METRO HEALTH FOUNDATION OF NH, INC.

DBA: GOLDEN VIEW HEALTH CARE CENTER

CORPORATE COMPLIANCE PROGRAM

Reviewed and Revised January 2016

Compliance reporting hotline: 603-677-4101

I. INTRODUCTION

Metro Health Foundation of NH, Inc. d/b/a Golden View Health Care Center (“Golden

View”) is committed to ensuring that it operates in accordance with its mission and values and

that its activities comply with applicable governing laws. Golden View has developed a

Compliance Program (the “Program”) intended for use by Golden View which includes The Inn

at Golden View, The Retreat at Golden View, The Pines at Golden View, The Terrace at Golden

View and The Cottage at Golden View. The Program focuses on the prevention of fraud and

abuse in federal, state and private health care plans and conveys the organization’s commitment

to integrity. The scope of the Program may be expanded in the future to cover other areas of

compliance to which Golden View is subject. With this Program, Golden View will seek to

promote full compliance with all legal duties applicable to it, foster and assure professional

standards of conduct and provide guidance to each employee and agent for his/her conduct. The

procedures and standards of conduct which are part of Golden View’s Program, define generally

the scope of conduct that the program is intended to cover and should not be considered as all

inclusive.

The Program is intended to prevent accidental and intentional noncompliance with

applicable laws, to detect such noncompliance, if it occurs, to discipline those involved in

noncompliant behavior, to remedy the effects of noncompliance and to prevent future

noncompliance. This Program is a “living document” and will be updated to keep Golden

View’s employees and agents informed of the most current information available pertaining to

compliance requirements in the health care industry. As such, the Board of Golden View

recognizes that the development of an effective program is an evolutionary process that will be

developed consistently and methodically over time.

Annually, the Board of Directors will review the Program and compliance efforts during the year

and will act on any suggested revisions necessary to improve the Program.

II. DEFINITIONS

These terms have the following meaning throughout this Program:

1. “Colleagues” include all Golden View’s employees and temporary, per diem personnel,

volunteers, students and others rendering paid or unpaid services to Golden View and its

residents.

2. “Federal health care offense” means a violation of, or a criminal conspiracy to violate,

any legal standard, if the violation or conspiracy relates to a health care benefit program.

3. “Federal health care program”, as defined at 42 U.S.C. § 1320a – 7b (f), include any plan

or program that provides health benefits to any individual, whether directly, through

insurance, or otherwise, which is funded directly, in whole or in part, by the United States

Government or state health care program including, but not limited to, Medicare,

Medicaid, CHAMPUS, Federal Bureau of Prisons, and Indian Health Services, but

excluding the Federal Employees Health Benefit Program.

4. “Health care benefit program” means any public or private plan or contract for the

provision of any medical benefit, item, or service to any individual.

5. “Golden View Agents” include all persons and entities that have contracted with Golden

View to provide health care related services, equipment or other goods or services.

6. “Golden View Employees” include those persons employed by Golden View, excluding

independent contractors and agents.

7. “Should know”, as defined under 42 U.S.C. § 1320a(1)(7), in relation to prohibited

activity, means that a person, with respect to information, acts with reckless disregard or

deliberate ignorance of the truth or falsity of the information.

8. “Upcoding” refers to utilizing a code to bill for a higher level of service or procedure and

causing an increase in, the reimbursement rate, when the medical record reflects that a

lower level of service or procedure was actually provided to the patient.

III. COMPLIANCE STANDARDS AND PROCEDURES

Numerous federal and state laws and regulations define and establish obligations for the

health care industry with which Golden View must comply. Any employee who violates these

laws and/or regulations not only risk individual criminal prosecution and penalties, but civil

actions for damages and penalties. Any Golden View employee who violates these laws may be

subject to immediate termination of his or her employment or affiliation with Golden View.

A. Discussion of Applicable Legal Standards

Set forth below are some of the major federal and state statues specifically applicable to

health care providers. This outline is not intended to identify all applicable laws and as

described below, Golden View employees should always consult with the Compliance Officer on

specific questions.

1. Fraud and Abuse Laws

a. Civil and Criminal False Claims (42 U.S.C. §1320a-7b (a) and (private insurance,

and 118E, §40).

Golden View and its Colleagues shall not knowingly and willfully make or cause to

be made any false statement or representation of material fact in any claim or

application for benefits under any federal health care program or health care benefit

program. In addition, Golden View and its Colleagues shall not, with knowledge and

fraudulent intent, retain federal health care program or health care benefit program

funds that have not been properly paid.

Examples of prohibited conduct include, but are not limited to: misrepresenting

services that were rendered; falsely certifying that services were medically necessary;

upcoding; billing for services not actually rendered; making false statements to

governmental agencies about Golden View compliance with any state or federal

rules; making false statements concerning the condition of or operation of Golden

View programs for which licensure/certification is required; billing federal health

care program rates in excess of applicable federal health care program established

rates; repeatedly violating the terms of a participating physician agreement; and

failing to refund overpayments made by a federal health care program.

b. Anti-Referral Laws (42 U.S.C. §1320a-7b (b), GA §43-IB “Patient Self Referral

Act of 1993).

Golden View and its Colleagues shall not knowingly and willfully solicit, offer to

pay, pay, or receive any remuneration, either directly or indirectly, overtly or

covertly, in cash or in kind, in return for:

(i) Referring an individual to a person for furnishing, or arranging for the

furnishing, of any item or service for which payment may be made, in

whole or in part, under any federal health care program; or

(ii) Purchasing, leasing, ordering, or arranging for, or recommending the

purchasing, leasing, or ordering of any good, facility, service or item for

which payment may be made in whole or in part, under any federal health

care program.

Remuneration may include not only kickback payments and bribes, but also rebates,

refunds, educational grants and other benefits to consumers. Certain legally permitted

practices, such as group purchasing agreements and price reductions to health plans,

among others, are excluded from this prohibition.

c. Civil Monetary Penalties Act (42 U.S.C. §1320a-7a)

Golden View and its Colleagues shall not knowingly present a claim to any federal health

care program or health care benefit program for an item or service the person knows or should

have known, was not provided, was fraudulent, or was not medically necessary. No claim for an

item or service shall be submitted that is based on a code that the person knows or should know

will result in greater payment than the code the person knows or should know is applicable to the

item or service actually provided.

Golden View and its Colleagues shall not offer to transfer, or transfer any remuneration

to a beneficiary under a federal or state health care program, that the person knows or should

know is likely to influence the beneficiary to order or receive any item or service from a

particular provider, practitioner, or supplier, for which payment may be made, in whole or in

part, under a federal health care program. Remuneration includes the waiver of coinsurance and

deductible amounts except as otherwise permitted, and transfers of items of services for free or

for less than fair market value.

d. Ethics in Patient Referrals Act of 1989 (42 U.S.C. §1395nn, (Stark 11).

Generally, Stark 11 prohibits physicians and psychologists who have an ownership or

compensation relationship with an entity that provides “designated health services” from

referring a patient in need of those services for which payment may be made under Medicare or

Medicaid to such entities unless that ownership or compensation arrangement is specifically

permitted under the Stark 11 safe harbors. Designated health services include clinical laboratory

services, physical therapy services, occupation therapy services, radiology services, radiation

therapy services and supplies, durable medical equipment and supplies, parenteral and enteral

nutrients, equipment and supplies, prosthetics, orthotics, and prosthetic devices and supplies,

home health services, outpatient prescription drugs, and inpatient and outpatient hospital

services. Golden View makes every effort to ensure that its referral relationships meet the Stark

11 safe harbors.

e. Health Care Fraud (18 U.S.C. §1347)

Golden View and its Colleagues shall not knowingly or willfully execute, or attempt to execute,

a scheme or artifice to:

(i) Defraud any health care benefit program; or

(ii) Obtain, by means of false or fraudulent pretense, representation, or promise, any of the

money or property owned by or under the custody or control of any health care

benefit program, in connection with the delivery of, or payment for, health care

benefits, items or services.

2. False Statement and False Claims Laws

a. Criminal False Statements Related to Health Care Matters (18 U.S.C. §1035).

Golden View Colleagues shall not knowingly and willfully make or use any false, fictitious, or

fraudulent statements, representations, writings or documents, regarding a material fact in

connection with the delivery of, or payment for, health care benefits, items or services. Golden

View and its Colleagues shall not knowingly and willfully falsify, conceal or cover up a material

fact by any trick, scheme or device.

b. Civil False Claims Act (31 U.S.C §3729(a))

Golden View and its Colleagues shall not:

(i) Knowingly file a false or fraudulent claim for payments to a governmental agency, or

health care benefit program;

(ii) Knowingly file a false or fraudulent claim for payments to a governmental agency, or

health care benefit program; or

(iii) Conspire to defraud a governmental agency or health care benefit program by attempting

to have a false or fraudulent claim paid.

Examples of false or fraudulent include, but are not limited to, double billing, upcoding,

unbundling, submitting or processing claims for items or services not provided, submitting or

processing claims for items or services not medically necessary, and billing for non-covered

services.

c. Criminal False Claims Act (18 U.S.C. §286, §287)

Golden View and its Colleagues shall not knowingly make any false, fraudulent or fictitious

claim against a governmental agency or health care benefit program. Conspiring to defraud a

governmental agency or health care benefit program is also prohibited.

3. Equal Employment Opportunity

In accordance with applicable federal and state laws, including Title VII of the Civil Rights Act

of 1964 and its subsequent amendments, Golden View shall provide equal opportunity to all

qualified persons in its effort to recruit, hire, train and promote personnel in all job classifications

without regard to age, race, color, religion, sex, sexual preference, disability or national origin.

Golden View shall also ensure that all employees are treated the same during their employment

without regard to age, race, color, religion, sex, disability or national origin in matters or

recruitment, employment, rates of pay, selection for training, promotion, transfer, layoff and

termination.

4. Other Federal and State Laws

Golden View is subject to a range of other federal and state laws and regulations including,

without limitation, wire and mail fraud, obstruction of criminal investigations, conspiracy laws

and the Federal Racketeering Act, which includes criminal and civil penalties, and State

administrative sanctions on providers who violate the rules, regulations and laws governing the

Medical Assistance program.

B. Compliance Guidelines

1. The Work Environment

Golden View’s Mission, Values, Standards of Conduct, Bylaws, Rules and regulations, and

policies and procedures (collectively, “Governance Documents”) are the foundation upon which

the organization functions and are the standards of Golden View and its Colleagues.

As a member of the organization, each Golden View Colleague is responsible for

understanding Golden View’s governance documents that address legal and ethical conduct.

Employees are expected to understand the applicable contents within Golden View’s employee

handbook. Each individual is expected to apply those principles in his or her daily work life at

Golden View. The commitment of each individual to building a positive work environment will

determine Golden View’s ability to maintain the type of culture that supports its values, high

quality patient care, patient satisfaction, the achievement of Golden View’s overall goals, and

that supports a fulfilling professional life for all Golden View Colleagues.

2. Ethical Conduct

Golden View expects that all Colleagues will carry out patient care, and will conduct

business with fairness, honesty and integrity, which means that each individual’s behavior is

characterized by truthfulness, the absence of deception or fraud, and respect for laws applicable

to Golden View’s business and industry. Even in cases where interpretation of the law could be

ambiguous, permissive or lenient, Golden View Colleagues will always choose the course of

honesty and integrity.

3. Equal Employment Opportunity

Golden View is an equal opportunity employer. Golden View is committed to providing

equal opportunity employment to all qualified persons; reaffirm our commitment to recruit, hire,

train and promote personnel in all job classifications without regard to age, race, color, religion,

sex, disability or national origin, and to ensure that all employees are treated the same during

their employment without regard to age, race, color, religion, sex, sexual preference, disability,

or national origin in matters of recruitment, employment, rates of pay, selection for training,

promotion, training, promotion, transfer, layoff and termination.

All personnel and all directors/designees who interview job applicants are required to

thoroughly familiarize themselves and comply with this policy.

4. Conflicts of Interest

In any organization, the potential for conflict of interest exists for decision-makers at all

levels. Golden View’s Conflict of Interest Policy provides that all Golden View employees shall

disclose any actual or potential conflicts of interest so that appropriate action can be taken to

ensure that such conflicts do not inappropriately influence important decisions.

5. Confidential Information

All Golden View Colleagues must safeguard Golden View confidential information and

trade secrets. To safeguard means (i) to refuse improper access to the confidential information

and trade secrets of the organization, including Golden View competitors; (ii) to refuse to share

confidential information with anyone inside who does not have a specific “need to know” in

order to do his/her job; and (iii) to exercise care in all conversations about confidential

information that may be overheard by people inside or outside Golden View.

“Confidential information” includes proprietary, medical, and personal information concerning

the medical, personal, or business operations and affairs of Golden View, its patients and

employees, and any other information that is not generally disclosed to the public. Golden View

Colleagues are responsible for understanding the Company’s HIPAA policies and procedures

and employee procedures as identified in the employee handbook.

Patient Information

Many Golden View Colleagues can and do access patient information as part of their job

responsibilities. However, it is unethical and illegal for a Golden View Colleague to reveal

personal information including, but not limited to, names addresses, ages birth dates, medical

information or appointment schedule and history, about any patient, including co-workers,

friends or relatives who become patients. It is unethical and illegal to access or release such

information unless required by the individual’s job responsibilities, without appropriate

authorization, or as required by law.

Confidential Business Information

Golden View leaders, administrators and directors frequently know about Golden View’s

business plans before that information is shared with the public. It is improper and unethical for

that information to be shared with friends, relatives, or any other party before the information

becomes public.

Release of Information to the News Media

Golden View Colleagues are not authorized to communicate with the news media unless

it is designated as part of their job responsibility or unless they are requested to do so by the

Administrator. Requests from the news media for patient information or any other type of

information must be referred to the Administrator.

6. Billing, Claims and records.

Documentation

All clinical services rendered must have substantiating documentation. If the appropriate

documentation is not provided, the service is not considered rendered. Medical records may not

be erased or altered. Medical records may be amended to correct an error or to complete

documentation, but only in accordance with established medical record procedures.

Clinical, administrative or clerical Colleagues involved in the preparation and/or

submission of charge or billing data must be fully aware of the applicable coding and

documentation practices, consistent with the requirement of their particular job. Golden View

Colleagues who suspect that inaccurate billing or documentation is occurring should

immediately follow the Reporting Process outlined in Section V hereof, or contact the

Compliance Officer.

Billing and Claims

Golden View bills only for services actually rendered and that are medically necessary.

Services rendered must be thoroughly documented and appropriately coded, and billing must

comply with the requirements of state and federal laws and guidelines, and conform to all payor

contracts and agreements.

Records

Golden View Colleagues may not receive or make any payments on behalf of Golden

View without fully understanding their purpose. The purpose must be the same as described in

the documents supporting the transaction.

Retaining Records

Billing data must be retained for periods provided by law and by approved Golden View

policies. Colleagues may not destroy or dispose of Golden View records or files without

permission. Laws and regulations provide how long certain records must be kept, particularly

when records involve tax, personnel, health and safety, environmental, contract and corporate

issues. Golden View maintains a Record Retention and Destruction Policy and reviews annually

to ensure compliance with governing laws and regulations. It is also important to keep all records

that are or may be involved in any government investigation, audits, or legal action. Destroying

such records before the matter is closed, or destroying records so that they may not be used in

legal proceedings, is illegal.

7. Use of Golden View Funds/Assets

Golden View assets are the sole property of Golden View for the benefit of its patients

and the organization. Golden View assets may not be used by Golden View Colleagues or other

Golden View representatives for personal gain.

8. Dealing with Suppliers/Referring Providers

Golden View Colleagues who work with businesses or providers that supply Golden

View with referrals, products or services, may face situations that test their integrity. Because

relationships with suppliers and referring providers can pose a variety of ethical or legal

problems, the following additional guidelines may help explain the boundaries of ethical

conduct:

� Kickbacks and Rebates – These perks can take many forms and are not limited to cash

payments or credits. Any time a Golden View Colleague or a member of his/her family is

offered something of value as a result of Golden View purchasing any product or services

or as a result of Golden View consideration of such purchase, the Colleague should

question both the ethics and legality of the offer. In general, if a Golden View Colleague

stands to gain personally from a Golden View business transaction, that transaction is

prohibited, and in many cases, may be illegal.

� Reciprocity – In some instances, Golden View may purchase goods and services from a

supplier who also buys goods and services from Golden View. Any form of pressure for

reciprocal business from a supplier is not ethical and may be illegal. Golden View

Colleagues should never ask a supplier to buy services from Golden Viewing return for

the opportunity to do business with Golden View.

� Gifts or Gratuities – Golden View recognizes that there are situations when employees

will be offered gifts from patients, family or business associates. However, in healthcare,

gifts pose a risk for conflict of interest of fraud and/or abuse related to anti-kickback laws

and regulations. In recognition of these issues, this policy provides guidelines for

accepting or providing gifts.

a. Golden View Employees and Colleagues are not allowed to accept any gifts,

tips or gratuities from a vendor, outside provider, resident, guarantor or

family member. Employees may accept a gift to share with the entire

shift/unit (for example, a box of cookies, candies, etc.) from families

wishing to give a gift as a small token of their appreciation. Nominal tokens

may be approved by the Administrator.

b. Golden View employees are prohibited from soliciting (asking/requesting)

gifts.

� Payments to Agents, Representatives and Consultants – Any agreement with agents, sales representatives or outside consultants must be reasonable in amount, in comparison to the

value of the service provided, as well as to trade practices.

� Payments to Government Employees – It is illegal to offer any government official or

employee a payment of money, gifts, services, entertainment or anything else of value.

� Other Improper Payments – The use of Golden View’s funds or assets for any unlawful

or unethical purpose is prohibited. It does not matter if Golden View Colleagues make

the payment directly, indirectly, or by a third party agent on behalf of Golden View. Such

payments are prohibited.

9. Political Contributions

While Golden View encourages all Colleagues to exercise their civic duty through voting

or being active in politics, any such activity must be undertaken in the Colleague’s individual

capacity and not as a representative of, or otherwise acting on behalf of, Golden View. Golden

View is prohibited from giving cash or in-kind contributions or reimbursing individuals for

expenses related to political campaigns and contributions.

It is against Golden View policy, and may be illegal, for Golden View to do any of the

following;

� Include political contributions on expense reports or any other account that causes

Golden View to pay the expense;

� Include the cost of fund-raising tickets or dinners for political functions on an expense

account even if Golden View’s business is discussed;

� Use Golden View property, facilities or personnel time for any type of political activity;

� Allow any candidate to use any Golden View facility for political campaigning or the

solicitation of contributions, or loan Golden View property to someone involved in a

political campaign; or

In order to assure that Golden View Colleagues do not feel pressure to make

contributions at the request of other Golden View Colleagues, no Golden View Colleagues is to

request political contributions of cash or in-kind services from another Golden View Colleague.

Golden View Colleagues should consult Legal Services before agreeing to do anything

with the political process that could involve Golden View at a federal, state or local level, or in

any foreign country.

10. Email, Voicemail, and the Internet.

Email, voicemail and the internet are available for use by Golden View Colleagues

primarily for Golden View business and in accordance with policies. All email and, voicemail

messages or other communications sent internally and externally using Golden View computers

or communications systems are the property of Golden View, therefore, Golden View

Colleagues should not expect that any message transmitted using the system is private.

Only employees who are authorized by the Administrator or her designee are allowed

access to facility voice mail, email, Internet access and other computer systems and networks.

The information or data contained on these systems are owned by and accessible at all times by

Golden View. Authorized users of electronic systems will be issued a password. Disclosing to or

sharing passwords with anyone, unless authorized to do so by the Administrator is strictly

prohibited. Use of any facility owned electronic system information or data by an employee not

authorized to do so is in violation of this policy. The Company’s systems may not be used for

any illegal activity. Electronic medical records may be accessed only through facility owned

computer systems unless authorized by the facility Security/Privacy Officer.

Golden View Colleagues using email should be aware that email messages are considered

documents and as such could be subject to discovery in any litigation involving Golden.

11. Safety, Health and the Environment

Golden View is committed to providing a safe and healthful workplace for Golden View

Colleagues, patients and visitors. Golden View Colleagues have a responsibility to follow safe

operating procedures, to safeguard their health as well as that of their coworkers, and to maintain

and use pollution control systems. Golden View is committed to practicing safe and responsible

techniques for handling and disposing of wastes in compliance with all applicable laws and

regulations.

All Golden View Colleagues are expected to notify, immediately, their supervisor and the

Compliance Office of any pending or threatened governmental audits or inspections, and to

cooperate with such activities. Golden View Colleagues are also expected to report to their

supervisor or manager any conditions that they see as unsafe or hazardous.

IV. COMPLIANCE OFFICER, OPERATIONAL COMPLIANCE COMMITTEE AND

AUDIT AND COMPLIANCE COMMITTEE.

A. The Compliance Officer

The Compliance Officer will have sufficient authority to fulfill the requirements of the

position and has direct access to the Board of Directors.

1. Chair of Committee: The Compliance Officer will chair the Operational Compliance

Committee Meetings.

2. Duties of the Compliance Officer: The Compliance Officer has individual responsibility

for the implementation and continued operation and maintenance of the Program. The

Compliance Officer shall:

a. Implement, oversee and run daily operations of the Golden View Program.

b. Review the content and performance of the Program on a continuing basis and take

appropriate steps to improve its effectiveness.

c. Develop an effective compliance training program and ensure that independent

contractors and agents who furnish medical services are aware of the requirements of

the Program.

d. Develop and maintain support documents related to the Program including, but not

limited to, the standards of conduct contained herein and in the employee handbook,

applicable policies and procedures and employee educational material.

e. Maintain internal compliance review and monitoring activities to ensure the integrity

of the compliance line and that the employees can report problems and concerns

without fear or retaliation.

f. Conduct investigations, when deemed appropriate, of alleged violations of law,

Standards of Conduct or any other system policies or procedures, in cooperation with

General Counsel or outside counsel as appropriate.

g. Report yearly or as needed to the Audit & Compliance Committee of the Board of

Directors.

All questions and concerns regarding compliance with the standards set forth in this

Program must be directed to or brought to the attention of the Compliance Officer. Golden View

Colleagues must fully cooperate and assist the Compliance Officer as required in the exercise of

his or her duties. If a Golden View Colleague is uncertain whether specified conduct is

prohibited, the Golden View Colleague should follow the Reporting Process below or Contact

the Compliance Officer for guidance prior to engaging in such conduct.

Golden View’s current presiding Compliance Officer is:

Rosemary Simino, NHA

B. The Operational Compliance Committee

This Program will be implemented under the guidance and supervision of the Operational

Compliance Committee, which will coordinate compliance efforts for Golden View.

1. Members: The initial members of the Operational Compliance Committee shall include:

a. Chair: Compliance Officer

b. Manager;

2. Meetings: The Operational Compliance Committee will meet four times per year or as

needed.

3. Committee Functions: The Operational Compliance Committee will carry out the

following functions;

a. Oversee the implementation of the Golden View Program;

b. Ensure the continued operation and maintenance of Golden View Program;

c. Provide oversight to ensure system compliance with all applicable laws, policies,

regulations, and Golden View’s employee handbook and topics contained herein;

d. Review activities of the Compliance Officer to ensure that all applicable duties and

responsibilities are being accomplished and that effectiveness of this position is

maintained;

e. Monitor and review the compliance awareness, education, and training programs.

Ensure proper and continuous training and education of all employees on the Golden

View Compliance Program;

f. Ensure employees can report, without fear of retribution, any improper activities,

misconduct, and violations of law and the standards outlined in the employee

handbook, and that employees can retain anonymous or confidential;

g. Ensure that all problems and concerns are properly investigated and resolved;

h. Review remedial actions to ensure that employees are uniformly disciplined,

according to a set policy, for any compliance related violations;

i. Analyze the specific risk areas for Golden View and recommend appropriate

monitoring and auditing plans to address the identified risk areas; and

j. Report to the Board of Directors on the status of Golden View’s Compliance

Program.

C. The Audit and Compliance Committee

The primary responsibility of the Audit and Compliance Committee is to provide

oversight of the development, implementation and operation of Golden View Program.

1. Members: The members of the Audit and Compliance Committee shall include the

Manager, Administrator and at least one member of the Board of Directors.

2. Meetings: The Audit and Compliance Committee will meet four times per year or as

needed.

3. Committee Function: Compliance

a. Ensure the continued operation and maintenance of the Golden View Program;

b. Provide sufficient opportunity for the Compliance Officer and the Operational

Compliance Committee to meet with the members of the Board to be briefed on their

independent evaluation of Golden View’s Corporate Compliance Program.

c. Enact such measures or such actions as may be necessary to assist Golden View in

conducting its activities in full compliance with all applicable laws, regulations, and

the standards of conduct contained herein and in the employee handbook, applicable

policies and procedures and employee educational material.

4. Committee Function: Audit

a. Review the annual financial statements, footnotes, audit adjustments, accounting

changes, and necessary filing requirements.

b. Recommend or approve the selection and/or retention of the external auditor;

c. Review the proposed scope and activities of the annual audit plan to ensure adequate

coverage;

d. Review the weakness and recommended improvements in the system of internal

control reported by the external auditor and to ensure that findings are appropriately

addressed;

e. Review the proposed internal audit program and its relationship to the scope of the

external audit plan;

f. Review the reports resulting from internal audit work as they relate to weaknesses

and recommendations for improvements.

V. REPORTING PROCESS

Golden View Colleagues are expected, and required, to report suspected violations of this

Program. The following steps may help the individual determine the best course of action to take

in making a report.

1. Discuss the situation with the supervisor.

2. Discuss the situation with a department head.

3. Discuss the situation with the Administrator.

A. Investigation of Suspected Non-Compliance

The Compliance Officer will conduct and investigation of any conduct that may be

inconsistent with this Program or departmental compliance policies. Golden View Colleagues

will cooperate fully with any investigations undertaken by the Compliance Officer and/or

counsel.

B. Governmental Investigations

All federal and state governmental investigations, which shall include but is not limited to

all requests for documentation and audits, shall be coordinated through the Compliance Officer.

To the extent that anyone learns of a governmental investigation, they shall contact the

Compliance Officer. To ensure accountability and consistency, any designee working on a

government investigation must be specified and such designee must notify the Compliance

Officer of the nature of their work and responsibilities.

C. Processing of Disclosures and Reports

The Compliance Officer will establish a mechanism for receiving disclosures and reports

from Golden View Colleagues who have information regarding suspected misconduct, and will

be responsible for investigating and reports of suspected misconduct. Records of suspected

misconduct and any subsequent investigation will be confidentially retained by the Compliance

Officer for at least three years to the extent possible.

No Golden View employee or Agent who, in good faith, reports suspected misconduct

will be retaliated against or otherwise disciplined by Golden View. The Compliance Officer may

review personnel records and information periodically to ensure that those who report suspected

misconduct are not subject to retaliation or other improper conduct. In addition, the Compliance

Officer has the authority to keep confidential the names of Golden View Colleagues who report

information. The Compliance Officer does not, however, have the authority to extend

unilaterally any protection or immunity from disciplinary action, prosecution or any other

sanction to those employees or agents who have engaged in misconduct.

All other departments will submit reports to the Operational Compliance Committee as

requested by the Compliance Officer.

VI. PREVENTING INDIVIDUALS INVOLVED IN ILLEGAL ACTIVITIES FORM

EXERCISION DISCRETIONARY AUTHORITY

No individual who has engaged in illegal or unethical behavior and/or who has been

convicted of health care related crimes will be allowed to occupy positions within Golden View

which involve the exercise of discretionary authority.

Any applicant for an employment position with Golden View, and any Golden View

Agent, will be required to disclose whether the individual or Golden View Agent has changed

his/her name and, in accordance with applicable law, whether he/she has ever been convicted of

a crime, including health care related crimes.

In addition, Golden View will reasonably inquire into the status of each prospective

Golden View Colleague, including, but not limited to the following:

� Conducting background checks of newly hired nurses, nurses aid, medical

directors, and those who deal with controlled substances; and

� Conducting a review of the General Services Administration’s list of parties

excluded from Federal Programs (available at http://www.sam.gov).

Golden View will remove any person in a position of authority who is not willing to

comply with this Program. Golden View will implement procedures to terminate Golden View

employees, or its relationship with Golden View Agents, who are convicted or excluded from

participation in federal or state programs, including immediate removal frim direct responsibility

or involvement in any federally and state funded health care programs. Golden View will

implement procedures to remove from direct responsibility or involvement in any federally or

state funded health care programs any Golden View Colleagues with pending criminal charges

relating to health care or proposed exclusion from participation in federally and state funded

health care programs.

VII. TRAINING AND EDUCATIONAL PROGRAMS

A. Golden View Colleagues

The manager, will receive a copy of this Program. This Program will be readily available

to all Golden View Colleagues in each department. All Golden View Colleagues who have not

received this Program will be encouraged to review this Program in its entirety. All Golden

View Colleagues will have access to an employee handbook, this Program, and other

information necessary to ensured compliance with these standards.

Golden View Colleagues are encouraged to ask questions or would like to offer

comments regarding this Program or his/her obligations should follow the Reporting Process or

contact the Compliance Officer.

B. Employee Training

1. Training: All Golden View Employees providing health care services and/or goods or

services associated therewith, or billing and collection services, will attend a training

session, which will be coordinated by the Compliance Officer and members of the

Operational Compliance Committee. All new Golden View Employees providing health

care services, goods or billing will be required to attend a training program following

their employment.

Separate specialized training sessions may be conducted to permit additional focus on

issues that may be specific to unique groups. The Compliance Officer may require additional

training sessions for some or all Golden View Employees as the need arises. Each Golden View

Employee providing health care services and/or goods or services associated therewith, or billing

and collection services, will attend training sessions at least every two years.

Adherence to the Program will be an element of each Golden View employee’s

performance review. Compliance with the Program and laws and regulations applicable to

entities participating in health care programs is a condition of employment or association with

Golden View and Golden View will take appropriate disciplinary action as set out in this

Program.

2. Updating: The Compliance Officer will ensure that training is updated at regular intervals

to include new developments in law.

VII: MONITORING AND AUDITING SYSTEMS

A. Audits

The Compliance Officer shall work with appropriate internal and external personnel to

fulfill the Program’s requirements. Audit procedures will be implemented that are designed

primarily to determine accuracy and validity of coding and billing submitted to

Medicare/Medicaid, other federal and state health care programs and other payers, as well as

compliance with the MDS standards, and to detect any instances of potential misconduct by

Golden View Colleagues as quickly as possible. Intake forms will be created, as directed by the

Compliance Officer, for the auditing process and for written reports of actual or suspected fraud.

Random samplings of records drawn from a cross-section of each department will be conducted

on an annual basis by persons designated to audit in coordination with the Compliance Officer.

In addition, special attention will be given to reviewing the reasons given for claim denials, to

reviewing significant increases in the use of certain procedure codes, and to analyzing other facts

that may suggest inappropriate conduct.

Any suspected incidents of noncompliance will be reported to the Complaince Officer

and the head of the department where such suspected noncompliance is occurring for review and

action. Golden View will repay any overpayments that it discovers.

B. Contracts

All contracts and other arrangements with physicians, laboratories, providers, referral

sources, and other persons will be reviewed by the Compliance Officer or counsel to verify legal

compliance.

IX: DISCIPLINARY PROCEDURES

Failure to comply with this Program, or the laws and/or regulations applicable to

participants in federally and state funded health care programs, may result in discipline up to and

including termination from employment. Failure of a Golden View Agent to comply with the

Program, or the laws and/or regulations applicable to participants in federally and state funded

health care programs, may result in termination of the agency relationship. The Compliance

Officer and/or designated management will investigate all bona fide claims of suspected

misconduct. When Golden View concludes that an employee has engaged in any misconduct

covered by this Program, the employee will be subject to appropriate disciplinary procedures.

Enforcement and discipline will be in the sole discretion of Golden View and may include:

� Discipline of individuals who fail to report known non-compliant conduct; and

� Discipline of those persons involved in the non-compliant conduct.

Appropriate disciplinary measures will be taken on a case by case basis. In addition to

taking any appropriate disciplinary or other action against the party engaged in the misconduct,

Golden View may take other corrective action including, but not limited to:

� Re-training Golden View Employees;

� Modification of the charges, coding and billing system where necessary;

� Adjustment to policy and procedures;

� Reporting the problem to authorities as required; and

� Consideration of restitution.

X. OTHER LEGAL MATTERS

Golden View is committed to full compliance with all state and federal laws and will cooperate

with all reasonable requests made by government investigation. Golden View also seeks,

however, to address any problems before the need for government investigation or other legal

action arises and to protect the legal rights of Golden View and its employees and agents. Golden

View has designated certain Golden View employees who have authority to receive subpoenas

or other legal documents or inquiries regarding Golden View business. All other Golden View

Colleagues who are asked to receive such subpoenas or other legal documents must refer the

individual who makes such requests to the Compliance Officer and appropriate legal counsel.

Adopted by Metro Health Foundation of NH, Inc. d/b/a Golden View Health Care Center Board

of Directors, Audit and Compliance Committee

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