White Horse Village Inc. (WHV), its leadership, and its dedicated team are steadfastly committed to upholding the highest standards of legal and ethical conduct in all aspects of their operations and professional relationships. This commitment forms the bedrock of the WHV Compliance & Ethics Program, meticulously designed to prevent both accidental and intentional non-compliance with all applicable federal and state laws, particularly those safeguarding against fraud and abuse within healthcare resources. The program’s core purpose is to cultivate a culture of quality, efficiency, and unwavering ethical business practices, ensuring robust internal controls and demonstrating a deep-seated commitment to responsible conduct for residents, team members, and the broader community.
At the heart of WHV’s mission is the creation of opportunities for “extraordinary living in a vibrant, diverse community through personal growth, connectedness, and relationships.” This vision is underpinned by core values of Compassion, Inclusiveness, Growth, Generosity, Respect, Relationships, and Stewardship. These values guide every interaction and decision, ensuring that WHV not only meets but exceeds the expectations of those it serves.
Program Administration and Oversight
The WHV Compliance & Ethics Program is administered under the authority of the Board of Directors, specifically through its Risk & Compliance Committee. The program is facilitated by a designated Compliance Official (CO), who also serves as a member of the Corporate Compliance Committee. To further enhance its compliance framework, White Horse Village participates in the Friends Services Alliance (FSA) Compliance Program, leveraging FSA’s expertise for program oversight through a contractual agreement.
The Compliance Committee convenes at least quarterly to assist the CO in the development, implementation, and monitoring of the program. This committee comprises the CO, a High-Level Official, the Privacy Officer, the Security Officer, and other appropriately appointed members. They report significant compliance-related issues to the Chief Executive Officer and the Compliance Official, ensuring transparency and prompt action.
The Compliance Official plays a pivotal role, functioning as an independent and objective point person for reviewing and evaluating compliance concerns. This role is granted unfettered access to the Board of Directors to ensure effective communication on all compliance matters. The CO’s primary responsibility is the robust development, implementation, oversight, and effective operation of the Corporate Compliance Program.
Code of Conduct: The Foundation of Ethical Practice
A critical component of the Compliance & Ethics Program is the Code of Conduct, which provides comprehensive guidance to all team members, managers, board members, associated providers, and vendors. This code ensures that WHV consistently meets ethical standards and adheres to all related laws and regulations. The Code of Conduct is supported by detailed compliance policies and procedures, and team members are expected to understand and adhere to both.
The Code of Conduct emphasizes several key principles:
- Service Excellence: Providing quality, compassionate, respectful, and clinically appropriate services.
- Professional Excellence: Maintaining the highest ethical standards in healthcare and business practices.
- Regulatory Excellence: Strict adherence to all federal, state, and local laws, regulations, and guidelines governing healthcare and business operations.
All team members, including employees, contractors, volunteers, and directors, are considered part of the WHV team and share a collective responsibility for upholding these standards.
Reporting Concerns and Non-Retaliation
WHV fosters a culture where reporting perceived misconduct, misappropriation, or violations of law, regulations, policies, or the Code of Conduct is not only encouraged but expected. An “open-door policy” is maintained at all management levels to facilitate reporting. Team members can communicate concerns through their chain-of-command, directly to the Compliance Official, or via the confidential FSA Compliance Line, which allows for anonymous reporting.
Crucially, WHV has a strict zero-tolerance policy for retaliation against any team member who reports a concern in good faith. Any individual found to have retaliated against another will face corrective action, up to and including termination.
The organization outlines a clear “Three Step Reporting Process”:
- Talk to your supervisor.
- If unable to speak with your supervisor, approach another member of the leadership team or Human Resources.
- If the concern remains unresolved, contact the Compliance Official, a member of the Compliance Committee, or the Compliance Hotline.
The Compliance Hotline, available at 800-211-2713, operates 24/7, ensuring that all compliance-related issues are addressed promptly and confidentially.
Key Policy Areas and Commitments
The Compliance & Ethics Program addresses a wide range of critical areas to ensure integrity and compliance:
- Auditing and Monitoring: Ongoing audits and monitoring are essential for proper execution and evidence of compliance.
- Business Courtesies: Offering or accepting gifts or entertainment that could influence decision-making is prohibited.
- Compliance Training and Education: Mandatory regular and annual compliance training is provided to all team members, officers, directors, and relevant contractors.
- False Claims Act & Anti-Kickback Statute: WHV is committed to preventing the submission of false claims and prohibiting illegal kickbacks or inducements for referrals, in compliance with federal and state laws.
- Physician Self-Referral Law (Stark Law): Full compliance with the Stark Law is maintained, prohibiting physicians from self-referring patients to entities with which they have a financial relationship.
- Conflict of Interest: Team members must disclose any actual or potential conflicts of interest to ensure objectivity in resident care and business activities.
- Elder Justice Act: All team members are obligated to report suspected crimes against residents to state regulatory authorities and local law enforcement within specified timeframes.
- Resident Rights and Confidentiality (HIPAA): WHV is dedicated to respecting residents’ rights, preserving their dignity, and protecting their privacy and confidential health information (PHI) in accordance with HIPAA.
- Abuse and Neglect: The organization has a zero-tolerance policy for any form of resident abuse or neglect, with immediate reporting required.
- Hiring and Employment Practices: WHV is committed to fair employment practices, complying with Equal Employment Opportunity laws and conducting thorough screening of team members.
- Workplace Safety and Drug/Alcohol Abuse: Maintaining a safe workplace and prohibiting the use, sale, or possession of alcohol or illegal drugs on company property are paramount.
- Vendor Agreements: All business relationships with vendors are governed by written agreements, ensuring compliance with legal and ethical practices, including HIPAA requirements where applicable.
- Billing and Business Practices: Honesty, accuracy, and completeness are required in all statements, submissions, and communications, with a zero-tolerance policy for false or inaccurate coding and billing.
- Referrals and Kickbacks: Resident referrals are based solely on clinical needs, and WHV strictly prohibits soliciting or accepting anything of value in exchange for referrals.
- Use of Property: All organizational assets must be used solely for legitimate business purposes, with no expectation of privacy when using company computers or electronic systems.
Conclusion
The White Horse Village Inc. Compliance & Ethics Program is fundamental to the organization’s sustained success and is driven by the integrity and commitment of its team members. The Code of Conduct and the overarching program establish clear standards for legal, professional, and ethical conduct, equipping the organization and its staff to navigate the complexities of delivering healthcare and related services. WHV’s dedication to fostering a supportive work environment, providing robust education, and upholding professional standards ensures the highest quality of care and service for its residents.
