The Arc of Monroe County, A Chapter of NYSARC, Inc.
CLASSIFICATION OF SITUATIONS REPORTED TO THE COMPLIANCE OFFICE
AND COMPLETION OF SUBSEQUENT INVESTIGATIONS
POLICY:
It is the policy of The Arc of Monroe County to conduct its business in compliance with
applicable federal, state and local laws and regulations, and to adhere to the highest ethical
standards.
STANDARD – CLASSIFICATION OF CONCERNS:
The Arc of Monroe County’s Quality Improvement Department is committed to responding in a
consistent manner to concerns that are reported there, per related policies and procedures (such
as non-compliance detection and response – please cross-reference). This standard and procedure
will be used to make a clear and consistent determination as to whether a situation meets the
threshold for a compliance concern or a non-reportable concern that needs to be handled by the
Quality Improvement Department, whether it meets neither set of criteria, whether it should be
referred to another agency department, and/or whether it can be handled internally within the
program.
To the extent that they do not meet the compliance concern criteria listed below, the following
shall not be considered compliance issues or concerns:
 Allegations of abuse or neglect as defined by 14 NYCRR part 624.
 Human resources issues or concerns such as difficulties in interpersonal relationships or
interactions between or among employees, or other employment-related concerns.
 Operational issues such as how programs are structured or run.
Situations that constitute a formal compliance concern requiring Quality Improvement
Department oversight:
1. Any situations which, after preliminary fact finding, are believed to be the result of
deliberate falsification of documentation/fraud. This includes but is not limited to
deliberate falsification of service-related documentation (habilitation plans, data sheets,
monthly summaries, etc.), educational credentials, timesheets, supervision checks such as
overnight checks, or expense reports.
2. Any situations reported directly to the Quality Improvement Department by nonmanagement staff where it is alleged that:
a. a program is overbilling or has overbilled for services
b. false documentation has or is occurring
3. Any reports which, after preliminary fact finding, suggest a program’s unwillingness to
properly adjust or payback money to which it is not entitled.
4. Any situation discovered during any compliance audit for which it is believed a financial
adjustment will be necessary.
5. Reports of an improper HIPAA disclosure which:
a. After completion of the risk assessment, meets the threshold for a HITECH
breach; OR
b. Is determined to be intentional or malicious; OR
The Arc of Monroe County, A Chapter of NYSARC, Inc.
c. Is between The Arc of Monroe County and any outside provider (NOTE: an
improper disclosure between 2 Arc programs which does not meet the criteria in
a. or b. would not be opened as a formal case but rather a non-reportable).
6. Alleged theft or significant misuse of agency property such as gas cards, vans, food
cards, food, agency supplies, etc. The determination as to whether a situation rises to the
level of a compliance concern will be made in conjunction with agency administration.
7. NOTE: Situations discovered by programs as part of their normal operations which
appear to be the result of staff inattention, an oversight, or poor judgment – even if they
result in the program making financial adjustments – will not necessarily rise to the level
of a formal compliance issue. This is viewed as part of programs’ responsibilities to
manage their departments. However, at the request of the program’s management, a
compliance case may be opened.
Situations that constitute a non-reportable concern:
1. Situations which, after preliminary fact finding do not rise to the level of a compliance
concern. Examples would include situations that initially appear as if they will require a
financial payback but based on fact finding will not.
2. As stated above, improper HIPAA disclosures between Arc of Monroe County programs
that is not intentional or malicious and/or does not meet the threshold for a HITECH
beach would be considered a non-reportable issue.
PROCEDURE:
1. Agency management is responsible for notifying their assigned Quality Improvement
Liaison or the Direct of Quality Improvement if/when a situation meets the threshold for
a compliance issue or concern as defined above.
2. In addition, programs must notify the Quality Improvement Department anytime that
there is a financial payback or adjustment totaling $5000 as part of a singular reason or
situation – even if the situation was found internally and is the result of staff inattention,
oversight, or poor judgment. For example, if a staff person exercised poor judgment in
the provision of services and the adjustments related to the poor judgment reached or
exceeded $5000, then the compliance officer needs to be notified even if it impacts more
than one person served. The Quality Improvement Department DOES NOT necessarily
need to be notified if, over the course of several months, the aggregate financial
adjustments for a given person reaches the $5000 mark provided that the adjustments are
the result of different situations or issues. If in doubt, management should contact the
compliance office for clarification. Please cross-reference the policy on voluntary
disclosure and self-reporting.
3. Concerns meeting these criteria will be documented formally in a consistent manner and
will be investigated consistent with the procedure for investigating concerns. The Quality
Improvement Department will also follow established policies, standards and procedures
regarding non-compliance detection and response (please cross-reference that policy).
The Arc of Monroe County, A Chapter of NYSARC, Inc.
4. Issues that meet the criteria for a non-reportable concern will be documented formally in
a consistent manner and archived. Included will be a statement indicating why it’s
believed that the situation does not rise to the level of a formal compliance concern.
5. For situations that do not meet the criteria for a compliance concern (i.e., are an
allegation of abuse, human resources issue, or an operations concern), QI department
staff will refer the situation or case to the appropriate department or party. A log of
referred cases will be maintained by the Quality Improvement Department.
STANDARD - INVESTIGATIONS:
The Arc of Monroe County’s Quality Improvement Department is committed to approaching the
investigation of compliance concerns in a consistent manner. This standard and procedure
identifies when a formal investigation is required and who may complete it under specific
circumstances.
Criterion for when a formal investigation/review is warranted:
1. A formal investigation is required when the determination is not self-evident. An
example of when a determination IS self-evident would include that a piece of
documentation was not completed or was completed late.
Criteria for when an investigation must be done by the Quality Improvement Department:
1. If it is alleged or believed that a program director or above is involved in the situation.
2. When the situation is discovered during a framework or other compliance audit.
3. Any compliance issue may be investigated by the Quality Improvement Department at
the request of a program’s management or agency administration.
Instances when an investigation may be done within a program:
1. Situations not meeting the criteria for when an investigation must be done by the Quality
Improvement Department may be investigated by the program in which the situation
occurred under the monitoring of the compliance officer or other QI department staff.
They have the authority to initiate their own investigation and/or request additional
investigative follow-up action at their discretion.
Note: Anytime that an investigation is completed, whether by the program itself or the Quality
Improvement Department, there will be formal documentation of the investigation, including
findings and a determination. It is acceptable for the compliance officer or other Quality
Improvement Staff to draw conclusions from and summarize in writing the findings obtained
through a program’s internal investigation.
Form date: 5/17/11
Approved by ICC: 5/23/11
Implementation date: 6/1/11
Revised: 6/6/12
Revised: 10/24/14
Revised: 7/29/15
Revised: 9/2/16