POLICY AND PROCEDURE ON ANTI-FRAUD
I. PURPOSE The purpose of this policy is to provide information regarding the prevention, elimination, monitoring, and reporting of fraud. abuse. improper activities of government funding in order to obtain and maintain integrity of public funds.
A holder of a license that IS issues by -Minnesota Department of Human Services (DHS), pursuant to MN Statues, chapter 245A Human Services Licensing Act). and who has enrolled to receive public governmental funding reimbursement for services is required to comply with the enrollment requirements as a licensing standard (M.N Statues, sections 245A.167 and subdivision 21). The company is a provider of services to person’s
whose services are funded by government/public funds.
Government funds may be from state or federal governments, to include, but not limited to -Minnesota's medical assistance, Medicaid, -Medicare, Brain Injury (BI) Waiver, Community Alternative Care (CAC) Waiver, Community Alternatives for Disabled Individuals(CADl) Waiver, Developmental Disability (DD) Waiver, Elderly Waiver (EW), and Minnesota's Alternative Care (AC) program. The company has a long-standing practice of fair and truthful dealings with persons served, Families, health professionals, and other businesses. Management, staff, , contractors, and other agents of the company shall not engage in any acts of fraud, waste, or abuse in any matter concerning the company's business, mission, or funds.
Definition: Types of fraud, abuse, or improper activities include, but are not limited to. the following:
1. Billing for services not actually provided.
2. Documenting clinical care not actually provided.
3. Paying phantom vendors or phantom staff
4. Paying a vendor for services not actually provided
5.Paying an invoice known to be safe
6. Accepting or soliciting kickbacks or illegal inducements from of services. Or offering or paying
7. Paying, or offering gifts, money, remuneration, or free to a entice a medicle recipient to use a particular vendor.
8. Using Medicaid reimbursements to pay a personal expense
9. Embezzling from the company
10. Ordering and charging over-utilized medical services that are not necessary for the person served.
12. Conversation (converting property or supplies owned by company for personal use
13. Misappropriation of funds of the. company or person served by the company
14. Personal loans to executives
15. Illegal orders
16. Maltreatment or abuse of person served by company
B. Public funds Compliance Officer. This company has the Director of Budget and Internal Audit as their Public Funds Compliance Officer.
share their questions, concerns, suggestions, or complaints regarding the company and its operations with someone who can address them properly. In most cases, this will be a staff person’s supervisor. However, if a staff person is not comfortable speaking with their supervisor is not satisfied with the supervisor's response, the staff person is encouraged to speak to the Director of Budget and Internal Audit, who is the designated Public Funds Compliance Officer, If the Staff is not comfortable speaking with the Public Funds
Compliance Officer, The Staff is encouraged to speak with the Owner/CEO/ Board of
Directors. Examples of applicable external agencies are local social services agency's
Financial manager or law enforcement. This policy is intended to encourage and enable person to raise serious concerns within the company prior to seeking resolution outside it.
D. Requirement of good faith: anyone filing a complaint concerning a violation or suspected violation of the law or regulation requirements must be acting on good faith and have a good reasonable grounds for believing the information disclosed indicates a violation. Any allegations that prove not to be substantiated and which prove to be made maliciously or knowingly to be false will be viewed as a serious disciplinary offense.
E. Confidentiality: Violations or suspected violations may be submitted on a confidential basis by the complainant or any other submitted anonymously. Reports of violations or suspected violations will be kept confidential to the extent possible, consistent with the need to conduct an adequate investigation
F. Report The Public Funds Compliance Officer, or designee, will acknowledge receipt of the reported violation or suspected violation by writing a letter (or e-mail) to the complainant within ten (10) business days, noting that the allegations will be investigated.
G. Responding to allegations of improper conduct: The Public Compliance Officer is for responding to allegations of improper conduct related to the provision or billing of Medical Assistance services. This may include but not be limited to: investigating, interviewing applicable individuals involved, viewing documents, asking for additional assistance, seeking input on process of the investigation, or seeking input on Medical Assistance laws md regulations interpretations to address all staff complaints and allegations concerning potential violation. The CEO will take on functions of the Public Funds Compliance Officer role if the complaint involve the Director of Budget and Internal Audit. If the complaint involves both the CEO and Director of Budget and Internal Audit, outside legal counsel or an applicable external agency will carry out the functions of the Public. Funds Compliance Officer. The Director of Budget and Internal Audit or its designee will implement corrective action to remediate any resulting problems.
H. Evaluation and monitoring for internal compliance: On a Regular schedule and as needed, the Director of Budget and Internal Audit, or its designee, will run routine financial reports to review financial information for accuracy and compliance. On a regular schedule and as needed, the Director of Budget and Internal Audit, or its designee, will review standard operations and procedures to ensure that they remain compliant.
I. External auditing for compliance: On a regular schedule, the company will have an external financial audit.
J. Promptly reporting errors: The Public Funds Compliance Officer shall immediately notify appropriate individuals of all reported concerns or complaints regarding corporate accounting practices, internal controls, or auditing. This may include the Chief Financial Officer, the owner/CEO, or the Chairperson of the Board of Directors. The Director of Budget and Internal Audit Will Promptly report to DHS any identified violations of Medical Assistance laws or regulations.
K. Recovery of overpayment: within 60 days of discovery by the company of a Medical Assistance reimbursement overpayment, a report of the overpayment to DHS will be completed and arrangements made with DHS for the recovery of the overpayment.
L. Training: Staff are trained on this policy and as needed, they may need to be re-trained. As determined by the company, staff may need to demonstrate an understanding of the implementation of this policy.
POLICY AND PROCEDURE ON DATA PRIVACY
I. PURPOSE The purpose of this policy is to establish guidelines that promote service recipient rights to ensure personal privacy, and record confidentiality of persons served.
According to MN Statues, section 245D.04 subdivisions 3, persons served by the program have protections-related rights that included the rights to:
Orientation to the person served and/or legal representative will be completed at services initiation and annually thereafter. This orientation will include an explanation of this policy and their rights regarding personal and data privacy. Upon explanation, the Designated Coordinator will document that this notification occurred and that a copy of this policy was provided.
This Company encourages data privacy in all areas of practice and will implement measures to ensure that data privacy is upheld according to MN Government Data Practices Act, section 13.46. The company will also follow guidelines for data privacy as set forth in the Health Insurance Portability and Accountability Act (HIPAA) to the extent the company performs a function or activity involving the use of protected health information and HIPAA's implementing regulations, Code of Federal Regulations, title 45, parts160-164, and all applicable requirements. The Data Privacy Officer will exercise the responsibility and duties of the "responsible authority" for all program data as defined in the Minnesota Data Practices, MN Statues, Chapter13. Data Privacy will hold to the standard of "minimum necessary" which entails limiting protected health information to the minimum necessary to accomplish the intended purpose of the use, disclosure, or request.
Access to records and recorded information and authorizations
A. The person served and /or legal representative have full access to their records and recorded information that is maintained, collected, stored, or disseminated by the company. Private data are records or recorded information that includes personal, financial, service, health, and medical information.
B. Access to private data in written or oral format is limited to authorized persons. The following company personnel may have immediate access to persons' private data only for the relevant and necessary purposes to carry out their duties as directed by The Coordinated Service and Support Plan Addendum. All support services or finance staff will have access to private data only to the extent necessary to carry out their duties under Treatment, payment, or Operations:
1. Executive staff.
2. Administration staff.
3. Financial staff.
4. Nursing staff assigned or consulting nurses.
5. Management staff including the Designated Manager.
6. Designated Coordinator.
7. Direct support staff.
C. following entities also have access to persons' private data in written or oral format as authorized by applicable state or federal laws, regulations, or rules.
1. Case manager
2. Child or adult foster care licensor, when services are also licensed as child or adult foster care.
3. Minnesota Department of Human Services and/or Minnesota Department of Health.
4. County of Financial Responsibility or the County of Residence's Social Services.
5. The Ombudsman for Mental Health or Development Disabilities.
6. US Department of Health and Human Services.
7. Social Security Administration.
8. State Departments including Department of Employment and Economic Development(DEED), Department of Education, and Department of Revenue.
9. County, state, or federal auditors.
10. Adult or Child Protection units and investigators.
11. Law Enforcement personnel or attorneys related to an investigation
12. Various county or state agencies related to funding support, or protection of the person.
13. Other entities or individual authorized by law.
D. The company will attain authorized to release information of persons served with consultants, sub-contractors, or Volunteers are working with the company to the extent necessary to carry out the necessary duties. Peoples Rights Committee members or any other consultants of the company will consider any information about persons served or their families private. Information may not be released unless authorized.
E. Other entities or individuals not previously listed who have attained written authorization from the person served and/or legal representative have access to written and oral information as detailed within that authorization. This includes other licensed care givers or health care providers as directed by the release of information.
1. Information will be released to law enforcement or judiciary agencies only upon completion of a written authorization or through a court order.
F. Information will be disclosed to appropriate parties in connection with an emergency if knowledge of the information is to protect the health or safety of the person served and or legal representative is unable to provide consent. The Designated Coordinator and Designated Manager will ensure the documentation of the following:
1. The nature of the emergency.
2. Type of information disclosed.
3.To whom the information was disclosed. How the information was used to respond to the emergency?
4. When and how the person served and /or legal representative was Informed of the disclosed information.
G. The service initiation process will comply with the right to personal privacy of records
1. Upon service initiation, the Designated Coordinator and/or Designated Manager will ensure that information about the right to privacy is explained and distributed to the person served and for representative.
2. The Designated Coordinator and/or Designated Manager will ensure completion of all required authorizations that protect the person’s privacy and releases of information-
3. If the person served and/or legal representative does not give authorization, the Designated Coordinator and/or Designated Manager will confer with the case manager to discuss If ongoing service provision is possible.
H. All authorizations or releases of information will be maintained in the person's record. In addition, all requests made to review data, have copies, or make alterations, as stated below, will be recorded in the person's record including:
1. Date and time of the activity.
2. Who accessed or reviewed the records.
3. If any copies were requested and provided.
Request for records or recorded information to be altered or copies
A. The person served and/or legal representative has the right to request that their records or recorded information and documentation be altered and/or to request copies.
B. If the person served and/or legal representative objects to the accuracy of any information, staff will ask that they put their objections in writing with an explanation as to why the information is incorrect or incomplete.
1. The Designated Coordinator and/or Designated Manager will submit the written objections to the data Privacy Officer who will make a decision in regards to any possible
2. If the objection is determined to be valid and approval for correction is obtained, the
Designated Coordinator and/or Designated Manager will correct the information and notify the person served and/or legal representative and provide a copy of the correction.
3. If no changes are made and distribution of the disputed information is required, the Designated Coordinator and/or Designated Manager will ensure that the objection accompanies the information as distributed, either orally or in writing
C. If the person served and/or legal representative disagrees with the resolution of the issue, they will be encouraged to follow the procedures outlined in the Policy and Procedure on Grievances.
Security of Information
A. A record of current services provided to each person served will be maintained on the premises where the services are provided or coordinated when appropriate. the services are provided in a licensed facility, the records will be maintained at the facility; otherwise, official records will be maintained at the company's program office. Files will not be removed from the program site without valid reasons and security of those files will be maintained at all times.
B. The Designate Coordinator and/or Designated Manager will ensure that all information for persons served is secure and protected from loss, tampering. or unauthorized disclosures. This includes information stored by computer for which a unique password and user
C. No person served and/or legal representative. or anyone else may permantly remove or destroy any portion of the person’s record
D. The Company and Its staff will not disclose personally identifiable information about any person when making a report to each person and case manager unless the company has the consent of the person. This also includes the use of other person’s information in another person’s record
E. Written and verbal exchanges or information regarding person served are considered to be private and will be done in a manner that preserves continentally, protects their data Privacy and respects their dignity.
F. All staff will receive training at orientation and annually thereafter on this policy and their responsibilities related to complying with data privacy practices.
A. Each person served will be afforded privacy for personal care and treatment. A Personal care or treatments requiring privacy will only be carried out in private areas, such as a bathroom or a bedroom, with doors and/or curtains closed. Staff will assist persons served in discerning when privacy is necessary. Staff will always honor a request by the person served and /or legal representative for privacy with any personal cares [personal hygiene activities], treatments, and medical treatments.
B. Each person served will be allowed privacy will engaging in personal activities, unless assistance by staff is required by the Individual Abuse Prevention Plan or Coordinated Service and Support Plan, or for other reasons of safety and assistance.
C. Each person served will be treated with full recognition of their dignity including, but not limited to:
1. Persons served will be provided privacy when talking on the telephone unless indicated otherwise in his/her Individual Abuse Prevention Plan, Coordinated Service and Support Plan, or Individual Rights.
2. Persons served and their guests will be provided with privacy during visits, taking into consideration his/her Individual Abuse Prevention Plan, and the rights of other persons served.
3. Staff will Knock on closed doors or announce their presence before entering unless there is reasonable concern that a person's health or safety is at risk.
4. Staff will wait for permission to enter a person's private living spaces [if applicable] until permission is granted, if the person served is capable.
D. Staff receiving a telephone call from someone asking if a person is served may acknowledge that the person does receive services from the company unless the person served has specifically made a request not to have their information released. All other requests to access information about the person must be accompanied by an authorization signed be the legal representative.
Improve To Make Better LLC
Serving individuals with all abilities
BELOW ARE POLICIES ON ADMISSION, ANTI-FRAUD,
AND DATA PRIVACY. FOR MORE POLICIES AND PROCEEDURES PLEASE CLICK ON THE TABS BELOW
POLICY AND PROCEDURE ON ADMISSION
The purpose of this policy is to establish procedures the ensure of care during admission, and service initiation of a person to receive services, including the company’s admission criteria and processes.
Services may be initiated for persons of all ages when the specific program can meet the needs of the person and is the best available placement, as determined by the person, the Designated Coordinator and /or Designated Manager and the Expanded support team. All Services will be consistent with the person's service-related and protection-related rights identified in Statues, section 245D.04. These services will be directed by the person to receive services, parent/legal representative, and county case manager. The company may provide service to persons with disabilities, including, but not limited to, developmental or intellectual disabilities, brain injury, mental illness, age related impairments, or physical and medical conditions.
A. Prior to admission, the program will provide information on the limits to available services, Knowledge and SHII of program staff and the program's ability to meet the service and support needs of the person.
B. Improve TO Make Better LLC programs which meet the definition of health care facilities according to Statues, chapter 245A, will notify all residents when a registered predatory offender is admitted into the program or to a potential admission when the facility is already serving a registered predatory offender. These include adult foster care homes, ICFUD, Supervised Living Facilities, md Community Residential Settings. This notification will be done according to the requirements of MN Statues, section 243.166.
C. When a person and/or legal representative request services from the company, a refusal to admit the person will be based upon an evaluation of the person's assessed needs and the company's lack of capacity to meet the needs of a person.
D. Improve To Make Better LLC will not refuse to admit a person solely upon the basis of:
1. The type of residential services the person is receiving
2. Severity of disability
3. Orthopedic or neurological handicaps
4. Sight or hearing impairments
5. Lack of communication skills
6. Physical disabilities
7. Toilet habits
8. Behavioral disorders
9.Past failures to make progress.
E. Documentation regarding the basis for the refusal will be completed using the Admission Refusal Notice and will be provided to the person and/or legal representative and case manager upon request. This documentation wilt be completed and maintained by the Designated Coordinator and/or Designated Manager or designee.
Admission process and Requirments
A. In the event of an emergency service initiation, the company will ensure the staff training on individual service recipient needs occurs within 72 hours of the direct support staff first having unsupervised contact with the person served. Improve To Make Better will document the reason for the unplanned or emergency service initiation and maintain the documentation in the person's file.
B. Prior to or upon the initiation of services, the Designated Coordinator and/or Designated Manager develop, document, and implement the Individual Abuse Prevention Plan
C. The Designated Coordinator and/or Designated Manager will ensure that during the admission process the following will occur:
1. Each person to be served md/or legal representative is provided with the written list of the Rights Of the Person Served identifies the service recipient's rights (MN Statues, section 245D.04, Subdivisions 2 and 3).
a. An explanation will be provided on the day of service initiation or within 5 working days of service initiation and annually after
b. Reasonable accommodations will be made, when necessary, to provide this information in other formats or languages to facilitate understanding of the rights by the person and/or legal representative.
2. Orientation to the programs Program Abuse Prevention Plan will occur within 24 hours of service initiation. for those people who would benefit more from a later orientation, the orientation will take place within 72 hours.
3. If the person served will be and receiving a wage, a 1-9 and a W4 will be obtained.
4. An explanation will be given of the following policies and copies will be provided within five  working days of service initiation to the person served and/or legal representative by the Designated Coordinator and/or Designated Manager:
a.Policy and Procedure on Grievances
b. Policy and Procedure on Temporary Service Suspension and' Termination
c. Policy and Procedure on Data Privacy
d. Policy and Procedure on Emergency Use of Manual Restraint
e. Policy and Procedure on Reporting and Reviewing of Maltreatment of Vulnerable Adults
5. Written authorization is obtained (and annually thereafter) by the person and or legal representative for the following:
a. Authorization for Medication and Treatment Administration
b. Agreement and Authorization for injectable Medications (if applicable)
c. Authorization to Act in an Emergency
d. Standard Release of Information
e. Specific Release of Information
f. Financial Authorization (if applicable)
This authorization will be obtained within 5 working days of the admission meeting and annual thereafter.
g. The Admission Form and Data Sheet is signed by the person and/or legal representative and includes the Date of admission, and readmission, identifying information, and contact information for members of the support team or expanded support team others identified by the person or case manager.
h.If applicable, the Designated Coordinator and/or Designated Manager will ensure that an Informed consent or Psychotropic Medications is signed, documented in the person’s file and that psychotropic medication monitoring procedures are initiated and followed
D. During the admission meeting, the support team or expanded support team will discuss:
1. The company's responsibilities regarding health service needs and the procedures related to meeting those needs as assigned in the Coordinated Services and Support Plan and/or Coordinated Services and Support Plan Addendum.
2. Review of the Coordinated Service and Support Plan and/or any other support plan prepared by the person, the parent /legal representative, and county case manager.
3. The direct frequency of progress reports and progress review meetings, at a minimum of annually.
4. The initial financial Authorization, if applicable. The Designated Coordinator and/or Designated Manager will survey, document, and implement the preferences of the person served and/or legal representative and case manager for the frequency of receiving statements that itemizes receipt and disbursements of funds or other property Changes will be documented and implemented when requested.
5. Documenting of the receipt of the above information and retention in the person's file.
E. If a person's licensed health care professional or mental health professional has determined that a manual restraint would be medically or psychologically contraindicated, the company 'Will not use a manual restraint to eliminate the immediate risk of harm and effectively achieve safety. This statement of whether or not a manual restraint would be medically or psychologically contraindicated will be completed as part of service initiation planning.
Admission Process follow up and timelines
A. The Designated Coordinator and/or Designated Manager or designee will ensure that the person’s other providers, medical and mental health care professionals, and vendors are notified of a change of address and phone number as applicable
B. The Designated Coordinated and/or Designated Manager of designee will ensure that the person’s record is created with Improve to Make Better LLC standards.
C. The Designated Coordinated and/or Designated Manager will ensure that there is documentation in a person's record including:
1. A physical examination licensed residential service location.
2. The person served is free from communicable diseases, when available,
3. The person served may or may not administer his/her own medications.
4. The person served docs not have any medical condition that may contraindicate the use of manual restraint if there is a Positive Support Transition Plan or an Emergency (Use Of Manual Restraint has occurred.
5. Any health related protocols and physician’s orders/prescriptions are obtained and coordinated with other providers including the pharmacy.
6. Other license holders serving the person including:
a. Contact person and telephone numbers
b. Services being provided
c. Services that requites coordination between two license holders
d. Name of staff responsible for coordination
D. Within 15 calendar days of service initiation, the Designated Coordinator and/or
Designated Manager will complete a preliminary Coordinated Service and Support Plan Addendum that is based upon Coordinated Service Plan. At this time, the person's name and date of admission will be added to the Admission and Discharge Register maintained by the Designated Coordinator and/or Designated Manager.
E. Before the 4.5-day meeting, the Designated Coordinator and/or Designated Manager will complete the Self-Management Assessment regarding the person's ability to self-manage in health and medical needs, personal safety, and symptoms or behavior, this assessment will be based on the person's status with in the last 12 months at the time of service initiation. restrictive interventions (formerly Rule 40) prohibited under MN Statues, chapter 245D, and is admitted after January 1, 2014:
1. The (Positive Support Transition Plan must be developed and implemented within 30 calendar days of service initiation.
2. No later than 11 months after the implementation date, the plan must be phased out.
G. Within 45 calendar days of service initiation, the support team or expanded support team will meet to assess and determine based on information obtained from the assessment, Coordinated Service and Support Plan, and person centered planning:
1. The scope of services to be provided to support the person's daily needs and activities.
2. Outcomes and necessary supports to accomplish the outcomes.
3. The person's preference for how services and supports are provided.
4. Whether the current service setting is the most integrated setting available and appropriate for the person.
5. How services for this person will be coordinated according to 245D licensed providers to ensure continuity of care.
6. The person's ability to, at a minimum and within the scope of services, self- manage health and medical needs, personal safety, symptoms or behaviors by using the Self-Management Assessment form.
H. Within 10 working days of the 45- day meeting, the Designated Coordinator will develop service plan that documents outcomes and supports for the person based upon the assessments completed at the 45-day meeting.
I. Within 20 working days of 45 meeting, the Designated Coordinator will obtain dated signatures from the person and/or legal representative and case manager to document completion and approval of the assessment and Coordinated Service and Support Plan Addendum.
1. If, within 20 working days of this submission, the legal representative or case manager has not signed and returned the assessments or has not proposed written modifications, the submission is deemed approved and the documents become effective
and revise the documents.
IV. ADDITIONAL PROCEDURES
In addition to the previously described procedures, when applicable, the follow additional procedures will be taken for Intermediate Care Facilities for Persons Intellectual Disabilities (ICF/ID):
A. Any person to be served must be in need of and receiving active treatment services from the time of admission to the facility. An individual evaluation wilt be completed for each person conducted by the facility or outside source that includes background information and valid assessments. These will be used to determine the person's needs and likely benefit from placement in the ICF/ID facility.
B. Within 30 days prior to o within three days after admission, each person will Ira', e a general medical history and physical examination by a Physician and will have a Physician Certification completed. The physician will complete a Physician Recertification 30 days after admission and annually thereafter. The physical examination will include that the person served does not require 24-hour nursing.
C. Prior to admission, a physician must establish a written plan of care that is completed in conjunction with the Expanded Support Team.
D. During the admission process (admission to 30-day meeting). An assessment of the person's medical status as identified by the physician is considered and address by the Expanded Support Team.
E. Each person served will have an individual program plan that has been developed by their Expanded Support team which describes the professions, disciplines, or service areas relevant to:
1. The person's needs (additional information found in the Comprehensive Functional Assessment)
2. Programs that are designed to meet the person's needs.
F. Within 30 days after admission, the Expanded Support team must;
Complete accurate assessments or reassessments as needed to supplement the preliminary evaluation that was completed prior to admission for each person. These assessments are intended to identify the functional abilities of the person. A Comprehensive Functional Assessment will be completed and will assess the following:
1. Age and implications for treatment of each stage for the person
2.Presenting problems and disabilities diagnoses and their causes, if possible
3.Specific developmental strengths
4. Developmental and behavioral management needs
5. Need for services without regard to availability of services needed
6. Physical developmental and health and nutritional status
7. Development in sensorimotor, affective, speech and language development and auditory functioning
8. Cognitive and social development and vocational skills, if applicable
9. Adaptive behaviors or independent living skills necessary for the person to function in the community
2. Prepare and individual program plan for each person that states the specific objectives necessary to meet the person's needs and the planned Services for dealing with the objectives.