LAC Department of Mental Health Public Portal

	LOS ANGELES COUNTY DEPARTMENT OF MENTAL HEALTH
	Policy 106.07 Compliance Program Steering Committee
	PROCEDURES

Compliance Program Steering Committee (CPSC) and Compliance Officer (CO) responsibilities are as follows:
1. CPSC and the CO will discuss and resolve issues that arise concerning policies and procedures that are beyond the scope of the Clinical Policy Review Committee and Compliance, Privacy, and Audit Services (CPAS) Bureau (DMH Policy 106.17).
  1. CPAS will revise policies and procedures as directed by CPSC. Upon completion of the revisions, the policies and procedures will be submitted to the Los Angeles County Department of Mental Health (DMH/Department) Executive Office for review and the Director’s signature/adoption.
2. CPAS is required to develop and implement an active education and training program (DMH Policy 106.10).
  1. The reasons for the training program are as follows:
    1. To promote understanding of and compliance with relevant federal, State, and local laws and regulations.
    2. To ensure implementation of DMH policies and procedures and that employees understand their role in the compliance program.
    3. To demonstrate the Department’s commitment to compliance and ensure that such commitment is carried out throughout the Department.
    4. To ensure that employees have knowledge of government requirements and to improve employees’ skills in identifying potential compliance issues.
  2. Accordingly, CPSC will:
    1. Review the annual compliance training plan to confirm that the training that is being provided to Department employees and other workforce members (interns, residents, volunteers, and locum tenens) is consistent with the reasons for training listed above.
    2. Periodically review reports (e.g., annual) on the status of completion of compliance training requirements throughout the Department.
3. CPSC and the CO recognize that compliance programs operate most effectively in Departments that encourage employees and business partners to report suspected wrongdoing so that it can be investigated and properly addressed (DMH Policy 106.01). Accordingly, it is the responsibility of the CPSC and the CO to:
  1. Create an environment in every segment of the Department where the employees feel free to report concerns, questions, and instances of improper conduct without fear of retribution or retaliation.
  2. Provide a mechanism for confidential or anonymous reporting for employees who are uncomfortable reporting concerns to a supervisor or to the CO.
  3. Track, document, and provide oversight mechanisms to ensure that reports of suspected non-compliance are fully and timely investigated and addressed.
  4. Provide mechanisms to assure that management is properly apprised of and can take appropriate action on issues identified during investigations that are a result of noncompliance.
  5. In addition, the CPSC will:
    
    i. Receive regular reports on trends or issues identified and ensure that there is an effective response.
    ii.Promote a culture with open communication.
4. The compliance program will include proactive monitoring and auditing functions designed to test and confirm compliance with federal, State, and County statutes, rules, regulations, policies, and procedures. Accordingly, CPSC will:
  1. Assure that the CPAS staff receive continuing education opportunities in regards to new and changing laws and work techniques.
  2. Be accessible to receive reports of severe adverse audit findings from the CO.
  3. Periodically review summary reports of audit findings.
  4. Work with the CO to implement corrective action.
5. CPSC and the CO recognize the effectiveness of an Department’s compliance effort is generally tied to its ability to affect the conduct of each individual in or associated with the Department. It further recognizes that when compliance failures occur, there must be a process for enforcing compliance standards and, when appropriate taking disciplinary actions (DMH Policy 605.01).
  1. Accordingly, CPSC will clearly communicate enforcement and disciplinary standards throughout the Department.
  2. Whereas, the CO will establish a working relationship between the compliance program and DMH Human Resources Bureau (DMH-HRB), and any other Departmental unit that has primary responsibility for disciplinary action.
6. When conduct is reported that is inconsistent with legal and policy requirements, it is the responsibility of the CO to investigate or respond to the allegation(s).
  1. Accordingly, the CO will:
    1. Consult with County Counsel as appropriate.
    2. Provide instructions to promptly halt or mitigate (to the extent possible) any ongoing harm caused by the suspected noncompliance.
    3. Fairly and expediently investigate to determine the existence, scope, and seriousness of the non-compliance, and to identify the underlying conduct or process that caused the noncompliance. If criminal in nature, the CO will refer the matter to the Auditor-Controller’s Office of County Investigations.
    4. Work with management to develop and recommend corrective action that will prevent such occurrences in the future.
    5. Work with management and DMH-HRB to implement measures, such as disciplinary action, to avoid similar instances of misconduct in the future.
  2. Whereas, the CPSC will:
    1. Provide guidance and direction of compliance efforts by reviewing:
      - Reports of findings.
      - Status reports.
      - Corrective action plans.
    2. Assure that the Department benefits from recommendations made by the CO, and from advice of counsel, when corrective action may require reports of non-compliance to outside parties, e.g., State or federal government.
7. It is an expectation of the Federal Government that compliance programs will periodically assess the risk of criminal conduct, as well as financial and legal risks/harm, and take appropriate steps. The results of the risk assessment should be in the compliance program work plan (DMH Policy 106.16).
  1. Accordingly, the CO will:
    1. Participate in the DMH risk management roundtable that is responsible for the identification of, and mitigation of, Departmental risk.
    2. Analyze and review the United States Department of Health and Human Services, Office of Inspector General Workplan to determine potential areas of risk to DMH.
    3. Include areas of risk identified in Sections A.7.a.i. and A.7.a.ii. above in the CPAS work plan.
    4. Provide periodic work plan status reports upon request.
  2. Whereas, the CPSC will:
    1. Participate in the risk assessment process.
    2. Review and approve the CPAS work plan.
    3. Advise the CO of additional information as it becomes available regarding potential risks so that the work plan can be adjusted as appropriate.
CPSC composition and Chair: The CPSC shall be composed of DMH’s Executive Management Team and the CO. The CPSC shall be chaired by the DMH Director. In the absence of the DMH Director, the CPSC shall be chaired by the Chief Deputy Director. In the absence of both the Director and the Chief Deputy Director, the CPSC shall be chaired by the Medical Director.
Frequency of CPSC meetings:
1. At a minimum, CPSC meetings will be held quarterly. It will be the responsibility of the CO to coordinate the scheduling of these meetings with the DMH Director’s and/or Chief Deputy Director’s office.
2. The CO may call a meeting of the CPSC on an as-needed basis upon the concurrence of the Chief Deputy Director.
Attendance at CPSC Meetings:
1. CPSC Members are expected to regularly attend the scheduled and called CPSC meetings; however, absence may be excused by the Chair for good cause.
2. The section heads of the CPAS may be permitted to attend the CPSC meetings for purposes of presenting findings and answering questions presented by the CPSC.