Conflict of Interest Compliance Implementation Plan

  • Form also available in Portable Document Format (PDF)

Provider Agency Name: __________________________________________________________________________

DBA: _________________________________________________________________________________________

Provider ID: __________________________________ FEIN # (Tax ID): _____________________________________

Address: ______________________________________________________________________________________

NHTD                                         TBI

The Conflict of Interest (COI) Compliance Implementation Plan must be submitted to the Regional Resource Development Center (RRDC) by March 1st, 2018. Agencies who have not submitted their COI Compliance Implementation Plan by this date will be put on vendor hold by the New York State Department of Health (NYSDOH).
All COI Compliance Implementation Plans must be reviewed and approved by the RRDC prior to the RRDC submission to the NYSDOH. If the RRDC, after review, feels the COI Compliance Implementation Plan is not written to satisfaction, the RRDC will ask that agencies edit their COI Compliance Implementation Plan until such time that they are adequate for NYSDOH submission.
If the RRDC feels a provider agency is not being responsive in editing and re-submitting their COI Compliance Implementation Plan, the RRDC will contact NYSDOH and the provider agency will be put on vendor hold.
Note: Each question must be answered by the agency – "N/A", "Send to RRDC" and variations will not be accepted.
  1. Approved regions, locator codes assigned to those regions and services approved for those regions.
  2. Identify any other corporate entities within this corporate structure (e.g. LHCSA and CHHA).
  3. Are Service Coordinators physically co–located with any other service staff provided by the organization?
    _____ Yes       _____ No
    If Yes, please identify addresses, staff assigned to that address and their function(s).
  4. Attach a chart indicating the geographic breakdown of ALL waiver services currently provided by the organization by county, including the number of individuals served in each county.
  5. Breakdown of all Service Coordinator caseloads:
    Provide a complete listing of all Service Coordinator assignments.
    Identify Service Coordinators, their caseload (name and CIN of each participant) and who supervises each Service Coordinator.
    Please attach as a separate document.
  6. Are there any conditions present that support a rural or cultural exemption within your organization? Please specify by county/cultural population. Provide a detailed explanation why a request for an exemption is appropriate.
  7. Organizational Chart:
    Provide a copy of the agency´s organizational chart that delineates the lines of supervision for all services provided in the organization. Delineate Waiver service provision staff and the chain of supervision.
    Please attach as a separate document.
  8. Explain provider selection process:
    What protocols does the organization have in place to ensure participant/applicant choice of providers and service selection?
    What protections are in place to ensure that your staff do not steer business to your agency?
  9. What criteria does the agency use to determine if it will accept a case? (e.g. case load capacity, location of the participant)
  10. Explain what assessments related to waiver services are completed by the provider and how the assessment findings are included in the Service Plan.
  11. Describe the process for Service Plan submission and approval and indicate time–lines, sign–off protocols and identify responsible staff.
  12. Describe who reviews service limits, frequency and duration of services in conjunction with the Service Plan reviews.
    What is the relationship of that staff to the Service Coordinator?
  13. Describe the agency´s dispute resolution process.
  14. Describe the internal mechanisms to accept complaints from Service Coordinators and/or waiver participants regarding the agency´s service provision.
  15. Describe the organization´s participant satisfaction survey process and how the agency responds to the data/issues presented.
  16. What quality assurance protocols do you have in place to confirm that services identified in the Service Plan are provided?
  17. Attach copies of relevant personnel and procedural guidelines developed/implemented to avoid Conflict of Interest.

Provider Attestation for the COI Compliance Implementation Plan

The Provider agrees:

Service Coordinators, the provider agency and their staff may not be Representative Payees or trustees for waiver participants´ financial interests;

Service Coordinators, the provider agency and their staff may not serve as a guardian, Power of Attorney, Health Care Proxy to a waiver participant, emergency backup or participate in any financial relationship with waiver participants;

Individuals providing Service Coordination and other waiver services are not related by blood or marriage to individuals on their caseload;

Individuals providing Service Coordination, the provider agency and their staff may not receive any financial benefit other than their employment from the provision of services;

Service Coordinators and Service Coordinator Supervisors may not complete functional assessments for individuals on their caseloads;

Service Coordinators and Service Coordinator Supervisors may not provide other waiver services to people on their caseloads;

Service Coordinators who terminate employment with a corporation/provider must have a "cooling off" period which includes a period of at least three (3) months before the participant may choose to move to the new agency where their former SC is now employed. If a rural exemption exists, the cooling off period may not apply. It should be noted that participants choose a provider agency not a specific staff person;

To notify the RRDCs of all Service Coordinator and Service Coordinator Supervisor staff terminations and the date employment with the provider ended within thirty (30) days of separation;

To be removed from the active provider list by the RRDC if the agency consistently refuses to interview new referrals or accept new participants until such time that they have the capacity and willingness to accept new cases;

To assign Service Coordinators and Service Coordinator Supervisors titles that distinguish staff as an approved Medicaid service provider and not a representative of the New York State Department of Health or the Regional Resource Development Center;

Effective January 1st, 2019, Service Coordination providers will implement full compliance with HCBS regulation related to Conflict of Interest.

The Regional Resource Development Center, as designees of the NYSDOH, shall have full access to all provider and participant records regarding the provision of HCBS Waiver services.

I acknowledge the information presented in this Attestation.

Provider agency                                                 Contact Person                                                 Title

Authorized by                                                      Signature                                                             Date

Contact Person                                                 Telephone

January 2018