less than six (6) years.

Third-Party Liability. It shall be the policy of Amazing that all reasonable measures shall be taken to ascertain the legal liability of third parties, for the purpose of, as consistent with Section 1902 of the Social Security Act, ensuring Medicaid is the payor of last resort.

Responsibility.

The policy is applicable to all Affected Individuals responsible for billing Medicaid.

Procedures.

Amazing shall implement the following procedures in accordance with this Policy:

Disclosure of potential third party resources will be required on all Medicaid claim forms.

Investigation will be conducted by the billing personnel to determine the existence of potential third parties that may be legally responsible to pay for the services to be billed, prior to actually billing Medicaid.

Any payment and/or reimbursement shall be sought from all potential third party payors prior to submitting the claim to Medicaid.

In the event Amazing receives payment and/or reimbursement from a liable third party, Affected Individuals responsible for billing shall either: (a) apply such payment to reduce any Medicaid claim; or (b) repay the Medicaid program within thirty (30) days after the third party reimbursement is received, if the claim was submitted before the third party’s liability was ascertained.

Relevant citations: 42 USC 1396a(a)(25); 18 NYCRR § 540.6.

Employee and Business Relationship Integrity.

The policies and procedures of Amazing are designed to maintain employee and business relationship integrity. These policies are described below.

1. Excluded Providers. In accordance with the requirements of applicable Federal and State law, including relevant OMIG Compliance Regulations (see 18 NYCRR Section 521-1.4(g)(3)), Amazing will confirm the identity and determine the exclusion status of all Affected Individuals.

Amazing will review the following Federal and State databases at least every thirty (30) days to determine the exclusion status of personal Affected Individuals:

New York State Office of the Medicaid Inspector General Restricted and Excluded Providers database; and
Health and Human Services Office of Inspector General’s List of Excluded Individuals and Entities; and
Excluded Parties List System (EPLS).

Amazing requires Contractors to comply with the provisions of this Policy by completing required exclusion checks for all persons employed or contracted with the Contractor.

Screening Policies and Procedures. Amazing has implemented the following screening policies in accordance with industry best practices, applicable OMIG Compliance Regulations, and other applicable Federal and State law: [9]

All employees, prospective employees, and other Affected Individuals, as applicable, are subject to exclusion screening on a monthly basis in accordance with Amazing’s exclusion policy set forth above. Amazing will prohibit the employment of individuals that are ineligible for participation in federal health programs or the Medicaid program. The purpose of this policy is to preclude: (a) payment by the Medicaid program for medical care, services or supplies ordered or prescribed by any person who is excluded from participation in the federal health care programs; and (b) involvement by such excluded persons in activities related to the furnishing of such medical care, services or supplies. This screening policy is conducted in the manner set forth under Section I(D)(1) of this Compliance Plan.
New or prospective employees shall be subject to initial screening to determine engagement in illegal activities or other conduct inconsistent with Amazing’s Standards of Conduct and the goals of this Compliance Plan, to the extent permitted by applicable Federal, State or Local law. The initial screening shall include a criminal history record check in accordance with applicable DOH Regulations and Amazing policy. Such initial screening shall demonstrate Amazing’s use of reasonable efforts to ensure this Compliance Plan remains effective.
For all new employees with discretionary authority to make compliance decisions or with compliance oversight, Amazing will conduct a reasonable and prudent review of the information obtained during the application process, including a reference check as part of evaluating candidates for employment by Amazing.
Amazing will prohibit the employment of individuals that do not meet all statutory or regulatory requirements for providing services to federal health programs or the Medicaid Program. Prior to employment and at regular intervals thereafter, Amazing will verify that an individual has all required licenses, certifications and other required credentials, and has received all required training.
Amazing shall use due care not to delegate substantial discretionary authority to individuals whom Amazing knows or should know have a propensity to violate the law or the Program. Amazing shall endeavor to appoint only those with the appropriate credentials, capabilities and values to leadership roles. To that end, Amazing may conduct additional vetting and provide additional training for candidates selected for positions of influence.

Stark and Anti-Kickback Statutes. Amazing’s resolve to have nothing other than the needs of the patients drive care-related decisions compels the company to strictly adhere to Federal and State anti- kickback and referral laws, both within Amazing and among its contractors. 42 U.S.C. § 1320a-7b(b); 42 USC § 1395nn; N.Y. Public Health Law § 238-a. Affected Individuals must never accept, offer, receive or solicit anything of value – directly or indirectly – for the purpose of inducing or rewarding the past or potential referral or generation of business reimbursable by government healthcare programs. This applies to the procurement, purchase, lease or order of any healthcare item or service and applies to compensation in the form of cash, commissions, gifts, gratuities, or discounts to or from vendors, suppliers, healthcare providers or beneficiaries or their family members, unless an exception or Safe Harbor applies under the law.[10] Cross-referral and swapping arrangements may also be problematic hereunder.

As part of Amazing’s goal of avoiding even the appearance of impropriety, Amazing will endeavor to keep transactions at arm’s length, for fair market value, and otherwise commercially reasonable, as well as refrain from essentially basing compensation of Affected Individuals in a position to refer or generate business on the volume or value of referrals or generation of business, thereby eliminating potential incentives for illicit referrals, overutilization, unnecessary services and the like.[11] Contracts and arrangements with actual or potential referral services are reviewed by counsel for compliance with applicable Regulations.

Given the extreme seriousness of this group of criminal and civil statutes and the unique complexity of their application, Affected Individuals are encouraged to seek counsel before offering or accepting anything of value in the workplace—either directly from the CCO or Amazing’s attorney or anonymously via the Compliance and Ethics Hotline.

Compliance as an Element of Performance Evaluations. It is the policy of Amazing that adherence to this Compliance Plan is a factor in evaluating the performance of all Affected Individuals. Affected Individuals are required, as a condition of any employment, contract or other association with Amazing, to:

Read and review this Compliance Plan in detail upon hire and periodically thereafter.
Assume responsibilities for carrying out the functions of this Compliance Plan and participating in Compliance Program initiatives and activities, as appropriate and applicable to their role within the company. While Amazing does not expect all Affected Individuals to become legal or compliance experts, Affected Individuals are expected to have a reasonable sense of right and wrong and have a general understanding of Regulations that relate directly to their respective responsibilities; at least enough to enable them to determine when to seek advice.[12] In the event that an Affected Individual feels that he or she would benefit from further clarification of any legal or regulatory requirement or any facet of the Compliance Program or the application of such directives to a certain situation, he or she is responsible to seek guidance from supervisors or appropriate compliance personnel. Guidance can also be sought anonymously via Amazing’s Compliance and Ethics Hotline.[13]
If any Affected Individual knows of or suspects a violation of the law, professional standards or the Program, the Affected Individual is obligated to report all pertinent information to the Compliance and Ethics Hotline, which affords complete anonymity if desired. The Affected Individual may also discuss the known or suspected issue with supervisors and/or appropriate compliance personnel. Failure to report a known or suspected violation is itself a violation of the Program and may result in disciplinary action up to and including termination.
Certify that they have received, read, understand, and agree to abide by the Compliance Plan upon hire and as part of annual compliance training thereafter.

Conflicts of Interest. Amazing insists that its mission to provide high quality care never be compromised by self-interest or financial interest of any kind. Consistent with this, Amazing has in place policies and procedures to ensure that the outside financial and other personal interests of all employees, officers, senior managers and members of the governing body do not compete with the interests of Amazing or influence decisions or actions taken on behalf of Amazing. Affected Individuals’ interests must yield to Amazing’s interests. Affected Individuals (other than Contractors) are required to disclose actual or potential conflicts of interest and avoid situations in which their duties and allegiances may be jeopardized—whether they are on the giving or receiving end of the benefit.[14] This is particularly relevant to Affected Individuals in positions of influence over business decisions, and, as such, select personnel may be required to make certain periodic disclosure statements in an attempt to eliminate even the appearance of misconduct.

Deficit Reduction Act. The OMIG Compliance Regulations and the federal Deficit Reduction Act require recipients of federal health care program funds to include in their policies and procedures detailed information regarding the federal False Claims Act, the Federal Program Fraud Civil Remedies Act, applicable state civil and criminal laws intended to prevent and detect fraud, waste, and abuse in federal health care programs, and whistleblower protections afforded under such laws. A copy of Amazing’s Deficit Reduction Act Policy is attached to the Company’s Employee Handbook and incorporated herein by reference. If you have questions regarding any of the laws discussed in the Deficit Reduction Act Policy, please contact the CCO.

Prohibition against Retaliation and Intimidation.

Amazing recognizes that the foundation upon which a strong detection and identification structure is built is a steadfast Policy of Non-Intimidation and Non-Retaliation. It is unreasonable and unrealistic to expect individuals to come forward with reports and concerns, candidly participate in investigations or proactively seek guidance on how to deal with questionable circumstances or understand legal requirements if they do not feel safe from retribution. Since Amazing does not merely encourage – but affirmatively requires – personnel to seek direction and report known or suspected violations or other genuine misgivings, the Program contains a strict Policy of Non-Intimidation and Non-Retaliation whereby anyone who participates in the Program in good faith is guaranteed complete protection from any harm, adverse action or intimidation.[15]

Thus, it is Amazing’s policy that no Affected Individual who in good faith reports a suspected compliance problem shall suffer harassment, retaliation, intimidation, or adverse employment consequence. Any person who retaliates against or intimidates a person for (a) reporting potential compliance issues to appropriate personnel; (b) participating in the investigation of potential compliance issues; (c) participating in self-evaluations; (d) participating in audits; (e) participating in remedial actions; (f) reporting instances of intimidation or retaliation; or (g) reporting potential fraud, waste or abuse to the appropriate State or Federal entities, will be subject to discipline.

Amazing recognizes that the authenticity and reliability of the entire Compliance Program rests upon the protection of Affected Individuals, patients, family members and others who come forward in good faith and report a suspected compliance issue, or who participate in other Compliance Activities. As such, Amazing takes the protection of these individuals from retaliation and intimidation extremely seriously. Disciplinary action will be firmly and fairly enforced against individuals who retaliate against or intimidate Affected Individuals in violation of this policy. Disciplinary action for violations of this policy may include termination of employment or contract, or any other action pursuant to the disciplinary policy set forth in this Compliance Plan.

If an Affected Individual fears retribution or feels uncomfortable openly requesting guidance or sharing information for any reason, he or she should report such fear or discomfort either anonymously via the Hotline or directly to a superior, the CCO or a CEC member.

Other Compliance-Related Policies and Procedures

Record Retention Policy. Amazing records and documents – including electronic medical records, billing records and documentation generated pursuant to this Compliance Program – shall be created, distributed, secured, retained and destroyed in accordance with the company’s record retention program and in line with relevant Regulations. Amazing will retain all records and related documentation in the following manner:

General Record Retention Policy.

Amazing has implemented a general record retention policy to ensure all medical records and other related records are retained in accordance with applicable Regulations.[16] In the event Amazing is subject to an audit or investigation by a governmental agency having jurisdiction over Amazing, Amazing shall continue to preserve and maintain relevant records until the later of the applicable statutory record retention period or the completion of such audit or investigation, including any appeals.[17]

Amazing shall safeguard and protect the confidential and private information of its patients in line with relevant Regulations, including, but not limited to, the Health Insurance Portability and Accountability Act (“HIPAA”), the Health Information Technology for Economic and Clinical Health (“HITECH”) Act and the Omnibus Rule of 2013.[18] The sensitive and private nature of much of the information handled at Amazing, coupled with the information-sharing culture in which we live, makes the protection of confidential material a particularly challenging issue. For example, the widespread use of text messaging as a means of communication, posting of photographs on social media and utilization of other mediums through which data is freely transmitted, requires Affected Individuals to remain vigilant in maintaining confidences appropriately and to reach out for guidance and direction when questionable situations arise.[19]

Compliance Record Retention Policy.

It shall be the policy of Amazing to maintain all records related to the adoption and implementation of the Compliance Program, including without limitation all adopted versions of this Compliance Plan and related policies and procedures, audit and investigation materials, corrective actions, training documentation, meeting minutes, compliance work plans and audit work plans, and any other documentation required to be maintained by this Compliance Plan or applicable Regulations, including without limitation the OMIG Compliance Regulations, for a period of not less than six (6) years from the date that such record was created. This requirement shall be interpreted to require the maintenance of copies of the Compliance Plan and all policies and procedures that were in effect for the preceding six (6) year period, even if the Plan or such policies and procedures were adopted prior to such six-year period.

Business Practices. Amazing shall integrate and adhere to the following general policies in its operations and business activities:
Amazing shall adhere to operative Regulations regarding cyber-security and appropriate planning for a possible cyber-attack to help avoid or mitigate potential compromising circumstances.
Amazing shall have proper business associate agreements in place before sharing confidential material – including protected health information – with certain vendors, contractors or other non-Amazing employees, in accordance with relevant Regulations.
Amazing shall maintain accurate books and records and shall ensure that all accounting entries and financial documentation are in line with relevant Regulations.
Advertising and marketing material shall comply with relevant Regulations and be truthful and accurately reflect the services provided by Amazing.
Affected Individuals shall treat each other with respect in accordance with relevant Regulations and refrain from abusive or harassing behavior of any kind.
Amazing shall adhere to operative Regulations regarding the health and safety of its personnel, including, but not limited to those involving the Occupational Safety and Health Administration (OSHA) and related state organizations.
Amazing personnel shall properly and timely complete and submit time cards and/or other documentation evidencing the time they work in accordance with company policies and procedures and operative Regulations, thus enabling Amazing to fulfill its desire to pay all employees for all time worked as appropriate.

Quality of Care. Amazing’s Compliance Program activities shall be integrated with Amazing’s quality of care standards and policies, which include:
Amazing is committed to providing each properly certified and eligible patient with necessary care and/or services reasonably expected to promote, maintain or restore health or lessen the effects of illness and disability and it is this commitment that shall guide everything done at Amazing.
Amazing shall follow operative Regulations for servicing patients, including, but not limited to, not discriminating based on payor source or race, color, religion, national origin, sex, age, disability or any other legally protected characteristic.
Amazing’s staff members shall be sufficiently competent and qualified to care for the unique needs of its patients, in accordance with relevant federal and state requirements and other relevant Regulations.
Amazing shall ensure that staff members obtain and maintain appropriate credentials, licensure, experience and expertise to carry out their respective tasks and in accordance with applicable Regulations; that staff members receive appropriate training and education; and that staff members are properly supervised. Amazing may require companies that serve as business associates or contractors to adopt similar programs regarding their employees who are providing services at or to Amazing.
Amazing shall not employ or associate with any individual or entity that is excluded from participation in the Medicare and/or Medicaid programs (see Excluded Providers above). Amazing shall similarly refrain from employing or associating with individuals or entities that have otherwise been disqualified from fulfilling the particular role for which they are being utilized, such as caregivers with direct patient access who have been found guilty of abuse, neglect or mistreatment or those with findings for similar physical or financial mistreatments on a state nurse aid registry or by a state licensure body. Those who were employed by or associated with government offices or agencies in certain capacities may also be precluded. In the event that an Affected Individual is found to be excluded or otherwise ineligible from continuing their association with the company, Amazing shall take swift appropriate action up to and including termination of employment or relationship.
Amazing shall fulfill its role, as appropriate, in the development and implementation of a comprehensive plan of care for each patient that uses an interdisciplinary and inclusive approach and involves all relevant parties – including the patient and/or family members – when feasible. The plan of care should, among other things, identify the services the patient needs, which healthcare professionals should give such services, how often the services will be needed, the medical equipment that is needed and the expected results from the prescribed treatment. The plan of care should be reviewed as often as necessary in accordance with operative Regulations.
Amazing shall endeavor to keep patients free from any harm, including, but not limited to, verbal, mental, sexual and physical abuse and neglect by, among other things, developing and implementing policies and procedures to prohibit, prevent, investigate, and respond to mistreatment, neglect and abuse of patients by staff or fellow patients as well as injuries from unknown origins; thoroughly investigating and reporting incidents to law enforcement, as required by relevant Regulations; and remaining attentive in safeguarding the dignity of patients.
Providing high quality care requires that incidents and accidents are acknowledged, investigated, addressed and corrected openly and honestly. To that end, Amazing shall comply with all applicable mandatory reporting Regulations by, among other things, timely and properly reporting events and issues, as well as compiling and maintaining documentation, all as required and appropriate. In no event shall an Affected Individual attempt to conceal or cover up any potential or actual violation, wrongdoing or illicit conduct.
Amazing shall endeavor to protect and promote the rights of each patient – including, but not limited to, patients’ rights of medical and financial self-determination; privacy; and access to personal records upon request – and hereby adopts operative Federal and State Patient Rights as part of the Compliance Program.[20]

THE CHIEF COMPLIANCE AND ETHICS OFFICER (“CCO”) AND THE COMPLIANCE AND ETHICS COMMITTEE (“CEC”)

Fundamental to the success of Amazing’s Compliance Program is the assignment of overall responsibility to oversee compliance with the guidelines set forth in the Manual – amid compliance with the law and the Program, more generally – to specific individuals within high-level personnel of the organization and allotting sufficient resources and authority to these individuals to achieve such compliance. This well-rounded group of Amazing employees, consultants and/or contractors include the CCO the CEC, which is chaired by the CCO.

Chief Compliance and Ethics Officer.

Amazing will, at all times, designate an individual to serve as the CCO. The CCO will be the focal point for Amazing’s Compliance Program and is responsible for the day-to-day operations of the Program. Any questions or concerns relating to any compliance related matter should be immediately referred to the CCO.

The Chief Compliance Officer is Mark Kiss.

The CCO can be reached directly by telephone (718-863-3300 ext. 123); e-mail (mkiss@amazinghc.com); or in person at his or her office.

In addition, anonymous reports to the CCO can be made by

calling Amazing’s confidential Compliance and Ethics Hotline 1-800-715-7021

The primary responsibilities of Amazing’s CCO shall include the following:

Overseeing and monitoring the adoption, implementation and maintenance of the Compliance Plan and evaluating its effectiveness;
Drafting, implementing, and updating no less frequently than annually or, as otherwise necessary, to conform to changes to Federal and State laws, rules, regulations, policies and standards, a compliance work plan which shall outline Amazing’s proposed strategy for meeting its compliance program obligations for the upcoming year, with a specific emphasis on (a) written policies and procedures; (b) training and education; (c) auditing and monitoring; and (d) responding to compliance issues;
Reviewing and revising the (a) Compliance Plan; (b) written policies and procedures; and (c) Standards of Conduct, to incorporate changes based on Amazing’s organizational experience and changes to Federal and State laws, rules, regulations, policies and standards;
Reporting directly, on a regular basis, but no less frequently than quarterly, to Amazing’s Governing Authority, chief executive, and CEC, hereinafter defined, on the progress of adopting, implementing, and maintaining the Compliance Plan;
Assisting Amazing in establishing methods to improve Amazing’s efficiency and quality of services, and reducing Amazing’s vulnerability to fraud, waste and abuse;
Investigating and independently acting on matters related to the Compliance Plan, including designing and coordinating internal investigations, as well as documenting, reporting, coordinating, and pursuing any resulting corrective action internally, as well as with Contractors and government agencies;
Ensuring that all of Affected Individuals have read and understood this Compliance Plan, and obtain a signed acknowledgment from Affected Individuals;
Ensuring that Affected Individuals have read, understood and agree to abide by Amazing’s Standards of Conduct (or with respect to Contractors, have adopted standards of conduct that satisfy the OMIG Compliance Regulations);
Ensuring that exclusion checks are conducted in accordance with this Compliance Plan;
Fostering a “culture of compliance” within Amazing by regularly communicating compliance expectations, and publicizing the anonymous Compliance Hotline and other ways of communicating with the CCO (such as through compliance posters);
Conducting an annual review of Amazing’s compliance efforts to be provided to the Governing Authority;
Regularly monitoring the Compliance Plan and Compliance Program to improve its effectiveness;
Monitoring proposed and enacted changes in laws, rules, regulations and program guidelines applicable to Amazing and ensuring that any such changes are adopted and implemented, including updating Amazing’s policies and procedures, providing training as appropriate, and using the Compliance Program’s auditing and monitoring processes to ensure such changes have been effective in practice;
Developing, coordinating and participating in compliance education and training programs and ensuring that staff are properly educated and trained concerning compliance, and attending annual compliance training as a participant;
Receiving, responding to, and investigating complaints and concerns submitted through the anonymous Compliance Hotline and other lines of communication to the CCO;
Maintaining a log of all compliance complaints and concerns, including the source of the complaint, the issue, the status of the investigation, and the resolution;
Ensuring that disciplinary policies for non-compliant behavior, participation in non-compliant behavior, and the encouragement, direction, facilitation or allowance of noncompliant behavior, is firmly and fairly enforced;
Conducting or overseeing ongoing internal and external audits and reviews to assess Amazing’s compliance with applicable laws, rules and regulations;
Ensuring that policies, procedures and processes found to be ineffective or outdated are revised;
Monitoring and identifying Risk Areas that should be the focus of Amazing’s annual audit plan and preparing and implementing Amazing’s annual audit plan;
Investigating, responding to, correcting and preventing compliance issues;
Developing and overseeing the implementation of corrective action plans, and ensuring that the implementation of corrective action plans are effective in preventing further non-compliance;
Reporting and returning overpayments identified through the Compliance Program in accordance with Amazing’s overpayments policy;
Enforcing Amazing’s policy against retaliation and intimidation; and
Taking actions the CCO deems necessary to ensure that Contractors are familiar with the Compliance Program, receive compliance training, and abide by the Compliance Plan.

The primary responsibilities of the CCO set forth above may be the sole duties of the CCO, or the CCO may be assigned additional duties, depending on the size, complexity, resources, and culture of Amazing and the complexity of the duties in question, provided that such additional duties do not hinder the CCO in carrying out their compliance responsibilities.

The CCO shall report directly to and be accountable to Amazing’s chief executive or another senior manager whom the chief executive may designate for reporting purposes provided, however, such designation does not hinder the CCO’s ability to carry out their primary responsibilities and to access the chief executive and Governing Authority.

Amazing will ensure that the CCO is allocated sufficient staff and resources to satisfactorily perform their primary responsibilities for the day-to-day operation of the Compliance Program based on Amazing’s Risk Areas. Amazing shall further ensure that the CCO and appropriate compliance personnel have access to all records, documents, information, facilities and Affected Individuals that are relevant to carrying out their primary responsibilities under this Compliance Plan.

Compliance and Ethics Committee. The CEC is tasked with supporting and assisting the CCO in the development, implementation and monitoring of the Compliance Program – as set forth in this Compliance Plan and the Compliance and Ethics Committee Charter – and the inculcation of its values across company operations. The CEC assists the CCO with implementation of the Compliance Program and ensuring Amazing is conducting its business in an ethical and responsible manner, consistent with this Compliance Plan.

The CEC also provides a mechanism to coordinate and integrate compliance activities across all Risk Areas. Given the distinctively holistic nature of the Program, the CEC may collaborate and consult with many different departments, as well as facilitate inter-department communication and cooperation. Furthermore, recognizing the natural synergy between the compliance and quality assurance operations in their shared, albeit complementary, purpose to continuously improve the quality of care and ridding the company of any detractions therefrom, Amazing anticipates interplay between the CEC and the Quality Assurance function (“QA”). Indeed, the CEC may, as appropriate, serve as an arm of QA in, among other things, identifying, developing and implementing methods for enhancing company systems and procedures; investigating possible violations and irregularities; and conducting auditing and monitoring tasks.

The CEC, with the CCO at the helm, shall take the lead in prioritizing the areas of greatest compliance risk to Amazing,[21] as well as generate compliance reports, work plans, budgets and/or other useful tools to communicate the compliance agenda to ownership, management and/or the governing body, as appropriate and required by Regulation. The CEC, in conjunction with the CCO, is responsible to ensure that compliance issues are identified; identified compliance issues are properly investigated; investigations include, as appropriate, assessing existing policies and trainings, carrying out corrective and disciplinary actions and conducting follow-up monitoring and auditing; and that investigations of identified issues are properly documented, logged and filed. The CEC shall ensure that the Program is effective and that it remains current with changes in operative laws, industry practices and circumstances at Amazing.[22]

The CEC shall be governed by a written CEC charter (the “Charter“).[23] The responsibilities of the CEC shall be set forth in the Charter and shall include:

Coordinating with the CCO to ensure written policies, procedures, and Standards of Conduct are current, accurate and complete, and that training required by this Compliance Plan is timely completed;
Coordinating with the CCO to ensure communication and cooperation by Affected Individuals on compliance related issues, internal or external audits, or any other function or activity required by this Compliance Plan;
Advocating for the allocation of sufficient funding, resources and staff for the CCO to fully perform their responsibilities;
Ensuring Amazing has effective systems and processes in place to identify compliance program risks, overpayments and other related issues, and effective policies and procedures for correcting and reporting such issues;
Advocating for adoption and implementation of required modifications to this Compliance Plan;
Propose revisions to the Compliance Plan as warranted;
Establish compliance policies and procedures across the organization deriving from the Compliance Plan;
Implement compliance initiatives and measure their effectiveness based upon an approved audit methodology;
Redesign compliance initiatives, policies and procedures as necessary;
Review compliance investigations and assist the CCO in conducting such investigations, as necessary;
Recommend and enforce action for actual compliance violations;
Assist in the collection, review and analysis of data from compliance audits, and reporting its findings to the Governing Authority; and
Serve as a risk management body with an emphasis on prevention of compliance issues, particularly fraud, abuse and waste.

Membership in the CEC shall be comprised of senior managers that represent functions that impact the Risk Areas, and may include external advisors. Amazing shall select CEC members who have demonstrated high integrity, good judgment, assertiveness, and an approachable demeanor, while eliciting the respect and trust of colleagues and having significant professional experience on a range of compliance-related issues. Those selected to serve on the CEC shall also have the requisite stature, seniority and experience in the organization and/or within their respective departments to carry out their duties and implement any recommended corrective action and procedure modifications. The selected CEC members shall then be adequately trained and educated to fulfill their responsibilities as enumerated herein.^[24] The names and contact information of the members of the CEC shall be distributed along with this Compliance Plan and/or posted in the company office.[25]

The CCO and the CEC shall be granted the autonomy, power, resources and access to information and records needed to carry out their responsibilities and operate an effective Program. The CEC shall not be subordinate to Amazing’s general counsel or financial officer but shall have direct access and report directly to ownership, the governing body and/or legal counsel.[26] These reports shall discuss the past, present and future of the Program itself, as well as specific compliance matters, as appropriate. And ownership and management, in turn, shall provide the necessary support to and assessment of the CEC and the CCO to ensure the enduring effectiveness and success of the Program.

The CEC shall meet no less frequently than quarterly. CEC meetings may be held in conjunction with other Amazing committee meetings, such as a quality assurance committee.

III. TRAINING AND EDUCATION

Amazing shall endeavor to communicate effectively its standards and procedures to all Affected Individuals and provide training and education to such individuals necessary to educate employees on their compliance-related obligations, the functioning and operation of the Compliance Program, and substantive requirements applicable to their relationship with Amazing. This Compliance Plan, which contains the Standards of Conduct and other compliance-related policies and procedures, serves as the primary written method of such communication. The Compliance Plan is complemented by training and education programs that reinforce the information contained therein by breathing life into the codified concepts. These are described below.

General Compliance Training.

General compliance training and education will emphasize the importance of compliance practices which are essential to the operation of Amazing, and Amazing’s commitment to detecting and preventing fraud, waste and abuse. In addition, the compliance training and will highlight key compliance issues and Risk Areas. The Standards of Conduct will be described during the compliance training and education, and copies of the same will be distributed.

Amazing’s compliance training has two essential objectives: (1) to train all Affected Individuals to perform their jobs in accordance with this Compliance Plan; and (2) to convey to all Affected Individuals that adherence to proper compliance practices is a condition of continued employment. Amazing’s compliance training and education program shall include, at a minimum, the following topics:

Amazing’s Risk Areas;
Amazing’s written policies and procedures set forth in this Compliance Plan;
The role of the CCO and the CEC;
Means for Affected Individuals to ask questions and report potential compliance-related issues to the CCO and senior management, including the obligation of Affected Individuals to report suspected illegal or improper conduct and the procedures for submitting such reports, and the protection from intimidation and retaliation for good faith participation in the Compliance Program;
Disciplinary standards, specifically such standards related to this Compliance Plan and prevention of fraud, waste and abuse;
The manner in which Amazing responds to compliance issues and implements corrective action plans;
Requirements specific to the Medicaid program and the services and treatments provided by Amazing;
Coding and billing requirements and best practices; and
Amazing’s process for claim development and submission.

The CCO and all Affected Individuals shall complete the compliance training program required by Section III of this Compliance Plan no less frequently than annually. Contractors may satisfy these requirements by providing training directly to their personnel in accordance with their own compliance program, provided that such training satisfies the requirements of the OMIG Compliance Regulations and addresses the above elements, as applicable. The training and education required by this Section III shall be made a part of the orientation of new Affected Individuals and shall occur promptly upon hiring.

Specialized Training

Amazing will provide more in-depth training on specific compliance issues to Affected Individuals whose job responsibilities implicate such specific compliance issues. Additional training will be provided as deemed necessary to address Risk Areas, implement corrective action, ensure the adoption of new or modified policies and procedures, or that are otherwise deemed necessary or appropriate by the CCO or the CEC.

General Training Policies

Training and education required by this Section III shall be provided in a form and format accessible and understandable to all Affected Individuals, consistent with Federal and State language and other access laws, rules or policies. Training sessions may serve as a refresher of established guidelines or an introduction of new ones; they may be conducted by Amazing staff or outside instructors;—all as needed and appropriate.

All training under this Section III will be reflective of the skills and experience of participants, utilize a variety of teaching methods, and include a post-evaluation for effectiveness. Amazing will utilize appropriate training methods which may include distribution of written compliance materials (provided adequate systems exist for verification of completion, including without limitation, dated memos documenting distribution to all Affected Individuals), in-house training and outside seminars, recorded videos, online training systems, interactive webinars or live classes. In addition, there may be occasional email blasts, posted bulletins or other circulated publications that convey legal or regulatory updates and/or explain particular issues of interest in a practical and understandable manner.[27] The nature, format and frequency of training and education programming may vary in accordance with the subject at hand as Amazing strives to keep personnel informed of developments in compliance and ethics issues in a way that is most conducive to genuine understanding.[28]

New employees responsible for complicated tasks that involve potential legal exposure will be monitored closely until all required training is completed. For all Affected Individuals, participation in the mandatory training programs is a condition of continued employment (or contracting), and failure to comply with the training requirements will result in disciplinary action. Appropriate certification of receipt and understanding of and commitment to compliance and ethics materials, as well as attendance at compliance and ethics training and education programs shall be maintained. Such certifications may be accomplished via executed acknowledgments, sign-in sheets, post-training exams or other acceptable methods.

The CCO will prepare and maintain a training plan. The training plan will, at a minimum, (a) outline the abovementioned subjects or topics for training and education; (b) the timing and frequency of the training; (c) how attendance will be tracked; and (d) how the effectiveness of the training will be periodically evaluated.

EFFECTIVE LINES OF COMMUNICATION

Open lines of communication between the CCO, CEC, Governing Authority, patients and their families, and all Affected Individuals, which protect the confidentiality of persons reporting compliance issues, is essential to the proper implementation of this Compliance Plan. Because a culture of candidness and critical introspection is crucial to the success of the Compliance Program and the fulfillment of our mission, Amazing desires to maintain open lines of communication whereby Affected Individuals, patients or anyone else can voice concerns, share observations, report known or suspected violations of any Regulation, offer feedback or seek guidance (collectively, to “Communicate” or a “Communication”) in a forum that provides confidentiality and anonymity, if preferred, as well as protection from any retribution for coming forward.

To foster open lines of Communication, Amazing has adopted a robust communication system driven by the following principles and components:

The Compliance Program shall be accessible to all Affected Individuals, patients and their families and provide a forum for questions regarding compliance issues and manner to report such compliance issues.
Amazing will publish information about its Compliance Plan, including how to report compliance issues and contact the CCO, along with a copy of its Standards of Conduct, on its website.
Compliance activities shall protect of the confidentiality of persons reporting compliance issues, and maintain such confidentiality unless the matter is subject to disciplinary proceedings, referred to, or under investigation by the Medicaid Fraud Control Unit (MFCU), OMIG, or applicable State, Federal, or Local law enforcement, or if disclosure is required during a legal proceeding.
Amazing shall protect any such persons Communicating issues under Amazing’s non-intimidation and retaliation policy.
While Affected Individuals can Communicate via the regular chain of command or directly to the CCO or a CEC member, the primary tool to Communicate under the Compliance Program is Amazing’s Compliance and Ethics Toll-Free Hotline (the “Hotline”) at 1-800-715-7021 which is available to Affected Individuals, as well as patients, family members and visitors 24/7/365. Callers will always get a live operator not affiliated with Amazing to receive and document Communications. This service is available in multiple languages, including English and Spanish, and callers will never be required to share their identity. Although detailed Communications – including revealing the identities of the parties involved – make a proper investigation more feasible, callers may maintain complete anonymity if they so desire.
Amazing shall advertise the Hotline by hanging posters in the office with the Hotline contact information or some alternative appropriate means.

In addition, all Affected Individuals are advised:

They must report conduct which a reasonable person would, in good faith, believe to be non-compliant, fraudulent or erroneous.
They must refuse to participate in unethical or illegal conduct.
To knowingly fail or refuse to Communicate non-compliant, fraudulent, or erroneous conduct is a violation of this Compliance Plan and can result in disciplinary action.
Adherence to and cooperation and participation with this Program and its policies, procedures and initiatives – as an essential element of employment by or association with Amazing – may be considered in evaluations and assessments of Affected Individuals’ standing with Amazing. Violations of the Program – whether active infringements or passive failures – may result in disciplinary action up to and including termination.[29]
The seriousness with which Amazing addresses Communications and the accompanying guarantees of confidentiality and anonymity for those who come forward makes this tool vulnerable to misuse by one who seeks to perpetrate harm on another. The use of any reporting method under the Compliance Program for disingenuous or dishonest means – including, but not limited to, submitting a report for vindictive purposes and/or that one knows to be untrue – may result in disciplinary action.
Amazing’s commitment to openness also requires all Affected Individuals to be forthcoming, honest and cooperative with all internal investigations, audits and requests for information by authorized Amazing compliance personnel or others acting on their behalf. No Affected Individual shall provide information that is imprecise, misleading, or incomplete.

Assistance with identifying potential compliance issues, as well as any compliance related questions and concerns for Affected Individuals, will be promptly addressed by the CCO.

The CCO will be responsible for promptly investigating and resolving all reports of fraudulent, erroneous or non-compliant conduct or other Communications, including implementing appropriate corrective action. Compliance reports – including those received via the Hotline – shall be shared with members of the CEC who have been suitably trained and educated regarding the appropriate treatment of such information, including properly maintaining anonymity and confidentiality. The confidentiality of all individuals who Communicate compliance issues will be maintained by the CCO and CEC, unless the matter is subject to disciplinary proceedings, referred to, or under investigation by the Medicaid Fraud Control Unit (MFCU), OMIG, or applicable State, Federal, or Local law enforcement, or if disclosure is required during a legal proceeding.

DISCIPLINARY POLICY

All Affected Individuals are subject to Amazing’s disciplinary policy. All Affected Individuals who fail to comply with the written policies and procedures, Standards of Conduct, or Regulations, as set forth in this Compliance Plan will be subject to discipline. Disciplinary action in response to non-compliance or violations of this Compliance Plan is subject to escalation based on the severity of behavior, with intentional or reckless acts or repeated acts of non-compliance resulting in more severe disciplinary action. Amazing’s disciplinary policy embodies the expectation that all Affected Individuals (a) act in accordance with the Standards of Conduct and (b) must refuse to participate in unethical, illegal or non-compliant conduct.

Amazing’s disciplinary policy will be fairly enforced. Disciplinary actions may be taken against, and sanctions imposed upon, any Affected Individual, regardless of an individual’s position within Amazing. Discipline may include the following, depending on the nature, frequency and impact of the offense, as well as mitigating and/or aggravating factors.:

Warnings (oral)
Warnings (written)
Reprimands/Write-Ups (written)
Probation
Demotion
Temporary suspension
Discharge from employment, removal from the Governing Authority and/or removal as an officer, as applicable
Referral for appropriate sanctioning by regulatory agencies and/or criminal prosecution
Termination of contract or agreement, for cause, for Contractors. [30]

AUDITING AND MONITORING

Amazing has established and will implement an effective system for the routine monitoring and identification of compliance risks. The system includes internal monitoring and audits, as well as external audits, as appropriate, to evaluate Amazing’s compliance with the requirements of the Medicaid program and the overall effectiveness of this Compliance Plan. The CCO is responsible for overseeing the auditing and monitoring activities set forth in this Section VI. All Affected Individuals are required to participate in and assist the CCO as requested in the implementation of these auditing and monitoring activities.

Amazing’s auditing and monitoring program is described below:

Timely Identification and Implementation of Changes in Laws, Regulations and Program Requirements.

Regarding Program updates, aside from the inevitable on-the-ground changes that occur at a company over time, the laws and regulations, as well as accepted practices, are constantly changing. A successful and effective compliance program must keep up. Therefore, the CEC – in collaboration with QA, outside consultants, counsel and Amazing staff – shall monitor updates to relevant governing rules, new and modified industry procedures and evolving realities in the company. This will include modification of Medicaid Updates, DOH guidance, OMIG Compliance Alerts, and other state and federal advisories, bulletins and publications that impact Amazing for potential changes in the laws, regulations and program guidelines applicable to Amazing.

The CEC – with the assistance of internal and/or outside consultants or auditors, as appropriate – shall use this information, as well as comments, compliments and criticisms from staff, patients and family members, to periodically revise and modify the Program. The CCO and CEC shall also be responsible for implementing required changes to Amazing’s internal policies and procedures necessary to comply with changes to the laws, regulations and program guidelines applicable to Amazing. The CCO and CEC will provide or arrange for additional training necessary or appropriate to explain changes to the laws, regulations and program guidelines to applicable Affected Individuals, and to ensure that such Affected Individuals understand the new requirements, policies and/or procedures.

Auditing and Monitoring of Risk Areas.

The avoidance and elimination of non-compliance is another cornerstone of compliance achievement. Amazing will perform routine auditing and monitoring, conducted by internal or external auditors who have expertise in state and federal Medicaid program requirements and applicable laws, rules and regulations, or have expertise in the subject area of the audit, in accordance with this subsection. The CCO shall be responsible for: (a) monitoring and evaluating potential areas of vulnerability for noncompliance within Amazing; (b) implementing a process for auditing such high risk areas; and (c) implementing preventative and corrective action to ensure compliance with respect to such high risk areas.

The CCO and the CEC shall be responsible for developing an annual audit plan for auditing and reviewing the internal operations of Amazing. The CCO will prioritize potential areas of audit and prepare and present a draft audit plan for auditing such prioritized areas to the Governing Authority (or a committee of the Governing Authority) for review and approval. Upon approval by the Governing Authority, the CCO, in conjunction with the CEC, shall oversee the completion of audits in accordance with the approved audit plan. Thus, the CCO, CEC, independently or in conjunction with QA, may gather and analyze certain care- or financial-related data, examine specific techniques, review pertinent records, assess particular relationships and/or conduct interviews, questionnaires or surveys in an attempt to uncover possible aberrations, troubling patterns, unsatisfactory methods or potential risk areas.[31] Amazing, through the CEC, may also employ the services of the QA, outside consultants or external auditors to review certain information or documentation in a manner that maintains independence and integrity to expose substandard practices or areas where improvement would be beneficial.

Annual audits shall be focused on Risk Areas and, in particular, those Risk Areas that the CCO and CEC deem to be areas of particular vulnerability for non-compliance. The annual audit plan may include audits focused on: (a) ongoing compliance with applicable laws, rules and regulations; (b) effectiveness of internal changes to policies and procedures to respond to changes in the law; and (c) high risk areas for noncompliance.

As discussed earlier, Amazing has developed communications systems to help detect and identify violations of law and of the Program, as well as possible instances of fraud, waste and abuse and weaknesses in company procedures. A key mechanism for this purpose is a reliable multidimensional reporting system that is available to employees, patients, family members and anyone who wishes to share known or suspected violations or apprehension regarding goings on at Amazing. Concerned parties can meet with, call or email the CCO, members of the CEC or supervisors.[32] Communications submitted by Affected Individuals related to potential compliance issues provide a valuable mechanism for the CCO and CEC to identify Risk Areas that should be a focus of such auditing and monitoring activities. Other sources from which the CCO may identify annual audit work plan topics may include:

OMIG/OIG Annual Work Plans;
OMIG and OIG Corporate Integrity Agreements;
OMIG compliance alerts and webinars;
Applicable OMIG Audit Protocol(s);
Audit findings of other providers of the same provider type;
Special Fraud Alerts,
Advisory Opinions;
Compliance issues identified through internal audits and reviews; and
Compliance issues identified through external audits, surveys and reviews (including those conducted by governmental agencies).

Audit methodology may include, among other things:

Visits and interviews with patients;
Analysis of patient records and supporting materials and documentation;
Testing of billing staff regarding claims submission requirements and official coding guidelines;
Assessment of existing relationships with physicians, hospitals and other potential referral sources;
Examination of Amazing’s complaint logs;
Reviewing the personnel records of individuals with past compliance reprimands and monitoring their current compliance performance;
Interviews with Affected Individuals involved in management, operations, claims development and submission, patient care, and other related activities;
Reviews of clinical documentation, financial records, and other source documents that support claims for reimbursement;
Validation of credentials of physicians and clinicians who authorize services provided by Amazing; and
Review of employee files.

The design, implementation, and results of any internal or external audits will be documented, and the results shared with the CEC and Governing Authority. In addition, the results of all internal or external audits, as well as audits conducted by State or Federal governmental agencies, will be reviewed by the CCO for potential corrective actions that are needed to prevent recurrence of any findings. Required corrective actions will be incorporated in Amazing’s compliance work plan and the CCO will oversee the prompt implementation of corrective action, such as through training, policy revisions, and/or disciplinary action to prevent recurrence. In addition, any Medicaid program overpayments that are identified as a result of routine audits will be reported, returned and explained in accordance with applicable OMIG Compliance Regulations and Amazing policy.

Annual Compliance Program Review.

The CEC and the Governing Body shall periodically – and no less than annually – reassess the Program to evaluate its effectiveness, uncover areas where improvements may be beneficial and identify modifications necessary to reflect developments within the organization and the industry. The purpose of such reviews shall be to determine the effectiveness of the Compliance Program, and whether any revisions, additions, improvements or corrective actions are required. This review may assess the efficacy of existing compliance policies and initiatives by reviewing Program use and activity; the extent to which previously identified systemic problems have improved; and the extent to which Program activity is being properly documented. As part of such reviews, the CCO’s performance shall be evaluated and a determination made as to whether the CCO’s and other CEC members’ other duties, if any, hinder them in carrying out their responsibilities under the Program.

The reviews may include on-site visits, interviews with Affected Individuals, review of records, surveys, or any other comparable method the reviewer deems appropriate, provided that such method does not compromise the independence or integrity of the review. The review may also seek feedback from employees via questionnaires or similar tools. Reviews may be carried out by the CCO, CEC, outside consultants or counsel, or auditors, or other Amazing staff (provided they have the necessary knowledge and expertise to evaluate the effectiveness of the components of the Compliance Plan they are reviewing and are independent from the functions being reviewed).

The CCO and CEC will document the design, implementation and results of its compliance program review, and any corrective actions that are identified as a result. Whenever the policies and procedures are found to be ineffective or outdated, they will be revised as appropriate. Implementation of such corrective actions shall be documented by the CCO. The results of the compliance program review, including any required corrective actions identified, will be shared with the chief executive, senior management, CEC and the Governing Authority.

VII. RESPONDING TO COMPLIANCE ISSUES AND DEVELOPING CORRECTIVE ACTION PLANS

Consistency breeds reliability, which, in turn, breeds endurance. Thus, the long-term success of this Program requires consistency in enforcing its principles. Amazing aims to maintain a successful Program by, among other things, appropriately rewarding outstanding compliance performance and participation as well as appropriately disciplining violations of the Program, complicity with or allowance of noncompliant behavior or failures to detect, address or report an offense hereunder—all in a consistent and fair manner.[33] This steadiness should provide the stability needed to build and maintain an effective, comprehensive and durable Program.

To accomplish this, compliance program procedures and systems will be established and maintained for: (a) promptly responding to compliance issues as they are raised; (b) investigating potential compliance problems as identified in the course of the internal auditing and monitoring conducted pursuant to Amazing’s auditing and monitoring program set forth in Section VI of this Compliance Plan; (c) correcting such problems promptly and thoroughly to reduce the potential for recurrence; and (d) ensuring ongoing compliance with Federal and State laws, rules and regulations, and requirements of the Medicaid program.

In the event that an offense is detected, a violation substantiated or a pervasive deficiency identified – through a prompt and proper investigation[34] conducted by QA, the CEC, Amazing personnel and/or outside consultants – Amazing shall take timely and decisive action to respond appropriately and to prevent recurrence.[35] This may include disciplinary action against offending Affected Individuals;[36] revisions to existing policies, training and education programs and company practices and/or the manner in which they are implemented; returning of improper payments; mandatory reporting;[37] voluntary disclosures; and/or modifications to the Compliance Program itself. The determination of the proper response to an offense shall be made by select Amazing personnel, CEC members, QA, consultants and/or legal counsel, based on the particular circumstances. Suitable Amazing personnel shall then implement the corrective action as soon and as publicly as practicable— facilitating lessons being learned and exhibiting the seriousness with which Amazing takes compliance and ethics. Follow-up auditing and/or monitoring may be employed when appropriate to ensure that corrective actions have had the desired effect and that underlying problems have been sufficiently remedied.[38] The CCO may retain outside experts, auditors, or counsel to assist with the investigation where appropriate.

In addition, external investigations, audits and requests for information may be initiated by federal and state government agencies, other third party payors or contractors, as well as law enforcement officials (collectively, “Requests“). While Amazing is absolutely committed to appropriately and candidly cooperating with proper Requests, the management of such cooperation will often require the input of legal and/or compliance personnel who can assess the many complicated – and often conflicting – rights and responsibilities involved. Therefore, please immediately refer all Requests to the office manager, who can contact the appropriate parties to properly respond after considering issues of privilege, privacy and numerous other factors under the law. Legal and compliance personnel will direct the truthful, timely and comprehensive cooperation with such Requests as required by law.[39]

The CCO will thoroughly document all compliance related investigations, including (a) documenting the nature of any alleged violation and a description of the investigative process used to investigate the alleged violation, and (b) written interview notes and other documents demonstrating the completion of a thorough investigation of the issue. For each compliance investigation, the CCO will promptly document his or her findings as to the following:

Whether, in fact, there is noncompliance;
What parties are responsible for such noncompliance;
What corrective action plan is appropriate (e.g., re-training, disciplinary actions, the formulation of procedures to prevent future noncompliance and other actions to improve the Compliance Plan); and
After consultation with legal counsel, whether a particular violation is reportable under applicable Federal or State law, and whether any overpayments exist that must be reported and returned in accordance with Amazing’s overpayment policy.

Finally, if Amazing identifies credible evidence of, or credibly believes that, a Federal or State law, rule or regulation has been violated, Amazing will promptly report such violation to the appropriate governmental entity, where such reporting is otherwise required by law, rule or regulation. The CCO will retain copies of any reports or information submitted to governmental authorities in connection with this requirement.

CONCLUSION

As stated above, this Compliance Plan is not an all-inclusive presentation of the rules and practices under the Compliance Program. Instead, it is a means of conveying Amazing’s ideals, the content and spirit of which should be applied appropriately by Affected Individuals through their use of good judgment. Should you desire further clarification of any aspect of this Compliance Plan or the Compliance Program, please reach out to the CCO or a CEC member or anonymously via the Hotline.

With our shared commitment and participation in the Compliance Program we will effectively prevent and detect wrongdoing and promote quality of care and thereby achieve long-term success.

ADOPTION BY GOVERNING AUTHORITY

This Compliance Plan and Policies has been adopted by the Governing Authority effective as of the 01of January, 2024. The Compliance Program will be reviewed, and as applicable, revised annually hereafter.

EXHIBIT A

STANDARDS OF CONDUCT

PURPOSE:

The purpose of these Standards of Conduct is to foster and maintain the highest level of professional and ethical standards in the conduct of the business of Amazing Home Care Services, LLC (the “Amazing”). Amazing places the highest importance upon its reputation for honesty, integrity and high ethical standards. The Standards of Conduct contain standards of ethical behavior and practices for Amazing and Affected Individuals (as defined below) that impact all dealings with colleagues, patients, the community and society as a whole, as well as standards governing personal behavior relating directly to the role and identity of Amazing. The Standards of Conduct are intended to serve as notice to Affected Individuals, local, state and federal government officials, and the community at large, that Amazing expects and requires all persons associated with Amazing to abide by all applicable laws and regulations, prevent, to assist in Amazing’s efforts to detect and deter fraud, waste and abuse, and to adhere to the standards set forth in these Standards of Conduct.

APPLICABILITY:

These standards can only be achieved and sustained through the actions and conduct of all persons whose job responsibilities impact or affect Amazing’s Risk Areas (as defined in the Compliance Plan), including Amazing’s employees, the chief executive and other senior administrators, managers, physicians, suppliers, vendors, contractors, agents, subcontractors, independent contractors, business associates, interns, volunteers, members of the Governing Authority and corporate officers (collectively, “Affected Individuals”). Every Affected Individual is obligated to conduct himself/herself in a manner to ensure maintenance of these standards. The actions and conduct of Affected Individuals and their compliance with these Standards of Conduct will be important factors in evaluating an Affected Individual’s judgment and competence, and an important component of all performance evaluations and contract renewal decisions.

POLICY:

Ethics and Compliance

Amazing has an ethical responsibility to the patients and the community it serves, and fulfills this responsibility through ethical care, treatment, services and business practices. All Affected Individuals are expected to uphold the values, ethics and mission of Amazing.

The mission of Amazing, Amazing’s policies and procedures, and Amazing’s business practices, shall be consistent in the support and protection of the rights of patients in all aspects of care, treatment and services provided.

All Affected Individuals shall conduct all personal and professional activities with honesty, integrity, respect, fairness and good faith in a manner that will reflect positively upon Amazing and in the best interest of the patient population and community served.

Affected Individuals must be cognizant of and comply with all applicable federal and state laws and regulations, as well as health care program requirements, accepted industry practices, professional standards that apply to and impact Amazing in the provision of services, documentation, billing, and the day to day activities of Amazing and its employees and agents. This includes requirements regarding confidentiality of personal health information.

Each Affected Individual who is materially involved in the provision of services, documentation, coding or billing has an obligation to familiarize himself or herself with all applicable laws and regulations, as well as Amazing’s internal policies and procedures related to such functions, and to adhere at all times to the requirements thereof. Where any question or uncertainty regarding these requirements exists, it is incumbent upon, and the obligation of, each Affected Individual to seek guidance from a knowledgeable officer of Amazing, such as the Chief Compliance Officer.

It is the responsibility of every Affected Individual to report any situations that may violate applicable Regulations or the requirements of this Compliance Program in accordance with the company’s Compliance Plan. Claims of ignorance, good intentions and bad advice are not acceptable as excuses for non-compliance or failing to report non-compliance. No one at Amazing has the authority to instruct or encourage an Affected Individual or anyone else to violate any law, rule or regulation, nor does the Governing Authority, the owners of Amazing, or its management desire for anyone to violate any requirement for any reason. Each Affected Individual is responsible for his or her own actions and will be held accountable appropriately.

Those in supervisory positions have the additional responsibility to verify that supervised personnel understand and comply with the standards of professional and business conduct set forth in these Standards of Conduct.

Patient Care and Amazing Practices Related to Provision of Services

Amazing is committed to providing each properly certified and eligible patient with necessary care and/or services reasonably expected to promote, maintain or restore health or lessen the effects of illness and disability and it is this commitment that shall guide everything done at Amazing.
Amazing shall follow operative Regulations for servicing patients, including, but not limited to, not discriminating based on payor source or race, color, religion, national origin, sex, age, disability or any other legally protected characteristic.
Amazing’s staff members shall be sufficiently competent and qualified to care for the unique needs of its patients, in accordance with relevant federal and state requirements and other relevant Regulations.

All Affected Individuals shall maintain competency and proficiency in healthcare industry and general business standards, as applicable.

Contracted providers of healthcare services must meet and adhere to the quality and ethical standards of Amazing, as well as the requirements of New York’s Social Services Law § 363-d.

Marketing materials shall accurately represent Amazing to the public as to the types or quality of care, treatment and services Amazing can provide, directly or indirectly by contractual arrangement.

Amazing shall not receive, accept or offer any remuneration for referrals or transfers of patients in violation of the Anti-Kickback Law.

Whenever possible, patients, families and legal guardians shall be included in decisions about patient care, treatment and services, including ethical issues, subject to all applicable privacy and confidentiality laws.

The effectiveness and safety of care, treatment and services provided by Amazing shall be consistent for all patients and is not dependent on the patient’s ability to pay.

Amazing shall implement and maintain a process to evaluate the quality of care or services rendered.

Billing and Claims

Amazing bills only for services that are actually ordered, coded accurately, verified, medically necessary, and adequately and accurately documented.

Billing practices of Amazing shall adhere to and be compliant with federal, state and local regulations, and applicable program requirements, including all requirements under Medicaid and/or Office of the Medicaid Inspector General (OMIG) and Department of Health (DOH) directives.

Amazing shall maintain all documentation required to support claims and payments for at least six years, or longer if required by applicable laws, rules or regulations, program requirements, or contractual requirements, or Amazing’s record keeping policies.

Business Practices

Affected Individuals are prohibited from exploiting their professional relationships for personal gain, and shall maintain the confidentiality of Amazing’s business and financial information and practices.

Affected Individuals shall safeguard Amazing’s confidential and proprietary information and trade secrets by, among other things, refraining from sharing any lists, reports, policies and procedures, forms, business plans, electronic media, processes or systems with competitors or anyone else outside of the company—even after employment by or relationship with Amazing has come to an end.

Affected Individuals shall refrain from participating in any endorsement or publicity that demeans the credibility and dignity of Amazing and the profession.

Affected Individuals shall not allow any outside financial interest or competing personal interest to influence their decisions or actions taken on behalf of Amazing. Affected Individuals must avoid any situation where a conflict of interest exists or might appear to exist between their personal interests and those of Amazing. All Affected Individuals must disclose any situation where a conflict of interest exists, or might appear to exist, between personal interests and those of Amazing. Affected Individuals may not engage in activities in which an actual or potential conflict of interest may exist unless such actual or potential conflict of interest has been disclosed to and approved by the Chief Compliance Officer and/or the governing authority of Amazing.

Amazing shall strive to continuously improve business management processes, functions and services.

Practicing or facilitating discrimination in any form is strictly prohibited. Amazing shall institute safeguards to prevent discriminatory practices. Affected Individuals shall adhere at all times to the prohibition against discrimination, and shall adhere at all times to policies and safeguards adopted by Amazing to prevent discrimination.

Amazing and its Affected Individuals shall never pay or provide any money, gift or anything else of value to an investigator or public official as a bribe; to induce certain action or inaction; or for any other illicit purpose.

VIOLATIONS:

Affected Individuals who ignore or disregard the principles of these Standards of Conduct will be subject to appropriate disciplinary actions, up to and including restitution and employment termination (or contract termination, in the case of contractors).

CERTIFICATION:

I hereby certify that I have received a copy of Amazing’s Standards of Conduct and have read, understand and agree to abide by the Standards of Conduct. I further agree to fulfill my obligations to assist Amazing in ensuring its compliance with applicable laws, rules and regulations, and preventing, detecting and deterring fraud, waste and abuse.

__________________________________

Name:____________________________

Date: _____________________________

[1] The incalculable number of applicable laws, rules, regulations and standards makes a complete presentation thereof unfeasible. Thus, the omission of a particular authority from this Compliance Plan or from express focus under the Compliance Program in no way diminishes Affected Individuals’ duty to adhere to all operative requirements. Further information on operative Regulations, as well as source materials and synopses thereof, are available upon request of the CCO or a CEC member or via the Hotline.

[2] Non-Amazing employees with little or no involvement in the delivery of or billing for healthcare services or supplies (i.e. maintenance contractors) may be exempted from portions of the Program, as appropriate.

[3] Amazing’s focus on making this uniquely essential Program as understandable and user-friendly for every Affected Individual as possible has given rise to written material that is deliberately designed to be less formal and more colloquial than other company policies and procedures. Nevertheless, the Program is no less authoritative than any other Amazing policy or procedure and is incorporated as part of the company’s canon.

[4] Program roll-out procedures may be modified for Contractors, as described in this Compliance Plan.

[5] Waiving such payments may also implicate the Anti-Kickback Statute (i.e. when offered in order to persuade residents to extend their course of treatment).

[6] Amazing may rely on outside parties to make such assessments, as appropriate.

[7] Highly sensitive areas that may warrant particular attention include medical necessity; Medicare or Medicaid eligibility; inadequate, substandard or deficient care; utilization assessments and classifications; overutilization; duplicate billing; conflict reports; upcoding; unbundling; allocation of costs related to home health coordination; accuracy of cost reports; and ensuring that billing entries correctly reflect the care provided and are properly documented, dated and signed. Additional vigilance may be deemed appropriate when altering or amending medical and billing records to ensure that acceptable methods are being employed.

[8] Wrongful possession of healthcare benefits, if confirmed, may warrant a report to state and/or federal agencies, depending on the specific circumstances. Such determinations will likely require the involvement of legal counsel.

[9] Amazing may also impose affirmative duties on Affected Individuals to disclose any exclusions, debarments, suspensions or convictions upon hire and if such adjudications occur at any point while affiliated with the company. Increased vetting may be conducted for and additional disclosures may be required of Affected Individuals in positions of influence or high-risk and those vested with discretionary authority. And Amazing may require business associates, agencies and contractors to adopt similar initiatives regarding their employees who are providing services at or to Amazing. Please check the Employee Handbook and Policies & Procedures Manual for details of any such policies and procedures.

[10] Common examples of potentially problematic “remuneration” include sports or theater tickets, lavish holiday gifts and travel arrangements—for which ill-intent may be imputed. Common examples of acceptable “remuneration” include inexpensive office supplies, simple meals and nominal gift cards—as long as no objective in the conveyance is to generate business. As stated above, the legitimacy of any benefit vis-à-vis the Anti-Kickback Statue will ultimately turn on the parties’ intent.

[11] This principle is particularly relevant to doctors pursuant to the federal Physician Self-Referral Law, commonly referred to as the Stark Law, and related state laws.

[12] Though the responsibility to be familiar with and abide by Regulations remains with each Affected Individual, Amazing may, from time to time, endeavor to promote awareness of and encourage compliance with certain Regulations—via programs, activities, classes and/or publications, as appropriate.

[13] The features and functionality of the Compliance and Ethics Hotline is addressed in detail below.

[14] Potentially problematic situations hereunder include: working for or with a competitor of Amazing; ownership in or employment by any outside entity that does business with Amazing; or use or disclosure of restricted or private information regarding Amazing for personal gain or for the gain of a family member. Any such arrangements should be discussed with and approved by the CCO, a member of the CEC and/or counsel, as appropriate.

[15] This policy buttresses and complements operative laws and regulations that prohibit reprisal against genuine compliance performance.

[16] HIPAA mandates a six-year minimum for retaining medical records, for example.

[17] In the event that regular document retention procedures must be suspended (i.e. audits, investigations, lawsuits), appropriate Affected Individuals shall be informed of such suspension along with instruction for the specific circumstances.

[18] Compliance efforts hereunder may include paper document safekeeping and cyber-security; restrictions on obtaining, discussing or destroying confidential information; limiting access to sensitive information to specific active Affected Individuals; and authorization and breach notification procedures, all in accordance with operative Regulations.

[19] Please refer to the appropriate manual and/or handbook for Amazing’s numerous policies and procedures regarding the protection and handling of private information; the use of electronic devices and social media; and disclosure and authorization processes.

[20] Federal and State Patient Rights statutes shall be made available to Affected Individuals.

[21] Areas of focus should be determined by industry-wide trends as indicated in government agency Work Plans and reports and investigations and enforcement actions, as well as company-specific trends as indicated in performance evaluations, internal and external audits and issues addressed under the Program. Interaction with and feedback from staff, patients and family members should also play a role in this process.

Prioritization plays a key role after potential issues or trends are identified as well, as assessments of the type and severity of the incident or issue and the role in the company of the parties involved should be considered in determining the urgency and gravity with which matters are addressed.

[22] Amazing’s commitment to patient safety and high quality care may compel the Quality Assurance function (“QA”) – for example, in the event of recurrent errors, inadequacies, lack of improvement in patient outcomes, adverse events or grievances relating to certain quality measures or Regulation issues[22] – to employ the services of the CEC, as appropriate, to investigate, assess, correct and/or monitor matters on behalf of QA, as well as conduct clinical reviews to help ensure patients receive appropriate services.

[23] The Charter shall be reviewed no less frequently than annually and updated as necessary. Annual reviews and revisions shall be appropriately documented.

[24] Other responsibilities of the CEC members shall be limited as needed to help ensure that their ability to fulfill their responsibilities hereunder are not hindered.

[25] In the event that CEC members are replaced or members’ contact information changes, the contact sheet may be revised and posted in the company office, distributed to personnel or otherwise shared with Affected Individuals.

[26] In the event of a significant concern or particularly troubling trend or incident, the CCO and/or the CEC may determine that escalation of the matter is appropriate and may determine that an immediate report to appropriate senior leadership is warranted.

[27] Topics for general and/or focused training and education curricula may include: quality of care risk areas; billing; reimbursement; documentation; exclusion from participation in healthcare programs; proper credentialing; remuneration to induce or reward referrals; marketing; duty to report; privacy and confidentiality; and areas in which regulations or industry practices recently changed.

[28] This compliance training and education is in addition to – and not in place of – Amazing’s comprehensive training and education program whereby anyone working for or with Amazing in any capacity is adequately guided and prepared to fulfill his/her responsibilities in accordance with accepted industry standards and practices. Furthermore, acknowledging the key role training and education plays in the provision of high quality care that is in line with operative laws and moral standards, the CEC may focus on the adequacy and effectiveness of relevant instruction material and programming as part of investigations of identified compliance issues and may suggest modifications as part of the corrective action process, as discussed below.

[29] While uniformity and evenhandedness are valued, participation obligations of Affected Individuals may vary by position and relationship. A manager or supervisor, for example, may be held to an elevated level of accountability for failure to detect or address legal or compliance issues.

[30] Disciplinary action shall be in accordance with company policy, which is set forth in the Employee Handbook. Furthermore, appropriate enforcement agencies may impose civil or criminal fines, program exclusion and/or imprisonment.

[31] Auditing, monitoring and/or spot-checking may be conducted in specific areas of focus as well as the Program itself.

[32] Amazing may also conduct employee exit interviews to solicit information regarding known or suspected noncompliance or substandard practices, among other accepted methods.

[33] While uniformity and evenhandedness are valued, participation obligations of Affected Individuals may vary by position and relationship. A manager or supervisor, for example, may be held to an elevated level of accountability for failure to detect, report or address legal or compliance issues.

[34] Investigations shall be thorough and transparent and may include, as appropriate, review of documentation or records; interviewing of parties involved and anyone else with useful information; viewing of surveillance footage; root cause analyses; inspection of possible missed opportunities to detect issues; and/or research of relevant laws and regulations.

[35] Although corrective action is generally taken only after substantiation of alleged misconduct, immediate steps to remediate potential further harm may be taken pending the outcome of an investigation when certain exceptionally sensitive and consequential issues are involved.

[36] Offenses under this Program include not only express violation of its precepts or spirit but encouraging, directing, facilitating or permitting noncompliant behavior and failing to report or address known or suspected violations as well.

[37] Outside groups to whom certain incidents or issues must be reported include, but are not limited to, state and/or federal health departments, compliance agencies, regulatory authorities and law enforcement officials.

[38] As expressed elsewhere in this Compliance Plan, the CEC shall endeavor to document and file all compliance efforts – from investigation strategies to interviews to document or evidence reviews to root cause analyses to plans of correction to performed remedial actions to follow-up auditing and/or monitoring and any other actions taken – all as appropriate and applicable.

[39] Routine government contact such as state health department surveys should be handled in accordance with Amazing’s regular policies and procedures.