Corporate Compliance Program at Beth Sholom Village
Our Corporate Compliance Program seeks to provide a written and operational commitment to abide by and uphold all applicable laws. This not only applies to the laws and regulations governing our operational policies and procedures concerning the care provided to our clients, but also the laws that govern our employees’ rights and protections. They include:
- Health Insurance Portability and Accountability Act (HIPAA) Omnibus
- Virginia state licensure laws
- Fraud and abuse laws
- False Claims and Anti-Kickback Statute
- Title VII of the Civil Rights Act of 1964
- Fair Labor Standards Act (FLSA)
- Age Discrimination in Employment Act (ADEA)
- Americans with Disabilities Act (ADA)
- Uniformed Services Employment and Reemployment Rights Act (USERRA)
- Equal Pay Act (EPA)
- Pregnancy Discrimination Act (PDA)
- Immigration Reform and Control Act (IRCA)
- Occupational Safety and health Act (OSHA)
- Family and Medical Leave Act (FMLA)
The Corporate Compliance Program is dedicated to the recognition, prevention, and resolution of any act that would be in violation of our values, as well as these applicable laws and regulations. We aspire to do business so that the intentional or unintentional violation of laws regulating nursing homes and employers is actively prevented. This is accomplished through policies and procedures, employee training and education, as well as processes in place to investigate and report potential violations.
Harassment Complaint Procedures
If an employee feels that he or she has been subjected to conduct which violates our Non-Harassment or Sexual Harassment policy, he or she should immediately report the matter to their supervisor, but in the event the employee is unable or unwilling to report to their supervisor they may report to the Director of Human Resources, Administrators, the Chief Financial Officer, or the Chief Executive Officer. If the employee is unable for any reason to contact one of these individuals, or if the employee has not received a satisfactory response within five (5) business days after reporting any incident of what the employee perceives to be harassment, the employee should contact the Corporate Compliance Officer.
Laura Gadsby, Compliance Officer
Beth Sholom Village
6401 Auburn Drive
Virginia Beach, VA 23464
Phone: (757) 420- 2512 ext 211
If the person toward whom the complaint is directed is one of the individuals indicated above, the employee should contact any higher-level manager in his or her reporting hierarchy. Every report of perceived harassment will be fully investigated and corrective action will be taken where appropriate. All complaints will be kept confidential to the extent possible, but confidentiality cannot be guaranteed.
In addition, the Organization will not allow any form of retaliation against individuals who report unwelcome conduct to management or who cooperate in the investigations of such reports in accordance with this policy. If an employee feels he or she has been subjected to any such retaliation, he or she should report it in the same manner in which the employee would report a claim of perceived harassment under this policy. Violation of this policy including any improper retaliatory conduct will result in disciplinary action, up to and including discharge. All employees must cooperate with all investigations.
Discrimination is Against the Law
In the event that you are the victim of discrimination, then you are encouraged to file a grievance with:
Rebecca Riebling, Director of Human Resources and Compliance
Beth Sholom Village
6401 Auburn Drive
Virginia Beach, VA 23464
Phone: (757) 420-2512 EXT 210
You can also file a civil rights complaint with the
U.S. Department of Health and Human Services, Office for Civil Rights,
Electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
Equal Employment Opportunity
Beth Sholom Village is an Equal Opportunity Employer that does not discriminate on the basis of actual or perceived race, creed, color, religion, alienage or national origin, ancestry, citizenship status, age, disability or handicap, sex, marital status, veteran status, sexual orientation, genetic information, arrest record, or any other characteristic protected by applicable federal, state or local laws. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.
The Organization will endeavor to make a reasonable accommodation to the known physical or mental limitations of qualified employees with disabilities unless the accommodation would impose an undue hardship on the operation of our business. If you need assistance to perform your job duties because of a physical or mental condition, please let the CEO and/or the Director of Human Resources and/or the Employee’s Supervisor and/or the Corporate Compliance Officer know.
The Organization will endeavor to accommodate the sincere religious beliefs of its employees to the extent such accommodation does not pose an undue hardship on the Organization’s operations. If you wish to request such an accommodation, please speak to the CEO and/or the Director of Human Resources and/or the Employee’s Supervisor and/or the Corporate Compliance Officer.
Any employees with questions or concerns about equal employment opportunities in the workplace are encouraged to bring these issues to the attention of the CEO and/or the Director of Human Resources and/or the Employee’s Supervisor and/or the Corporate Compliance Officer. The Organization will not allow any form of retaliation against individuals who raise issues of equal employment opportunity. If an employee feels he or she has been subjected to any such retaliation, he or she should bring it to the attention of the CEO and/or the Director of Human Resources and/or the Employee’s Supervisor and/or the Corporate Compliance Officer. To ensure our workplace is free of artificial barriers, violation of this policy including any improper retaliatory conduct will lead to discipline, up to and including discharge. All employees must cooperate with all investigations.
Fair Housing Act, Title VII of the Civil Rights Act of 1968
The Fair Housing Act protects people from discrimination when they are renting or buying a home, getting a mortgage, seeking housing assistance, or engaging in other housing-related activities. Beth Sholom Village is committed to upholding the Fair Housing Act standards. It is illegal discrimination to take any of the following actions because of race, color, religion, sex, disability, familial status, or national origin:
- Deny the opportunity to any qualified application to apply for or to lease housing suitable to his or her needs
- Provide housing that is not equitable to that provided to others
- Subject anyone to segregation by wing or floor
- Restrict anyone’s access to benefits available to others related to the housing program
- Deny access to the same level of services
- Deny the opportunity to participate in a planning or advisory committee
- Discriminate based on that person’s relation or association with another individual
In addition, it is illegal discrimination to:
- Threaten, coerce, intimidate or interfere with anyone exercising a fair housing right or assisting others who exercise the right
- Retaliate against a person who has filed a fair housing complaint or assisted in a fair housing investigation
Health Insurance Portability and Accountability Act (HIPAA)
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please contact the office of the Beth Sholom Village Privacy Contact Person:
Beth Sholom Village
6401 Auburn Drive
Virginia Beach, VA 23464
Phone: (757) 420- 2512 ext 224
Who Will Follow This Notice
This notice describes Beth Sholom Village’s privacy practices including:
- All employees, staff and other healthcare personnel associated with Beth Sholom Village.
Our Pledge Regarding Medical Information:
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you.
We create a record of the care and services you receive at Beth Sholom Village. We need this record to provide you with quality care and to comply with certain legal requirements.
This notice applies to all of the records of your care generated at Beth Sholom Village.
This notice tells you about the ways in which we may use and disclose your medical information. It also describes your rights and certain obligations we have regarding use and disclosure of information.
We Are Required By Law to:
- Make sure that medical information that identifies you is kept private;
- Give you this notice of our legal duties and privacy practices; and
- Follow the terms of the notice that is currently in effect.
How We May Use and Disclose Medical Information About You.
The following categories describe the different ways we may use and disclose medical information. For each category of uses or disclosure we will explain what we mean and give examples. Not every use or disclosure in a category will be listed, however all of the ways we are permitted to use and disclose information fall within one of the categories.
- For treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other Beth Sholom Village personnel and care providers who are involved in your care. Among those caring for you are medical, nursing, and other health care personnel in training who, unless you request otherwise, may be present during your care as part of their education. We may use still or motion pictures and closed circuit television monitoring of your care. We may also share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work, X-rays and emergency medical transportation, as well as with family members or others providing services that are part of your care.
- For payment. Beth Sholom Village may use and disclose your medical information so that it or other entities involved in your care may obtain payment from you, an insurance company, or a third party for treatment and services you receive. We may disclose your medical information to any person, Social Security Administration, insurance or benefit payer, health care service plan or worker’s compensation carrier which is, or may be, responsible for part or your entire bill. We may also tell your insurer about a treatment you are going to receive to obtain prior approval, to determine whether your plan will cover the treatment, or to resolve an appeal or grievance. Beth Sholom Village is required to agree, if you request, to restrict disclosure of PHI to a health plan for any healthcare item or service which you have paid in full out of pocket.
- For Health Care Operations. We may use and disclose medical information about you for our health care operations. These uses and disclosures are necessary to run Beth Sholom Village and make sure that all of our patients receive quality services. For example, we may use medical information to review our treatment and services, to evaluate the performance of our staff, and to survey you on your satisfaction with our treatment and/or services. We may combine medical information to decide what additional services Beth Sholom Village should offer, what services are not needed, and whether certain new treatments are effective. We may disclose information to doctors, nurses, technicians, students training with Beth Sholom Village, and other Beth Sholom Village personnel for review and learning purposes. We may combine the medical information we have with other medical information from other health care entities to compare how we are doing and see where we can make improvements in the care and services we offer. Beth Sholom Village may also disclose information to private accreditation organizations. We may use your information to assist in granting hospital privileges to providers. We may also provide to others information that does not identify you so that that they may use it to study health care.
- Appointment Reminders. We may use and disclose your information to remind you of an appointment.
- Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
- Health-Related Benefits and Services. We may use and disclose your information to tell you about health related benefits or services.
- Fundraising Activities. Beth Sholom Village does not engage in fundraising activities at this time.
- Research. Under certain circumstances, we may use and disclose medical information about you for research purposes, regardless of the funding for such research. For example, a research project may involve the use of one anesthetic agent compared to another anesthetic agent in patients with similar conditions. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its medical information, trying to balance the research needs with the patient’s need for privacy of their medical information. Before we use or disclose medical information for research the project will have been approved through this research approval process.
- As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law. This includes, but is not limited to, disclosures to mandated patient registries.
- To Avert a Serious Threat to Health or Safety. We may disclose medical information about you to a person able to help prevent a serious threat to your health and safety or the health and safety of the public or another person.
- To Sponsors of Group Health Plans. We may disclose your medical information to the sponsor of a self-funded group health plan, as defined under ERISA. We may also give your employer information on whether you are enrolled in or have dis-enrolled from a health plan offered by your employer.
- Marketing. Beth Sholom Village does not engage in marketing activities utilizing PHI.
- Activities Requiring Authorization. Beth Sholom Village requires specific patient authorization for disclosure of Protected Health Information in the event of 1) Disclosure that constitutes a sale of PHI, 20 Disclosures of PHI for Marketing purposes and, 3) Disclosure of psychotherapy notes. You may revoke an authorization at any time.
- Military and Veterans. We may release medical information about members of the domestic or foreign armed forces as required by the appropriate military command authorities.
- Workers’ Compensation. We may release medical information about you for workers’ compensation and similar programs.
- Public Health Activities. We may disclose medical information about you for public health activities. These activities include the following:
- to report child abuse or neglect
- to report reactions to medications or problems with products;
- to notify people of recalls of products they may be using;
- to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
- to notify appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence where you agree or when required or authorized by law.
- Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, but are not limited to, audits, investigations, examinations, inspections, and licensure.
- Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request. We also may disclose information to Beth Sholom Village’s attorneys and, in accordance with applicable state law, to attorneys working on Beth Sholom Village’s behalf.
- Law Enforcement. We may release medical information if asked to do so by a law enforcement official:
- In response to a court order, subpoena, warrant, summons or similar process;
- To identify or locate a suspect, fugitive, material witness, or missing person;
- About the victim of a crime if, under certain limited circumstances, we are unable to obtain the patient’s agreement;
- About a death we believe may be the result of criminal conduct;
- About criminal conduct at the location of an Beth Sholom Village entity; and
- In emergency circumstances to report a crime; the location of crime or victims; or the identity, description of location of person(s) who committed the crime.
- Coroners, Medical Examiners and Funeral Directors. We may release medical information to a coroner, medical examiner or funeral director as necessary for them to carry out their duties.
- National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, or other national security activities.
- Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state or conduct special investigations.
- Inmates. If you are an inmate of a correctional institution or under the custody of law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
- Uses and Disclosures Regarding Food and Drug Administration (FDA)-Regulated Products and Activities. We may disclose protected health information, without your authorization, to a person subject to the jurisdiction of the FDA for public health purposes related to the quality, safety or effectiveness of FDA-regulated products or activities such as collecting or reporting adverse events, dangerous products, and defects or problems with FDA-regulated products.
- All Other Uses & Disclosures of PHI. Any other use and/or disclosure of your PHI not specified in this notice will require a signed authorization prior to use.
Your Rights Regarding Medical Information We Maintain About You.
You have the following rights regarding your medical information:
- Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing on a form provided by Beth Sholom Village. You have a right to obtain paper or electronic copy. You may also request where the information is to be sent. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by Beth Sholom Village will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
- Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for Beth Sholom Village. To request an amendment, your request must be made in writing on a form provided by Beth Sholom Village and submitted to Beth Sholom Village. You must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
- Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
- Is not part of the medical information kept by or for Beth Sholom Village;
- Is not part of the information which you would be permitted to inspect and copy; or
- Is accurate and complete.
- Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you. It does not include disclosure made for treatment, payment, health care operations, disclosure you authorize or other disclosure for which an accounting is not required under HIPAA. To request this list or accounting of disclosure you must submit your request in writing on a form provided by Beth Sholom Village. Your request must state the time period which may not be longer that six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically.) The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
- Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. We are not required to agree with your request. If we do agree, we will comply with your request restrictions. You must make your request in writing on a form provided by Beth Sholom Village. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, i.e. disclosures to your spouse.
- Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we contact you at work or by mail. To request confidential communications, you may make your request in writing to Beth Sholom Village. You may also telephone the office of the Privacy Contact Person, however in order to protect your privacy we may not be able to accommodate requests made by telephone. We will not ask you the reason for your request, and will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
- Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice at any time, even if you have previously agreed to receive this notice electronically. To obtain a paper copy of this notice, please write or call Beth Sholom Village.
- Right to Breach Notification. In the event that unsecured protected health information is inappropriately disclosed, an investigation of the event will be conducted. If it is determined to be a breach of your information, you will receive notification of the breach by first class mail.
- Rights of the Deceased. PHI of an individual that has been deceased for 50 years or more is NOT covered by HIPAA. Covered Entities are permitted to disclose a deceased person’s PHI to family members and others who were involved in the care or payment for care if not contrary to prior expressed preference.
Change to this Notice.
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice with the effective date in Beth Sholom Village. We will post a current updated copy of this notice on our website, http://www.bethsholomvillage.com.
If you believe your privacy rights have been violated, you may file a complaint with Beth Sholom Village or with the Secretary of the Department of Health and Human Services. To file a complaint with Beth Sholom Village, contact the Privacy Contact Person. All complaints must be submitted in writing. You will not be penalized or retaliated against for filing a complaint.
Other Uses of Medical Information.
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us with permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of care and services that we provide to you.
Beth Sholom Village provides public notice of their policy to fully comply with Title VI of the Civil Rights Act of 1964, requiring that no person shall be excluded or denied benefits, or any other type of discrimination based on race, color, national origin, gender, age, economic status or limited English proficiency under any program that our company receives Federal financial assistance.
Any individual that feels as though they have been denied benefits, or otherwise subject to discrimination for which Beth Sholom Village provides assistance, due to discrimination based on race, color, national origin, gender, age, economic status or limited English proficiency is encourage to file a formal verbal or written complaint.
To submit a formal complaint, or to request additional information on Title VI, please contact:
Laura Gadsby, Compliance Officer
Beth Sholom Village
6401 Auburn Drive
Virginia Beach, VA 23464
Phone: (757) 420- 2512 ext 211
Notice Under the Americans with Disabilities Act
In accordance with the requirements of title II of the Americans with Disabilities Act of 1990 (“ADA”), the Beth Sholom Village will not discriminate against qualified individuals with disabilities on the basis of disability in its services, programs, or activities.
Employment: Beth Sholom Village does not discriminate on the basis of disability in its hiring or employment practices and complies with all regulations promulgated by the U.S. Equal Employment Opportunity Commission under title I of the ADA.
Effective Communication: Beth Sholom Village will generally, upon request, provide appropriate aids and services leading to effective communication for qualified persons with disabilities so they can participate equally in Beth Sholom Village’s programs, services, and activities, including qualified sign language interpreters, documents in Braille, and other ways of making information and communications accessible to people who have speech, hearing, or vision impairments.
Modifications to Policies and Procedures: Beth Sholom Village will make all reasonable modifications to policies and programs to ensure that people with disabilities have an equal opportunity to enjoy all of its programs, services, and activities. For example, individuals with service animals are welcomed in Beth Sholom Village offices, even where pets are generally prohibited.
Anyone who requires an auxiliary aid or service for effective communication, or a modification of policies or procedures to participate in a program, service, or activity of Beth Sholom Village, should contact the office of Rebecca Riebling, Director of Human Resources and Compliance as soon as possible but no later than 48 hours before the scheduled event.
The ADA does not require the Beth Sholom Village to take any action that would fundamentally alter the nature of its programs or services, or impose an undue financial or administrative burden.
Complaints that a program, service, or activity of Beth Sholom Village is not accessible to persons with disabilities should be directed to Rebecca Riebling, Director of Human Resources and Compliance.
Beth Sholom Village will not place a surcharge on a particular individual with a disability or any group of individuals with disabilities to cover the cost of providing auxiliary aids/services or reasonable modifications of policy, such as retrieving items from locations that are open to the public but are not accessible to persons who use wheelchairs.
Grievance Procedure Under the Americans with Disabilities Act
This Grievance Procedure is established to meet the requirements of the Americans with Disabilities Act of 1990 (“ADA”). It may be used by anyone who wishes to file a complaint alleging discrimination on the basis of disability in the provision of services, activities, programs, or benefits by the Beth Sholom Village.
The complaint should be in writing and contain information about the alleged discrimination such as name, address, phone number of complainant and location, date, and description of the problem. Alternative means of filing complaints, such as personal interviews or a tape recording of the complaint, will be made available for persons with disabilities upon request.
The complaint should be submitted by the grievant and/or his/her designee as soon as possible but no later than 60 calendar days after the alleged violation to:
Director of Human Resources and Compliance
6401 Auburn Drive, Virginia Beach, VA 23464
Within 15 calendar days after receipt of the complaint, Rebecca Riebling or her designee will meet with the complainant to discuss the complaint and the possible resolutions. Within 15 calendar days of the meeting, Rebecca Riebling or her designee will respond in writing, and where appropriate, in a format accessible to the complainant, such as large print, Braille, or audio tape. The response will explain the position of the Beth Sholom Village and offer options for substantive resolution of the complaint.
If the response by Rebecca Riebling or her designee does not satisfactorily resolve the issue, the complainant and/or his/her designee may appeal the decision within 15 calendar days after receipt of the response to the [City Manager/County Commissioner/ other appropriate high-level official] or [his/her] designee.
Within 15 calendar days after receipt of the appeal, the [City Manager/County Commissioner/ other appropriate high-level official] or [his/her] designee will meet with the complainant to discuss the complaint and possible resolutions. Within 15 calendar days after the meeting, the [City Manager/County Commissioner/ other appropriate high-level official] or [his/her] designee will respond in writing, and, where appropriate, in a format accessible to the complainant, with a final resolution of the complaint.
All written complaints received by Rebecca Riebling or her designee, appeals to the [City Manager/County Commissioner/ other appropriate high-level official] or [his/her] designee, and responses from these two offices will be retained by Beth Sholom Village for at least three years.