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Advocating for people with intellectual, developmental, and other disabilities to lead full and equitable lives.
AHRC New York City

Advocating for people with intellectual, developmental, and other disabilities to lead full and equitable lives.

Section 4.11: Documentation of Compliance Activities

Section: 4.11
Issued: 12.31.2005
Updated: 03.24.2023

Purpose

The purpose of this policy is to provide guidance on how to properly document compliance related activities.

Procedure

Maintenance and Handling Procedures for Documents

The vice president of Corporate Compliance will create and maintain, or oversee the maintenance of, all compliance program documentation including compliance policies and procedures and the date on which these policies were adopted and updated, if applicable.

The vice president of Corporate Compliance will maintain a log which will include the date and final disposition of all compliance related complaints. It will be made available upon request of the chief executive officer or any member of the Board of Directors.

Activities related to Compliance may result in the creation or receipt of documents that are of a confidential nature. These may include business documents, investigation materials, or records of people supported that must be protected from general disclosure or distribution. The vice president of Corporate Compliance in consultation with counsel, where necessary, will determine which documents should be designated and maintained as confidential documents.

Many of the records that will be generated by the vice president of Corporate Compliance or obtained in the course of AHRC NYC business will be of a confidential nature as the result of a communication with legal counsel. Those documents will be marked on each page: “CONFIDENTIAL ATTORNEY-CLIENT PRIVILEGED COMMUNICATION – NOT FOR REDISCLOSURE.”

Documents to be Maintained/Indexed

The vice president of Corporate Compliance and other AHRC NYC staff with compliance-related responsibilities will maintain the following types of compliance documents. The following list of compliance documents is illustrative only and is not an exhaustive list:

Program Development

  • Board Resolution(s) and/or minutes regarding compliance.
  • Compliance implementation schedules/work plans.
  • Results of compliance risk assessment, if any.

Written Policies and Procedures/Standards of Conduct

  • Past and current versions, including dates reviewed, revision dates and responsible parties of all Compliance Policies and Procedures
  • The AHRC NYC Code/Standards of Conduct.

Vice president of Corporate Compliance and Compliance Committee

  • Names, titles, and backgrounds for all members of the Compliance Committee, including the vice president of Corporate Compliance
  • Job descriptions for the vice president of Corporate Compliance and any compliance staff
  • Agendas and records/minutes of Compliance Committee meetings
  • Copies of reports made to the Board and/or chief executive officer by the vice president of Corporate Compliance.

Organizational and Employee Development

  • Organizational and Employee Development and Corporate Compliance Policies and Procedures regarding the hiring of new personnel.
  • Documentation evidencing each person’s background check.
  • Information collected during exit interviews regarding compliance issues.

Compliance Training

  • Information regarding the development and roll-out of the compliance training program.
  • Information regarding the development and implementation of specialized training for certain groups of personnel.
  • Information regarding attendance at training sessions.
  • Agendas and contents of training, including length of session and instructor(s).
  • Copies of all training handout materials and instructor guides.
  • Copies of sample quizzes or tests administered.

Dissemination of Compliance-Related Materials

  • Copies of all notices sent to the Board, employees, independent contractors, agents, and vendors regarding AHRC NYC Compliance.
  • Copies of all newsletters and other company publications that address Compliance.

Monitoring and Auditing

  • Information regarding the number and frequency of audits of claims and documentation requirements.
  • Information regarding any risk assessments or benchmarks and progress made on these assessments.
  • Information regarding the credentials of people and entities who perform audits on behalf of AHRC NYC, if outsourced.
  • Information (e.g., job titles, other credentials) regarding the people that make up the audit team, if audits are conducted internally.

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