Corporate Compliance

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Anonymous, Confidential Hotline – 585-658-2023

ARC GLOW CORPORATE COMPLIANCE PLAN

As a not-for-profit health and human services organization dedicated to improving the everyday lives of people with intellectual and other disabilities, Arc GLOW is committed to complying with the rules and regulations of federal, state and local government, including but not limited to those promulgated by the U.S. Centers for Medicare and Medicaid Services (“CMS”), NYS Office of Medicaid Inspector General (OMIG) and the New York State Office for People With Developmental Disabilities (OPWDD). Arc GLOW seeks to provide a work environment where high standards of ethical and legal behavior are recognized and practiced.

Because Medicaid funding makes up a significant portion of Arc GLOW’s operating budget, we are under ongoing scrutiny to ensure that our services are appropriate, timely and properly reimbursed. As Medicaid providers, we are subject to the federal and state laws that govern this program.

In developing this Corporate Compliance Plan, we have relied upon a number of resources including The Arc New York’s Corporate Compliance Plan and numerous government issuances. In summary, in order to demonstrate that we have developed an effective compliance program, we must demonstrate that we have (1) developed standards and procedures in order to reduce the prospect of improper conduct; (2) designated a high-level individual to oversee compliance; (3) not delegated authority to individuals who have exhibited a propensity for misconduct; (4) taken steps to communicate the standards to our employees and agents; (5) engaged in auditing and monitoring activities and established a reporting system in which employees can report potential misconduct without fear of retribution; (6) taken appropriate disciplinary measures against individuals found to have violated the Corporate Compliance Plan or related policies and procedures; (7) taken reasonable steps to respond and prevent future violations; and (8) ensure a culture of non-intimidation and non-retaliation in regards to reporting compliance issues.

The Corporate Compliance Plan was instituted by the Board of Directors on June 26, 2002, with updates and Board of Directors’ approval on an annual basis. Our Corporate Compliance Plan also supports and complies with The Arc New York Board of Governors’ policy requiring that each chapter of NYSARC, Inc. implement an effective Corporate Compliance program.

Arc GLOW developed this Corporate Compliance Plan, including our Code of Conduct and a wide array of policies and procedures that address key risk areas, to guide our best efforts to operate under ethical and legal standards. Arc GLOW expects that all aspects of customer care and business conduct will be performed in compliance with this Corporate Compliance Plan, professional standards, and applicable governmental laws, rules and regulations. The plan is applicable to all employees, volunteers, students, interns, and Board of Directors members, as well as independent contractors (e.g., vendor, consultant, agent/appointee) that contribute to Arc GLOW’s entitlement to payment under the Medical Assistance Program (affected individuals).

A complete list of policies is available in the Corporate Compliance Plan Table of Contents and with Element I below. The content of these policies covers all elements of this compliance plan and gives further guidance for implementing our compliance program.

ELEMENT I: CORPORATE COMPLIANCE PLAN – WRITTEN POLICIES AND PROCEDURES

Our compliance philosophy is expressed within this Corporate Compliance Plan and related documents, including our Code of Conduct and other policies and procedures related to compliance, clinical operations, human resources and fiscal management. Collectively, these documents establish standards and procedures that must be followed by Arc GLOW employees, volunteers, students, interns, the Board of Directors, and independent contractors (e.g., vendor, consultant, agent/appointee) that contribute to Arc GLOW’s entitlement to payment under the Medical Assistance Program. Understanding and following these standards will reduce the prospect of unethical, illegal and criminal conduct.

A. Code of Conduct

The purpose of the Arc GLOW Code of Conduct is to provide information and guidance to all employees, volunteers, students, interns, independent contractors and the Board of Directors to assist in carrying out the day-to-day responsibilities within legal and ethical standards.

The Arc GLOW Code of Conduct (Policy # 304) is a set of guiding principles that are more completely developed in the Corporate Compliance Plan and its related policies and procedures. Our Code of Conduct, which reflects our tradition of caring, provides guidance to ensure our work is done in an ethical, legal manner. Our Code of Conduct emphasizes our mission, vision and the shared common values and culture we seek to cultivate that guides our actions each day. It is updated as necessary based on implementation of the Corporate Compliance program.

Arc GLOW requires that each employee, volunteer, student, intern, independent contractor that contributes to Arc GLOW’s entitlement to payment under the Medical Assistance Program, and Board member sign a written acknowledgment that he or she understands and will follow the Agency’s Code of Conduct. Suspected violations of the code of conduct may be investigated by the Human Resources Director, Corporate Compliance Officer, or any key employee designated by the Executive Director. All who acknowledge receipt of the Code of Conduct also acknowledge that they understand that violations may result in disciplinary and / or corrective actions.

B. Other Written Policies and Procedures

Arc GLOW has developed and continues to develop, review or revise policies and procedures to implement the Corporate Compliance Plan. These policies and procedures establish the activities and processes that the Agency will undertake to operate in conformance with all applicable laws and regulations. Arc GLOW will review, revise and develop new policies and procedures, annually, to ensure that the Agency’s operations are conducted following regulatory requirements and using “best practices.” The policies and procedures of not only the health regulatory components of Arc GLOW, but also those related to human resources, environmental health and safety, and financial operations shall apply broadly to each employee through this Corporate Compliance Plan. The following policies, along with our Code of Conduct, offer guidance for all affected individuals to implement this compliance plan:

Corporate Compliance Structure – Policy # 308
Documentation of Compliance Activity – Policy # 312
False Claims Act – Policy # 316
Code of Conduct – Policy # 304
Reporting Compliance Concerns/Anti-Retaliation – Policy # 323
Conflict of Interest – Policy # 305
Political Contributions/Lobbying – Policy #320
Compliance Investigations – Policy #318
Gifts and Entertainment to referral Sources – Policy # 317
Documentation of Services – Policy # 311
Exit Interviews – Policy # 315
Exclusion Checks – # 314
Compliance Education and Training – Policy # 313
Discipline and Incentive Program – Policy # 310
Contractual/Financial Arrangements with Physicians – Policy # 306
Background Checks for Employees and Others – Policy # 301
Prohibition of Inducements: – Policy # 303
Billing Third Party Payors – Policy # 302
Responding to Government Inquiries Policy # 324
Auditing and Monitoring – Policy # 300
Detecting and Responding to Compliance Violations Policy # 309
Policy Management – Policy # 319
Training and Education – Policy # 350
Record Retention – Policy # 322
HIPAA Privacy Plan -Policy # 345 (and all policies within)
Confidentiality – Policy # 352
Review of IRS Form 990 – Policy #326
Access to Forms 1023, 990, 990-T, Conflict of Interest and Financial Statement – Policy # 327
Red Flag Identity Theft Program – Policy # 330
CEO Performance and Compensation – Policy # 328
Whistleblower Protections – Policy # 351

ELEMENT II: DESIGNATION OF EMPLOYEE WITH RESPONSIBILITY FOR THE DAY-TO-DAY OPERATIONS OF THE COMPLIANCE PROGRAM

Arc GLOW is committed to the operation of an effective compliance program and has assigned compliance oversight responsibilities to individuals at the management level. The designated Corporate Compliance Officer (Director of the Corporate Compliance Department) is ultimately responsible for the daily operation of the compliance plan. Other individuals with day-to-day compliance oversight authority occupy high levels (Department Directors, Program Coordinators / Managers, and other Supervisors as deemed appropriate by Department Directors or the Corporate Compliance Officer) in Arc GLOW’s organizational structure, to ensure a culture of compliance. They are empowered to implement the Corporate Compliance program, investigate compliance concerns, and report compliance concerns directly to those in higher positions of authority, up to and including, the Arc GLOW Board of Directors and the Executive Director. The Corporate Compliance Officer reports to the Executive Director and also has direct access to the Board of Directors and legal counsel at her discretion. At least once per year the Compliance Officer meets with the Board of Directors in Executive Session to review the compliance plan and hear any concerns. At this meeting all are encouraged to contact the Compliance Officer at any time with concerns or complaints about the compliance program and its operations. The Compliance Officer also provides annual compliance training to the Board of Directors and other training as deemed necessary or requested.

The Arc has established a Corporate Compliance Committee comprised of all Program Directors and three Arc of Livingston-Wyoming Board of Director members (one of whom is the chairperson) with responsibility to meet regularly to advise the Corporate Compliance Officer, to identify and resolve compliance concerns and to continue to improve and refine the Agency’s overall compliance activities. The Arc GLOW Board of Directors is an integral part of the Corporate Compliance program, will be knowledgeable about the content and operation of the Agency’s Corporate Compliance Plan and will exercise oversight with respect to the implementation and effectiveness of the Corporate Compliance Plan. Effective 2014, the Board of Directors visit program sites, which increases their opportunities to report any concerns to the Corporate Compliance Department. The Corporate Compliance Committee provides regular reports to the Board of Directors on compliance activity and concerns.

ELEMENT III : EDUCATION AND TRAINING

The Board of Directors, all employees, volunteers, students, interns, and, as applicable, independent contractors, must be informed about regulatory requirements and Arc GLOW policies and procedures that implement these requirements, as they apply to each individual. Therefore, Arc GLOW trains the Board of Directors, high-level personnel, substantial authority personnel, employees, volunteers, students, interns, and affected independent contractors on the organization’s standards and procedures, commensurate with their responsibilities and /or affiliation with the agency. The Agency continuously identifies training topics, including those arising as a result of self-monitoring, audits by regulatory agencies, and regulatory developments, and provides ongoing education to applicable personnel.

New employees will receive training in the Arc GLOW Code of Conduct, this Corporate Compliance Plan and those policies and procedures relevant to their job duties as part of an orientation program, and annually thereafter. Arc GLOW tailors its training based on the roles and responsibilities of each group of individuals and in a manner that the individual can understand. Site / program specific training on compliance and documentation responsibilities also occurs during the orientation period and ongoing as needed.

ELEMENT IV: LINES OF COMMUNICATION TO THE RESPONSIBLE COMPLIANCE POSITION

Each affected individuals is made aware of his/her responsibility to report through our compliance processes any activity by any colleague, clinician, independent contractor or anyone else that appears to violate applicable laws, rules, regulations, accreditation standards, standards of medical practice or the Corporate Compliance Plan. We encourage a culture in which all affected individuals feel free to report behaviors or actions which they believe should be reported. Therefore, the effectiveness of our Corporate Compliance program depends on the willingness and commitment of these affected individuals in all relationships and at all levels of Arc GLOW to step forward, in good faith, with questions and concerns. Therefore, we are committed to making every effort to maintain, within the limits of the law, the confidentiality of the identity of any individual who reports a concern in good faith. Affected individuals receive training on what to report and how to do so. Various policies within this compliance plan offer more specific guidance.

It is an expected good practice, when one is comfortable with it and thinks it is appropriate under the circumstances, for concerns to be raised first with a supervisor of the program. If this is not comfortable or not a viable option, then affected individuals are encouraged to contact the Corporate Compliance Hotline at 585-658-2023 where reports may be made confidentially. This hotline number, along with the name and number of the Corporate Compliance Officer, is posted at all Arc GLOW locations to ensure accessibility. Reports may also be made directly to the Corporate Compliance Officer, Pattie Kepner, at any time via telephone at 585-343-1123 ext. 1153, email correspondence at pkepner@arcglow.org or in person at 122 Caroline Street, Albion, NY.

ELEMENT V: DISCIPLINARY ACTION AND INCENTIVES TO ENCOURAGE GOOD FAITH PARTICIPATION

Arc GLOW also seeks to reward employees who foster a culture of compliance. The Corporate Compliance Officer encourages all to recognize others for compliance efforts during initial compliance training, and strives to send personal as well as public messages for same.

Failure to comply with the Corporate Compliance Plan, the Code of Conduct and/or laws and regulations applicable to Arc GLOW and our operations may result in disciplinary action. Retraining of staff will occur if misconduct is based on a lack of awareness or understanding of a regulatory obligation, policy or procedure. Resolution of disciplinary issues will be determined through the Corporate Compliance Plan structure in direct cooperation with the appropriate manager, Human Resources Director, and the Corporate Compliance Officer and, as appropriate, legal counsel and the Executive Director of Arc GLOW. The degree of discipline may include counseling, verbal warnings, written warnings, recommended change or discontinuation of privileges, termination of a contract, termination of employment or removal from a particular position or function. The Agency endeavors to be consistent in its approach to discipline, with similar disciplinary action for similar offenses.

Any employee who intentionally makes a false accusation with the purpose of harming or retaliating against a colleague will be subject to appropriate disciplinary action.

ELEMENT VI: A SYSTEM FOR ROUTINE IDENTIFICATION OF COMPLIANCE RISK AREAS

Arc GLOW is committed to routinely conducting internal audits of concerns that have regulatory or compliance implications. The Corporate Compliance Department annually conducts quality and limited fiscal audits of all programs, based on a schedule recommended by the Corporate Compliance Committee and approved by the Board of Directors. Internal auditing and monitoring activities increase as new services are begun, as billing standards change, and anytime deemed necessary by the Corporate Compliance Committee based on implementation of the compliance program. Risk areas identified by internal and external audits are incorporated into the compliance work plan.

As each annual compliance work plan is updated, program directors review the prior year’s risk areas and progress to date toward mitigation with the Corporate Compliance Committee. It is then determined whether or not the risk needs to be a focus area for the new plan. They also determine new risk areas, based on their knowledge of upcoming changes or focus areas from external auditors or other resources, including but not limited to, NYSARC, OPWDD, OMIG, OMH, and OIG.

Risk areas may also be identified via mandatory reporting of compliance issues and investigation findings; monitoring of billing and payment activities; interviews with affected individuals; background, credentials, or excluded provider checks; compliance program assessments; or any other compliance activities.

Appropriate individuals in key management positions are responsible for engaging in self-monitoring processes conducted within specific departments/divisions. All service programs have routine auditing practices in place to ensure that billing information sent to the Finance department is timely, accurate and complete.

Arc GLOW will also contract with external auditors on an as needed basis. We believe that a combination of various compliance reviews will permit us to maintain a consistent conformity to relevant laws and regulations, while fulfilling a commitment to identify and share best practices.

ELEMENT VII: A SYSTEM FOR RESPONDING TO COMPLIANCE ISSUES

Arc GLOW is committed to fostering our culture of compliance through detecting, correcting and preventing non-compliance behaviors. Through the process of our corporate compliance reporting structure and the articulation of compliance-related roles and responsibilities at every level of the Agency’s operations, detection and correction of problems is expedited.

Risk areas identified are incorporated into the compliance work plan. Risks are identified by the Corporate Compliance Committee based on review of quality and compliance data, which includes internal and external audits, training and incident reporting compliance, compliance investigations, and billing adjustments, voids and self-disclosures. The Compliance Officer also works with all program directors to identify areas of focus based on upcoming regulatory changes and trends in audit findings in the health care field.

Compliance issues may be detected by mandatory reporting by affected individuals via direct report or the confidential hotline; as a result of program or compliance department internal audits; as a result of an external audit; during the course of an investigation of a different issue; or as a result of compliance program assessments.

Corporate Compliance issues are formally documented and investigated by the Corporate Compliance Officer, based on the nature of the complaint. The Compliance Officer may delegate the investigation at her discretion, barring no conflicts of interest, or may choose to refer the matter to legal counsel. In all cases, the Corporate Compliance Officer works with the department to ensure that the investigation is thorough, a root cause is explored, and strategies are implemented to prevent recurrence. In the event that a concern is raised that is not a compliance issue, the Compliance Officer refers to the appropriate personnel for review and follow-up.

If an internal investigation substantiates a reported violation, then it is our policy to engage in a two-fold process: (1) to initiate corrective action, including, as appropriate, making prompt restitution of any overpayment amounts, notifying the appropriate governmental agency, instituting whatever disciplinary action is necessary; and (2) implementing systemic changes to prevent a similar violation from recurring in the future. The Compliance Officer and Program Management work in collaboration to ensure implementation of the above.

Results of compliance investigations are minimally shared with the Corporate Compliance Committee and additionally with others as deemed appropriate for learning and compliance purposes.

ELEMENT VIII: NON-INTIMIDATION AND NON-RETALIATION

Arc GLOW strives to provide an environment that encourages individuals to report any suspected violation without fear of retaliation, intimidation or retribution. Strict adherence to Arc GLOW’s Corporate Compliance Plan and Code of Conduct is vital. Arc GLOW requires all affected individuals to promptly report any known or suspected violations of the Corporate Compliance Plan, Code of Conduct, policies and procedures or any of the laws, rules or regulations by which this Agency is governed.

Arc GLOW will not impose any disciplinary or other action in retaliation against individuals who make a report or complaint in good faith regarding a practice that the individual believes may violate any of the above.

Employees are trained on how to report compliance concerns upon hire and annually. Initial Corporate Compliance training is conducted by the Corporate Compliance Officer / designee, to ensure thorough understanding by employees, comfort with reporting, and accessibility of the Corporate Compliance Officer. Review of the Code of Conduct, the False Claims Act, Reporting Compliance Concerns, Conflict of Interest, and Whistleblower Protection policies are part of Corporate Compliance training. These policies are also shared with all other affected individuals.

Background Checks

Arc GLOW uses due care not to employ, contract with or delegate substantial discretionary authority to any individual with a propensity to engage in illegal activities. In order to maintain the integrity of our services and financial and business operations, it is critical that Arc GLOW hire and contract with individuals and entities that have the same respect for applicable legal and ethical obligations that the Agency has. This standard applies to personnel in positions with “substantial” control over Arc GLOW, including, but not limited to those having the ability to affect and determine policy and to negotiate contracts. All current and prospective employees will be required to disclose, on a periodic basis, whether he or she has committed a crime, including health care related crimes.

Arc GLOW also complies with requirements promulgated under state law with respect to background checks and appropriate screening activities as those requirements apply to personnel within the Agency’s operations.

License Verification

Prior to hiring or contracting with licensed clinical staff or providers, screening occurs with The Office of Professions to ensure they have a current NYS license and are meeting the requirements of The NYS Education Department. Monthly checks of continued licensure occur.

Exclusion Checks

Further, Arc GLOW checks, prior to employment / service and periodically thereafter, to determine if new hires or existing employees and independent contractors have been excluded from participation in the federal healthcare programs by checking the Office of the Inspector General’s “List of Excluded Individuals/Entities,” (a database which provides a list of parties excluded from participation in federal healthcare programs) and the NYS Office of the Medicaid Inspector General’s list of Restricted, Terminated or Excluded Individuals or Entities. Similarly, the General Services Administration maintains the List of Parties Excluded from Federal Procurement and Non-procurement Programs, which identifies those parties excluded from receiving federal contracts or certain subcontracts and certain types of federal financial and non-financial assistance and benefits.

Compliance Officer and Board of Directors Communication

At least once each calendar year, the compliance officer provides compliance training to the entire board of directors. She also attends monthly board of directors meetings and serves as staff liaison to the Corporate Compliance Committee. Verbal updates are provided at these monthly meetings and compliance committee meeting minutes are shared with the entire board of directors. These minutes include annual data, which is also made available for review in a secured portal. In addition to this contact with the full board, the compliance officer meets at least once per year in executive session to ensure that any compliance concerns can be raised in the absence of the Senior Management team. As stated above, the compliance officer has unrestricted access to the board of directors as necessary or appropriate.

2026 Quality Improvement Plan

Arc GLOW has a Quality Improvement Plan in place for 2026 that outlines a variety of internal processes we follow to guide us in providing services of the utmost quality. The 2026 Quality Improvement Plan identifies nine key goal areas where we intend to focus our attention. These include the following:

Goal: Arc GLOW would like to improve compliance with the various regulations governing Behavior Support services, thereby decreasing the total number of ECF’s and SOD’s in the area of Behavior Supports for the calendar year 2026.

To achieve this, Arc GLOW will be doing the following:

Quality/Compliance to conduct additional internal audits on BSP’s and measure/track results
Increase tracking of SOD’s/ECF’s to better glean how many BSP’s are identified with concerns versus simply how many SOD’s/ECF’s (since we could have multiple citations for one plan, for example)
Members of the Clinical Team will continue to conduct audits on Behavior Supports records. This will include: monitoring for 85% completion of monthly site review reports for sites through quarterly audits, monitoring for 85% completion of six-month reviews for sites through quarterly audits, and monitoring for 85% completion of written informed consent prior to implementation of plan or expiration of verbal consent.
Behavior Intervention Specialist’s (BIS) will transition Mental Health Med Monitoring Plans to Behavior Support Plans (BSP) for cases in which there is an identified non-co-occurring psychiatric disorders by Q3.
Behavior Support Supervisor will continue to hold monthly supervision meetings with Behavior Intervention Specialists

Goal: Arc GLOW would like to make continued improvements to the overall quality and physical plant at a specific IRA.

To achieve this, Arc GLOW will:

Continue to monitor and address the acuity of needs at the IRA to ensure staff can safely and adequately meet the needs of individuals residing there. There were some recent internal moves in early 2026 to help with this effort.
A new admission for the IRA is coming with some additional funding from OPWDD to address some specific needs. This will likely enhance the setting for all individuals in the IRA. Specifically, the Clinical team will be contracting with experts to complete an environmental assessment at the home to enhance the environment. This may include environmental modifications and staffing adjustments as formally recommended.
New Management team at the IRA has been working in better collaboration the Clinical team to ensure staff are well trained on person specific plans. Compliance with person specific plans will be monitored through weekly Nursing site visits, dinner observations conducted by Clinical staff, weekly site visits by the Behavioral Specialist and further monitoring through monthly summary compilation, and through monitoring of Safe Transfer and Movement (STM) plan implementation.
Arc GLOW will monitor a number of metrics at the IRA to measure improvement, including number of events files, number of BPC deficiencies, as well as any complaints.

Goal: Arc GLOW would like to improve compliance with contemporaneous note requirement across all programs in 2026.

To do this, Arc GLOW will:

Program Directors and/or Coordinators will continue to monitor for compliance with the contemporaneous note requirement.
Quality/Compliance staff will be conducting an audit each quarter on compliance with the requirement for notes to be conducted “contemporaneously.” A random check of approximately 5% of the cases for each program will be reviewed and reported on quarterly. When/if more than 5% are found with concerns, a review of the program by Compliance will be conducted to determine the next course of action.

Goal: Arc GLOW would like to improve communication between programs and families, thereby improving this percentage to at least 73% (a 5% increase) or more for the 2026 survey for the question, “I am satisfied with the amount of communication I receive from program(s).”

To do this, Arc GLOW will be doing the following and reporting on such quarterly at the Quality meeting.

Residential will be focusing on enhancing their outreach efforts to families, including at key times such as leadership turnover, to discuss illness, injury, and/or events, and even general communication to families to share how their loved one is doing.
Day and Employment program plans to implement the following strategies:

- They will send or record the sending of the SAP to the family in eVero (measurable). This would also help encourage staff to get the email addresses into the system for families, which help can help facilitate more communication with ease.
- They will use the DA Log (in the electronic health record) to document conversations with families. This would then allow us to run reports.
- They will encourage the use of personal log books

Arc GLOW will continue to evaluate and strategize methods of improve communication with families.

Goal: Arc GLOW would like to increase use of its internal gift card recognition program.

To do this, Arc GLOW, will be doing the following:

HR will be working on reintroducing and re-educating Arc employees about the gift card program.
HR will be tracking and reporting on usage, which include program (giving and receiving), as well as what brand trait was being recognized in the employee. Data will be shared quarterly at the Quality meetings.

Goal: Arc GLOW would like to improve the compliance rating (from 2025 data) for completion of mandatory trainings in the first 90 days of employment.

To achieve this, Arc GLOW will be doing the following and reporting on such on a quarterly basis at the Quality meeting.

The Training Department will continue to provide program leaders with training status updates of their respective employees, and this issue will continue to be address in performance evaluations as appropriate.
When there are significant concerns with compliance in this area, employees are suspended until current on their trainings. Arc GLOW will track the number of staff suspended due to non-compliance.

Goal: Arc GLOW will strive to have training sites completed and in use by the end of 2026.

Training will report progress quarterly at the Quality Committee (through quarterly QIP updates).

Goal: To improve employee satisfaction in the areas of feedback, recognition, and cooperation between departments. Improvement will be measured and noted by comparing survey responses from 2025 to 2026.