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1.17 – Internal Compliance Program

Regulatory standards outlined by the Ohio Department of Developmental Disabilities require all providers of service to develop and implement an Internal Compliance Program.  The components of Open Door Internal Compliance Program are as follows:

Written Policies and Procedures

Open Door has developed a review schedule for each policy to be reviewed at least annually by Executive Committees and the Board of Directors and revised, as necessary. All Open Door staff receive updates through payroll notification email when policies are revised.  All staff receive initial and annual training on Open Door policies and procedures.

Program Oversight

Open Door has established management teams that are responsible for program oversight. Open Door provides 24/7 on-call systems to allow employees to receive guidance and to report any incident. Additionally, Open Door has audit systems and task management assignments that assist with mock survey reviews and follow-up on any issues identified. Open Door has adopted electronic submissions of all audit and observation forms that are automatically routed for management review. The audits are also used for staff meeting and on-going training development for our employees. All of these policies are outlined in the 3.00 and 4.00 series of our policy manual.

Training and Education

Open Door complies with all training and education requirements outlined by regulation. In addition, Open Door has checklist and mock surveys which assist with monitoring and tracking completion of training and education for all employees. All employees receive annual training on Internal Compliance. Open Door has adopted electronic submissions of all new hire onboarding, orientation, training, audits, and observation forms that are automatically routed for management review and follow-up.

Open Lines of Communication

Open Door maintains an open door policy for management. Open Door has established multiple avenues that are available for all stakeholders to report any concern or to ask questions. Open Door has a 24/7 on-call person available through our incident hotline at 614-701-6993. Open Door has adopted electronic submissions of all phone logs, satisfaction surveys, and complaints that are automatically routed for management review and follow-up.

Audits and Quality Improvement Monitoring

Each department/service area has established audits and required checklists to complete that identify compliance issues and areas that need addressed. Each have a follow-up task grid that is monitored by department representatives to ensure correction/completion. In addition, Open Door has Quality Improvement Program outlined in Policy 3.10. Door has adopted electronic submissions of all new hire onboarding, orientation, training, audits, and observation forms that are automatically routed for management review and follow-up.

Consistent Discipline

Open Door has established Standards of Conduct that are outlined in policy 2.15. Consistent discipline is applied according to the Standards and Disciplinary policy and procedure for all departments within Open Door.

Billing Procedures/Overpayment Obligations

Open Door has developed billing systems that meet regulatory requirements. Open Door has developed specific policy for Health care fraud, waste, abuse in policy 1.16. If and when Open Door becomes knowledgeable regarding a billing error resulting in overpayment, the Accounting Department works diligently to correct the billing entry by backing out the billing. The documents outlining the overpayment cause and correction are maintained in the shared folder reflecting the reference number of the correction being completed.

Conducting Background Checks

Open Door conducts background checks for all employees as outlined in regulation. Open Door utilizes Rapback for the on-going monitoring of offense reporting. Additionally, Open Door’s policy requires that employee report ANY and ALL charges, convictions, or violations within 7 days of their occurrence for management review. This is reviewed pre-hire, in orientation, and annual trainings.

Kickback Prohibition

Open Door has developed specific policies on ethics (2.00) that prohibit kickbacks and other prohibited actions. All employees are trained on this policy at least annually.

Individual Funds Management

Open Door has developed full policies on management of individual funds. Policies 4.20 and 4.20A contain detailed procedures around individual funds including audit procedures and reporting any discrepancy.

Service Delivery Documentation Requirements

Open Door has developed documentation systems that meet service delivery requirements for each service area, including, but limited to, location of service, address of service, start and end time of service, provider number, billing code, the individuals served, verification of provision of service, mileage readings, destination for travel, name of staff completing service, etc. Each department has systems to review and analyze data to identify any concerns/issues for follow-up.

Signed by:

Rebecca Sharp Porter
Chief Executive Director

Last Revised: 2/23/24

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