Legal Information

Created November 9, 2009 (Revised January 14, 2011 and May 03, 2011)

Pesach Tikvah Hope Development, Inc. seeks to conduct itself in accordance with the highest level of business and community ethics and in compliance with applicable governing laws. Pesach Tikvah recognizes the problems that deliberate as well as accidental misconduct in the health care industry can pose to society and is therefore committed to ensuring that it operates under the highest ethical and moral standards and that its activities comply with applicable laws.

Pesach Tikvah's compliance policies are contained in a Compliance Plan, which spells out compliance expectations of the agency a whole and for all Pesach Tikvah employees. The Compliance Plan focuses on the prevention of fraud, abuse and waste in federal, state and private health care plans. The scope of the Plan may be expanded in the future to cover other areas of compliance to which Pesach Tikvah is subject. With this Compliance Plan, Pesach Tikvah seeks to promote full compliance with all legal duties applicable to it, foster and assure ethical conduct, and provide guidance to each employee and agent of Pesach Tikvah for his/her conduct. The procedures and standards of conduct contained in the Compliance Plan are intended to generally define the scope of conduct which the plan is intended to cover and are not to be considered as all inclusive. The Compliance Plan is intended to prevent accidental and intentional noncompliance with applicable laws, to detect such noncompliance if it occurs, to discipline those involved in noncompliant behavior, to remedy the effects of non-compliance and to prevent future noncompliance. This Compliance Plan is a "living document" and will be updated periodically to keep Pesach Tikvah's employees and agents informed of the most current information available pertaining to compliance requirements in the health care industry.

Pesach Tikvah's Compliance Plan describes the overall operation of the compliance program, provides guidance to employees on dealing with compliance issues and on how to communicate compliance issues to appropriate compliance personal, and describes how potential compliance problems are investigated and resolved. Compliance Work Plans, which are formulated on a yearly basis, describe planned compliance activities for the current year. Work Plans provide a detailed description of the implementation of the Compliance Program, specifically addressing monitoring and auditing activities that are carried out in order the facilitate compliance with relevant laws and regulations. Work Plans provide a description of the nature of activities to be carried out for each quarter, the manner in which findings will be reported, and—more broadly—the manner in which findings will be responded to and integrated into the ongoing operations of the relevant programs. Compliance Reports are created on a quarterly basis and contain the findings of monitoring and auditing activities carried out for each 2 quarter. These quarterly reports are reviewed by the compliance committee and are submitted to Pesach Tikvah's Board of Directors.

Numerous federal and state laws and regulations define and establish obligations for the health care industry with which Pesach Tikvah, Pesach Tikvah Employees and Pesach Tikvah Agents must comply. Any Pesach Tikvah Employee or Pesach Tikvah Agent who violates these laws and/or regulations not only risks individual criminal prosecution and penalties, civil actions for damages and penalties and administrative exclusion, but also subjects Pesach Tikvah to the same risks and penalties. Any Pesach Tikvah Employee or Pesach Tikvah Agent who violates these laws may be subject to immediate termination of his or her employment or affiliation with Pesach Tikvah.

The following policies have been developed to facilitate compliance with regulations issued by the New York State Office of Medicaid Inspector General ("OMIG") that require certain health care organizations to implement a corporate compliance program.

The Regulations are codified at 18 N.Y.C.R.R. Part 521. They require certain entities to adopt and implement an effective compliance program. The Regulations apply to:

Entities licensed under Article 28 or 36 of the New York Public Health Law or Article 16 or 31 of the New York Mental Hygiene Law.

Persons or entities that submit claims for, order, bill for or receive payment for Medicaid covered services with a value of at least $500,000 during any 12-month period.

Set forth below are some of the major federal and state statutes specifically applicable to health care providers. This outline is not intended to identify all applicable laws, and as described below, PT Employees should always consult the Compliance Officer with specific questions.

a. Civil and Criminal False Claims (42 U.S.C. §1320a-7b(a) and (applicable state Medicaid regulations)

Pesach Tikvah, Pesach Tikvah Employees and Pesach Tikvah Agents shall not knowingly and willfully make or cause to be made any false statement or representation of material fact in any claim or application for benefits under any federal health care program or health care benefit program. In addition, Pesach Tikvah, Pesach Tikvah Employees and Pesach Tikvah Agents shall not, with knowledge and fraudulent intent, retain federal health care program or health care benefit program funds, which have not been properly paid.

Examples of prohibited conduct include, but are not limited to: misrepresenting services that were rendered; falsely certifying that services were medically necessary; "up-coding"; billing for services not actually rendered; making false statements to governmental agencies about Pesach Tikvah's compliance with any state or federal rules; billing federal health programs rates in excess of applicable federal health care program established rates; repeatedly violating the terms 3 of a participating physician agreement, and failing to refund overpayments made by a federal health care program.

b. Anti-Kickback Laws (See Chapter IX, VENDOR RELATIONS POLICY, for discussion of applicable anti-kickback laws).

c. Civil Monetary Penalties Act (42 U.S.C. §1320a-7a)

Pesach Tikvah, Pesach Tikvah Employees and Pesach Tikvah Agents shall not knowingly present a claim to any federal health care program or health care benefit program for an item or service the person knows or should have known, was not provided, was fraudulent, or was not medically necessary. No claim for an item or service shall be submitted that is based on a code that the person knows or should know will result in greater payment than the code the person knows or should know is applicable to the item or service actually provided.

Pesach Tikvah, Pesach Tikvah Employees and Pesach Tikvah Agents shall not offer to transfer, or transfer, any remuneration to a beneficiary under a federal or state health care program, that the person knows or should know is likely to influence the beneficiary to order or receive any item or service from a particular provider, practitioner, or supplier, for which payment may be made, in whole or in part, under a federal health care program. Remuneration includes the waiver of coinsurance and deductible amounts except as otherwise provided, and transfers of items or services for free or for less than fair market value.

d. Ethics in Patient Referrals Act of 1989 (42 U.S.C. §1395nn) ("Stark II")

Physicians (the definition of which also includes psychologists) who have an ownership or compensation relationship with an entity that provides "designated health services" shall not refer a patient in need of designated health services for which payment may be made under Medicare or Medicaid to such entities unless that ownership or compensation arrangement is specifically permitted under the Stark II laws and regulations.

e. Health Care Fraud (18 U.S.C. §1347)

Pesach Tikvah Employees shall not knowingly or willfully execute or attempt to execute, a scheme or artifice to:

(i) defraud any health care benefit program; or

(ii) obtain, by means of false or fraudulent pretense, representation, or promise any of the money or property owned by or under the custody or control of any health care benefit program, in connection with the delivery of, or payment for, health care benefits, items, or services.

a. Criminal False Statements Related to Health Care Matters (18 U.S.C. §1035)

Pesach Tikvah, Pesach Tikvah Employees and Pesach Tikvah Agents shall not knowingly and willfully make or use any false, fictitious, or fraudulent statements, representations, writings or documents, regarding a material fact in connection with the delivery of, or payment for, health care benefits, items or services. Pesach Tikvah, Pesach Tikvah Employees and Pesach Tikvah Agents shall not knowingly and willfully falsify, conceal or cover up a material fact by any trick, scheme or device.

b. Civil False Claims Act (31 U.S.C. §3729(a) and applicable state regulations.

Pesach Tikvah, Pesach Tikvah Employees and Pesach Tikvah Agents shall not:

1. Knowingly file a false or fraudulent claim for payments to a governmental agency, or health care benefit program,

2. Knowingly use a false record or statement to obtain payment on a false or fraudulent claim from a governmental agency or health care benefit program, or

3. Conspire to defraud a governmental agency or health care benefit program by attempting to have a false or fraudulent claim paid.

Examples of false or fraudulent claims include, but are not limited to, double billing, upcoming, unbundling, submitting or processing claims for items or services not provided, submitting or processing claims for items or services not medically necessary, and billing for non-covered services.

(18 U.S.C. §§286, 287)

Pesach Tikvah Employees shall not knowingly make any false, fraudulent or fictitious claim against a governmental agency or health care benefit program. Conspiring to defraud a governmental agency or health care benefit program is also prohibited.

Other Federal and State Laws

Pesach Tikvah is subject to a range of other federal and state laws including wire and mail fraud, obstruction of criminal investigations, conspiracy laws and the Federal Racketeering Act, which includes criminal and civil penalties, and State administrative sanctions on providers who violate the rules, regulations and laws governing the Medical Assistance program (130 CMR 450.238).

While this Compliance Plan does not address every situation that may arise in the billing, coding and documentation requirements for outpatient mental health services, the following are some of the specific risk areas for which Pesach Tikvah Employees and Pesach Tikvah Agents will receive training and supervision.

It is the responsibility of all employees to report suspected fraud, abuse or other improper activity relating to the operation of Pesach Tikvah, whether committed by Pesach Tikvah employees, vendors, clients or others. Examples of the types of activity that must be reported by employees include, but are not limited to, the following:

Employees have several options for reporting fraudulent, abusive or other improper conduct. Employees may file reports with their supervisor or program director, the Compliance Officer or any other member of the Compliance Committee with whom the employee feels comfortable.

Pesach Tikvah has also established a toll-free telephone hotline and a private e-mail box that employees may call to file reports anonymously.

The Compliance Officer will be responsible for monitoring information submitted to the hotline and e-mail box, responding to filed complaints, and ensuring that all employees are aware of the hotline number and e-mail address and understand that reports may be filed through either of these means on an anonymous basis. The Compliance Officer will also publicize the availability of the hotline and e-mail box through regular reminders, posters and organized compliance awareness events.

All reports of fraudulent, abusive or other improper conduct, if not made to the Compliance Officer or through the hotline or e-mail box, will be promptly forwarded to the Compliance Officer for review. The Compliance Officer, in consultation with other Pesach Tikvah staff and legal counsel as appropriate, will determine whether the report warrants an investigation. The Compliance Officer will use best efforts to make this determination within ten days of the receipt of the report.

If the Compliance Officer determines an investigation is warranted, he or she will promptly coordinate the investigation. The Compliance Officer may obtain the assistance of other Pesach Tikvah staff and outside legal and financial advisors, as necessary, to carry out a proper investigation. All employees will be required to cooperate in such investigations. The Compliance Officer will monitor the activities of any outside advisors performing investigative services for Pesach Tikvah. Pesach Tikvah will make reasonable efforts to protect the identity of 6 any individuals filing non-anonymous reports except when disclosure of the individual's identity is necessary to conduct an effective investigation.

New York Labor Law Article 20-C, "Retaliatory Action by Employees," affords protections to employees who report inappropriate activities. Under this article, which contains New York Labor Law §§ 740-741, an employer may not take any retaliatory action against an employee because the employee:

No employee who files a report of suspected fraud, abuse or other improper conduct in good faith or otherwise participates in Pesach Tikvah's Compliance Program may be subject to retaliation in any form for such activity. It is also prohibited to retaliate against an employee for refusing to carry out any activity that is the subject of a good faith report of suspected fraud, abuse or other improper conduct. No employee may threaten to retaliate against another employee for filing such a report.

Retaliation is prohibited even if it is determined that the allegedly improper conduct covered by a report was proper or did not occur, provided that the report was made in good faith. Pesach Tikvah reserves the right to take disciplinary action against any employee who maliciously files a report he or she knows to be untrue.

All employment application forms will require applicants for employment to indicate whether they have been excluded from participation in Medicare, Medicaid or any other government health care program. Applicants will certify on such forms that the information they have provided regarding such exclusions is accurate and complete. While a prior exclusion that is not in effect at the time of the application does not automatically bar an applicant from employment by Pesach Tikvah, no offer of employment may be made to such an applicant without the approval of the Compliance Officer.

The Compliance Officer screens all current employees on a monthly basis against the LEIE, the EPLS and the OMIG Exclusion Lists. Pesach Tikvah is prohibited from offering employment to any individual who is included on the LEIE, EPLS or OMIG Exclusion Lists.

Upon receipt of notification from the U.S. Department of Health and Human Services Office of Inspector General or the New York State Office of Medicaid Inspector General that an employee has been excluded from a state or federal health care program, Pesach Tikvah will promptly terminate the employee's employment. If any employee obtains information indicating that another employee is subject to such exclusion, the employee who obtained such information will 7 promptly notify the Compliance Officer, who will be responsible for investigating the matter.

All newly hired employees must receive basic compliance training within 30 days of the initial date of employment. Training will be scheduled by the Director of Human Resources as part of his or her responsibility to oversee general orientation for new employees. Basic compliance training will be no less than one hour.

The curriculum for basic compliance training will be developed and updated as necessary by the Compliance Officer in consultation with the Director of Human Resources, legal counsel and others deemed appropriate by the Compliance Officer. The curriculum will be designed to provide employees with an overview of key compliance issues faced by Pesach Tikvah. The topics covered by basic compliance training will include, but not be limited to:

Basic compliance training will provide guidance on the state and federal False Claims Acts and Anti-Kickback laws. In addition, employees will be advised of their obligation to report suspected fraud or abuse, the opportunity for anonymous reporting through Pesach Tikvah's compliance hotline and the prohibition on retaliating against employees for making reports in good faith. As part of basic compliance training, each employee will receive a copy of Pesach Tikvah's Code of Conduct and Compliance Program.

All employees will be required to sign a written form acknowledging the receipt of basic compliance training and the Code of Conduct. Such forms will be retained in employees' personnel files for no less than six years.

The Compliance Officer will determine the format of basic compliance training (e.g., in-person, on-line, video, etc.) and is authorized to retain outside vendors to provide training components. The Compliance Officer will keep records for six years of all basic compliance-training programs, including course descriptions, frequency of training and hours of each training session.

The Compliance Officer, in consultation with each program director, will determine whether it is necessary and appropriate to develop a curriculum of supplemental compliance training for employees in his or her Program. Supplemental compliance training will consist of in-depth guidance on the fraud prevention and other compliance issues arising in connection with the operation of the Program. Employees will also be provided with all policies and procedures relevant to the performance of their duties. All supplemental compliance-training curricula must be approved by the Compliance Officer. The Compliance Officer will keep records for six years of all supplemental compliance-training programs, including course descriptions, frequency of training and hours of each training session.

The Compliance Officer will prepare an annual refresher compliance training program, which will reinforce the key principles covered by basic compliance training and summarize any changes in Pesach Tikvah's Code of Conduct, Compliance Program or applicable government standards during the prior year. All employees will be required to attend an annual refresher training session. The Director of Human Resources will be responsible for scheduling refresher training sessions in consultation with the Compliance Officer.

All employees will be required to sign a written form acknowledging the receipt of annual refresher compliance training and, if applicable, the revised Code of Conduct. Such forms will be 8 retained in employees' personnel files for no less than six years.

The Compliance Officer will be responsible for overseeing Pesach Tikvah's internal auditing system. The Compliance Officer is authorized to delegate auditing duties to other Pesach Tikvah personnel as well as outside attorneys, accountants and vendors as necessary and appropriate. Internal audits will cover at least the following subjects:

The Compliance Officer, in consultation with other Pesach Tikvah personnel as appropriate, will identify other issues that should be covered by the internal auditing program.

The Compliance Officer will develop audit tools and procedures for carrying out the audits required by this policy. The Compliance Officer, with the approval of the Executive Director, may contract with outside companies to perform certain auditing functions. The Compliance Officer will oversee the services provided by any outside vendors.

The Compliance Officer will, whenever feasible, seek to have audits carried out by Pesach Tikvah employees who are not otherwise involved in the delivery of the services subject to the audit. It is understood, however, that it may be appropriate for employees to perform an audit of their own program's activities if Pesach Tikvah does not have sufficient staff available in other programs to conduct the audit or the staff in other programs lacks the relevant expertise to effectively carry out the audit. If a program audits its own activities, the Compliance Officer will design audit procedures that minimize auditing by employees of their own work.

In the event the Compliance Officer determines it is in the best interests of Pesach Tikvah to keep the contents and/or findings of any audit confidential, the Compliance Officer will arrange for in-house or outside legal counsel to conduct and/or supervise the audit. In such event, employees will be advised that the audit is being conducted under the attorney-client privilege and the audit report will indicate that such privilege is applicable.

On an annual basis, the Compliance Officer will develop a schedule for internal audits for the upcoming year, which will be approved by the Compliance Committee. The schedule will specify the subject of each audit, the audit methodology, the time period during which the audit will be carried out and the personnel or contractors to be used to perform the audit. Audit subjects will be selected from among the topics specified in this policy and will include any other topics deemed appropriate by the Compliance Officer. The Compliance Officer will select audit subjects based on the level of risk associated with the subject, any prior history of violations, the length of time that has passed since the most recent audit on the same subject and the cost of performing the audit. The Compliance Officer will ensure that any internal audits mandated by law or contract be carried out on a schedule consistent with such requirements. Nothing in this policy is intended to require internal auditing on all of the matters specified herein each year or on any other specific schedule. The Compliance Officer will use best efforts to minimize any disruption of Pesach Tikvah's business activities caused by internal audits.

Upon completion of an audit, the Compliance Officer will arrange for the preparation of a written audit report. The report will set forth the subject of the audit, the audit methodology, the audit findings and any recommended corrective action. The report will be provided to the Compliance Committee, the Executive Director and any appropriate program directors. The Compliance Committee will work with the relevant program director to ensure that all recommended corrective action is taken and will require the program director to report to the Compliance Officer when implementation is completed. Any overpayments or fraudulent or abuse activity discovered through an audit will be handled in accordance with Pesach Tikvah's Fraud Reporting Policy. All audit reports will be maintained by Pesach Tikvah for six years.

The Compliance Plan is implemented under the guidance and supervision of the Compliance Committee, which coordinates compliance efforts for Pesach Tikvah.

Members. The members of the Compliance Committee are:

a. Irwin Shinder, Psy.D., Executive Director
b. Bas Shevy Miller, CPA, Controller
c. Armin Kelleter, MA, Corporate Compliance Officer
d. Dina Lazar, Chief of Staff
e. Joe Bistricer, Director, Recovery Based Services
f. Arthur Heimowitz, LCSW, Director, Family Services Center
g. Brenda Katz, LCSW, Director, Continuing Day Treatment Program
h. Zalman Kotzen, LCSW, Director, Geriatric Services Division
i. Miriam Ryba, Director, Medicaid Service Coordination & In-home Residential Habilitation
j. Chanie Shindler, Director, Intermediate Care Facility
k. Esther Sperber, Director, Children's Program

Meetings. The Compliance Committee shall meet a minimum of one time annually, and may schedule additional meetings as needed.

The Compliance Officer. The Compliance Officer shall be a compliance contact or full-time employee of Pesach Tikvah reporting to Pesach Tikvah's Executive Director and the Board of Directors.

Chair of Committees. The Compliance Officer shall chair the Compliance Committee. The Executive Director shall chair such meetings in the absence of the Compliance Officer.

Duties of the Compliance Officer.The Compliance Officer will assume the managerial and administrative tasks involved in establishing, monitoring, and updating this Plan.
The Compliance Officer shall:

a. Supervise the implementation of this Compliance Plan;
b. Notify Pesach Tikvah Employees and Pesach Tikvah Agents, and oversee the training and education of all Pesach Tikvah Employees and Pesach Tikvah Agents involved in the clinical and billing/coding areas, about applicable compliance standards;
c. Supervise and evaluate monitoring and auditing procedures;
d. Oversee Pesach Tikvah's hotline and e-mail box for compliance reports;
e. Investigate suspected intentional and accidental misconduct;
f. Establish and maintain open lines of communication with programs and departments, including the billing department, and Pesach Tikvah Employees and Pesach Tikvah Agents to ensure effective and efficient compliance policies and procedures;
g. Compile existing policies and procedures, coordinate these policies and procedures, and develop new policies and procedures (which shall be standardized, except to the extent that specific department needs require customized policies and procedures);
h. Work with the auditors;
i. Periodically update and modify the Compliance Plan; and
j. Prepare quarterly compliance reports for Pesach Tikvah's Board of Directors and prepare an annual report to the Board describing the general compliance efforts undertaken during the preceding year, identifying any changes necessary to improve the compliance program.

All questions and concerns regarding compliance with the standards set forth in this Compliance Plan shall be directed to or brought to the attention of the Compliance Officer. All Pesach Tikvah Employees and Pesach Tikvah Agents must fully cooperate and assist the Compliance Officer as required in the exercise of his or her duties. If a Pesach Tikvah Employee or Pesach Tikvah Agent is uncertain whether specified conduct is prohibited, the Pesach Tikvah Employee or Pesach Tikvah Agent shall contact the Compliance Officer for guidance prior to engaging in such conduct, or utilize the established reporting mechanism.