Compliance Program and Plan

Partnering to improve quality of life as a nonprofit organization dedicated to mental health and wellness


The Mental Health Center of Boulder County, Inc. d/b/a/ Mental Health Partners (“MHP”) is committed to complying with the laws and regulations governing the way we care for clients and conduct business. MHP developed a comprehensive compliance program to define and guide our business activities and to provide an effective framework for a policy of compliance with standards. It is a fundamental policy of MHP that its business and other practices be conducted in compliance with applicable laws and regulations of the United States, the State of Colorado, and other local laws and ordinances. This Compliance Plan and Program (the “Compliance Program”) has been carefully considered and formally adopted by our Board of Directors.

The Compliance Program is more than a set of policies that employees and agents must follow. It is the underpinnings of MHP’s culture, how we care for its clients, and meet regulatory demands that allow it to continue providing that quality care. Employees and agents must read and understand our Compliance Program and the obligations each of us has to follow regarding the requirements that govern the way we do business and care for our clients.

Mental Health Partners is committed to providing quality services related to its Mission for all persons and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status in any of its activities or operations. These activities and operations include, but are not limited to recruitment, hiring, and termination of staff, recruitment and selection of volunteers, selection of vendors and provision of services. We are committed to maintaining an environment that respects the dignity of each individual in our community. Prohibited discrimination in any form or context will not be tolerated.

Applicability and Definitions

The Compliance Program applies to all employees and agents. The term ‘agents’ includes members of the Board of Directors, temporary staff, contractors, volunteers, and vendors of MHP.

Purpose of our Compliance Program

The purpose of the Compliance Program is to provide reasonable assurance that MHP: Mental Health Partners Compliance Plan

  • Sets forth standards that promote and encourage respect for clients and enhances quality of care;
  • Effectively foster and promotes a culture of compliance throughout MHP;
  • Assigns to management overall responsibility to oversee compliance with those standards;
  • Authorizes compliance standards and procedures that are reasonably calculated to reduce the likelihood of violation of applicable laws or regulations, or criminal conduct by employees and agents or other forms of misconduct that may expose MHP to criminal or civil liability;
  • Empowers employees and agents to prevent, detect and resolve actions or behavior (such, as fraud, abuse, and waste) that do not comply with our Code of Conduct or applicable laws and regulations;
  • Enhances communications with governmental entities with respect to compliance activities including promoting self-auditing, self-policing, and providing for the voluntary disclosure of violations of laws and regulations, and satisfies the conditions of participation with payers and the Medicaid integrity Plan as a Medicaid provider and Centers for Medicare and Medicaid;
  • Institutes reasonable steps to respond appropriately to offenses that have been detected and to prevent further similar offenses, and
  • Establishes consistent disciplinary mechanisms to deal with violations of law or policy, or the failure to detect or report an offense.
The Core Components of Our Program
  1. Leadership and Structure
  2. Written Compliance and Practice Standards
  3. Qualifications, Education and Training
  4. Open Lines of Communication
  5. Internal Auditing and Monitoring
  6. Responding to Questions and Potential Violations
  7. Enforcing Standards and Corrective Action Processes

1. Leadership and Structure

The Board of Directors has designated a Compliance Officer who has day-to-day responsibility for management of the Compliance Program and oversees the organization’s commitment to ethical, honest and lawful conduct. The Compliance Officer is responsible for proposing and developing policies and for advising other departments and functions on the development and implementation of their own policies, procedures and practices designed to ensure compliance with the applicable regulatory requirements of our business. The Compliance Officer reports to the CEO (or their designee) with direct access to and regular communication with the Board of Directors. The Compliance Officer is empowered to act independently and free of any conflict of interest while managing MHP’s compliance program with this organizational structure.

MHP has established a Compliance Committee (the “Committee”), appointed by management and the Compliance Officer, to participate in the evaluation of compliance issues and to support the Compliance Program. The Committee includes members of MHP who can effectively review and influence company policies and can impact problem resolution. The Committee meets periodically to review issues and provide input and guidance to the Compliance Officer and other managers on standards applicable to our organization and act according to the Committee’s charter.

All of management is expected to guide and lead the staff in accordance with our Compliance Program.

2. Written Compliance and Practice Standards

Code of Conduct

MHP has adopted and makes available to all employees and agents the general standard of conduct through the dissemination of the Code of Conduct (“the Code”). All employees and agents are expected to adopt and follow the Code when providing client care and conducting business on behalf of MHP as an expression of MHP’s culture of compliance.

Policies and Procedures

Policies and procedures are developed to address activities where quality client care or risk of regulatory violation makes setting forth a clear standard prudent for our business. In essence, policies and procedures are provided to empower MHP employees and agents to do the right thing. Specific, written compliance policies, standards and practices are developed and periodically reviewed for updating with the intent to address areas of risk and regulatory vulnerability to MHP. These policies, standards and practices are developed under the initiative of the Compliance Officer, Compliance Committee and/or Management and are made available to all employees and agents.

3. Qualifications, Education and Training

MHP will only hire employees or contract with agents who are appropriate to work within their scope of practice. Individuals, including Board Members, must have and maintain adequate and current licenses or accreditation required for the position; appropriate background checks and screenings must be conducted prior to engagement, and individuals must be checked for exclusion or debarment with relevant federal and state authorities. Qualifications will be verified periodically throughout the term of employment or contracting.

The Compliance Officer (or their designee) will develop and deliver training covering the principles and standards of MHP’s Code, Compliance Program, compliance policies and procedures, and overviews of the regulations that apply to MHP. This training will be required of all new hires shortly after they begin work and shall be conducted with all employees and agents, as appropriate, on a periodic and recurring basis. Specialized training shall be developed as needed for functional areas with increased regulatory complexities or risks. The Compliance Officer will coordinate with the lead in each such area to develop and facilitate the delivery of these specialized training programs.

Training shall be updated periodically by the Compliance Officer (or their designee) , and there will be, from time to time, training memos and bulletins issued on our changing regulatory environment and applicable new laws and rules that apply to MHP and our patients.

4. Open Lines of Communication

MHP strives to maintain an environment that is open, receptive and non-retaliatory for voicing concerns, raising questions or reporting violations or potential violations of the Code, Compliance Program, policies and procedures or our regulatory requirements. MHP makes a number of avenues of communication and information available to employees and agents to raise such concerns. MHP expects its management team to promote and support such an open environment.

Employees and agents are free to access whatever avenues they prefer to raise those questions. Questions and concerns regarding the Code, the Compliance Program or any policy and procedure can be addressed to the supervisor, any member of the management team, Human Resources or the Compliance Officer in person, by phone, letter or e-mail; the Compliance Officer will be notified of any compliance-related concerns.

Confidential Disclosure Program:

MHP also recognizes that there may be times that an individual would prefer to report a concern confidentially or anonymously. There is a Compliance Hotline at 855-696-4385 available to request information or indicate a potential concern if a discussion with the supervisor, management or Human Resources is not desired or has proven unsatisfying. This Hotline is monitored by the Compliance Officer and reports can be made confidentially, if requested. Additionally, reports may be made anonymously through the staff website, but anonymous reporting may limit the ability of the Compliance Officer to investigate complaints or respond fully to the party making the report.

Duty to Report

All employees and agents are required to raise concerns about compliance with MHP. Anyone who knows or suspects wrongdoing must report that information to their supervisor, a member of management or the Compliance Officer. Supervisors or management are responsible for notifying the Compliance Officer of any compliance-related concerns. Failure to report or intentional false reports will be considered a wrongdoing itself.

Non-retaliation Policy

MHP intends that no retaliation will be taken against any employee that raises a concern about compliance in good faith, solely on the basis that they reported an actual or potential violation to the appropriate party within the organization. Retaliation will be considered a wrongdoing itself.

5. Internal Auditing and Monitoring

MHP takes reasonable steps to achieve compliance with this Compliance Program, its policies and standards and the regulatory requirements that guide this organization, and to document that compliance. Ongoing internal checks and reviews are conducted to monitor, assess and evaluate its operations in high risk areas. The Compliance Officer conducts these reviews or facilitates other departments as they conduct their own reviews. Industry guidance as well as assessment of the operations of MHP inform the reviews that are to be conducted. Reports of results are delivered to the Committee, management, or Board of Directors by the Compliance Officer or department or function lead, as applicable.

6. Responding to Questions and Potential Violations

All concerns and inquiries are addressed according to the nature of the report. If interdisciplinary investigations are warranted among such areas as Compliance, Information Systems and Human Resources, there shall be collaboration on research, investigations and corrective actions as each situation dictates. Legal counsel or other outside resources shall be consulted when appropriate, as determined by the Compliance Officer or management.

The supervisor or manager shall refer compliance concerns to the Compliance Officer for response. Documentation of concerns and reports are compiled by the Compliance Officer and reported to the Committee and Board of Directors on a periodic basis or as issues warrant.

Responding to Government Inquiries and other Regulatory Authority Inquiries

It is MHP’s intent to comply fully with the laws and regulations that govern us. Inquiries received from regulatory agencies shall be referred immediately to the supervisor and the Compliance Officer. MHP will cooperate and respond in accordance with the request or inquiry being made.

7. Enforcing Standards and Corrective Action Processes

The Code, this Compliance Plan and Program, and all policies and procedures are made available to all employees and agents at all times. Updates are disseminated as they are issued.

A key element of our Compliance Program is addressing and correcting areas or processes that are found not to meet established policies, standards or regulatory requirements or that may be inconsistent with their intent. Concerns that indicate violations or potential violations should result in revisions to processes, systems or policies and procedures, or in corrective actions with individuals. These revisions and corrective actions will be verified and confirmed as appropriate.

Disciplinary Action

Violations of our Code, Compliance Program, the policies and procedures, or laws and regulations governing MHP shall be addressed according to the nature of the violation. Management, in consultation with Human Resources, will take disciplinary action that is appropriate, proportionate and consistent based upon the seriousness of the violation committed, up to and including termination. Violations of law will be reported to the appropriate legal authority.


Our Compliance Program sets forth and describes policies and expectations about appropriate job-related conduct and client care. The Compliance Program policies are intended to help employees and agents of MHP understand and fulfill their responsibilities and prevent and detect violations. Refer to these additional materials and documents for details and specific expectations.

Compliance Plan Version 3.0 January 1, 2016