Scope & Purpose of This Handbook - Beacon Light
Scope & Purpose of This Handbook
This employee handbook has been prepared to give you general information about some of the work rules, work environment, and policies under which we operate. More extensive information is available from supervisors, human resources staff or on the network on the N/knowledgebase/policies and procedures should you have questions concerning interpretation of specific sections. From time to time, you may receive updated information concerning changes in policy. If you have any questions regarding any policies, please ask your supervisor for assistance.
This handbook is not a contract, express or implied, guaranteeing employment for any specific duration. Although we hope that your employment relationship with us will be long term, either you or the agency may terminate this relationship at any time, for any reason, with or without cause or notice. This at-will relationship remains in full force and effect, notwithstanding any statements to the contrary made by the agency and employees or representatives, or set forth in any other document. No employment agreement shall be enforceable unless it is in writing.
WELCOME!
Welcome to Journey Health System, Beacon Light Behavioral Health System, Beacon Light Adult Residential Services, and Forest Warren Mental Wellness Association and the opportunity to make a difference in the lives of our clients. We have a proud commitment among our employees at the agency of offering the best possible services to the community.
This booklet was written to give you the answers to those most often asked questions about human resources policies and benefits, what we expect from you, and what you may expect of us in our combined efforts to serve our customers well. The more you learn about the agency, the better employee you will be, so study this handbook, refer to it often, and if your questions are not answered, talk to your supervisor.
The growth of this organization can be attributed to our employees' knowledge, skill and commitment to providing outstanding client and customer service. Our employees are a part of a team that values the individual strengths that each employee contributes.
We are pleased that you have decided to join our team and we look forward to working together with you to fulfill our mission.
Human Resources Department
ABOUT THE AGENCY
Agency Background
Beacon Light Behavioral Health System® is a “doing business as” name used by the three agencies of our corporate structure in the provision of children’s behavioral health and education services, combining the resources of each corporation into one delivery system. Beacon Light Behavioral Health Systems holds no administrative authority over the three corporations. Beacon Light is a non-profit corporation that provides a full range of Mental Health, Mental Retardation and Educational services to children and adults. The Agency was incorporated in 1903 and operates three subsidiary corporations. These are:
• Legal Name: Children’s Home of Bradford
• DBA: Journey Health System
o Supporting Management: Provides support services for both The Children's Center for Treatment and Education and Ramsbottom Center, Inc. Administrative services include Human Resources, Public Relations, Dietary and Maintenance.
• Legal Name: Children’s Center for Treatment and Education
• DBA: Beacon Light Behavioral Health System
o Providing mental health services in a residential, educational and community setting.
• Legal Name: Ramsbottom Center Inc.
• DBA: Beacon Light Adult Residential Services
o Providing residential and day programming for intellectually developmentally disabled adults
Agency History
At the turn of the century, children from the Bradford area who had no home or who were mistreated or living in squalor were taken into the Beacon Light Mission, then located on Barbour Street in downtown Bradford. The mission had been founded by C.C. Husted, primarily to address the needs of children living in the Whitechapel (Bennett and Barbour Streets) settlement of shacks inhabited by lumber workers and the impoverished during Bradford's early history.
The mission soon outgrew its Barbour Street location, however, and moved to the Browntown Road area in Custer City. It was here that it was incorporated in 1903.
In 1915, a fire destroyed the Custer City location and the home was relocated to it's present site at 800 East Main Street at what was then known as the Edgewood Club.
Again, in 1924, fire destroyed a good portion of the building and in 1925, Mr. John Ley donated the money to build roughly half of the present main building. The other half was then constructed from funds donated by Mr. Thomas Kennedy in 1935. Later, funds donated by Mr. A. J. Bond were used to add a living room to the main building.
In 1940, the name of the agency was changed to The Children's Home of Bradford.
In 1970, the present campus facilities of the Home were completed with the addition of three cottages which were built through a donation from the estate of Grace Ramsbottom.
Through the years, the services and level of care provided to youngsters at The Children's Home have dramatically changed. During the late 1950's and 1960's, there was a change of attitude about the care of children by the Commonwealth. Keeping a child with their family or in foster homes was considered preferable to institutional placement. Children without parents were usually placed with other relatives or in private foster homes.
At the same time, adolescent children who were unable to cope within their families and communities, or who committed minor crimes, were no longer placed in locked jails. Rather, they were assigned to supervised group care facilities with treatment capabilities.
Consequently, in 1973, the Board of Directors of The Children's Home changed the emphasis of the agency program and began the development of a residential treatment center. Here, young people could learn new ways to live and function within the community.
In 1981 the Alternative Education Program was developed to meet the specialized educational needs of the Children's Home individuals. Initially, the program started with just two students and was located in the basement of the present main building. During the past fifteen years the program's enrollment has grown to over 120 students from both the Children's Home and surrounding communities. The present Alternative Education Program operates two facilities, it's main program at the Children's Center for Treatment and Education in Custer City, and a satellite program in Port Allegany, PA.
Due to the increasing needs of both residential and community individuals, the Intensive Treatment Program (Adolescent Psychiatric Partial Hospitalization Program), was implemented in the Fall of 1992. This program focuses on the mental health needs of children and adolescents. The purpose of the program is to provide preventive clinical intervention services to the young person as an alternative to in-client care or as a more intensive treatment program than is afforded by out-client settings.
In the Spring of 1993, the Children's Center for Treatment and Education was opened in Custer City. This former elementary school building was remodeled to house the Alternative Education Program, Intensive Treatment Program and offices for treatment staff. In addition to the new facility, the Children's Center for Treatment and Education was formed as a subsidiary of the Children's Home of Bradford. The Children's Center for Treatment and Education operates Residential Treatment, Therapeutic Foster Care, In-School Wrap Around, Alternative Education and Intensive Treatment Programs.
In November, 1996, the agency achieved accreditation with Commendation from the Joint Commission for Accreditation of Hospital Organizations (JCAHO). JCAHO accreditation sets a high standard of quality for every agency program and service. In October, 1997, the agency combined the three separate divisions, Children's Home of Bradford, Children's Center for Treatment and Education and Ramsbottom Center under the umbrella of a common name - Beacon Light Behavioral Health Systems. The new name was chosen to represent both our history - our agency began as the Beacon Light Mission a century ago - as well as the multi-faceted behavioral health treatment center we are today
The Emergency Crisis Shelter Program was opened in October, 1998 and was housed in the Main Building at 800 East Main Street. In 2001 ground was broken for a new 20 bed emergency shelter on the main campus. In April 2002 the new shelter opened its doors. The Shelter Program is designed to provide emergency crisis shelter to children and adolescents. It was initially designed to provide care and supervision services only, to a maximum of ten clients, both males and females.
The agency opened a 16 bed Residential Treatment Facility in Towanda, PA located in northeastern PA in August 2000 to broaden the area we serve to include all of northern Pennsylvania.
In 2004 The Agency took over management of an 8 bed group home in Warren, PA. In 2006 the Agency built a new 16 bed Residential Treatment facility in Youngsville, PA to replace the Warren Group Home.
In March of 2006 the Agency dedicated 10 beds at the First Street building to new programming for children with sexual offending issues. This program was named First Street Residential Treatment Center and is presently called the SAY Program (Sexually Aggressive Youth).
In 2007, Beacon Light acquired a small outpatient clinic known as Port Psychological in Port Allegany, PA and was moved to Bradford and operates out of the Main Building site.
2009
July of 2009 the Agency began the Multi-Systemic Therapy (MST) program in McKean, Warren, and Elk Counties.
November of 2009 the Agency opened a new program titled Peer Support Service as a joint venture with Dickenson Mental Health. This program employs individuals with mental health or criminal backgrounds to assist individuals in our care with similar backgrounds.
December of 2009 the Agency opened the new Short Term Adolescent Recovery (STAR) program located at the First Street Residential Treatment Center. During this move, the current Shelter was moved to another existing group home location reducing the regular Residential Treatment Facilities (RTF’s) by one home.
2010
In 2010 the Agency convened the Adult Consumer Advisory Board.
June of 2010 – the Student Assistance Mentor Program began in Warren County.
July of 2010 – the Drop-In Center, located on the Warren State Hospital grounds opened.
August of 2010 – the Warren Alternative Education program opened, located at 121 Central Avenue in Warren, PA.
October of 2010 – the School Based Mental Health Program began in the Warren County School District.
2011
March of 2011 – the Agency opened a new specialized RTF program for MH-IDD children. This program is titled STRIDE and is a dual diagnosis program and will be located at the Lorana Avenue home.
April of 2011 – Mobile Medication in in Warren and Elk Counties began.
May of 2011 – The Bridgeport Academy, located in Port Allegany, PA, opens with a new addition; including an on-site clinic.
July of 2011 – The Recovery Assistance Program opens in Warren County.
September of 2011 – STRIDE East opens at our Towanda, PA facility – sharing a facility with our regular RTF.
2012
April 2012 – School Based Mental Health Program begins in DuBois and Clearfield School Districts. The program is now called the Children’s Clinical Home.
The Mobile Medication Program expands into Clearfield County.
The Parent-Child Interactive Therapy program starts in Warren, PA.
2013
Adult Recovery Center Construction is completed and all services move into new building on Market Street. Renowned Recovery expert Dr. Patricia Deegan keynotes the grand opening celebration.
Affiliation with Stairways Behavioral Health of Erie is announced.
Family home on East Main Street in Bradford is purchased.
RCAP grant money and private capital campaign raises money to build new STRIDE wing on First Street Building in Bradford and add training center to main administration building in Bradford.
2014
Affiliation with Stairways is finalized.
2015
Expanded School Based Programs to include McKean County.
2017
Opened a new STAR unit in McClure, PA and began DDTT services in the State College area and surrounding counties.
Ramsbottom Center, Inc.
Ramsbottom Center, Inc. is a non-profit corporation established to provide Mental Retardation/Development Disability services, originally under the Community Living Arrangement (CLA) model, providing services to CEMP Mental Health/Mental Retardation Department. The cottages were donated by the estate of Grace Ramsbottom in 1970.
Cottage I was opened in March of 1972, as a Behavior Shaping Unit for eight children. The Child Development Unit opened in 1974, which housed three children (this is currently the Ramsbottom Office). Cottage III followed in opening in December of 1975 as an Adolescent Unit for eight individuals. Cottage II opened in June of 1981, again for eight children.
In April of 1982, the program was approved and licensed as an Intermediate Care Facility for the Mentally Retarded (ICF/MR). At this time the Child Development Unit was closed and these individuals were placed within one of the three cottages.
As these individuals began to graduate from the public school system, a day program was not available within the Bradford Community. As a result the Adult Day Services Program was started on 8/12/85 for six individuals in the basement of Cottage II. This program expanded and moved to the Main Building at The Children's Home in the Spring of 1986 with twelve individuals. ADS moved to its present location in November of 1989 after the Alternative Education Program moved to Congress Street.
Cottage I went from eight individuals to six on 8/14/96, to provide a higher staff to client ratio for an intensive behavior unit.
In July of 2001 Ramsbottom open a 2 bed community Waiver program to allow current higher functioning individuals to live in a less restrictive setting in the community and later changed the program to accommodate 3 residents.
In 2007 an adult female MH group home was established on Congress Street to accommodate 3 residents transitioning from higher levels of care and re-entering community living.
In 2009, IDD Community Supports was initiated. This is much like wraparound services on our Children’s Center division but for IDD adults. An Autism Waiver was also began at this time and is also similar to wraparound (BSC services available, in-home supports, and job finding skills).
In July of 2014, the new CSRU (Community Stabilization and Rehabilitation) Unit opens in Sunbury, PA. This program was designed to assist dual diagnosed adults in pursuing a better community self-sustaining quality of life. The waiver program expands and a new home opens on East Main Street.
The CRRS programs expand and new homes are purchased in Bradford, PA and Warren, PA in 2014.
In 2017, the agency began a Supported Living program with some of our consumers.
Today, the agency is a major treatment center for Pennsylvania, serving over 30 counties.
MISSION STATEMENT
Our mission is to advocate passionately for the individuals and families we serve.
OUR COMMITMENTS
1. We will strive to recognize and support the ability of every individual and family to change.
2. We will strive to recognize the strengths of every individual and family and help them build on those strengths.
3. We will strive to respect each individual we come in contact with, including clients, consumers, families and staff.
4. We will strive to take personal responsibility for all of our actions and interactions each and every day.
5. We will strive to be responsible stewards of our financial resources recognizing them as community given.
6. We will strive to provide safe, respectful, and healing environments.
7. We will strive to create flawless and consistent processes.
8. We will strive to build and maintain educational environments that provide every individual an opportunity to learn.
9. We will strive for permanency in the lives of those we serve.
10. We will strive to support full participation in community life for every individual we serve.
GENERAL EMPLOYMENT
EQUAL EMPLOYMENT POLICY
An HRIS (Human Resource Information System) has been established and will be maintained. It is the policy of the agency to hire and administer all human resource actions without regard to race, religion, color, sex, age, ancestry, disability, or national origin or in any manner prohibited by the laws of the United States or the Commonwealth of Pennsylvania. The agency complies with specifications of Title VII of the Civil Rights Act of 1964, the Pennsylvania Human Relations Act of 1955, the Rehabilitation Act of 1973, the Age Discrimination in Employment of 1967, Title IX of the Education Amendment of 1972, Pregnancy Discrimination Act of 1978, the Equal Pay Act of 1963, the Americans Disabilities Act of 1990, and any regulations promulgated pursuant to these Acts.
Human Resources policies, procedures and practices will be designed to prohibit discrimination on the basis of race, color religious creed, disability, ancestry, national origin, age or sex.
Employment opportunities shall be provided for applicants with disabilities and reasonable accommodations shall be made to meet the physical or mental limitations of qualified applicants or employees. Any employee who believes he/she has been discriminated against may file a complaint of discrimination with any of the following:
• Journey Health Systems, Human Resources Department
• Pennsylvania Human Relations Commission
• Department of Human Services, Bureau of Equal Opportunity
• U.S. Department of Health and Human Services, Office for Civil Rights
• U.S. Department of Health and Human Services, Centralized Case Management Operations
• Equal Employment Opportunity Commission
HARASSMENT POLICY
Types of Harassment
SEXUAL HARASSMENT: Unlawful sexual harassment occurs where:
a. job benefits are granted on an employee's agreement or acquiescence to sexual demands or advances;
b. job benefits are withheld based on an employee's refusal to agree to sexual advances or demands;
c. the working environment is oppressive to employees of one sex because of the actions of co-workers, supervisors, vendors or customers.
Sexual harassment includes, among other things:
a. Threats or insinuations by a supervisor that an employee's refusal to submit to sexual advances will adversely affect the employee's employment, evaluation, wages, advancements, assigned duties, work schedules, or any other conditions of employment or career development.
b. Sexual relations or conduct with a supervisor or co-worker that an employee does not want and to which the employee has not freely agreed, including unnecessary touching, patting or pinching, the constant brushing against another person's body, and physical assault.
c. Verbal harassment or abuse of a sexual nature such as degrading comments, propositions, including offensive and unwelcome sexual flirtations and advances, jokes, tricks and persistent remarks about another person's clothing, body, appearance or sexual activities.
d. The display in the work place of sexually suggestive objects or materials.
Sexual harassment of any agency employee in any form is prohibited. Such harassment may result in disciplinary action up to and including termination when brought to the attention of the Director of Human Resources, a Vice-President of the agency, or the employee's immediate supervisor in a timely manner.
Other Unlawful Harassment: Other unlawful harassment includes derogatory remarks, slurs, or actions motivated by an employee's age, race, national origin, color, religion, sexual orientation, gender orientation or disability which create a hostile, intimidating, or offensive working environment.
The agency also prohibits harassment based on age, race, sexual orientation, gender orientation, disability, religious creed and national origin. Employees are responsible for immediately reporting any incidents of unlawful harassment to the Director of Human Resources, a Vice-President of the agency, or the employee's immediate supervisor in a timely manner.
Unlawful harassment of any employee of the agency in any form is prohibited. Such conduct may result in disciplinary action up to and including termination.
Reporting Harassment
If an employee, in good faith, believes to have encountered any such harassment from supervisors, fellow employees or others, that employee should report the harassment promptly to the Director of Human Resources. If, for some reason, it is inappropriate to report harassment to the Director of Human Resources, it should be reported to another Vice-President of the agency, or the employee's immediate supervisor. Such reports will be kept as confidential as reasonably possible. A prompt, thorough and fair investigation will then be made. Investigations will be conducted, insofar as reasonably possible, to protect the privacy and minimize suspicion toward all parties concerned. After review of all the evidence, the Director of Human Resources in conjunction with Executive Management and the employee’s immediate supervisor will make a determination as to whether the claim has been substantiated.
Discipline for Harassment
If the claim is substantiated, the Director of Human Resources with the approval of the Executive Director and Vice President of Human Resources of the agency, will take appropriate action, including discipline and possibly termination.
Employees knowingly making false claims are subject to disciplinary action up to and including termination.
To protect those employees reporting harassment, any employee (including Management), who discusses confidential reports of harassment with individuals not involved with the investigatory or discipline process, is subject to disciplinary action, up to and including termination.
Any questions regarding this policy should be directed to the Director of Human Resources.
ABOUT YOUR JOB
EMPLOYEE CATEGORIES
Throughout this Handbook, you will see references to several employee categories with which you should become familiar. They are as follows:
All employees within the agency are classified as either Exempt or Non-exempt staff according to the definitions provided by the US Department of Labor. Each individual employee's classification may be found on their job description.
NON-EXEMPT EMPLOYEES: Actual hours worked in excess of forty hours in a single workweek will constitute overtime hours, and compensation will be made at the rate of 1 1/2 times the regular hourly rate of pay in compliance with the Fair Labor Standards Act.
EXEMPT EMPLOYEES: Are considered exempt from the Overtime Provisions of the Fair Labor Standards Act. Compensation is based on an annual salary. Working hours may exceed 40 hours in a single workweek for the employee to be able to complete all job duties and responsibilities.
DEFINITIONS - EMPLOYEE CATEGORIES
Probationary Period
All persons newly hired (or rehired) are considered probationary employees until the completion of ninety (90) calendar days of employment. All employees who change position are on a ninety (90) calendar day probationary status from effective date of job change.
Regular - Full time
A regular scheduled full time employee is one who is employed on a regular basis on a schedule of 40 hours a week. Regular full-time employees are eligible for all benefits as described in the Employee Handbook.
Regular - Part time
Employees scheduled for thirty-nine (39) or less hours a week are eligible for employee benefits or a prorated basis, in relation to their scheduled hours worked, up to forty (40). Note: Part-time employees who work 30 hours per week are eligible or insurance benefits.
Temporary
A temporary full-time employee is one who is employed on a schedule of forty (40) hours a week for a defined and/or limited period of time and is so informed at the time of hire. The person is not eligible for benefits
NOTE: Employees who are scheduled to work only as needed (Relief Workers, TSS, PT BHRS, etc.) are not eligible for employee benefits.
NEW EMPLOYEE ORIENTATION
When beginning employment with the agency, you will also be asked to complete all necessary paperwork at this time, such as, medical benefits plan enrollment forms, beneficiary designation forms, and appropriate federal, state, and local tax forms. At this time, if you have not previously done so, you will be required to present information establishing your identity and your eligibility to work in the United States in accordance with applicable federal law. You will not be allowed to begin working unless this information has been provided. You will also be given time to familiarize yourself with applicable policy and procedures. We encourage you to ask any questions you may have at this time so that you will understand all guidelines that affect and govern your employment relationship with us.
Our New Employee Orientation Program is designed to welcome new employees into the spirit and culture of our agency, to clearly establish performance standards, and to set the stage for success. During your first month of employment, you will participate in an orientation program conducted by Agency representatives. During this program, you will receive important information regarding the performance requirements of your position, basic education in Mental Health and IDD topics, plus other information necessary to acquaint you with your job.
MEDICAL SCREENINGS
The agency is under a contractual arrangement with Occupational Health Services at several locations throughout Pennsylvania. This arrangement allows for all pre-placement and employment related physical examinations to be conducted through these offices. This arrangement allows for physical examinations to be conducted by a physician with intimate knowledge of the various agency jobs and their corresponding duties. In addition, the examinations will be conducted in a uniform and consistent fashion. All required examinations will be scheduled by the Human Resources Department.
Medical examinations are conducted for one of the following reasons: 1) Pre-Placement - all new hires will be required to have a physical examination prior to their first day of employment. 2) Periodic - Various programs within the Agency operate under different regulatory guidelines, some of which require physical examinations on a periodic schedule beyond the pre-placement examination. (Note: Both Pre-placement and Periodic physical examinations will include Mantoux testing for Tuberculosis, and screening for other communicable diseases.) 3) For Cause- The Agency reserves the right to require individual employees to have a medical examination at any time when, in the opinion of the President, Director of Human Resources or Executive Director, a potential exists that clients or other staff may be exposed to a communicable disease or where an employee's physical condition may limit their ability to carry out their employment responsibility. 4) Upgrade/Transfer - as indicated by position. 5) Return-to Work - as indicated by the physician.
As a part of pre-employment medical screening the applicant is required to undergo a drug test. Any offer of employment that an applicant receives from the agency is contingent upon, among other things, satisfactory completion of medical screening and drug test and a determination by Employee Health that the applicant is capable of performing the essential functions of the position that has been offered, with or without reasonable accommodations.
As a condition of continued employment, employees may also be required to undergo periodic medical examinations, and/or alcohol and drug screening (for cause or random), at times specified by the agency. All company required medical screenings, alcohol and drug testing are paid in full by the agency.
LICENSURE
Persons being considered for employment whose occupations are regulated by a State licensing board must present proof of licensure, if applicable, before beginning work. Employees are responsible for renewing their licenses when necessary and ensuring that the license is kept current. An employee who fails to present or maintain a valid license as requested will not be allowed to work. If the license is required to perform your duties at the agency, the Agency will reimburse the employee for the cost of the license.
SMOKING
The Agency has been declared a tobacco-free workplace. Tobacco is not permitted on agency grounds. Under no circumstances should an employee smoke in the presence of a client.
PROBATION PERIOD
It is the policy of the agency to place employees on probation, when first hired, when employees accept new positions within the agency, or for disciplinary reasons.
All new employees and those employees who move into new positions are placed on a 90 day EMPLOYMENT probationary period. This time is to orient the employee with the agency and their job duties as well assess if the employee can satisfactorily perform the duties of the position they were placed in.
Persons promoted to new positions within the agency will be placed on ADVANCEMENT PROBATION for a period of three months. Any probation period may be extended at the discretion of the Program Manager with approval of the Director of Human Resources but may not extend beyond six (6) additional months.
Employees may be placed on DISCIPLINARY PROBATION up to 30 days due to failure to follow the personnel procedures of the agency, failure to perform according to the job requirements as outlined in the job description, or for misconduct while performing their duties.
Employees on any type of probationary period cannot qualify for salary increases during the probationary period, however, may be eligible for an increase following the successful completion of probation, upon the recommendation of their supervisor. While on probation, a worker may not bid for posted positions within the agency.
IDENTIFICATION BADGES
The agency provides each employee with a photo ID badge upon the start of employment. Employees are required to have the badge with them any time they are working and must wear the badge (in a visible location) when they are in public areas of the agency (i.e. Administrative Offices, etc.). The Identification Badge is required to ensure the security of the individuals and to enable the individuals, staff and others to identify and address employees by name.
Job Postings
The purpose of Job Posting is to provide opportunities for upward mobility of employees through promotions to positions of greater responsibility. All job posting notices are posted on the agency Intranet. Employees who have been in their current position for a period of six months are eligible to bid on available positions. If you are under your 6 month period for your position, approval must be obtained from your Executive Director to bid on an available position.
Promotions
It is the policy of the agency to promote from within whenever possible. All promotions are made based on the fitness of the applicants. Fitness includes professional training, experience, ability, personality, the full knowledge acceptance of the stated job description and not being on disciplinary probation.
SECURITY
All vehicles, lockers, desks, offices or containers that are agency property, as well as briefcases, backpacks, parcels and other personal belongings of employees, are subject to inspection and search for cause by agency management or their designated agents.
PERFORMANCE REVIEW
Written performance evaluations will be prepared on each employee after three months of employment and annually thereafter. The agency may exercise the right to prepare interim performance evaluations in addition to the initial or annual evaluation.
Probation evaluations are conducted to document the employee has been demonstrated the duties of the position and has then performed the duties satisfactorily.
Annual performance evaluations are intended to document and maintain satisfactory performance on a part of an individual by providing a means of measuring an employee’s effectiveness on the job, identifying areas where an employee is in need of training or improving and maintaining a high level of motivation through feedback and the setting of specific goals on the basis of this feedback.
Interim evaluations are intended to provide immediate feedback to a staff person on there work.
VOLUNTARY RESIGNATION
An employee wishing to resign in good standing shall submit to the supervisor a resignation letter dated and signed stating the effective date of the resignation. Professional and supervisory employees are expected to give a minimum of 30 calendar days’ notice of their intent to resign. All other staff, including direct care staff, is expected to give 14 calendar days’ notice. Failure to give adequate notice shall result in forfeiture of all accrued Paid Time Off (PTO) benefits, the withholding of future employment references, and the notation of "quit without notice" becoming a part of the employee's personnel file. Employees who are terminated for cause will not be paid for accrued PTO time.
STAFF RIGHTS
Each employee who provides direct (hands on) professional services to clients shall reserve the right to refuse, at any time, to participate in the care or treatment of any particular client or group of clients on the grounds of religious, ethnic, cultural, or moral considerations or persuasions. Please refer to Human Resources Policies for details.
VISITORS AT WORK
All employees are asked to discourage friends and family from visiting them on the job. A visitor not only distracts you from your duties but can also jeopardize the maintenance of client confidentiality. If an employee does receive a visitor during working hours they are asked to briefly greet the visitor and discreetly inform them of an appropriate time outside of work to visit. At no time should client supervision or employment duties be compromised to greet a visitor.
All visitors should be instructed to report to the reception area/front door area, at which time, if possible, the employee will be contacted to come greet their visitor. All visits should be conducted in an area where client confidentiality will not be compromised.
TELEPHONES
Agency telephones are intended to be used for agency business only. The Agency expects employee cooperation in making personal calls (either cell phones or agency phones) only when they are absolutely necessary and limiting conversations and use as much as possible. Any personal long distance calls are prohibited. Personal calls should be kept to a minimum in frequency and length and should never occur in a situation where performance of employment duties will be compromised. Staff are also prohibited from using cell phones while driving agency vehicles, to take pictures of clients or agency documentation at anytime.
The use of cell phones or personal communication devices is prohibited during client centered therapeutic activities unless approved for a limited purpose by the program director. Staff in direct interaction with clients may not use cell phones or personal communication devices to send or receive a call, text message or produce digital photographs.
GIFTS AND TIPPING
Employees will not accept gratuities, gifts and tips from clients, clients’ families, vendors and customers. Solicitation from a client, client’s family, vendors and customers by an employee of money, gifts, loans etc, are not permitted.
GARNISHMENT OF WAGES
The agency honors wage garnishments. Employees will be notified immediately upon their receipt through the payroll department.
COMPENSATION
The Human Resources Department has Agency Pay Ranges incorporating all of the organization’s positions. The ranges list the base pay by position. The ranges are reviewed and updated as needed.
Pay adjustments may be by one of the following methods:
• An across the board cost of living increase established by the Board of Directors at a fixed percentage or fixed rate due to all staff.
An Executive Team member may request a Pay adjustment for individual staff for one of the following reasons.
• A Pay increase as recommended by the individual’s supervisor based on the performance of the employee as reflected in their annual performance evaluation.
• A Pay increase due to expansion of responsibilities for that person.
• A Pay increase due to an increase in the credentials that would benefit the Agency.
• A Pay increase upon completion and observation at a satisfactory level of a Tier Level completion.
In the case of individual pay adjustments the Executive Team member requesting the increase must provide evidence based information to justify the increase and receive approval from the Director of Human Resources. If approval is not given the President/CEO will review the information and make the final decision. All pay adjustments are contingent on available funding in the budget.
WORK HOURS, OVERTIME, REST PERIODS
Working hours vary with the nature of the job to be performed and must be mandated by the need for service. All persons are on a forty hour week in compliance with the US Department of Labor Fair Labor Standards Act as amended.
Actual hours worked in excess of forty hours a week will constitute overtime hours, and compensation will be made at the rate of 1 1/2 times for regular hourly rate of pay for non-exempt employees in compliance with the Fair Labor Standards Act.
The Agency has the right to establish daily and/or weekly hours of work by groups of employees, and/or individual employees and the hours to be worked, including starting and quitting times. Such schedules may be changed from time to time by the Agency due to varying needs for coverage. The Agency alone shall determine what tasks and work shall be assigned to various employees.
DIRECT DEPOSIT
Your paycheck can be automatically deposited into your bank through Direct Deposit. Your paycheck can be deposited into the financial institution of your choice, at no cost to you, and your money is available for use on payday. You may arrange Direct Deposit through the Payroll Department. Direct Deposit is required by the agency.
STANDARDS OF CONDUCT
Employees of the agency are expected to accept certain responsibilities, adhere to accepted business and professional principles in manners of personal conduct, and exhibit a high degree of personal integrity at all times. This responsibility not only involves sincere respect for the rights and feelings of others, but also demands that both in professional and in personal life employees refrain from any behavior that might be harmful to the employee, coworkers, and/or the agency or that might be viewed unfavorably by current clients or by the public at large.
REMEMBER OUR IMAGE
We view service to our clients and their families as our most important responsibility. You are expected to help us attain this goal by extending every courtesy and assistance towards clients and families, as well as your co-workers.
APPEARANCE/DRESS GUIDELINES
Employees represent the Agency whenever they come in contact with the public; therefore the attire of staff members should be conservative and in good taste, suited to the job that they are performing in the name of the Agency.
A dress code provides a standard for our professional appearance. It establishes a standard that the average employee is comfortable with and can, with a few changes, live with.
• Employees are only permitted to have exposed tattoos if they are appropriate in nature.
• Tattoos depicting any type of illegal substance, drug, alcohol, inappropriate act, or lewd conduct, regardless of their locations must be concealed at all times.
• Employees with piercings may wear earrings or studs that are small and conservative in nature. Dangling earrings and piercings may be a safety issue when dealing with clients who have the potential for violence and are not permitted.
Below are the guidelines for dress.
All employees are expected to follow the following guidelines:
• Undergarments should not be visibly seen.
• Footwear for those working directly with clients must have a back on it.
• Hats, head coverings, or ball caps are not permitted to be worn in non-residential Agency buildings unless otherwise requested due to a bona-fide religious reason.
• Sweatpants, exercise pants, shorts in general, bib overalls, and any form-fitting pants are not permitted. Skirts or skorts that fall above the knee, sun dresses, beach dresses, bathing suit cover-ups, low-cut shirts, low-cut blouses, spaghetti-strap dresses or tops, and flip-flops are not permitted.
Staff to include Office staff, Directors, Executive Team, Teachers, Teachers Aides, Therapists and Licensed Professionals should follow the following guidelines:
• Casual dress slacks that are well fitted and in good condition are appropriate depending on the schedule for the day. A shirt, tie and suit jacket may be appropriate on some occasions.
• 3 Button shirts, dress shirts, turtleneck shirts and sweaters are permitted.
• Jeans are not permitted unless it is a designated agency jean day, in which jeans should be in good condition (not faded, don’t have holes or are frayed).
• Skirts, suits with skirts, dresses, split skirts, capris or cropped pants that are knee length or longer, with finished edges and that are fitted loosely enough to permit bending are permitted.
Staff to include Direct Care Staff and Group Home Managers should follow the following guidelines.
• Jeans that are in good condition (not faded, don’t have holes or are frayed) Collared and collarless shirts in good condition with or without logos are permitted. Logos must be in good taste and are permitted depending on the activity of the day. Logos that advertise alcoholic beverages or that suggest or portray illegal or inappropriate activities are not permitted.
• For more formal activities (Christmas party, administrative meetings, court appearances, etc.) casual dress slacks that are well fitted and in good condition and 3 button shirts, dress shirts, turtleneck shirts and sweaters are permitted. Pants that are below the knee with finished edges, dressier gauchos and capris, skirts, skirted suits and dresses that are knee length or longer and fitted loosely enough to permit bending are permitted.
• Clothing should be loose fitting and suitable for participating in the scheduled activities of the day as well as the weather conditions.
Staff to include Maintenance, Dietary and IT Technician staff should follow the following guidelines:
• Jeans that are in good condition (not faded, don’t have holes or are frayed) or casual dress slacks that are well fitted and in good condition are appropriate depending on the schedule for the day. Pants must be of ankle length.
• Collared and collarless shirts in good condition with or without logos are permitted. Logos must be in good taste and provide a good role model for clients. Logos that advertise alcoholic beverages or that suggest or portray illegal or inappropriate activities are not permitted.
• Footwear should be closed toe with backs on them and should be appropriate for the duties to be performed.
DISCIPLINARY ACTION
When an employee violates agency policy and procedures or work standards, his/her supervisor is responsible for acting promptly to correct the situation and to prevent further occurrences for mutual benefit. Progressive discipline (verbal warning, written warning, suspension and termination) will be used on all employees who violate any of the agency policies or standards of employee conduct and behavior, or whose performance is not acceptable. The type of discipline used will be determined by the Director of Human Resources based on the severity of the incident.
COMPLAINT PROCEDURE
In the event a staff person wishes to exercise this option, the following procedure should be followed:
1. Employees are encouraged to speak with their direct supervisor first to try and remedy the issue.
2. If the employee does not accept the results from speaking with their supervisor or feel they cannot approach their supervisor they may present their concerns in writing to the Director of Human Resources within ten (10) days of the incident which prompted the concern. The Director of Human Resources will investigate the complaint and will set a meeting with the parties involved to discuss the issue. The employee may bring an employee of their choosing to the meeting. Investigations will be completed in a timely manner. Following the meeting the Director of Human Resources will provide a written response to the employee and supervisor.
3. If the employee is further dissatisfied with the decision, he/she may submit the original concern and response to the President/CEO of the agency with further explanation, information, or justification for consideration within ten (10) days of receipt of the Director of Human Resources response. Within ten (10) working days of receipt of the letter, the President/CEO of the agency will inform the staff, in writing, of the disposition of the complaint.
The employee will be notified by the President/CEO of the disposition of their complaint within fifteen (15) working days.
In all cases of complaints, the original decision of the supervisor will stand and be acted upon as Agency policy until a final decision is forthcoming.
The decision of the President/CEO shall be final with no further appeal available.
EMPLOYMENT AT WILL
The agency believes in and adheres to the doctrine of employment at will, unless or except as modified by applicable law, the agency and its employees each have the right to terminate the employment relationship with or without cause at any time for any reason in accordance with company policy.
CONFIDENTIAL INFORMATION
The agency will maintain the confidentiality of “protected health information” (“PHI” as defined by HIPAA) and other information that is deemed to be confidential by other laws. This information may include, but is not limited to, information on clients, employees, and financial and business operations. Such information is made confidential by law (such as “protected health information” or “PHI” under the federal Health Insurance Portability and Accountability Act) or by agency policies. Confidential information may be information in any form: e.g., written, electronic, oral, overheard or observed. Access to all information is granted on a “need to know basis”. A “need to know” is defined as information that is required in order to do your job. During your daily work, you may be exposed to information that is considered strictly confidential. This information should not be discussed with anybody, including; other clients, co-workers, other families, your family, and friends. You must be alert to others overhearing your professional discussions regarding a client's condition or an employee's behavior/performance. Any inquiries from the media concerning a client should be referred to the COO or Director of Corporate Communications. Disclosure of confidential information is grounds for disciplinary action up to and including termination. All business records provided to you or in your possession must be returned to the agency upon termination of your employment.
LATENESS OR ABSENTEEISM FROM WORK
You are expected to be on the job as scheduled. Absences and tardiness seriously interfere with the smooth functioning of your program and cause an extra burden for your fellow workers. It is your responsibility to notify your Supervisor or the On-Call person promptly of the anticipated duration of your absence and/or tardiness. Notification should be made to your Supervisor or the On-Call person at least two hours prior to starting time in accordance with agency policy for call-offs. Unless unforeseen circumstances have caused a delay in notification, the Agency may reserve the right to withhold payment of Paid Time Off (PTO) benefits.
The agency may require a Physician's excuse from an employee in cases of absence in excess of two (2) consecutive work days. The agency also reserves the right to require an employee to furnish a Physician's excuse for each sick day following the use of three (3) sick days in a calendar year in cases where sick leave is being abused.
Any unauthorized absence of two (2) or more work days shall be considered an abandonment of employment and a voluntary resignation.
Remember, clients and co-workers are counting on you to be on the job and to be there on time!
The smallest increment of sick leave (PTO) that may be used is one (1) hour. Medical or dental appointments which cannot be secured outside of work hours may be taken as part of sick leave (1 hr minimum) or the time made up within the workweek.
STATEMENTS TO THE PRESS
All statements to the press and/or news media concerning any agency related material (i.e., incidents, policy, procedure or client information), will be given only by the CEO/President, Communications Department or Vice Presidents.
ALCOHOL AND DRUG USE
The agency is committed to being a drug and alcohol free and safe workplace. Our employees must be physically and mentally fit to perform their duties in a safe and efficient manner. Therefore, no employee shall work or report to work while under the influence of alcohol, illegal drugs, or any substance that would affect his/her ability to perform the job in a safe and efficient manner.
No employee shall consume, display, sell, distribute, or have in his/her possession, alcoholic beverages or illegal drugs or any substance that would affect their ability to perform the job in a safe and efficient manner, at any time during the workday, including during lunch, breaks, and on-call hours. This applies in the workplace (whether agency premises or community settings where the employees’ job responsibilities are performed) and in agency vehicles. Any private vehicle used for transportation of clients is also to be alcohol and drug free, while transporting consumers or performing other agency business.
Violations of this policy could jeopardize the safety of the employee, other employees, agency equipment or property; negatively impact the agency’s relations with the public; and create liability for the employee or the agency. Any violation of this policy subjects the employee to disciplinary action, up to and including discharge.
This policy supports and adheres to the Drug Free Workplace Act of 1988 and all of its provisions.
SLEEPING ON DUTY
Under no circumstances will any employee be allowed to sleep on duty or while providing care for clients. Employees found violating this policy will be subject to disciplinary action up to and including termination.
PERSONNEL RECORDS
You have the right to examine the contents of your individual personnel file except for confidential employment references. The file may not be moved from the Personnel office or copied. You may correct any information you feel is inaccurate with the permission of the Director of Human Resources. Program Supervisors will only be allowed to review information on a need-to-know basis. Appointments to review personnel files should be scheduled in advance with the Human Resources Department.
If there is any change in your name, address, telephone number, marital status, number of
dependents, life insurance beneficiary designation, education and training, and/or person to notify in case of an emergency, please contact the Human Resources Department to complete the appropriate forms.
BENEFITS/SERVICES
HOLIDAYS
The agency to recognize the following paid holidays:
1. New Year's Day
2. Memorial Day
3. Independence Day
4. Labor Day
5. Thanksgiving Day
6. Christmas Day
Exempt and non-exempt employees scheduled to work on one of the above holidays and do not receive another day off will receive compensation for that holiday. This time will be paid in the payroll following the Holiday pay period according to the guidelines set forth in the following procedures.
The agency will offer 3 Floating Holidays that can be taken during a calendar year that best suites our employees.
When requesting your 3 Floating Holidays, please provide as much advance notice to your supervisor as possible to assist in accommodating your request. A Floating Holiday may not be used for a call-off. Floating Holidays will not be paid out if not used. If they are not used by the end of the calendar year, they will be forfeited. Floating Holidays will not be paid out upon separation of employment.
Newly hired employees will receive Floating Holidays on the following schedule:
If hired between January and April 3 Floating Holidays
If hired between May and August 2 Floating Holidays
If hired between September and December 1 Floating Holiday
Agency administrative buildings will only be closed on the 6 standard Holidays identified above.
Holiday time will be taken and accounted for in full day increments up to 8 hours.
PAID TIME OFF (PTO)
All regular part and full-time employees are eligible for the paid time off (PTO) plan. Regular part-time employees earn PTO on their FTE percentage.
PTO is earned on a per pay basis and credited to an employee’s PTO bank after each pay period in which the PTO was earned. Eligibility to earn PTO is contingent on an employee having worked or used PTO for the pay period. PTO is not earned for pay periods when unpaid leave is taken.
Temporary, Relief Workers, contract employees or those whose job descriptions specifically exclude this benefit are not eligible for PTO.
Employees accrue PTO based on years of service and the date when they began continuous regular employment with the agency. PTO will accrue consistent with the following maximum accrual rates.
Employees hired on or prior to 6/30/2009:
|Hours of PTO Accrual |0-4 years |5-9 years |10-14 years |15-20 years |20 or more years |
|Support |104 |160 |208 |216 |264 |
|Professional |184 |200 |216 |264 |264 |
|9 month Teacher |138 |150 |162 |198 |198 |
|10 month Teacher |153 |167 |180 |220 |220 |
Employees hired on or after 7/01/2009:
|Hours of PTO Accrual |0-4 years |5-9 years |10-14 years |15-20 years |20 or more years |
|Support |104 |104 |144 |160 |200 |
|Residential Direct Care |104 |104 |144 |160 |200 |
|Professional |144 |144 |192 |200 |200 |
|9 month Teacher |108 |108 |144 |150 |150 |
|10 month Teacher |120 |120 |160 |167 |167 |
New employees begin accruing PTO in the first pay period they work.
Employees who have accrued to their maximum rate will continue to accrue time with it being placed directly into their Supplemental Bank. When a Supplemental Bank is at the maximum days, any accrued time will be forfeited.
Sign-up for PTO time in the Residential programs will occur in one week blocks by seniority in December and June. Any vacations scheduled after the early sign-up period will be on a first come first serve basis. All vacations must be approved by the employees immediate supervisor. Other non-residential staff must sign up for vacation with their immediate supervisor according to department procedures. PTO time must be scheduled in one hour increments.
Call-offs due to illness will follow the Agency policy on call-offs.
All other arrangements for PTO should be requested and approved in advance by a worker’s immediate supervisor. The worker’s immediate supervisor maintains the discretion to grant PTO without advance notice. In such cases, the supervisor may or may not grant PTO based on the business and operational needs of the unit.
Staff must utilize all available PTO for days they will be absent from work. Once all PTO is utilized, days absent will be unpaid. Advanced scheduling of days off without pay will not be honored. Employees needing to call off due to illness, without pay, must follow the call of policy and procedure.
A supplemental bank will be established for all staff to be used only for illnesses lasting longer than 24 consecutive sick day hours Employees unable to use filled PTO time during the year, or wanting to save some additional time, are able to do so by carrying over PTO days to their Supplemental Bank. Staff may accumulate up to 130 days in their supplemental bank. The Supplemental Bank is not eligible to be paid out to employees upon voluntary or involuntary termination of employment.
This bank may be used as follows:
• Provided pay after 24 hours of consecutive absence due to a non-work related injury or illness.
• Provided pay for the waiting period preceding a Workers’ Compensation illness or injury.
• Provided pay for intermittent appointments for FMLA qualifying intermittent leave (for self or to care for an immediate family member).
Upon completion of each year of service, while an employee is PTO eligible, eligible employees will receive 3 supplemental days in their supplemental bank until it reaches a minimum of 15 days. Eligible part-time employees will receive an amount of time based on their hours worked for the year (percentage of 2080 hours). If an employee, at any time during employment, should fall below 15 days in their supplemental bank, they will receive 3 days on their anniversary date until they reach the minimum 15 days.
Employees may donate up to 5 days of PTO to an employee when the employee or an immediate family member has been diagnosed with a serious medical condition or has a family emergency that will take the employee away from the work environment for a period greater than 3 days. The donated time shall not result in a leave greater than 6 weeks. The time will be placed in a separate column in the PTO database for the employee to use during the leave
In order to donate PTO, the following conditions must be met:
1. The employee in need must have exhausted all current PTO and Supplemental Bank time they have available to be eligible to receive donated PTO.
2. The employee in need must remain a benefit eligible employee, although on leave.
3. The employee wishing to donate time, must complete the PTO Donation Request Form.
4. The employee transferring the time must submit the request, in writing, to the Director of Human Resources for approval.
5. Once approved, payroll, human resources, the employee’s supervisor and the employee will be notified of the transfer of time.
SICK LEAVE
It is the policy of the agency to offer sick leave to full-time and part-time employees pro-rated based on the hours worked in their normal workweek. Temporary employees do not receive sick leave benefits. The agency may require a physician's certificate in cases of absence in excess of three (3) consecutive working days or if the employee is deemed to have abused this sick leave policy.
The agency retains the right to require an employee to use sick leave if the presence of the employee would jeopardize others by reason of their exposure to a contagious disease.
If a holiday observed by the agency is celebrated within the period of time an employee is taking sick leave, the holiday will not be included in the calculation of sick leave used.
The smallest increment of sick leave that may be used is one hour. Medical or dental appointments which cannot be secured outside of work hours may be taken as part of sick leave or the time made up within the workweek.
STAFF EDUCATION BENEFITS/CAREER DEVELOPMENT
The agency has established an education assistance program to help eligible employees develop their skills and upgrade their performance. Any full-time employee of the agency who has been with the agency at least twelve months prior to his/her date of application and meets the loan application guidelines is eligible for an educational loan from the agency. Applicants for educational loans must make application each year. A letter requesting educational benefits which includes the number of credits requested, total cost, transcripts of all previous educational studies, a recommendation of their immediate supervisor, and any other information deemed necessary by the agency must be submitted to the staff's Executive Director prior to March 1 for the following school year (September to June). Further information may be obtained from the Director of Human Resources.
From time to time the Agency may find the need for staff with specific degrees. In these cases the management team will determine the number of positions it needs to fill and will advertise internally for any staff interested in returning to school in the designated degree area. Staff will be required to submit a resume and cover letter explaining why they would be the best candidate. All qualified applicants will be interviewed by a selection committee, who will choose the best qualified applicant.
LEAVES OF ABSENCE (LOA)
The agency, on occasion, will give consideration to employees who need a leave of absence without pay. This decision will be at the discretion of the President based upon the reason and duration of the leave, as well as the ability to find adequate staff coverage during the leave of absence. Any employee on an unpaid leave of absence who engages in other employment without the consent of the President shall be considered as voluntarily terminating his/her employment. While on a leave of absence, there will be no accrual of sick leave, vacation, holidays or employee benefits for the duration of the leave. The employee may purchase health insurance from the agency if he/she desires coverage.
A leave of absence without pay will be subject to the following rules and regulations:
• The employee must have completed one (1) year of service.
• The leave may be granted at such times as are consistent with the provisions of full service to, and in the best interest of the agency.
• A request for the leave of absence must be submitted to the supervisor in writing with the reason and duration of the leave outlined.
• A request for a leave of absence may be for a period of time not to exceed sixty (60) days. No accrual of sick leave, vacation or holidays will occur while on a leave of absence without pay.
In no case will more than one personal leave of absence be granted to an employee within a one-year period.
JURY DUTY LEAVE
Any absence for jury duty or on a subpoena as a witness in a court hearing which the employee is not the plaintiff, defendant or a voluntary witness shall be excused. The wages paid by the Agency during such an absence shall be at the regular rate less the fee paid by the court for such service exclusive of transportation allowance. This leave will not exceed a period of one month. The employee shall promptly return to work each day after the jury duty obligation or appearance as a witness has been fulfilled
BEREAVEMENT LEAVE
The agency provides employees three (3) consecutive calendar days of paid bereavement leave upon the death of a member of their immediate family (parents, parents-in-law, spouse, children, brothers & sisters). Two additional days may be granted at the discretion of the Director of Human Resources when required travel is in excess of 200 miles (one way). For death involving non-immediate family, the employee may request, from their supervisor and the Director of Human Resources, time off not to exceed eight (8) hours. The period of absence shall be between the day of death in the family and the day following the funeral or three (3) consecutive calendar days, whichever is less. Pay for each absence will be made for actual time lost from work. Should the death occur at a time when the employee is not scheduled to work, no payment is due, and no additional time off is due in the event that the employee is on vacation or some other approved leave. Funeral leave pay may not be retroactive, postponed, or split.
MILITARY LEAVE
The agency grants leaves of absences to serve active duty in the Armed Forces of the United States without pay. Upon completion of active service, the employee may return to the agency. This must be done within the time period indicated in the Universal Military Training and Service Act. The employee will be offered a position with the same seniority status, pay and benefits equivalence that he would have had if he had not gone into the service. During the term of this leave, all employee benefits will cease, but upon return to a full-time status, will be reinstated without any break in service.
The Agency also grants leave of absences to all employees who are required to spend two weeks or less in annual training for the Armed Forces Reserves or the National Guard. The agency will pay the difference between the pay received for reserve military training and the employee's regular salary, provided the regular salary is greater than the military salary, for a maximum of two weeks annually. Reservists and guardsmen are entitled to pay for holidays that fall during their periods of absence for Training Duty. All employee benefits will remain in effect during the period of this Military Training Leave. The agency will not compensate employees for monthly reserve duty. The employee must make arrangements with his/her supervisor for time off or a schedule change.
FAMILY MEDICAL LEAVE
Eligible employees are entitled to twelve (12) weeks of family and medical leave during any twelve (12) month period for the following reasons:
1) the birth of the employee’s child and in order to care for the child;
2) the placement of a child with the employee for adoption or foster care and to care for the newly-placed child;
3) to care for a spouse, child or parent of the employee who has a serious health condition;
4) a serious health condition which renders the employee incapable of performing his/her job functions; or
5) a qualifying exigency arising out of the fact that an employee's spouse, child or parent is called up for or is on active duty in the Armed Forces in support of a military contingency operation as defined by law and the employee’s circumstances justify his/her need for leave.
The twelve (12) month period (“leave year”) is a “rolling” 12-month period measured backward from the date leave is to begin.
Leave for the birth of a child or the placement of a child for adoption or foster care must end within twelve (12) weeks after the date of the birth or placement. Spouses employed by the agency who request leave for birth or placement of a child or to care for an ill parent may only take a combined total of 12 weeks leave during any 12-month period for these purposes.
Additionally, eligible employees can take up to twenty-six (26) weeks of FMLA leave in a single twelve (12) month period because their spouse, child, parent or next of kin (nearest blood relative) is seriously ill or injured as a result of serving on active duty in the Armed Forces. This “service member family leave” is only available during a single 12-month period, which begins the first day the employee takes leave. During this single 12-month period, the combined amount of all types of FMLA leave an employee utilizing service member family leave may use is twenty-six (26) weeks.
Spouses employed by the agency who request service member family leave may only take a combined total of twenty-six (26) weeks of leave during a single 12-month period for such purposes. In addition, spouses may only take a combined total of twenty-six (26) weeks of all types of family and medical leave during this single 12-month period. The limitation for spouses relating to a combined total of twelve (12) weeks of leave in the case of the birth or placement of a child or to care for an ill parent runs concurrently with the foregoing service member family leave limitations.
Employees who are eligible may request leave on an intermittent or reduced work schedule basis if such leave can be certified by a health care provider as being medically necessary due to their own serious health condition or to care for a covered relative with a serious health condition or with an illness or injury as a result of serving in active duty in the Armed Forces.
Employee Notice of Leave
An employee requesting a leave of absence must notify the Human Resources Department in accordance with this Policy. An employee's failure to provide timely notice may result in the request being delayed or denied and the absence(s) not being considered FMLA-covered.
When requesting a leave of absence for the first time for a particular FMLA-qualifying reason, the employee must state the qualifying reason or otherwise explain the reason for needing such leave and provide the anticipated timing and duration of the leave (if foreseeable). The employee must specifically mention the FMLA-qualifying reason or the need for “FMLA leave” when subsequently requesting leave for the same FMLA-qualifying reason.
An employee intending to take family and medical leave which is foreseeable must provide at least thirty (30) days advance written notice. If thirty (30) days advance written notice is not possible, the employee must provide notice as soon as practicable. For foreseeable leave due to a qualifying exigency, notice must be provided as soon as practicable, regardless of how far in advance such leave is foreseeable. If the need for leave is not foreseeable, the employee must provide as much notice as practicable. Accordingly, an employee requesting an unforeseeable leave of absence must comply with the call-off procedure outlined in Policy #1113710 – Sick Leave, absent unusual circumstances. Failure to provide the requested notice may result in denial or delay of leave.
In all cases, an employee requesting family and medical leave must complete a Family and Medical Leave Request Form and return it to the Human Resources Department. The completed application must state the reason for the leave, the expected duration of the leave, and the expected starting and ending dates of the leave. Unless the employee completes the written Family and Medical Leave Request Form, leave not otherwise designated by the agency as FMLA leave may not be considered by the agency as FMLA leave for any purpose.
Eligibility and Rights & Responsibilities Notice
Within five (5) business days after requesting leave under this Policy, the agency will provide to the requesting employee a Notice of Eligibility and Rights and Responsibilities, absent extenuating circumstances. This Notice shall inform the employee whether he or she is eligible for FMLA leave, and, if not, it shall state at least one reason why the employee is not eligible. This Notice also states whether the employee must submit additional information to determine whether the absence(s) will qualify as FMLA leave, such as the need to submit a medical certification or other necessary documentation. Finally, this Notice also informs the employee of the expectations and obligations of the employee and explains any consequences of failure to meet these obligations.
Designation Notice
The Agency will issue a Designation Notice within five (5) business days after it has enough information to determine whether a leave request is FMLA-qualifying and inform the employee of its designation decision, absent extenuating circumstances. This Notice will specify the amount of leave being counted towards the employee's FMLA leave entitlement (if known at that time), and will also state whether a fitness-for-duty certification will be required for the employee to return to work. If it is not possible to specify the amount of leave being counted against the FMLA leave entitlement (such as in the case of unforeseeable intermittent leave), then the Agency shall provide notice of the amount of leave counted against the employee's FMLA leave entitlement upon request by the employee, but not more often than once in a thirty (30)-day period and only if leave is taken during such period.
Substitution of Paid Leave
Family and medical leave is unpaid leave. If leave is taken because of the birth or placement of a child, or to care for a covered relative, any accrued vacation leave will be substituted for unpaid family and medical leave. If leave is taken due to the employee’s serious health condition, any accrued sick and vacation time will be substituted for unpaid family and medical leave. The remainder of family and medical leave will be unpaid. The substitution of paid leave for unpaid leave does not extend the twelve (12) week or twenty-six (26) week leave entitlement.
Employees on short-term disability or workers’ compensation are required to take FMLA leave concurrently. For example, employees who are absent from work for four months due to a workers’ compensation injury will have the first twelve weeks of that absence applied to FMLA leave. If disability and/or workers' compensation benefits are less than 100% of the employee's normal pay, then the agency and the employee may mutually agree to supplement such disability or workers' compensation benefits with accrued sick and vacation time. Should disability or workers' compensation benefits cease while the employee remains on FMLA leave, accrued sick and vacation time will be substituted for unpaid leave in accordance with the agency PTO/Call Off policies.
Although an employee taking FMLA leave while receiving workers' compensation benefits cannot be required to take a light duty assignment, the employee's refusal to take a light duty assignment may disqualify the employee from receiving certain workers' compensation benefits.
Required Certifications
Employees must submit a sufficient and complete appropriate certification form to the Human Resources Department within fifteen (15) days of being provided with a Notice of Eligibility and Rights and Responsibilities. An appropriate certification form will be provided to the employee at the time he or she is provided with the Notice of Eligibility and Rights and Responsibilities. Employees who request leave because of a serious health condition of the employee or the employee’s spouse, child or parent or to care for a covered service member’s serious injury or illness must provide a Medical Certification completed by the health care provider of the employee or relative. The Certification must state the date on which the health condition commenced, the probable duration of the condition, and the appropriate medical facts regarding the condition.
If the employee is needed to care for a spouse, child or parent, the Certification must so state and provide the amount of time that the employee is needed for such care. If the employee has a serious health condition, the Certification must state that the employee cannot perform the functions of his or her job.
If the Certification is for intermittent leave, or leave on a reduced work schedule for planned medical treatment, the dates of the treatment and duration must be provided and a statement indicating why the treatment could not be scheduled on dates or times when intermittent leave or leave on a reduced work schedule is not necessary. If the employee is planning medical treatment, the employee must first consult with the agency regarding the dates of such treatment and make a reasonable effort to schedule the treatment so as not to unduly disrupt the agency’s operations, subject to approval by the health care provider.
An employee requesting FMLA leave because of an immediate family member being on active duty or called to active duty will be required to provide certification of the need for leave to the extent specified by federal regulations.
Employees on leave due to their own serious health condition or to care for a covered relative must contact the Human Resources Department on the 1st and 15th of each month regarding the status of the condition and intention to return to work. Absent unforeseeable circumstances, employees must inform the Human Resources Department within two (2) business days of any changes in circumstances that would necessitate a shorter or longer period of leave than initially requested. The agency may require second and third medical opinions as it deems necessary.
An employee may be required to submit a sufficient and complete recertification, at his or her own expense, and within fifteen (15) days of the agency’s request, in connection with a new absence that occurs for a medical condition already subject to an approved FMLA leave. An employee may also be required to submit a recertification if the employee requests an extension of the initial leave period; if circumstances described in the last certification have significantly changed; or if information casts doubt on the employee's stated reasons for the absence or on the continuing validity of the last certification. In instances regarding recertification for an FMLA-leave for the employee's own serious health condition, The agency reserves its right to provide the employee's health care provider with information about his/her attendance and ask the health care provider to evaluate whether the employee's attendance pattern is consistent with the need to be absent for the condition in question.
Failure to provide a timely, sufficient and complete Certification or recertification may result in delay or denial of leave.
Medical and Other Benefits during leave
During a period of family and medical leave, eligible employees will continue to participate in the agency’s group health plan under the same terms and conditions that applied before leave commenced. To continue participation in the health plan, the employee must continue to make any premium contributions that he or she made to the health plan before taking leave. Payments are to be made by check to the appropriate company the employee is employed by, on or before the last day of each month for coverage for the following month. Health care coverage will cease if premium payments are not made in a timely manner. If the employee's payment is more than fifteen (15) days late, the employee will be notified in writing that his/her coverage may cease if payment is not received within fifteen (15) days of receipt of the notice.
Employees may continue the payment process to continue their benefits for up to six months, at which time they are removed from the plans and offered COBRA.
If you elect not to return to work at the end of the leave period, you may be required to reimburse the agency for the cost of the premium paid by the agency for maintaining coverage during the period of unpaid leave.
An employee is not entitled to accrue any seniority or other employment benefits while on unpaid family and medical leave.
Employees who request intermittent leave or leave on a reduced work schedule for planned medical treatment may be temporarily transferred to an available alternate position which better accommodates the recurring leave.
Restoration to Employment
An employee who takes family and medical leave (with the possible exception of “highly compensated employees”) will be restored to the position he or she held when leave began or an equivalent position, as determined by the agency, upon return from leave. The agency cannot guarantee that an employee will be returned to the same position held prior to taking family and medical leave.
If an employee accepts a light duty assignment while still eligible for FMLA leave, he/she will be entitled to reinstatement to his/her original position or to an equivalent job, but only until the end of the leave year.
If an employee was on leave because of his or her serious health condition, the employee must present the agency with a fitness-for-duty certification completed by the employee’s health care provider certifying the employee’s fitness to return to work and ability to perform the essential functions of the position. An employee taking intermittent or reduced schedule leave for their own serious health condition will be required to successfully complete a fitness-for-duty certification every thirty (30) days while taking such leave if reasonable safety concerns exist. The employee will have fifteen (15) days to obtain this certification.
An employee who fails to return to work following expiration of family and medical leave will be terminated from employment unless an extension of leave is approved. Requests for extensions of leave must be made in writing as soon as the employee becomes aware of the need to extend the leave of absence.
Fraudulent Claims
Employees who make fraudulent claims for leave may be denied restoration and/or disciplined up to and including discharge.
Additional Information
The agency has posted information concerning family and medical leave at bulletin boards at each work location where personnel notices are posted. Any question concerning family or medical leave should be brought to the attention of the Director of Human Resources.
HEALTH INSURANCE
The agency provides full-time and part-time eligible (30 hours per week) employees an opportunity to participate in the employee health plan. Should there be any discrepancy between this handbook and the Summary Plan Description (SPD), the provisions under the SPD will govern.
Eligibility:
Full-time and part-time benefited employees (those working at least 30 hours per week) are eligible to apply for coverage within 30 calendar days from their hire date, within 30 calendar days of a change of status, or during the annual Health Insurance Open Enrollment period usually conducted during the month of November for coverage beginning January. Coverage will be continued as long as you remain on active status. In order to prevent loss of coverage while on leave without pay, you must make arrangements to continue to pay your premiums.
DENTAL INSURANCE
Full-time and part-time benefited employees (those working at least 30 hours per week) are eligible to apply for coverage within 30 calendar days from their hire date, within 30 calendar days of a change of status, or during the annual Dental Insurance Open Enrollment period usually conducted during the month of December for coverage beginning January. Coverage will be continued as long as you remain on active status. In order to prevent loss of coverage while on leave without pay, you must make arrangements to continue to pay your premiums.
VISION SERVICES PLAN
Full-time and part-time benefited employees (those working at least 30 hours per week) are eligible to apply for coverage within 30 calendar days from their hire date, within 30 calendar days of a change of status, or during any point through the calendar year. Coverage will be continued as long as you remain on active status. In order to prevent loss of coverage while on leave without pay, you must make arrangements to continue to pay your premiums.
CONTINUATION OF HEALTH INSURANCE BENEFITS
The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances such as voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events. Qualified individuals may be required to pay the entire premium for coverage up to 102 percent of the cost to the plan.
LIFE INSURANCE
The agency provides you with group life insurance valued at two times your annual income, at no charge if you are a full-time or part-time eligible employee (those working at least 30 hours per week). This insurance policy also provides remuneration for accidental death and dismemberment. You are required to sign up for this insurance and designate your beneficiary at the beginning of your employment.
SUPPLEMENTAL INSURANCE
Optional Health Insurance benefits are available to full-time employees and their families through a third party provider. These benefits include but are not limited to:
• Short Term Disability
• Cancer/Intensive Care
• Accident
• Optional Life Insurance (Term or Universal)
These insurances are optional to the employee who is responsible for the cost. The payments will be made through payroll deduction and is pre-taxable under Section 125 of the IRS Code.
FLEXIBLE SPENDING ACCOUNTS
The agency offers you the opportunity to save tax dollars by participating in flexible spending accounts for dependent care and medical expenses. You may enroll in the Flexible Spending Account Programs within 30 days of employment or during the annual Health Insurance Open Season period. You may choose to have a designated amount of your salary deducted from your pay check on a pre-tax basis for reimbursement of dependent care or medical expenses.
LONG TERM DISABILITY
All full-time and part-time benefited employees are eligible for long term disability insurance, this is provided to eligible employees of subsidiaries. Disability benefits may begin as early as the 91st day after absence from work and must be requested by contacting the Human Resources Department, prior to the 90th day of disability. Disability benefits received will be based on a percentage of an employee's salary.
AGENCY RETIREMENT PLAN
The Agency has established a Retirement Plan for employees. Employees may join the retirement plan at the beginning of employment but Agency match will not begin until the employee has been employed for at least one year with the agency and worked 1,000 in that year. The employee is not vested until at least three years of employment with the Agency.
Beginning 01/01/2018 the agency will have automatic deferrals of 3% for all new hires. New hires may opt out of this automatic enrollment or increase/decrease the deferral percentage by going online to the retirement website.
WORKER'S COMPENSATION
The Agency provides Worker's Compensation Insurance to cover injuries sustained by employees while in the performance of their work. Employees must immediately report all work related injuries, however minor, to the employee's supervisor. Failure to timely report injuries may result in the denial of workman's compensation benefits.
When an employee incurs an injury which results in loss of work, the employee may not return to work unless certified by the agency physician as being capable of carrying out work responsibilities as outlined in his/her job description. From time to time, employees may return to light duty employment at the discretion of the Agency. Any such light duty assignments will be of limited duration (60 days or less) and will be determined on a case-by-case basis. Any extensions of light-duty assignments will also be determined on a case-by-case basis.
EMPLOYEE RECOGNITION PROGRAMS
The Mission Award will recognize staff whose actions have enhanced or reflect furtherance of our Mission and Commitments. Those who recognize a co-worker receive 1 point. Those receiving a Mission Nomination receive 3 points. Points may be used to participate in raffle items that we give-a-way throughout the year.
Examples of Criteria for Determination of Award Recipients:
• Nominee has gone above and beyond basic expectations of the program or of the individual making the nomination.
• Nominee has significantly impacted the lives of those we serve.
• Nominee has implemented ideas that have resulted in improved service, cost savings, or streamlined processes.
• Single situations or overall excellent work can be highlighted for nomination.
• Nominee has positively impacted the rights of those persons we serve.
• Nominee has used innovative approaches that have positively impacted programs or individual clients.
• Nominee’s actions have demonstrated the agency’s mission and commitments in significant ways.
EMPLOYEE RESOURCES PROGRAM
The Employee Resources Program is a listing of all agencies and facilities provided to employees and their families of BLBHS to help with any type of assistance they may need.
This does not excuse employees from complying with normal policies or from meeting normal job requirements during or after receiving assistance. Nor will participation in the program prevent the BLBHS from taking disciplinary action against an employee for performance problems that occur before or after the employee's seeking assistance through the program.
CREDIT UNION
The agency establishes a relationship with credit unions in each of our services areas for our employees. The agency does not provide any contribution with regard to the employee's credit union.
EMPLOYEE SERVICE LEAGUE
The Employee Service League (ESL) was founded in 2001 by a group of employees. The purpose of the ESL is to organize special activities for employees and to provide assistance through the Sunshine Fund to employees of the agency who are in crisis situations. Employees can contribute to the ESL through payroll deduction of at least $1 per pay. Employees in need of assistance due to crisis must contact the president of the ESL. Crisis Requests are confidential and must be approved by vote of the ESL committee.
SAFETY
FIRE PREVENTION
Safety is the responsibility of every employee. Every reasonable precaution is taken to provide a safe environment for employees. Safety rules are for your protection and for the protection of our clients and co-workers. The agency needs your support and cooperation to maintain a good fire safety program. To help prevent fires, you should:
• Keep work areas free from unnecessary combustible materials.
• Be especially careful handling flammable materials.
• Know the location of fire fighting equipment in your work areas.
• Stay away from the fire scene if you are not directly involved in removing persons to safety.
• Avoid using the telephone after the fire is reported. All telephone lines must be kept open for emergency calls.
• Above all, be ready and know the special fire procedures in your work area.
Know what you should do in the event of a fire.
WORKPLACE VIOLENCE
The agency is committed to providing a safe and secure workplace and an environment free from physical violence, threats and intimidation. Therefore, it is expected that all employees will report to the work site to perform their jobs in a nonviolent manner.
In addition, the Agency believes that violence is a form of serious misconduct that undermines the integrity of the employment relationship. Conduct and behaviors of physical violence, threats or intimidation by an employee may result in disciplinary action up to and including discharge, and/or other appropriate action.
Corporate Compliance Program
XII.
COMPLIANCE PLAN
The previous sections of this document describe this Compliance Plan’s overall goals and objectives. The following sections discuss the eight fundamental components of the agencies’ Compliance Plan:
1. The designation of a Compliance Officer and a Compliance Committee.
2. The identification of specific areas of potential non-compliance and the development and implementation of written policies, procedures and standards of conduct related to each area.
3. The effective training and education of employees.
4. The development and implementation of effective methods of communication so that all suspicion of non-compliant activities is promptly reported.
5. The development of disciplinary guidelines related to documented non-compliant activities.
6. The development of an on-going program of internal audits and reviews.
7. The development of corrective actions to immediately address detected offenses.
8. The development of methods for determining the effectiveness of the Compliance Plan.
1. Designation of a Compliance Officer and a Compliance Committee. – Effective July 1, 2011, the Director of Quality Assurance, Compliance & Outcomes was designated as the agency Compliance Officer. Soon thereafter, several Agency employees were identified as relevant members of the Compliance Committee and the first meeting occurred on September 21, 2011. The Compliance Committee is scheduled to meet every quarter, however, meetings occur more often, as needed.
2. Identification of specific areas of potential non-compliance and the development and implementation of written policies, procedures and standards of conduct related to each area. - Upon initiation of the Compliance Plan, the agency hired experienced behavioral health care consultants to assist the agency in identifying areas of potential non-compliant activity, and to develop appropriate policies and procedures relative to all identified risk areas. This included the review of a sample of medical records from several programs, the review of existing policies and procedures, and the review of other pertinent information. Over the past several years, this list of potential problem areas was continually updated based on behavioral health care trends and perceived weaknesses within the agency. Moving forward, Risk Assessments will be completed annually in order to ensure all areas that have a high potential for fraud, waste or abuse are identified and addressed.
Additionally, the following Compliance Standards of Conduct were developed to aid each employee of the agency in his/her attempt to maintain complete compliance with all laws and regulations:
Standards of Conduct
These basic principles of integrity serve as a path to what is proper in most work situations, regardless of the job at hand. The following standards are intended as a guideline for all employees:
Standard 1 - Antitrust
All employees are expected to comply with applicable antitrust laws that regulate competition. Examples of conduct prohibited by laws include:
1) Agreements to fix prices, bid rigging, collusion (including price sharing) with competitors.
2) Boycotts, certain exclusive dealing and price discrimination agreements.
3) Unfair trade practices including bribery, misappropriation of trade secrets, deception, intimidation and similar unfair practices.
The Compliance Officer can provide clarification to employees when they are confronted with any of the above situations.
Standard 2 – Tax
The agency and its employees will not engage in compensation agreements, which do not accurately reflect fair market value. The agency will report all payments received to the appropriate taxing authority, and all tax returns will be filed accurately and timely.
Standard 3 – Fraud and Abuse
The agency expects its employees not to engage in any activities that violate fraud and abuse laws. These laws prohibit:
1) Payment, either direct or indirect, in exchange for referral of clients
2) Submission of false, fraudulent or misleading claims to any payer
3) Misrepresenting information to any person or entity in order to gain either personal or financial gain.
Standard 4 – Lobbying/Political Activity
Each employee will not engage in activities, which could jeopardize the tax exempt status of the organization, including lobbying and political activities. The Compliance Officer can provide clarification to employees who are considering engaging in these activities.
Standard 5 – Environmental
The agency expects all employees to respect our environment, and conserve natural resources. As an organization, our policy is to adhere to, and conform to, all regulations with regards to the environment.
Effective Training and Education of Employees. – Proper education and training of employees is an essential part of this Compliance Plan. A variety of training sessions will be offered, and will be based upon current compliance trends and initiatives. This training will utilize both internal staff and external consultants as necessary.
The development and implementation of effective methods of communication so that all suspicion of non-compliant activities is promptly reported. – The agency has methods for an employee to communicate a suspicion to the Compliance Officer, as follows:
a) Compliance Hotline –A dedicated telephone line has been set up as the Compliance Hotline. The phone number of this line is 814-817-1400 Extension 1441. This line is equipped with private voicemail which allows persons making complaints to do so at any time.
b) Postal or Inter-Agency Mail – The Compliance Officer has a private mail box located at the Administrative Office building at 800 East Main Street, Bradford, PA, 16701.
If an employee wishes to report a suspicion using the phone number or address provided, he/she should include the following information:
• Employee name and department, unless employee wishes to remain anonymous.
• Date and time of report.
• A detailed description of the suspected misconduct.
• The name(s) of any other employees who know about the problem.
• The name(s) of any other employee or supervisor to which the problem has been reported.
• Whether the caller is willing to meet about his/her suspicion.
All employees are expected to realize that the purpose of the dedicated phone number/ext. and postal/interagency mail is to report compliance suspicions. It is not a forum for voicing displeasure about a co-worker, or any other personnel related issues that are covered in the Personnel Manual. Any abuse will result in appropriate disciplinary action against the employee.
Upon receipt of a compliance complaint via telephone, in person or by written report, a Compliance Incident Report is completed. All reports are handled in a confidential manner and at no time will the reporting of a valid suspicion by an employee results in any type of repercussion regardless of the eventual resolution of the report. If an employee wants to receive information about the resolution of the issue he or she has reported, their request must be documented on the completed Compliance Incident Report.
Development of Disciplinary Actions Related to Detected Misconduct. – An employee may be subject to discipline for failing to participate in the compliance efforts, including, but not limited to:
a) The failure of an employee to perform any obligation required of the employee relating to compliance with the program or applicable laws or regulation;
b) The failure to report suspected violations of compliance program laws or applicable laws or regulations to an appropriate person; and
c) The failure on the part of a supervisory or managerial employee to implement and maintain policies and procedures reasonably necessary to ensure compliance with the terms of the program or applicable laws and regulations.
Any discipline should follow existing policies and procedures covered in the Human Resources Policy and Procedure Manual.
Development of an Ongoing Internal Audit Program – An ongoing evaluation process is critical to the success of this Compliance Program. The agency will conduct the following two types of internal review as part of this Compliance Plan:
a) Compliance Incident Report Review – Upon receipt of the report of a suspicion through the Hotline, the Compliance Officer will immediately conduct a review of the pertinent information in order to determine the existence of, and effect of, any misconduct. This audit will include the review of patient medical records, the review of related billing records, the interviewing of appropriate staff, and the review of pertinent regulations and other information. The results of this review will be reported to the CEO when the Compliance Officer has reached an opinion as to the validity and effect of the reported misconduct.
b) Ongoing Review – Based upon the current list of areas of potential risk and the protocols that have been developed in response to those areas, the Compliance Officer will conduct audits of pertinent clinical and billing records in order to identify activities that do not follow recommended protocols. These reviews will occur on a cyclical basis. The results of these audits will be reviewed by the Compliance Committee, CEO and Board of Directors.
Sufficient competent evidential matter will be obtained through inspection, observation, inquiries and confirmation to afford a reasonable basis for an opinion to be rendered. These audits will be based upon a reasonably sized sample, and will consist of a fair representation of records. A set of audit work papers will be maintained by the Compliance Officer, for future reference and use.
Development of Corrective Actions to Address Detected Misconduct – Upon the report of suspected misconduct, the Compliance Officer will conduct a review to determine if a material violation has occurred, as outlined above.
A) Possible Criminal Activity. If the investigation reveals what appears to be criminal activity by an employee, or business unit, the agency will undertake the following steps.
a) In the event that Medicare and Medicaid claims are involved, the agency shall notify the programs through the local United States Attorney’s Office or the local office of the United States Department of Health and Human Services, Office of the Inspector General Division (“OIG”), as counsel for the agency deems appropriate. The agency, through counsel, shall attempt to negotiate a voluntary disclosure agreement prior to the disclosure. Unless otherwise directed by the United State’s Attorney’s Office or the OIG, it shall immediately stop all billing related to the problem in the unit(s) where the problem exists until such time as the offending practices are corrected.
b) If an employee’s conduct appears to have been intentional, willfully indifferent or undertaken with reckless disregard for the applicable Medicare or Medicaid law, the agency will initiate appropriate disciplinary action.
B) Other Non-Compliant Activities. If the investigation uncovers billing or other problems which do not appear to be the result of conduct which is intentional, willfully indifferent, or with reckless disregard for the applicable Medicare and Medicaid laws, the following steps will be undertaken.
a) Improper Payments. If the investigation results in the discovery of duplicate payments by Medicare or Medicaid, or payments for services not rendered or provided other than as claimed, the agency will:
1) Correct the practice as soon as possible,
2) Calculate and repay the appropriate payer source all duplicate or improper payments that resulted from the act or omission,
3) Assess the circumstances that led to the improper payment and, if appropriate, initiate disciplinary action. The appropriate disciplinary action may include, but is not limited to, reprimand, demotion, suspension and discharge; and
4) Conduct training, appropriate to the misconduct, in order to prevent a repeat of the detected misconduct.
b) If the investigation results in detecting misconduct which did not result in overpayment, the agency will:
1) Correct the practice as soon as possible,
2) Assess the circumstances and initiate disciplinary action. The appropriate disciplinary action may include, but is not limited to, reprimand, demotion, suspension and discharge.
3) Conduct training, appropriate to the misconduct, in order to prevent a repeat of the detected misconduct.
Development of methods for determining the effectiveness of the Compliance Plan.
A.) Annual Review – An annual review of all audit results and any corresponding Corrective Action Plans will be conducted. A summary of this review will be provided to the Compliance Committee, CEO and Board of Directors for review.
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COMPLIANCE ISSUE REPORT
EMPLOYEE NAME (OPTIONAL) ______________________________________
DEPARTMENT (OPTIONAL) __________________________________________
DATE & TIME of REPORT ____________________________________________
DETAILED DESCRIPTION OF SUSPECTED ISSUE (Use additional pages if necessary):
ARE OTHERS AWARE OF THIS ISSUE? (Y/N):
NAME OF OTHER PERSON(S) AWARE OF THIS ISSUE (OPTIONAL):
DO YOU HAVE DOCUMENTATION TO SUPPORT YOUR REPORTING OF THIS ISSUE? (Y/N):
IF YES, PLEASE DESCRIBE:
ARE YOU WILLING TO TALK TO THE COMPLIANCE OFFICER/C.E.O. TO DISCUSS THIS ISSUE? (Y/N):
ARE YOU WILLING TO MEET WITH THE COMPLIANCE OFFICER/C.E.O. TO DISCUSS THIS ISSUE? (Y/N)
RECEIPT FOR EMPLOYEE HANDBOOK
My signature on this form is to acknowledge that I have received a copy of the Employee Handbook.
I understand that it is my responsibility to read the Handbook. If I have questions concerning the information herein, I will bring them to the attention of my Manager or to the Human Resources Department.
I understand that the policies and procedures contained in the Handbook constitute management and employee guidelines only, and are in no way to be interpreted as a contract between the agency and any of its employees. I further understand that the agency reserves the right to change, modify, or delete any of its work rules and policies at any time.
___________________________ ________________________________
PRINT Employee Name Employee Signature/Date
___________________________ ________________________________
PRINT Witness Name Witness Signature/Date
Original 05/2008, Revised 10/2009, Revised 09/2010, Revised 01/2011, Revised 01/2012, Revised 11/2012, revised 06/2014, revised 11/2014, revised 02/2016, revised 11/2017, revised 01/2018, revised 12/2018
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