Corporate Compliance Plan Summary
Asbury Heights Corporate Compliance Plan has been developed in accordance with applicable law and policies issued by state and federal authorities. Through the Plan, Asbury Heights will promote full compliance with all legal duties applicable to it and its employees, foster and assure ethical conduct, and provide guidance to each employee and agent of Asbury Heights for their conduct. The procedures and standards of conduct contained in the Plan are intended to generally define the scope of conduct which the Plan is intended to cover and are not to be considered all-inclusive.
The important provisions of Asbury Heights's Corporate Compliance Plan are summarized in this brochure. If you have any questions regarding these provisions, or wish to view a full copy of the Plan, please contact the Asbury Heights Corporate Compliance Officer.
Standard of Conduct
Asbury Heights shall conduct its activities in accordance with the highest level of business and community ethics, and in compliance with applicable governing laws. The maintenance of extremely high standards of honesty, integrity, impartiality, and conduct is essential to assure the retention of the residents’ and the public’s trust in Asbury Heights. The preservation of that trust and of Asbury Heights's reputation requires close observance of these standards on the part of its Directors, Officers, employees and agents. Asbury Heights is committed to ensuring that it operates under the highest ethical and moral standards, and that its activities comply with the applicable legal requirements in this Plan.
Asbury Heights has developed a Standard of Conduct to provide standards by which all Asbury Heights employees will conduct themselves in order to protect and promote organization-wide integrity, and to enhance Asbury Heights's ability to achieve its mission. Compliance with the Standard of Conduct will be the responsibility of every manager, officer, employee, agent or representative of Asbury Heights. Asbury Heights's Standard of Conduct provides the guiding standards for our decisions and actions as members of the Asbury Heights community. The Standard of Conduct cannot cover every situation in the daily conduct of our many varied activities nor substitute for common sense, individual judgment or personal integrity. Listed below are some of the guiding principles of Asbury Heights's Standard of Conduct. Refer to the Standard of Conduct for all principles.
- Ethics, Integrity and Job Performance
- Quality of Care and Commitment
- Work Directly with Residents
- Overseeing the Care Provided to Residents
- Conduct with Residents and Colleagues
- Conflict of Interest
- Privacy and Security
Corporate Compliance Officer and Committee
Asbury Heights's Corporate Compliance Plan will be implemented under the guidance and supervision of the Corporate Compliance Officer and a Committee consisting of the upper-level management of the organization. These individuals will be responsible for developing policies and practices designed to ensure that Asbury Heights meets the compliance standards set forth in the Plan. The Corporate Compliance Officer will be accessible to all Asbury Heights employees.
Training and Education
The key to maintaining compliance with applicable law is to ensure that Asbury Heights’s personnel receive training and education to enable them to identify potential fraud and abuse issues, and conform their conduct to the applicable requirements of law. The Plan requires Asbury Heights to provide employees with the training necessary to ensure compliance with applicable federal and state laws and regulations. Accordingly, Asbury Heights will schedule periodic and annual training for employees on the requirements of the Plan itself, as well as other substantive areas relating to their job functions.
Policies, Procedures and Protocols
Asbury Heights has already adopted numerous policies and procedures to provide the best care possible to our residents and to ensure that operations are conducted in accordance with law. Those policies will continue to remain in place under the Plan. The Corporate Compliance Officer will also coordinate the development of specific policies designed to address recordkeeping, contracting, billing, reimbursement and clinical issues as well. Asbury Heights's policies and procedures will be regularly reviewed to assess their effectiveness. When appropriate or required, the Corporate Compliance Officer will direct revisions to these policies and procedures to correct errors, to make operations more efficient, or to improve the quality of care provided to our residents.
Compliance Reporting Obligations and Investigations
As reflected in the Standard of Conduct, each and every employee of Asbury Heights is required to report all instances of suspected misconduct or potential violations of law to the Corporate Compliance Officer. This can be done anonymously through the Hotline established by Asbury Heights. The Hotline number is 412-571-5105. Employees may also report potential compliance issues to their supervisors. Asbury Height's Corporate Compliance Officer will review all reports received by the company, and will conduct an appropriate investigation into all instances of claimed misconduct or noncompliance. Asbury Height’s employees are required, when requested, to assist the Corporate Compliance Officer in these investigations. At the conclusion of an investigation, the Corporate Compliance Officer, in conjunction with Asbury Height's legal counsel, will implement corrective action initiatives and, where required, make the appropriate disclosures to governmental agencies. It is important to emphasize that Asbury Heights will not tolerate retaliation against employees or agents who report suspected abuse in good faith, nor will Asbury Heights allow abuse of its reporting processes.
Self-Monitoring and Auditing
Asbury Heights recognizes the need to monitor and audit its operations to determine the effectiveness of this Plan’s implementation and the company's overall compliance with applicable law. The Corporate Compliance Officer will oversee all auditing systems. Audit procedures will be implemented which are designed to determine accuracy and validity of coding and billing submitted to Medicare and other federal health programs, to ensure compliance with Federal Requirements of Participation, and to detect other instances of potential noncompliance by Asbury Height’s employees and agents as quickly as possible. Auditing techniques will include on-site visits, sampling reviews of claim submissions, and interviews of key personnel. Each audit will generate a Compliance Report, which shall be forwarded to the Corporate Compliance Committee and the Board of Directors for review and action.
Employee, Officer and Manager Duties Under the Plan
Promotion of and adherence to the Plan shall be an element of each Asbury Heights employee’s performance standards. Each employee’s compliance performance will be taken into account in connection with performance evaluations. Managers and supervisors have the additional responsibility to ensure that persons under their supervision are advised of their responsibilities under the Plan and under applicable laws and regulations. Conduct in violation of this Plan is outside of the scope of an employee’s job responsibilities and authority and may subject the employee to disciplinary action, including suspension, imposition of monetary penalties or termination. Appropriate disciplinary measures shall be imposed on a case-by-case basis, and shall be consistent with the disciplinary actions contained in the Employee Handbook.
Most Important Concepts Under Asbury Heights' Corporate Compliance Plan
- Be honest, tell the truth and act in accordance with the provisions of Asbury Heights's Standard of Conduct. There are consequences for failing to do so.
- Be aware of the laws and regulations that govern your job responsibilities and follow them. Ask questions if unsure of the applicable legal requirements before taking action.
- Report suspected misconduct or potential compliance issues to your supervisor or the Corporate Compliance Officer through the Hotline at 412-571-5105.
- Assist in the development of policies and procedures designed to enhance Asbury Heights's operations and fully cooperate in all self-auditing and monitoring activities.
- Participate in Asbury Heights's educational training sessions on compliance.
- Make compliance a part of your day-to-day job performance.
Compliance Hotline Number