What is an Internal Compliance Program?

The rules listed below require each agency provider to have an internal compliance program.

Unlicensed Certified Providers – 5123: 2-2-01

An agency provider shall demonstrate that it has an established internal system to ensure compliance with requirements for:

Provider certification in accordance with this rule; 5123:2-2-01

Background investigations and appropriate actions in accordance with rule 5123:2-2-02

Service delivery, service documentation, and billing for services for the specific home and community-based services provided

Licensed Waiver Residential facilities – 5123:2-3-01

The operator shall demonstrate that it has an established internal system to ensure compliance with requirements for:

Residential facilities in accordance with rules in Chapter 5123:2-3 of the Administrative Code

Background investigations and appropriate actions in accordance with 5123:2-2-02

Service delivery, service documentation, and billing for services for the specific home and community-based services provided

Licensed ICF Residential Facilities – 5123: 2-7

The operator shall demonstrate that it has an established internal system to ensure compliance with requirements for:

Residential facilities in accordance with rules in Chapter 5123:2-3 of the Administrative Code;

Background investigations and appropriate actions in accordance with rule 5123:2-2-02 of the Administrative Code, for its administrator, licensee, operator, and each employee, contractor, and employee of a contractor who is engaged in a direct services position; and

Service delivery, service documentation and billing for services for ICF providers can be found in Chapter 5123:2-7 of the Administrative Code related to ICF cost report process

A compliance plan should achieve the following:

Establish the frequency in which monitoring will occur

Establish monitoring processes and practices that keep your operations compliant with rules and expectations outlined in OAC

Assist in identifying any weaknesses or vulnerabilities

Outcomes of an Effective Internal Compliance Program

An effective internal compliance program should result in positive compliance review outcomes.

The effectiveness of the internal compliance program should result in staff that know what is expected.

There are 7 Core Elements of the Internal Compliance Program

Core Element #1 - Compliance Program Oversight

The compliance officer is responsible for ensuring a working and effective internal monitoring program.

It may be one person or a group of persons.

Core Element #2 - Written Standards of Conduct, Policies and Procedures

Written policies show that the agency operates in a fair and consistent manner

Written policies are like the agency’s FAQs

Policies should be:

Detailed and specific

Easy to read and understand

Accessible to all employees

Updated as laws and rules change

Core Element #3 – Effective Lines of Communication

Expect staff to be knowledgeable about their job duties, the agency policies and the needs of individuals.

Expect agency management to routinely communicate with staff.

Core Element #4 – System of Consistent Discipline

Expect the agency to have a policy or procedure on staff supervision or a disciplinary policy.

Expect the agency management to be able to describe hoe the agency handles issues with maintaining compliance in the 3 major areas.

Core Element #5 – Education and Training Programs

Expect the agency to have a policy or training plan.

Expect staff training records to be up to date for initial and ongoing training requirements.

Core Element #6 – Auditing and Monitoring

DODD requires a policy for internal monitoring and evaluation procedures to improve services delivered.

The agency should have a policy for internal monitoring.

The agency should have a way for any member of the agency to report compliance issues.

Core Element #7 – Prompt Corrective Action

Expect errors in documentation, training and background check information to be identified and corrected on an ongoing basis.