Policy and Procedure: Compliance
Topic: Reporting of Compliance Concerns and Non-Retaliation
Purpose:
Crystal Run Village, Inc. (CRVI) (sometimes referred to as the “Agency”) recognizes that a
critical aspect of its compliance program is the establishment of a culture that promotes
prevention and detection of conduct that does not conform to Federal and State requirements,
as well as the Agency’s ethical and business policies. The Agency also recognizes that any form
of retaliation or retribution against those that report misconduct in good faith can undermine
the compliance process.
To promote this culture, CRVI established a reporting process and a strict non-retaliation
policy to protect employees and others from retaliation arising from reporting problems and
concerns in good faith.
Policy:
1. The term “Misconduct”, includes actual or potential violations of laws, regulations, Agency
policies or procedures, the Agency’s Compliance Plan, or the Agency’s Code of Conduct.
2. A report of Misconduct in “Good faith” means that the individual believes that the
Misconduct or potential Misconduct actually occurred or is reasonably likely to occur.
3. All employees have an affirmative responsibility to promptly report any known or
suspected Misconduct.
4. An “open-door policy” will be maintained at all levels of management to encourage
employees to report problems and concerns relating to Misconduct. No employee shall be
turned away from any level of management or discouraged to report any problems or
concerns relating to Misconduct.
5. CRVI will maintain a Compliance Hotline through which employees may report their
compliance concerns confidentially to the Compliance Officer. The Compliance Hotline is
answered by a service who will keep the identification of the reporter anonymous. The
service will then forward the concerns to the Compliance Officer.
6. Any form of retaliation against any employee for reporting perceived or potential
Misconduct in good faith is strictly prohibited.
7. Any employee who commits or condones any form of retaliation will be subject to
discipline up to, and including, termination.
8. Employees will not be excused for their own Misconduct by reporting the issue, but selfreporting will be taken into account in determining the appropriate course of action.
Approved 9/10/2013
Procedures:
Procedures that apply to all employees
1. An employee that sees or learns of Misconduct by an Agency employee, must immediately
report such Misconduct to their supervisor, a member of management, the Director of
Human Resources, the Compliance Officer, or the Compliance Hotline.
2. Employees must also report obligations for actual or suspected Misconduct committed by
the Agency’s vendors or contractors.
3. Employees may report their compliance concerns anonymously to the Compliance Hotline
or they may provide his or her identity.
4. If the caller wishes to make the report anonymously to the Compliance Hotline, no
attempt will be made to trace the source of the call or identify of the person making the
call. It may not be possible to preserve anonymity if they choose to identify themselves,
provide other information that identifies them, the investigation reveals their identity, or if
they inform others that they have called the Compliance Hotline.
5. Confidentiality will be maintained to the extent that is practical and allowable by law. The
Agency is legally required to report certain types of crimes or potential crimes and
infractions to law enforcement or other governmental agencies.
6. The Compliance Hotline number will be published to employees and visibly posted in
locations frequented by Agency employees.
7. CRVI will not impose any disciplinary or other action in retaliation against individuals who
make a report in good faith regarding Misconduct.
8. Employees are strictly prohibited from engaging in any act, conduct, or behavior that is
intended to result in, retaliation against any employee for reporting his or her concerns
relating to a Misconduct or potential Misconduct.
Approved 9/10/2013
9. If an employee believes that he has been retaliated against or threatened with retaliation for
reporting Misconduct or for participating in any investigation of a report or complaint of
Misconduct, the employee should immediately report the retaliation to the Compliance
Officer or the Compliance Hotline. The report should include a thorough account of the
incident(s) and should include the names, dates, specific events, the names of any
witnesses, and the location or name of any document that supports the alleged retaliation.
10. Knowledge of a violation or potential violation of the Reporting of Compliance Concerns
and Non-retaliation Policy must be reported directly to the Compliance Officer or the
Compliance Hotline.
Procedures that apply to management (which includes officers, directors, managers,
and supervisors)
1. Any member of management who receives a report of a violation or suspected violation
will immediately notify the Compliance Officer and complete a Compliance Issue Report
Form (attached to this Policy). The completed Form will be forwarded to the Compliance
Officer.
2. Management must take appropriate measures to ensure that all levels of management
support this policy and encourage the reporting of Misconduct or potential Misconduct.
At a minimum, the following actions should be taken and become an ongoing aspect of
the management process:

Annually, meet with department staff and discuss the main points within this policy;
and

Provide all department staff with a copy of this policy.
Procedures that apply to the Compliance Officer
1. The Compliance Officer will ensure that all reports of violations or suspected violations
are recorded on a Compliance Issue Report Form.
2. The Compliance Officer (with consultation with appropriate members of management)
will determine the appropriate course of action to respond to each report, including the
investigation process and notifications to be made.
3. The Compliance Officer will be responsible for assuring that there is an appropriate
investigation and follow-up of any reported Misconduct or retaliation against an
employee for reporting a compliance concern or participating in the investigation of a
compliance concern.
4. The Compliance Officer will report the results of each investigation to the group
deemed appropriate, such as the Compliance Committee or the Board of Directors.
Approved 9/10/2013