Page 13
to the Compliance Officer. Compliance Plan 4 - 3 Revised December 12, 2018 IV. Maintaining Employee Confidentiality If requested, FHCP will attempt to protect the identity of the employee who has made a report to the maximum extent permitted by law. While in some circumstances it may be feasible to keep the identity of the complainant confidential while the complaint is being investigated, that is not always the case. If final resolution cannot occur without the employee coming forward to substantiate the allegation, the complainants will be informed of this fact prior to divulgence of their identity. V. Information Dissemination FHCP is committed to keeping its employees, First-Tier, Downstream and Related Entities apprised of new policies and procedures, key risk areas, and other compliance and anti-fraud, waste and abuse initiatives and information. In addition to the mandatory education and training programs, the following are some of the dissemination methods by which FHCP shall share such information: A. Manager and staff meetings Department meetings are generally held monthly. These meetings provide forums for communication of general compliance information that is not of an urgent nature. B. Interoffice Mail The interoffice mail system reaches all FHCP facilities and employees. In general, all interoffice mail is delivered to the recipient within 24 hours. It is typically used for formal compliance correspondences, reports, and items of a confidential nature. C. Internal e-mail The internal electronic mail system is a fast and efficient communications method for alerts, advisories, meeting notices, and education announcements that are relatively short in length. It is an effective way to share information in a fast and accurate manner. Email distribution lists facilitate communications to specific groups such as managers, and performance improvement teams. Currently, the e-mail system reaches all managers and supervisors and many employees, including 100% of the Compliance Committee. D. Fax All departments either have a fax machine or ready access to one for distribution of hardcopy material that does not exceed 10 pages in length. All such communications include a cover sheet that instructs the recipient to whom the correspondence should be sent and any action that is required. E. Voice Mail Voice messages can be broadcast using distribution lists. This system is generally used as a compliment to another method of information dissemination. For example, a voice mail may be left at all extensions informing the employees to be on the lookout for an upcoming urgent correspondence from the Compliance Department. Compliance Plan 4 - 4 Revised December 12, 2018 F. Vigilant Policy Center The FHCP Corporate Compliance Plan, Code of Conduct, and administrative policies and procedures are available to all employees at all times through the FHCP intranet, Vigilant Policy Center. G. First-Tier, Downstream and Related Entities of FHCP As necessary, FHCP disseminates, via the US Postal Service and email, bulletins and notices to the affected FHCP First-Tier, Downstream and Related Entities apprising them of new regulatory requirements and other compliance concerns and initiatives. Informal communications also may be undertaken on a case-by-case basis as appropriate. Employee feels a suspected violation should be reported Inform employee of investigation results Employee should report event(s) through the Help Line Collect information from Help Line Employee wants to report event(s) to supervisor Collect information and forward to Compliance Officer Forward findings to Compliance Committee Employee wants to report event(s) to a member of the Compliance Comm. Collect information and forward to member of the Compliance Committee Employee wants to report event(s) to Compliance Officer If allegation warrants, initiate investigation No Yes No No Review findings and actions Employee Supervisor Compliance Committee Compliance Officer Compliance Communication Flow Chart Yes Yes Compliance Plan 5 - 1 Revised December 12, 2018 ALLEGATIONS I. Preliminary Evaluation All reports made through the Ethics and Concerns Help Line or reports received in any other form will be referred to the Compliance Officer, regardless of whether such report originates from a FHCP employee, provider or a contractor. Once a report of a suspected violation or irregularity has been received, the Compliance Officer shall immediately initiate a preliminary evaluation to determine if the report warrants an investigation. Such an evaluation shall seek to determine: • Has the individual spoken to their supervisor about the issue? If not, why? If so, what was determined? • Is there anyone else that may be aware of the situation, e.g., a coworker? • What specific law, rule, regulation, policy or procedure has been violated? • What outcome does the individual expect or desire? • Is an individual, member, or any other party vulnerable in any way, i.e., is immediate action necessary? • Seek permission to discuss the case with those best able to handle it. If the individual wishes to remain anonymous, respect his/her wishes, but advise the individual that final resolution may require the individual to come forward at some point in the investigation. Results of all preliminary evaluations shall be retained by the Compliance Officer including the determination of whether to proceed with an investigation or to close the case because the allegation could not be substantiated. II. Investigation The investigation attempts to determine the cause, nature and extent of any and all suspected violation or irregularity including identifying all those involved and those that were aware of the wrongdoing. Specifically, the investigation will attempt to: • Determine how the incident or practice was identified, and the origin of the information that led to its discovery. • Describe FHCP's efforts to investigate and document the incident or practice (e.g., use of internal or external legal, audit or consultative resources). • Document the chronology of the investigative steps taken in connection with the organization’s internal inquiry into the disclosed matter and may include:: - Listing of all individuals interviewed, including each individual's business address, telephone number, and his/her position(s) and title(s) in the relevant entities during both the relevant period and at the time the disclosure is being made. For all individuals interviewed, FHCP will provide the dates of those interviews and the subject matter of each interview, as well as summaries of the interview. FHCP will be Compliance Plan 5 - 2 Revised December 12, 2018 responsible for advising the individual to be interviewed that the information the individual provides may, in turn, be provided to regulatory entities; - List those individuals who refused to be interviewed and provide the reasons cited; - Description of files, documents, and records reviewed with sufficient particularity to allow their retrieval, if necessary; - Copies of notices to any applicable First-Tier, Downstream and Related Entity regarding the cooperation FHCP expects in connection with such investigation; and - A summary of auditing activity undertaken and a summary of the documents relied upon in support of the estimation of losses. These documents and information will accompany the investigation report; • Description of the actions by FHCP and, if applicable any First-Tier, Downstream or Related Entity to stop the inappropriate conduct. • Description of any related