Compliance Program Overview

Westchester Jewish Community Services (WJCS) is committed to providing its services in compliance with all applicable laws, rules, regulations, and our policies and procedures. In striving to achieve and maintain the highest quality of services, WJCS maintains a Compliance Program whose purpose is to assist staff to adhere to optimal standards applicable to all aspects of agency functioning. Our Compliance Program is anchored by our Code of Ethics and Code of Conduct. These codes have been developed to acknowledge our responsibility to clients, staff, Board of Directors, volunteers, consultants, vendors, and the community at large.

In addition to striving for excellence, WJCS and our staff have a commitment to integrity and “doing the right thing.” However, there could be a time when you are concerned that WJCS and/or a particular staff member might be violating applicable laws, rules, regulations, or our policies and procedures, either intentionally or unintentionally. At such times, if approaching your co-worker directly makes you uncomfortable, it is hoped and expected that you bring the matter to your supervisor, their supervisor, Human Resources, the Compliance Officer, Executive Staff, Board member, or call the Compliance Helpline. Our Compliance Program is only successful when you ask questions and seek answers when you are not sure how to fulfill your responsibilities or you believe that another staff member or the agency is not abiding by applicable laws, rules, regulations, policies, or procedures.

WJCS has specific policies and procedures that address Medicaid (insurance) fraud, waste, and abuse that outline your and the agency’s responsibility for preventing, detecting, reporting, and assisting to resolve suspected or real violations of any applicable Federal/State law, act, rule, or regulation including the Federal/NYS False Claims Acts. Failure to fulfil these responsibilities can result in disciplinary action including termination of employment, and possible civil/criminal penalties. Our Code of Ethics and Conduct, Anonymous Compliance Helpline, Whistleblower and Non-Retaliatory policies are described in the Employee Handbook, and other related compliance policies and procedures, can be found in the Jitbit Knowledge Base.

The success of the Compliance Program depends on maintaining effective channels of communication. Most of the time a staff member’s concern can be addressed by speaking with other agency staff. In some instances, a person is not able to discuss the issue with other agency staff and so Westchester Jewish Community Services has instituted a Compliance Helpline for use by anyone who knows of, or suspects any illegal, unethical or questionable activity. The Compliance Helpline is a confidential voicemail box system.

To access the Compliance Helpline, simply call (914) 761-0600 ext. 1207. Please leave your name, telephone number, and the nature of the problem. If you would like to remain anonymous, please leave a message with as much detail as possible. Although we encourage talking with a supervisor first, the Helpline is available to those who are particularly uncomfortable speaking with a supervisor, or those who may not be satisfied with a supervisor’s response to a compliance issue.

Compliance Helpline: (914) 761-0600 ext. 1207

Compliance Officer: (914)761-0600 ext. 2216

President, Board of Directors: [email protected]

Please note: Employers are not allowed to retaliate against employees who provide confidential information in good faith regarding possible questionable activities in the workplace.

The Compliance Helpline is not intended to address non-compliance issues. If you are experiencing difficulties with your supervisor or another employee unrelated to compliance, please communicate your concerns with the appropriate staff (the person, your supervisor, Human Resources, etc.).

Thank you for your ongoing support and commitment to the Westchester Jewish Community Services Compliance Program. Your understanding of the requirements and participation in the program is critical to its success.

WJCS promotes and is dedicated to complying with all applicable laws, rules, and regulations. WJCS expects staff to discuss any concern that they may have regarding the agency’s ability to achieving compliance with the laws and regulations that govern our services with their supervisor. If this is not possible then the staff member should contact an Executive Staff member or board member. If you have a need to remain anonymous then using the Compliance Help Line described above is another avenue to communicate your concern.

All reviews into the reported concern will be conducted in a confidential and sensitive manner, so that information will be disclosed only as needed to facilitate the review of the compliance issue.

In accordance with New York State Labor Laws and WJCS policies, WJCS will not take any retaliatory action against an employee if the employee in good faith discloses information about our policies, practices or activities to a regulatory, law enforcement or other similar agency or public official. Similarly, no retaliatory action will be taken against an employee who assists in the compliance review or plan of correction.

All allegations of intimidation or retaliation will be fully and completely reviewed by the Compliance Officer and the Compliance Committee.

If you have any questions, comments, or concerns about a compliance issue and you do not need to remain anonymous then please contact the Compliance Officer at (914) 761-0600 ext. 2216; or by mail – 845 N. Broadway, White Plains, NY 10603. If preferred, you can mail (same address as above) or e-mail ([email protected]) to our agency’s Chief Executive Officer, or to the President of the Board of Directors.

The information in this Compliance Program cannot cover every ethical situation or issue that arises. If it is unclear what to do or if it simply “does not feel right,” then discuss the situation with your supervisor, division head or the Compliance Officer. You may also choose to call the Compliance Helpline (914)761-0600, ext. 1207. These resources are available to help resolve any questions you have. Every WJCS employee is expected to support the values and principles that are presented in the Employee Handbook, WJCS policies and procedures, and all provided training.

General Statement

Employees of WJCS must not use their positions to their personal advantage. A conflict of interest may occur if your outside activities or personal interests influence or give the appearance of having influence over your ability to make objective decisions in the course of performing your job responsibilities. All employees must discuss any relationship that could be perceived as a conflict of interest with their supervisor.

The following is a list of some circumstances that could give rise to a conflict of interest:

  • To hold a direct or indirect material financial interest in any outside concern from which WJCS secures goods or services.
  • To compete with WJCS either directly or indirectly in the purchase or sale of property, property rights, services or interests.
  • To solicit or accept gifts from vendors, contractors, clients or their families. Gifts include any item of value, cash, services or entertainment. This does not include acceptance of items that are of nominal or minor value that clearly are tokens of respect and are not related to agency activities or transactions.
  • To disclose any information about WJCS to one’s friends or relatives that would result in personal profit or advantage.

Employees and Board members are required to sign a Conflict of Interest Form at the time they join the agency, and annually thereafter, to acknowledge their awareness of, and reaffirm their commitment to, this policy.

All staff members have a responsibility to disclose any potential or actual conflict of interest to their supervisor or the Compliance Officer. Following a review of the situation a determination will be made as to whether a conflict exists and, if so, how it will be resolved by the relevant supervisory and Executive Staff in accordance with all applicable laws, rules, regulations, and agency policies and procedures.

WESTCHESTER JEWISH COMMUNITY SERVICES, INC. COMMUNITY PROGRAMS OF WJCS, INC.

This Code of Ethics has been developed to acknowledge our responsibility to clients, staff, board members, volunteers, consultants, and the community at large. As an Agency, we believe in the ethics and values outlined below, and we embrace these behaviors in our interactions with each other and those we serve. Adherence to the Code of Ethics is the fundamental responsibility of each member of this organization and all affiliated professionals. It requires all staff members to conduct themselves in a manner consistent with all of its provisions as well as related policies and procedures.

PRINCIPLES OF ETHICAL BEHAVIOR

  • To ensure the dignity of all individuals at all times by acting with integrity, respect and courtesy.
  • To fairly and accurately represent the organization and its services to the general public.
  • To provide a uniform standard of care and conduct throughout the organization, regardless of the individual’s race, age, gender, sexual orientation or ability to pay.
  • To preserve the integrity of all clinical decisions and to ensure that such decision-making is uncompromised by financial considerations.
  • To regard the health and safety of individuals as the first consideration and thus offer each individual the full measure of professional skill, ability and experience.
  • To continuously strive to enhance professional knowledge consistent with our best professional judgment.
  • To uphold the dignity and honor of one’s profession, and to accept its ethical principles and codes.
  • To expose and report any illegal or unethical conduct of any staff member or other person associated with the agency including vendors, consultants, Board members and volunteers without reprisal.
  • To seek fair remuneration for professional services and never engage in practices in which fees are divided or other such exploitation in connection with the rendering of professional services.
  • To conduct and maintain relationships with individuals, other healthcare providers, educational institutions, payers, and vendors free of conflicts of interest and with full disclosure of potential conflicts.
  • To respect the confidential and personal nature of records, always refusing to reveal their contents without proper individual consent or other formal (legal) authorization.
  • To offer information to individuals regarding services truthfully, accurately, and fully, and not mislead individuals regarding the nature, cost, and/or value of these services.
  • To encourage individuals (families and significant others) to participate in the planning of their care to the extent that it is practical and possible.
  • To inform all individuals of the therapeutic alternatives and the risk(s) associated with the care they are seeking.
  • To respect each individual’s background, culture, religion, and heritage.
  • To resolve conflicts among and between individuals, staff, and members of the board fairly, objectively and as swiftly as possible, and in cases where mutual satisfaction is not achieved, to pursue available appeals processes.
  • To respect the rights, views, and positions of all staff, regardless of their degrees, discipline, status or duties.
  • To regularly evaluate one’s own professional strengths, limitations, biases, and level of effectiveness; to strive for self-improvements and professional development through further education and training.
  • To refrain from using any substance that could diminish one’s professional performance or conduct, or commit a violation of law.
  • To address the identified needs of individuals to the best of one’s abilities, without knowingly resorting to unnecessary or non-efficacious care or treatment.

The WJCS Code of Conduct reflects the organization’s commitment to ethical behavior and establishes the standards by which the agency’s business is conducted. The Code of Conduct is the backbone of the Compliance Program and the basic reference guide for the agency.  It provides a process for proper decision-making and sets standards for everyday business practices.

Employees are expected to conduct themselves in a professional and respectful manner, and to abide by the policies and procedures of the Agency.  Courtesy to clients/individuals that we serve, coworkers, and other people who may have business with the Agency is a basic job requirement of all employees.

Employees shall conduct themselves in such a manner as to ensure the well-being, growth, and development of clients and coworkers. Employees are expected to show sensitivity for client’s needs and strengths in their attitude, language and personal relationships.

WJCS treats all individuals with dignity and respect and values their right to privacy.  All information about clients/individuals is strictly confidential and should be treated in a professional manner.  The Agency will share information related to the care of clients/individuals only on a need-to-know basis.

WJCS’ Commitment to Those We Serve

  • WJCS is committed to the highest standards of quality care.
  • WJCS is committed to treating our clients with dignity and compassion.
  • WJCS is committed to treating our clients with properly credentialed and licensed professionals.
  • WJCS is committed to informing clients of the plan of care for their unique treatment.

WJCS’ Commitment to Employees

  • WJCS is committed to providing standards of ethical behavior for its employees and agents.
  • WJCS is committed to developing and enforcing policies and procedures that ensure compliance with local, state and federal laws, rules, regulations, and professional standards.
  • WJCS is committed to providing a safe and healthy workplace for employees, clients/individuals, agents, and visitors to all the WJCS sites.

All workplace hazards or unsafe conditions must be reported to a WJCS supervisor or the Safety Officer. Please contact the Safety Office/Director of Facilities Management (914)761-0600, ext. 2206 for assistance.

  • WJCS is committed to providing a workplace free of sexual harassment, cultural degradation or intimidation. (Please also see related agency policies for Discrimination/Harassment Complaint Process).
  • WJCS is committed to training every employee and agent about the Code of Ethics, the Code of Conduct, and the Compliance Helpline.
  • WJCS is committed to ensuring that no employee will be retaliated against for reporting potential violations.
  • WJCS is committed to monitoring the effectiveness of the Compliance Program and to modify the Program as changes occur to laws, rules, and/or regulations.
  • WJCS is committed to providing a work environment where employees are free to ask questions about compliance issues or report violations.
  • Supervisors are encouraged to create an atmosphere of high ethical standards and support. They will provide leadership to staff who have compliance questions and evaluate the staff’s adherence to the compliance program.
  • WJCS is committed to addressing violations of the Compliance Program. Conduct in violation of these standards and rules may lead to serious sanctions, including termination of employment.

 WJCS Employees have a Responsibility to:

  • Be honest in dealing with other staff, clients, volunteers, board members, vendors, and third parties.
  • Treat colleagues with respect and dignity.
  • Understand and follow the laws, rules and regulations that govern the job.
  • Keep accurate, complete, and truthful records and documentation that support the services provided.
  • Refrain from assisting, participating, facilitating in or ignoring fraud, abuse, or waste involving any funding source including, but not limited to federal, state, county, and grants.
  • Bill for actually rendered services in a timely, accurate, and legible manner.  To code services in an accurate manner without:
    • Billing for services that pay at a higher rate than documentation warrants
    • Billing for services separately when they should be considered one unit
    • Billing for services that are not necessary
  • Maintain the confidentiality of client information and information related to WJCS business operations. Client information is only given to those authorized to have it and should be treated with the highest level of confidentiality and comply with all HIPAA standards.
    • It should never be used for personal purposes or be misappropriated.
    • Safeguard WJCS computer records and keeping data, client financial information, passwords, pricing, affiliations, and tax examinations confidential to only those authorized to have that information.
    • Comply with the law and cooperate with any government investigation.
    • Comply with the antitrust laws in promoting fair competition. No employee shall enter into any understanding, agreement, plan or scheme with any competitor with regard to prices, fees, terms or conditions of sale of any service or product.
    • Avoid putting oneself in a position in which one’s own personal interests and those of WJCS are in conflict and consequently would interfere with the ethical performance of their job responsibilities.
    • Refrain from giving or accepting any form of gifts or gratuities that might influence, or appear to influence, another person’s judgment in the performance of their job duties.
    • Refrain from offering or receiving anything of value to induce another person to purchase an item or service from WJCS, to refer to WJCS, or to market WJCS’ products or services.
    • An occasional non-cash gift from providers, contractors, accounts, etc., that are limited to meal expenditures or entertainment must be disclosed to Executive Staff.
    • Occasional nominal non-cash gifts from people we serve and their families should be disclosed to your supervisor and when more than nominal, should be disclosed to Executive Staff.
    • Honorariums offered to staff for activities performed during the work day should be disclosed to Executive Staff.
    • Refrain from using WJCS property or services for personal gain; you may not remove or dispose of WJCS materials without proper authorization.
    • Attend all mandatory annual training sessions.
    • Report any actual or potential violations of the law, the Code of Conduct, Code of Ethics, Compliance program or other agency policies. Reports, questions, and concerns can be brought to a supervisor, the Compliance Officer (914)761-0600 ext. 2216 or the Compliance Helpline (914)761-0600 ext.  1207.