HUTHER-DOYLE CORPORATE COMPLIANCE PROGRAM

Effective January 2006

Revised November 2007

I. POLICY STATEMENT

Preventing and detecting health care fraud and abuse activities is an important fiduciary responsibility of the Board of Directors, management and all staff. Huther-Doyle is committed to comply with all federal and state standards.

As such, Huther-Doyle has adopted a Corporate Compliance Program, effective January 2006, to help ensure that the organization maintains a high level of honesty and ethical behavior in all aspects of its delivery of services and relations with clients, third party payers, employees, agents, and independent contractors.

Our intent is to reasonably design, implement and enforce a Corporate Compliance Program that will disclose, prevent and detect misconduct. All staff, employees, officers, board members, agents, and independent contractors are expected to understand and adhere to this Compliance Program.

II. CODE OF CONDUCT

All employees and board members shall comply with the Code of Conduct herein. In addition, all employees who are licensed, credentialed or certified shall also comply with the Code of Ethics adopted by their respective professional organizations.

• Assets -All assets of the organization shall be used solely for the benefit and purpose of the organization.
• Billing -Claims shall only be submitted for services that the organization has reason to believe are reasonable and necessary and that were authorized by an individual with authority to do so. Documentation to support billing claims shall be maintained for ten years.
• Gifts and Gratuities -Loans to or from any individual or business (other than recognized financial institutions) that furnish or receive supplies or services to Huther-Doyle are prohibited.
• Cash and Bank Accounts -All internal control procedures shall be adhered to at all times.
• Confidential Information -All persons associated with the organization shall respect the confidential nature of client and organization information and shall refrain from disclosing or discussing issues of a confidential nature, except as permitted by CFR42, part 2 federal regulations.
• Information obtained through employment or association with Huther-Doyle must not be used to benefit other employees or organizations.
• Conflict of Interest -All persons associated with the organization shall annually disclose any potential conflict of interest and refrain from any activity that represents an unfair business advantage by virtue of their business interest or employment with Huther-Doyle. Employees may hold a second job in addition to employment with Huther-Doyle Pursuant to procedures outlined in the Employee Manual.
• Financial Reports -Expense reports, reimbursement requests, financial statements and cost reports shall be completed thoroughly and accurately.
• Financing/Loan Agreements -The organization shall maintain a familiarity with the terms, conditions and covenants contained in any financing/loan agreements and shall refrain from engaging in any activity in direct conflict or breach of these terms, conditions or covenants.
• Non-Discrimination -All persons associated with the organization shall adhere to the non-discrimination policies outlined in the Employee Manual.
• Grants -All individuals associated with an organizational sponsored Grant shall conduct their activity in accordance with the grant guidelines. All grant funds shall be used only in accordance with the grant approval with documentation to support all grant activity.
• Tax Exemption -The organization shall not engage in any prohibited activity that violates or could result in a challenge of its tax exemption status.

III. OVERSIGHT RESPONSIBILITY

A. The responsibility of overseeing and coordinating the Huther-Doyle Corporate Compliance Program will rest with a Compliance Officer, appointed by the President/CEO and reporting to the Director and Board of Directors.

B. The duties and responsibilities of the Compliance Officer shall be as follows:

1. Ensure that the organization takes steps to effectively communicate its code of compliance and program procedures to all staff and agents. Ensure there is a training program that presents the elements of the Compliance Program and ensures that all employees and management are knowledgeable of and able to comply with pertinent federal and New York State standards.

2. Ensure that the organization takes reasonable steps to achieve compliance with its standards by utilizing monitoring and auditing systems reasonably designed to detect misconduct by its employees and agents.

3. Investigate any detected or reported incidents of possible misconduct under the direction and supervision of legal counsel.

4. Report any and all compliance activity to the Executive Director at least semi-annually and to the Board of Directors at least annually.

5. Assist the President and Board of Directors in establishing methods to improve the organization's efficiency and quality of services and to reduce the facility's vulnerability to fraud, abuse, and waste.

6. Delegate appropriate levels of monitoring and review of systems to other staff and/or outside agencies to promote effectiveness, efficiency, and to avoid any potential conflicts of interest.

7. Annually review and revise, as necessary, the Compliance Program in light of changes in the needs of the organization, and in the law and policies and procedures of government and private payer health plans.

8. Ensure that independent contractors and agents that furnish services to the organization are aware of the requirements of the Compliance Program.

9. Encourage employees to report suspected fraud and other improprieties without fear of retaliation.

10. Review and consider any and all Special Fraud Alerts issued by the Office of Inspector General that relate to the organization. Assist management in ceasing or correcting conduct criticized in such Alerts or taking reasonable action to prevent such conduct from occurring in the future.

11. Assist management in coordinating internal compliance review and monitoring activities, including annual or periodic reviews of departments.

C. Outside legal counsel shall be required to render all legal opinions, advise the Compliance Officer on developments and changes in laws, regulations and policies that affect the Compliance Program; review and approve the Compliance Program and any revisions; and advise on any enforcement or discipline pertaining to reports of misconduct.

IV. COMMUNICATION AND TRAINING

A. All management staff will have a training session to ensure that they understand and appreciate all aspects of the Compliance Program, including the risks of noncompliance. Initial training will be completed by within six (6) months of the date of adoption of this Program.

B. All staff shall receive a written explanation of the Compliance Program, including notification of how and where they can receive more extensive information and details on the program.

C. A description of the Compliance Program shall be included in all new employees' orientation training packets. The employee handbook will include a section on the Compliance Program.

D. Compliance Program information shall be posted on the employee bulletin board to assist communication of policy and procedures of program, as well as the Compliance Hotline number for reporting concerns of misconduct.

E. Annual review of, and training in, the Compliance Program shall be included in Huther-Doyle's mandatory in-services for all staff.

F. Personnel may seek clarification directly from the Compliance Officer. Questions and responses shall be documented, if appropriate, and policies and procedures shall be updated and improved to reflect any changes or clarifications.

V. MONITORING AND AUDITING

A. All staff shall be aware of Code of Conduct expectations of the organization and report any suspected violations to reasonably ensure that all activities are in compliance with the organization's Code of Conduct standards and procedures.

B. The organization shall have an annual financial audit conducted by certified public accountants to examine, on a test basis, evidence supporting the proper handling and reporting of amounts and disclosures relating to financial activity of the organization.

C. The organization shall conduct and document annual reviews of business and contractual agreement relationships to reasonably ensure that activities are in compliance with the organization's Code of Conduct standards and procedures.

D. The organization shall maintain a disclosure listing of all individuals associated with the organization who have identified outside party interests that represent potential conflicts of interest.

E. The organization shall conduct an annual review of compliance with regards to the terms, conditions and covenants contained in the organization's financing/loan agreements.

F. The organization shall conduct and document an annual review of its billing practices to reasonably ensure that all activities are in compliance with the organization's Code of Conduct standard and procedures.

VI. REPORTING AND RESPONSE SYSTEM

All employees of the organization have a duty to report suspected misconduct, anonymously if they choose, and without any fear of retaliation or breach of confidentiality.

1. Individuals may approach the Compliance Officer directly to report suspected misconduct.

2. Individuals may submit, in writing, reports of suspected misconduct anonymously to the Compliance Officer.

3. Individuals may report suspected misconduct by phone or voice mail by contacting the Compliance Officer's voice mail.

4. Employees may report suspected misconduct directly to the New York State Office of Alcoholism & Substance Abuse Services and/or New York State Department of Health And New York State Attorney General directly.

The Compliance Officer shall initially and promptly review the report and, through the Chief Operating Officer, direct any concerns to legal counsel for opinions, advice and direction on any further investigation, enforcement or discipline.

Reports of misconduct that do not warrant further investigation or review with legal counsel shall be clearly documented as to why no further investigation was undertaken.

The Compliance Officer shall coordinate policy and procedure modifications with respect to correcting and preventing further misconduct of a similar type as a result of a misconduct investigation.

The Compliance Officer shall maintain a log that records reports, including the nature of any investigation and its results. Such information shall be included in reports to the President and Board of Directors.

VII. ENFORCEMENT AND DISCIPLINE

The organization's Code of Conduct shall be consistently enforced through appropriate discipline mechanisms, including discipline of individuals for failure to report misconduct.

1. Disciplinary procedures for abuse of the organization's Corporate Compliance Program and Code of Conduct standards will follow the guidelines under existing personnel policies of the organization and may result in immediate discharge.

2. Grievance procedures for opportunities to respond to allegations or evidence of misconduct will follow the guidelines under existing personnel policies of the organization.

3. Disciplinary measures that are appropriate shall be determined on a case-by-case basis and should involve the advice of legal counsel.

4. Disciplinary measures and procedures may involve consideration and direction from outside third parties (i.e. governmental agency, law enforcement agency), including fines, reimbursement of funds, criminal prosecution and imprisonment.

5. The Compliance Officer shall consult with the Executive Director, and legal counsel if necessary, to determine whether it is necessary and/or appropriate to report possible misconduct to third parties, including but not limited to the New York State Office of Alcoholism and Substance Abuse Services, New York State Health Department, law enforcement agencies, and the New York State Attorney General.