Compliance Plan

Policy

It is the policy of Heritage Christian Services, Inc. (HCS) to comply with all applicable federal, state and local laws and regulations. HCS has established this Compliance Plan and commits to maintaining an effective Compliance Program.

Applicability

Agency Wide.

Procedure

Commitment

HCS is committed to our responsibility to conduct our business affairs with integrity based on sound ethical and moral standards. HCS will hold our employees, contracted practitioners, and vendors to these same standards.

HCS is committed to maintaining and measuring the effectiveness of our compliance policies, procedures, and standards through monitoring and auditing systems reasonably designed to detect noncompliance by our employees, contracted practitioners, and vendors. HCS shall require the performance of regular, periodic compliance audits by internal and/or external auditors who have expertise in federal and state health care statutes, regulations, and program requirements.

Responsibility

All employees, contracted practitioners, and vendors shall acknowledge that it is their responsibility to report any suspected instances of suspected or known noncompliance to the Compliance Officer. Reports may be made anonymously without fear of retaliation, retribution, or breach of confidentiality. Failure to detect or report known noncompliance or making a willful false report will be grounds for disciplinary action, which may include termination of employment or a contractual agreement. Reports related to harassment or other workplace-oriented issues will also be referred to the Office of Workforce and Talent Development.

Policies and Procedures

HCS will communicate its compliance standards, policies and procedures through required training and communication initiatives to all employees, contracted practitioners, and board members. HCS is committed to these efforts through distribution of this Compliance Plan as well as the HCS Code of Ethics and Governing Principles Policy.

Enforcement

This Compliance Plan will be consistently enforced through appropriate disciplinary mechanisms as well as support from the Board of Directors and Compliance Committee.

Agency Response

Detected noncompliance through any mechanism, such as compliance auditing procedures or confidential reporting, will be responded to in an expedient manner. HCS is dedicated to the resolution of such matters and will take all reasonable steps to prevent further similar violations, including any necessary modifications to the Compliance Plan.

Due Diligence

HCS will exercise due diligence regarding background checks, excluded provider screenings, and professional license investigations for all prospective employees, contracted practitioners, vendors, and members of the Board of Directors.

Non-Retaliation, Non-Intimidation, and Whistleblower Protections

HCS will not take any retaliatory action against an employee or contractor who, in good faith, reports actual or suspected noncompliance or illegal activities or for good faith participation in the Compliance Program.

HCS will not take any retaliatory action against an employee if the employee discloses certain information about HCS policies, practices, or activities to a regulatory, law enforcement, or other similar agency or public official. Protected disclosures are those that assert that HCS is in violation of a law that creates a substantial and specific danger to the public health and safety; or that constitute healthcare fraud under the law; or that assert that the employee, in good faith, believes constitutes improper quality of care.

HCS’s Compliance Program includes the following key elements:

Element 1: Policies and Procedures and Standards of Conduct.

To support the operation of HCS Compliance Program, policies and procedures are established to provide direction to employees and contractors and to address components of the Compliance Plan.

All employees and contractors are expected to be familiar with and knowledgeable about the Compliance Program Policies and Procedures.

Element 2: Compliance Program Oversight

The Compliance Officer has primary responsibility for Compliance Program development, implementation, monitoring, and evaluation for effectiveness.

The Compliance Committee is appointed by the President of the Board of Directors and CEO to advise and assist the Compliance Officer with the implementation of the Compliance Program. The Compliance Committee reports into the CEO and Board of Directors.

Element 3: Education and Training

Education and training are critical elements of the Compliance Program. All employees and contractors are expected to be familiar with and knowledgeable about HCS Compliance Program and have a solid working knowledge of their responsibilities under the Compliance Program. Compliance Program Policies and Procedures and Standards of Conduct will be communicated to all employees and contractors through required participation in training programs.

Element 4: Lines of Confidential Communication

Open lines of communication between management, the Compliance Officer, and each employee and contractor subject to this Compliance Plan are essential to the success of HCS Compliance Program and commitment to comply with all applicable laws and regulations and the prevention of Medicaid or Medicare fraud, waste, and abuse.

All employees and contractors must report compliance concerns. Failure to report is deemed misconduct and a violation of this requirement.

All employees and contractors have an obligation to refuse to participate in any wrongful course of action and to report the actions.

Element 5: Discipline and Enforcement of Compliance Standards

Employees and contractors who fail to comply with HCS Compliance Program and Standards of Conduct, or who, upon investigation, are found to have committed illegal or unethical acts or violations of applicable Federal and State laws and regulations, the Compliance Program, the Standards of Conduct, or HCS policies and procedures, will be subject to appropriate disciplinary action, up to and including termination of employment, contract, assignment, or appointment with the Organization.

When the determination is made that a compliance violation occurred involving a contractor or vendor, the Compliance Officer will notify the CEO and work collaboratively to determine and execute the appropriate corrective action.

Element 6: Auditing and Monitoring

The audits and reviews will examine HCS compliance with specific rules and policies through onsite visits, personnel interviews, general questionnaires (submitted to employees and contractors), and record reviews.

Results of all auditing and monitoring activities will be reported to the Compliance Committee and Board of Directors.

Element 7: Response to Compliance Issues

HCS maintains a formal confidential and anonymous compliance reporting process to encourage the reporting of any compliance concerns. Employees and contractors must promptly report any compliance concerns to Compliance Officer, an immediate supervisor, a member of management, or a member of the Compliance Committee. People supported, vendors, and any party conducting business with HCS may report compliance concerns to the Compliance Officer through the confidential or anonymous reporting process.

As part of its Compliance Program, HCS will ensure that all reports of compliance concerns are immediately and objectively investigated and resolved promptly. Such investigations may be conducted by the Compliance Officer, members of the Compliance Committee, other employees or external parties as indicated or recommended by the Compliance Officer, the CEO or legal counsel.

The Compliance Officer will take immediate measures to secure relevant evidence or documentation and will ensure the confidentiality of any information obtained from a report, interview or through an investigation, unless otherwise required by law.

Unless a potential conflict of interest exists, the Compliance Officer will inform the CEO of any pending investigations. The Compliance Officer or CEO will arrange to retain legal counsel, as deemed appropriate.

Responsible Party: Vice President Corp Compliance & Risk Mgmt Policy Number: 760 Section: 01. Corporate Governance Function: 05. Corporate Compliance Last Review Date: 12/5/2025

Source Reference

• NYCRR Title 18 Part 521