hcgc board approved policies

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Access HealthColumbus (AHC) d/b/a Healthcare Collaborative of Greater Columbus Summary of Board Approved Policies (revised: January 20, 2016) Note: Copies of all policies are available on our website (www.hcgc.org) 1. Conflict of Interest and annual certification (2003, part of code of regulations)

Purpose: To protect the interest of the corporation when it is contemplating making a grant, or entering into a transaction or arrangement, (a) that might benefit the private interest of an officer or Director of the corporation or (b) with respect to which an officer or Director of the corporation may have conflicting interests or interests which may appear to conflict with the interests of the corporation. This policy is intended to supplement but not replace any applicable state laws governing conflicts of interest applicable to nonprofit corporations.

2. Board Job Description (2004) Purpose: To outline Board of Director responsibilities for advancing AHC’s mission and ensuring that it operates within the mission as well as in accordance with the state and federal laws that affect its operations.

3. Code of Ethics (2004) Purpose: To strive for the highest ethical conduct from all of its officers, staff and board members. AHC is particularly sensitive to persons who hold management and governance positions of trust and confidence in fulfilling the mission and goals of the organization. This AHC Code of Ethics is intended to supplement (but not replace) any laws governing ethics applicable to AHC. In an effort to achieve the highest standards of conduct, each AHC officer and staff and board member is required to acknowledge and to agree annually to be bound by this AHC Code of Ethics. All AHC officers and staff and board members are required and are expected to exercise the highest ethical standards of conduct and to practice fundamental honesty in carrying out their respective duties and responsibilities on behalf of AHC.

4. Contracting Guidelines (2004) Purpose: To provide guidelines for contracting with consultants and vendors to provide services in support of approved program and/or projects.

5. Financial Authorization Signature Policy (2009) Purpose: To provide guidance so that significant expenditures, contractual obligations and other actions which commit AHC financially and/or legally are reviewed and authorized on a consistent basis.

6. Record Retention (2009) Purpose: To ensure that necessary records and documents of AHC are adequately protected and maintained and to ensure that records that are no longer needed by AHC or are of no value are discarded at the proper time. This Policy is also for the purpose of aiding employees of AHC in understanding their obligations in retaining electronic documents - including e-mail, Web files, text files, sound and movie files, PDF documents, and all Microsoft Office or other formatted files.

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7. Whistleblower (2009) Purpose: To ensure no director, officer or employee who in good faith reports a violation of the Code shall suffer harassment, retaliation or adverse employment consequence. An employee who retaliates against someone who has reported a violation in good faith is subject to discipline up to and including termination of employment. This Whistleblower Policy is intended to encourage and enable employees and others to raise serious concerns within the Organization prior to seeking resolution outside the Organization.

8. Capital Expenditures (2010) Purpose: To define capital acquisition of individual asset and/or class of assets for purposes of accounting and financial reporting.

9. Confidentiality (2010) Purpose: To recognizes the importance of maintaining the confidentiality of the proprietary and sensitive information shared with AHC. At the same time, AHC also has a desire and need to share critical data and information that is obtained from such projects and activities with the community to maintain transparency and provide useful information resulting from AHC's projects and activities. In order to maintain the confidentiality of the proprietary information and data AHC receives from its Participants, yet maintain the ability to provide the community with important information, data and analyses resulting from its projects, AHC has adopted this Confidentiality Policy.

10. Operating Reserves (2011) Purpose: To define a framework for managing and monitoring the organization’s operating reserves.

11. Financial Literacy (2011) Purpose: To provide support to AHC Board Directors on financial literacy.

12. Media Relations (2011) Purpose: To ensure a consistent message and avoid conflicting statements from AHC in response to inquiries from the media.

13. Risk Management (2012) Purpose: To protect Access HealthColumbus’ (AHC) human, financial, and goodwill assets and resources through the practice of effective risk management.

14. Fiscal Sponsorship Contracting Policy (2016) Purpose: To ensure compliance with IRS tax laws when the 501c3 provides fiscal sponsorship services to an external group/organization, and the group/organization directs 501c3 to contract with LLC for professional services.

Access HealthColumbus

ARTICLE X: CONFLICTS OF INTEREST POLICY

Section 10.1. Purpose. The purpose of the conflicts of interest policy is to protect the interest

of the corporation when it is contemplating making a grant, or entering into a transaction or

arrangement, (a) that might benefit the private interest of an officer or Director of the corporation

or (b) with respect to which an officer or Director of the corporation may have conflicting

interests or interests which may appear to conflict with the interests of the corporation. This

policy is intended to supplement but not replace any applicable state laws governing conflicts of

interest applicable to nonprofit corporations.

Section 10.2. Definitions.

(a) Interested Person. An interested person is any Director, principal officer, or

member of a committee with Board delegated powers who either (1) has a direct

or indirect financial interest, as defined below, or (2) has any personal, business,

professional or other interest including an interest as a current or former director

or officer of or substantial contributor to a for-profit or nonprofit organization.

(b) Financial Interest. A person has a financial interest if the person has, directly or

indirectly, through business, investment or family –

(1) An ownership or investment interest in any entity with which the

corporation has a transaction or arrangement; or

(2) A compensation arrangement with the corporation or with any entity or

individual with which the corporation has a transaction or arrangement; or

(3) A potential ownership or investment interest in, or compensation

arrangement with, any entity or individual with which the corporation is

negotiating a transaction or arrangement.

Compensation includes direct and indirect remuneration as well as gifts or favors

that are substantial in nature.

A financial interest is not necessarily a conflict of interest. Under Section 10.3, a

person who has a financial interest will have a conflict of interest only if the

person declares a conflict of interest or if the appropriate Board or committee

decides that a conflict of interest exists.

Section 10.3. Procedures.

(a) Duty to Disclose; Declaration of a Conflict of Interest.

(1) In connection with any actual or possible conflict of interest, an interested

person must disclose the existence of his/her financial or other interest and

must be given the opportunity to declare a conflict of interest.

(2) If an interested person declares a conflict of interest, he/she may (but shall

not be required to) answer any questions raised by the Directors and

members of committees with Board delegated powers considering the

grant, transaction or arrangement. If an interested person declares a

conflict of interest, he/she shall leave the meeting during the discussion of,

and the vote on, the grant, transaction or arrangement that results in the

conflict of interest; provided, however, that the remaining Board or

committee members may decide to permit the interested person to remain

in the meeting during the discussion and/or vote.

(3) If an interested person discloses the existence of his/her financial or other

interest but does not declare a conflict of interest, he/she shall answer any

questions raised by the Directors and members of committees with Board

delegated powers considering his/her financial or other interest or the

grant, transaction or arrangement. The determination of whether a conflict

of interest exists shall be made in accordance with the procedures of

Section 10.3(b).

(b) Determining Whether A Conflict Of Interest Exists In The Absence Of A

Declaration. If an interested person discloses the existence of his/her financial or

other interest but does not declare a conflict of interest, after disclosure of the

financial or other interest, and after answering any questions, he/she shall leave

the Board or committee meeting while the determination of a conflict of interest is

discussed and voted upon. The remaining Board or committee members shall

decide if a conflict of interest exists. For this purpose, a material financial

interest shall be deemed a conflict of interest while an interest other than a

material financial interest is sufficient to, but need not, constitute a conflict of

interest.

(c) Procedures For Addressing The Conflict Of Interest In The Case Of A

Transaction Or Arrangement. If the conflict of interest pertains to a transaction or

arrangement:

(1) An interested person may (but shall not be required to) answer any

questions raised at the Board or committee meeting, and after providing

such answers, he/she shall leave the meeting during the discussion of, and

the vote on, the transaction or arrangement that results in the conflict of

interest; provided, however, that the remaining Board or committee

members may decide to permit the interested person to remain in the

meeting during the discussion and/or vote.

(2) The chairperson of the Board or committee shall, if appropriate, appoint a

disinterested person or committee to investigate alternatives to the

proposed transaction or arrangement.

(3) After exercising due diligence, the Board or committee shall determine

whether the corporation can obtain a more advantageous transaction or

arrangement with reasonable efforts from a person or entity that would not

give rise to a conflict of interest.

(4) If a more advantageous transaction or arrangement is not reasonably

attainable under circumstances that would not give rise to a conflict of

interest, the Board or committee shall determine by a majority vote of the

disinterested Directors whether the transaction or arrangement is in the

corporation's best interest and for its own benefit and whether the

transaction is fair and reasonable to the corporation and shall make its

decision as to whether to enter into the transaction or arrangement in

conformity with such determination.

(d) Violations Of The Conflicts Of Interest Policy.

(1) If the Board or committee has reasonable cause to believe that a member

has failed to disclose actual or possible conflicts of interest, it shall inform

the member of the basis for such belief and afford the member an

opportunity to explain the alleged failure to disclose.

(2) If, after hearing the response of the member and making such further

investigation as may be warranted in the circumstances, the Board or

committee determines that the member has in fact failed to disclose an

actual or possible conflict of interest, it shall take appropriate disciplinary

and corrective action.

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Role Description Board Directors

Approved: May 2004

Statement The Board of Directors is ultimately responsible for advancing AHC’s mission and ensuring that it operates within the mission as well as in accordance with the state and federal laws that affect its operations. The fiduciary responsibility of the Board involves a duty to act for the common good of community. Please refer to the Code of Regulations. Standards of Conduct Duties

The Duty of Commitment which requires Directors to be faithful to the AHC’s mission, acting in a way that is consistent with the purposes of AHC and applicable law.

The Duty of Care which requires Directors to exercise reasonable care by staying informed, participating in decisions and acting in good faith when making decisions on behalf of the AHC.

Board of Director Responsibilities

Directors will identify issues confronting access to health care for vulnerable populations, prioritize these issues and set long and short-term goals consistent with the mission of AHC to address these prioritized issues.

Directors will monitor on-going changing conditions within Franklin County in order to identify modifications to current priorities and initiatives.

Directors will identify key indicators for monitoring the status of access to health care; will develop and/or adopt policy recommendations and programs to improve access to health care in areas identified.

Directors will systematically assess the AHC’s mission, programs, initiatives and strategies; and recommend modifications to enhance the effectiveness of the organization.

Directors have fiduciary responsibility for AHC and are responsible to: o review, modify and approve the annual budget for AHC as recommended by the Executive Committee,

including all project budgets; o receive and accept the annual audit and/or financial report; o take action on the auditor’s recommendations; o remain informed regarding AHC’s financial status.

Directors will work to implement strategies to ensure the financial sustainability of AHC;

Directors will advance AHC’s public image, listening to and speaking with constituents and public figures regarding the role and effectiveness of AHC. The executive director is usually the primary spokesperson for the AHC but it is essential that the board provide support in communicating the AHC’s mission, purpose and effectiveness.

Ensure legal and ethical integrity and maintain accountability, adhering to the Articles of Incorporation and Code of Regulations.

Additional responsibilities of Directors are to: o participate in at least 80% of scheduled Board meetings, up to 6 meetings per year

(no delegates should attend Board meetings when Directors are unavailable);

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o participate in at least one committee or task force per year; o assist in recruiting and orienting new Directors where appropriate; o assist in promoting and gaining support for the work of AHC; o strengthen the effectiveness of the Board by periodically assessing the Board’s performance, reviewing

Board composition, structure, and the Director selection process; o Provide input as requested on performance of Executive Director.

Affiliated Organization Responsibilities Access HealthColumbus operates as a public-private partnership and its Directors participate as representatives from affiliated organizations. Therefore Directors have unique roles when compared to other voluntary Boards.

Directors will insure their affiliated organizations use AHC as a forum for discussing access to health care issues.

Directors will insure they understand and communicate the perspectives of their affiliated organizations when collaborating with others at the AHC table on matters of programs, policies, and actions.

Conflicting Demands

Enlightened Self Interest: Directors may encounter conflicts associated with balancing the priorities of AHC with those of their affiliated organizations. Directors are expected to discuss the objectives of AHC and their organization, with the intention of finding a mutually acceptable approach.

Priority Issues vs. Particular Issues: There will undoubtedly be issues impacting a segment of Franklin County’s population that will be brought to the attention of the Directors -- some of which will have great compassionate appeal. Directors will be challenged to remain focused on the priority issues while determining appropriate responses to such particular issues.

Balancing Needs and Priorities with Resources: Needs, even prioritized needs, will exceed resources available to AHC, including resources of the “time” of Directors, as well as financial and staff resources. Directors will be challenged to direct resources to the identified priorities and seek additional resources to meet expanded priorities and needs.

Clarifying the Appropriate Role of AHC: There are multiple partners in Franklin County addressing issues that impact access to health care. As issues are identified and priorities are set, Directors will be challenged to clarify the role of AHC in addressing the particular issue.

Access Health Columbus

Code of Business Conduct and Ethics [Board approved: March 21, 2007]

It is the intent of Access HealthColumbus (AHC) to strive for the highest ethical conduct from all of its officers, staff and board members. AHC is particularly sensitive to persons who hold management and governance positions of trust and confidence in fulfilling the mission and goals of the organization. This AHC Code of Ethics is intended to supplement (but not replace) any laws governing ethics applicable to AHC. In an effort to achieve the highest standards of conduct, each AHC officer and staff and board member is required to acknowledge and to agree annually to be bound by this AHC Code of Ethics. All AHC officers and staff and board members are required and are expected to exercise the highest ethical standards of conduct and to practice fundamental honesty in carrying out their respective duties and responsibilities on behalf of AHC. Consistent with and in support of AHC’s standards of high ethical conduct, in performing his or her duties and responsibilities for AHC, each such person WILL NOT: • Deceive, defraud, or mislead any other AHC officer, staff or board member, or other persons

with whom AHC does business or has any other relationship.

• Intentionally misrepresent AHC in any negotiations, dealings, contracts, or agreements.

• Divulge or release any information of a proprietary or confidential nature relating to AHC’s plans, mission, or operations without appropriate prior approval.

• Use AHC’s name in a manner adverse to the interests of AHC to obtain a personal, professional or business advantage or benefit.

• Accept gifts from any third party on the basis of his or her position with AHC (other than occasional individual gifts valued at no more than $50, or if valued at more than $50, gifts made available generally for sharing with other AHC officers, staff and/or board members—e.g., fruit baskets, boxes of candy, etc.).

• Use AHC’s property or financial resources, or the services of other AHC personnel, for personal benefit or financial gain.

• Intentionally or willfully violate any laws or ordinances applicable to AHC.

• Engage in any other unethical business practice or conduct of any type.

AHC requires honest and accurate recording and reporting of information in order to insure responsible business decisions. All of the books, records, accounts and financial statements of AHC must be maintained in reasonable detail, must reflect appropriately AHC’s transactions and must conform both to applicable legal requirements and to AHC’s system of internal controls. Unrecorded or “off the books” funds or assets should not be maintained and all transactions involving AHC should be reflected in its books and records unless otherwise permitted by applicable law or regulation. Each director, officer and staff member of AHC is required to report any misstatement, omission or accounting irregularity known to him or her in order to bolster and support AHC’s system of internal accounting controls.

AHC’s business records should be retained and/or destroyed in accordance with AHC’s record retention and destruction policies and applicable law. In accordance with such policies and laws, in the event of the commencement of any litigation or governmental investigation involving AHC, all such records should be maintained and not destroyed until and unless otherwise instructed by AHC’s legal counsel.

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Persons who violate the standards in this AHC Code of Ethics may be subject to disciplinary action. Infractions of this Code are to be reported directly to any member of the AHC Board’s Finance and Audit Committee. If deemed appropriate by such committee, the committee shall bring the infraction to the attention of the Executive Committee of the AHC Board for disciplinary or corrective action as deemed appropriate by such Executive Committee.

All directors, officers and staff members of AHC are encouraged to contact the chairperson of the AHC board of directors or a member of the Finance and Audit Committee of the AHC board to report any observed actual or perceived illegal or unethical conduct or behavior by any person who is subject to this Code. Any such report may be made on a confidential basis at the request of the reporting person. It is the policy of AHC not to allow retaliation against a reporting person for reports of misconduct by others made in good faith by the reporting person. All AHC directors, officers and staff members are expected to cooperate with AHC management in connection with any internal investigations of misconduct or other violation of this Code.

ACKNOWLEDGEMENT AND AGREEMENT

I have read and I understand AHC’s Code of Ethics as set forth above. I agree to be bound by such code.

Signature Date

Name (please print)

Date: April 23, 2004 To: AHC Executive Committee From: Jeff Biehl Subject: Contracting Guidelines As the Executive Director, there will be an ongoing need to engage consultants and vendors to provide services in support of approved program and/or projects. I propose the following:

The Executive Director is granted to authority to enter into appropriate vendor/consulting contracts for programs or projects approved by the AHC Board or AHC Executive Committee.

The Executive Director will use his/her professional judgment to involve others in the vendor evaluation process, as appropriate.

The Executive Director will report contractual commitment to the AHC Executive

Committee during standing committee meetings.

The Executive Director should be prepared to demonstrate the cost-effectiveness to the AHC Executive Committee and/or AHC Board for any contracts awarded that exceed $50,000.

The Executive Director should maintain arms-length transactions with consultants/vendors and disclose any existing relationships.

Approved by Executive Committee, May 27, 2004

FINANCIAL AUTHORIZATION & SIGNATURE POLICY

Finance & Audit Committee

Approved: 08/27/2008

Revised: 11/3/2009 (Finance Committee approval)

The following policy outlines the highest level of authorization and signature required for various types of financial transactions. The purpose of this policy is to provide guidance so that significant expenditures, contractual obligations and other actions which commit the Access HealthColumbus financially and/or legally are reviewed and authorized on a consistent basis.

Area Limit Authorization

Purchases (capital and non-capital)

$10,000 >$10,000

Access HealthColumbus President 2nd signature by Board Officer required

Contracts/Leases $50,000 > $50,000


Checks** $10,000 >$10,000


** Policy Exception: per leased employee agreement with the Columbus Medical Association Foundation, a monthly invoice for staff salaries and benefits typically exceeds the $10,000 signing limit. These monthly payments will require only one signature if within approved budget amounts.

RECORD RETENTION AND DESTRUCTION POLICY Board Approved: May 20, 2009

1) Purpose

The purpose of this Policy is to ensure that necessary records and documents of Access HealthColumbus are adequately protected and maintained and to ensure that records that are no longer needed by Access HealthColumbus or are of no value are discarded at the proper time. This Policy is also for the purpose of aiding employees of Access HealthColumbus in understanding their obligations in retaining electronic documents - including e-mail, Web files, text files, sound and movie files, PDF documents, and all Microsoft Office or other formatted files.

2) Policy

This Policy represents the Access HealthColumbus policy regarding the retention and disposal of records and the retention and disposal of electronic documents. The disposal of records will be conducted based on retention periods identified in this document.

3) Administration

Attached as Appendix A is a Record Retention Schedule that is approved as the initial maintenance, retention and disposal schedule for physical records of Access HealthColumbus and the retention and disposal of electronic documents. The President (the “Administrator”) is the officer in charge of the administration of this Policy and the implementation of processes and procedures to ensure that the Record Retention Schedule is followed. The Administrator is also authorized to: make modifications to the Record Retention Schedule from time to time to ensure that it is in compliance with local, state and federal laws and includes the appropriate document and record categories for Access HealthColumbus; monitor local, state and federal laws affecting record retention; annually review the record retention and disposal program; and monitor compliance with this Policy.

4) Suspension of Record Disposal In Event of Litigation or Claims

In the event Access HealthColumbus is served with any subpoena or request for documents or any employee becomes aware of a governmental investigation or audit concerning Access HealthColumbus or the commencement of any litigation against or concerning Access HealthColumbus, such employee shall inform the Administrator and any further disposal of documents shall be suspended until shall time as the Administrator, with the advice of counsel, determines otherwise. The Administrator shall take such steps as is necessary to promptly inform all staff of any suspension in the further disposal of documents.

5) Applicability

This Policy applies to all physical records generated in the course of Access HealthColumbus’ operation, including both original documents and reproductions. It also applies to the electronic documents described above.

Created: May 2009 Created by: President Page 2 of 10 Revised:

APPENDIX A - RECORD RETENTION SCHEDULE

SECTION TOPIC A. Accounting and Finance B. Contracts C. Corporate Records D. Correspondence and Internal Memoranda E. Electronic Documents F. Grant Records G. Insurance Records H. Legal Files and Papers I. Miscellaneous J. Payroll Documents K. Pension Documents L. Personnel Records M. Property Records N. Tax Records O. Contribution Records P. Programs & Services Records Q. Fiscal Sponsor Project Records A. ACCOUNTING AND FINANCE

Record Type Retention Period

Accounts Payable ledgers and schedules 7 years

Accounts Receivable ledgers and schedules 7 years

Annual Audit Reports and Financial Statements Permanent

Annual Audit Records, including work papers and other documents that relate to the audit

7 years after completion of audit

Annual Plans and Budgets 2 years

Bank Statements and Canceled Checks 7 years

Employee Expense Reports 7 years

Notes Receivable ledgers and schedules 7 years

Investment Records 7 years after sale of investment

Credit card records (documents showing customer credit card number)

2 years


1. Credit card record retention and destruction

All records showing customer credit card number must be locked in a desk drawer or a file cabinet when not in immediate use by staff. If it is determined that information on a document, which contains credit card information, is necessary for retention beyond 2 years, then the credit card number will be cut out of the document.

B. CONTRACTS


Contracts and Related Correspondence (including any proposal that resulted in the contract and all other supportive documentation)

7 years after expiration or termination

C. CORPORATE RECORDS


Corporate Records (minute books, signed minutes of the Board and all committees, corporate seals, articles of incorporation, bylaws, annual corporate reports)

Permanent

Licenses and Permits Permanent

D. CORRESPONDENCE AND INTERNAL MEMORANDA

General Principle: Most correspondence and internal memoranda should be retained for the same period as the document they pertain to or support. For instance, a letter pertaining to a particular contract would be retained as long as the contract (7 years after expiration). It is recommended that records that support a particular project be kept with the project and take on the retention time of that particular project file. Correspondence or memoranda that do not pertain to documents having a prescribed retention period should generally be discarded sooner. These may be divided into two general categories: 1. Those pertaining to routine matters and having no significant, lasting consequences should be

discarded within two years. Some examples include:


Routine letters and notes that require no acknowledgment or follow-up, such as notes of appreciation, congratulations, letters of transmittal, and plans for meetings.

Form letters that require no follow-up.

Letters of general inquiry and replies that complete a cycle of correspondence.

Letters or complaints requesting specific action that have no further value after changes are made or action taken (such as name or address change).

Other letters of inconsequential subject matter or that definitely close correspondence to which no further reference will be necessary.

Chronological correspondence files.

Please note that copies of interoffice correspondence and documents where a copy will be in the originating department file should be read and destroyed, unless that information provides reference to or direction to other documents and must be kept for project traceability.

2. Those pertaining to non-routine matters or having significant lasting consequences should generally be retained permanently.

E. ELECTRONIC DOCUMENTS

1. Electronic Mail: Not all email needs to be retained, depending on the subject matter.

Staff will strive to keep all but an insignificant minority of their e-mail related to business issues.

Access HealthColumbus will archive e-mail for six months after the staff has deleted it, after which time the e-mail will be permanently deleted.

All Access HealthColumbus business-related email should be downloaded to a service center or user directory on the server.

Staff will not store or transfer Access HealthColumbus-related e-mail on non-work-related computers except as necessary or appropriate for Access HealthColumbus purposes.

Staff will take care not to send confidential/proprietary Access HealthColumbus information to outside sources.

2. Electronic Documents: including Microsoft Office Suite and PDF files. Retention also depends

on the subject matter.

PDF documents – The length of time that a PDF file should be retained should be based upon the content of the file and the category under the various sections of this policy. The maximum period that a PDF file should be retained is 6 years. PDF files the employee deems vital to the performance of his or her job should be printed and stored in the employee’s workspace.

Text/formatted files - Staff will conduct annual reviews of all text/formatted files (e.g., Microsoft Word documents) and will delete all those they consider unnecessary or outdated.


3. Web Page Files: Internet Cookies

Access HealthColumbus does not automatically delete electronic files beyond the dates specified in this Policy. It is the responsibility of all staff to adhere to the guidelines specified in this policy.

Each day Access HealthColumbus will run a tape backup copy of all electronic files (including email). This backup is a safeguard to retrieve lost information within a one-year retrieval period should documents on the network experience problems. The backup copy is considered a safeguard for the record retention system of Access HealthColumbus, but is not considered an official repository of Access HealthColumbus records. In certain cases a document will be maintained in both paper and electronic form. In such cases the official document will be the electronic document.

F. GRANT RECORDS


Original grant proposal 7 years after completion of grant period Grant agreement and subsequent modifications, if applicable

7 years after completion of grant period

All requested IRS/grantee correspondence including determination letters and “no change” in exempt status letters


Final grantee reports, both financial and narrative


All evidence of returned grant funds 7 years after completion of grant period All pertinent formal correspondence including opinion letters of counsel


Report assessment forms 7 years after completion of grant period Documentation relating to grantee evidence of invoices and matching or challenge grants that would support grantee compliance with the grant agreement


Pre-grant inquiry forms and other documentation for expenditure responsibility grants




Grantee work product produced with the grant funds


G. INSURANCE RECORDS


Annual Loss Summaries 10 years

Audits and Adjustments 3 years after final adjustment

Certificates Issued to Access HealthColumbus Permanent

Claims Files (including correspondence, medical records, injury documentation, etc.)

Permanent

Employee Insurance Plans - Active Employees Permanent

Inspections 3 years

Business Insurance Policies (including expired policies)

Permanent

Journal Entry Support Data 7 years

Loss Runs 10 years

Releases and Settlements 25 years

H. LEGAL FILES AND PAPERS


Legal Memoranda and Opinions (including all subject matter files)

7 years after close of matter

Litigation Files 1 year after expiration of appeals or time for filing appeals

Court Orders Permanent

Requests for Departure from Records Retention Plan 10 years


I. MISCELLANEOUS


Consultant's Reports 2 years

Material of Historical Value (including pictures, publications)

Permanent

Policy and Procedures Manuals – Original Current version with revision history

Policy and Procedures Manuals - Copies Retain current version only

Annual Reports Permanent

J. PAYROLL DOCUMENTS


Employee Deduction Authorizations 4 years after termination

Payroll Deductions Termination + 7 years

W-2 and W-4 Forms Termination + 7 years

Garnishments, Assignments, Attachments Termination + 7 years

Labor Distribution Cost Records 7 years

Payroll Registers (gross and net) 7 years

Time Cards/Sheets 2 years

Unclaimed Wage Records 6 years

K. PENSION DOCUMENTS AND SUPPORTING EMPLOYEE DATA

General Principle: Pension documents and supporting employee data shall be kept in such a manner that Donors Forum can establish at all times whether or not any pension is payable to any person and if so the amount of such pension.


Retirement and Pension Records Permanent


L. PERSONNEL RECORDS


Commissions/Bonuses/Incentives/Awards 7 years

EEO- I /EEO-2 - Employer Information Reports 2 years after superseded or filing (whichever is longer)

Employee Earnings Records Separation + 7 years Employee Handbooks 1 copy kept permanently Employee Medical Records Separation + 6 years Employee Personnel Records (including individual attendance records, application forms, job or status change records, performance evaluations, termination papers, withholding information, garnishments, test results, training and qualification records)

6 years after separation

Employment Contracts – Individual 7 years after separation Employment Records - Correspondence with Employment Agencies and Advertisements for Job Openings

3 years from date of hiring decision

Employment Records - All Non-Hired Applicants (including all applications and resumes - whether solicited or unsolicited, results of post-offer, pre-employment physicals, results of background investigations, if any, related correspondence)

2-4 years (4 years if file contains any correspondence which might be construed as an offer)

Job Descriptions 3 years after superseded Personnel Count Records 3 years

Forms I-9 3 years after hiring, or 1 year after separation if later


M. PROPERTY RECORDS Record Type Retention Period Correspondence, Property Deeds, Assessments, Licenses, Rights of Way

Permanent

Original Purchase/Sale/Lease Agreement Permanent Property Insurance Policies Permanent

N. TAX RECORDS

General Principle: Donors Forum must keep books of account or records as are sufficient to establish amount of gross income, deductions, credits, or other matters required to be shown in any such return. These documents and records shall be kept for as long as the contents thereof may become material in the administration of federal, state, and local income, franchise, and property tax laws.


Tax-Exemption Documents and Related Correspondence

Permanent

IRS Rulings Permanent

Excise Tax Records 7 years

Payroll Tax Records 7 years

Tax Bills, Receipts, Statements 7 years

Tax Returns - Income, Franchise, Property Permanent

Tax Workpaper Packages - Originals 7 years

Sales/Use Tax Records 7 years

Annual Information Returns - Federal and State Permanent

IRS or other Government Audit Records Permanent


O. CONTRIBUTION RECORDS


Records of Contributions Permanent

Access HealthColumbus or other documents evidencing terms of gifts

Permanent

P. PROGRAM AND SERVICE RECORDS


Research & Publications Permanent (1 copy only)

Q. FISCAL SPONSOR PROJECT RECORDS


Sponsorship agreements Permanent

Whistleblower Policy Board Approved: March 2009

General

The Access HealthColumbus Code of Ethics and Conduct (“Code”) requires directors, officers and employees to observe high standards of business and personal ethics in the conduct of their duties and responsibilities. As employees and representatives of the Organization, we must practice honesty and integrity in fulfilling our responsibilities and comply with all applicable laws and regulations.

Reporting Responsibility

It is the responsibility of all directors, officers and employees to comply with the Code and to report violations or suspected violations in accordance with this Whistleblower Policy.

No Retaliation

No director, officer or employee who in good faith reports a violation of the Code shall suffer harassment, retaliation or adverse employment consequence. An employee who retaliates against someone who has reported a violation in good faith is subject to discipline up to and including termination of employment. This Whistleblower Policy is intended to encourage and enable employees and others to raise serious concerns within the Organization prior to seeking resolution outside the Organization.

Reporting Violations

The Code addresses the Organization’s open door policy and suggests that employees share their questions, concerns, suggestions or complaints with someone who can address them properly. In most cases, an employee’s supervisor is in the best position to address an area of concern. However, if an employee is not comfortable speaking with his/her supervisor or he/she is not satisfied with the supervisor’s response, he/she is encouraged to speak with someone in Human Resources or someone else in management with whom he/she is comfortable approaching. Supervisors and managers are required to report suspected violations of the Code of Conduct to the Organization’s Compliance Officer, who has specific and exclusive responsibility to investigate all reported violations. For suspected fraud, or when an employee is not satisfied or uncomfortable with following the Organization’s open door policy, individuals should contact the Organization’s Compliance Officer directly.

Compliance Officer

The Organization’s Compliance Officer is responsible for investigating and resolving all reported complaints and allegations concerning violations of the Code and, at his discretion, shall advise the Executive Director and/or the Finance committee. The Compliance Officer has direct access to the Finance committee of the board of directors and is required to report to the Finance committee at least annually on compliance activity. The Organization’s Compliance Officer is the chair of the Finance committee.

Accounting and Auditing Matters

The Finance committee of the board of directors shall address all reported concerns or complaints regarding corporate accounting practices, internal controls or auditing. The Compliance Officer shall immediately notify the Finance committee of any such complaint and work with the committee until the matter is resolved.

Acting in Good Faith

Anyone filing a complaint concerning a violation or suspected violation of the Code must be acting in good faith and have reasonable grounds for believing the information disclosed indicates a violation of the Code. Any allegations that prove not to be substantiated and which prove to have been made maliciously or knowingly to be false will be viewed as a serious disciplinary offense.

Confidentiality

Violations or suspected violations may be submitted on a confidential basis by the complainant or may be submitted anonymously. Reports of violations or suspected violations will be kept confidential to the extent possible, consistent with the need to conduct an adequate investigation.

Handling of Reported Violations

The Compliance Officer will notify the sender and acknowledge receipt of the reported violation or suspected violation within five business days. All reports will be promptly investigated and appropriate corrective action will be taken if warranted by the investigation.

This policy was written with the following attribution: National Council of Nonprofit Associations, www.ncna.org.

http://www.ncna.org/

CAPITAL EXPENDITURES POLICY

Board approved: November 17, 2010

Definition

A capital acquisition is an individual asset and/or class of assets that has a useful life of

more than one year and a cost of $1,000 or more.

Budget

Anticipated capital acquisitions shall be included in the normal budgetary process, and

when necessary, as part of the separate capital acquisitions budget. The annual budget

shall include purchase requests for all new and replacement acquisitions.

Executive Authority

The chief executive shall have the authority to make purchases that are part of the

approved annual budget without additional approval from the board. Such acquisitions

shall be reported to the board and finance committee at their next regular meeting.

CONFIDENTIALITY POLICY

Board approved: November 17, 2010

Purpose. Access HealthColumbus ("AHC") conducts and is engaged in various projects and

activities to improve access to health care in the community. In connection with such projects

and activities, AHC convenes partnerships with and among public and private institutions and

individuals and has access to various proprietary and sensitive information and data from health

care providers, payors and other organizations that participate in AHC's projects (the

"Participants"). AHC recognizes the importance of maintaining the confidentiality of the

proprietary and sensitive information shared with AHC by its Participants. At the same time,

AHC also has a desire and need to share critical data and information that is obtained from such

projects and activities with the community to maintain transparency and provide useful

information resulting from AHC's projects and activities. In order to maintain the confidentiality

of the proprietary information and data AHC receives from its Participants, yet maintain the

ability to provide the community with important information, data and analyses resulting from its

projects, AHC has adopted this Confidentiality Policy.

Restrictions on Use of Information that Identifies a Participant. AHC shall maintain the

confidentiality of Participant's data and information that is disclosed to AHC, including the use

of data and information in any reports, research, benchmarking, and studies, in such a way as to

protect against revealing the identity of the Participant or any of its patients, members or clients.

The Participants' data and information that is subject to such confidentiality shall be any such

data and information furnished by a Participant to AHC that identifies (or could be used to

identify) a Participant or any of Participant's patients, members or clients. AHC shall maintain

the confidentiality of the Participants' data and information in compliance with applicable

federal, state and local laws and regulations, and AHC’s Record Retention and Destruction

policy.

Permissible Uses of Information Provided by Participants. From time to time, AHC may

publish and distribute community reports, analyses, presentations or other documents or

materials containing data and information supplied to AHC from Participants (the "Community

Reports"). The Community Reports shall report data and information provided by Participants in

aggregate form only and shall not identify specific Participants or disclose the data and

information in any way that attributes such data and information to individual Participants,

unless otherwise agreed to in advance by a Participant and as permitted by law. AHC staff, its

board, board committees and AHC contractors shall be entitled to review data and information

supplied by Participants in order to analyze such data and produce Community Reports,

provided, however, that all such individuals shall maintain the confidentiality of such data and

information and not disclose the same to any unauthorized individual or third party.

OPERATING RESERVES POLICY

Board approved: 7/20/2011

Purpose: to define a framework for managing and monitoring the organization’s

operating reserves

Policy:

Access HealthColumbus will maintain up to twelve months (ceiling) of operating

reserves in banking accounts insured by the FDIC

The ceiling will be calculated by averaging the current and previous years total

operating expenses from board approved budgets

Reserves can be directed to support board approved projects as recommended by

staff and approved by a majority of the board of directors

Reserves will be reviewed at scheduled Finance Committee meetings as part of

the review of financial statements

FINANCIAL LITERACY POLICY


Purpose: to provide support to Access HealthColumbus Board Directors on financial

literacy

Policy:

During orientation sessions for new board directors, the Access HealthColumbus

executive director will provide in-depth review of the organization’s most recent tax

return (IRS form 990) and financial statement.

As requested, individual board directors will be provided with a personal overview of

the organization’s tax return and/or financial statements by contacting Access

HealthColumbus’ treasurer or executive director.

MEDIA RELATIONS POLICY


Purpose: to ensure a consistent message and avoid conflicting statements from Access

HealthColumbus in response to inquiries from the media

Policy:

If a board director is contacted by media to discuss Access HealthColumbus’

organizational perspective on a news-related topic, board directors should refer the

media to Access HealthColumbus’s president as the primary media contact for the

organization.

If Access HealthColumbus’ president is not available, media should be referred to

either the board chair or vice-chair.

RISK MANAGEMENT POLICY Board approved: July 18, 2012

Purpose: To protect Access HealthColumbus’ (AHC) human, financial, and goodwill assets and resources through the practice of effective risk management. Policy: Annually the AHC Executive Committee and management will:

identify AHC’s (internal) weaknesses and (external) threats;

conduct an analysis of weaknesses and threats;

identify strategies and planned actions to reduce weaknesses and threats;

engage AHC Board in review of strategies and planned actions to reduce weaknesses and threats.

Access HealthColumbus d/b/a Healthcare Collaborative of Greater Columbus (HCGC)

Fiscal Sponsorship Contracting Policy - draft Board approved: January 20, 2016

Purpose: To ensure compliance with IRS tax laws when HCGC provides fiscal sponsorship services to an external organization/group; and the external organization/group directs HCGC to contract with AHC Enterprises LLC (HCGC’s for-profit subsidiary) for professional services. Policy: • HCGC Board will approve (via a simple majority vote) a written resolution outlining the

fiscal sponsorship, scope of services, and a statement that demonstrates HCGC is contracting with its LLC based on fair-market value for its services.

• LLC Board of Managers serving on the HCGC Board must recuse him/herself from voting on the resolution.

• HCGC will limit its fiscal sponsorship services to initiatives that impact health or healthcare.

• HCGC’s treasurer will sign the professional services agreement between HCGC and the LLC on behalf of HCGC.

hcgc board approved policies

Documents

documents of ahc

ahc officers

ahc code of ethics

behalf of ahc

code of regulations

board members

ethics applicable

board job description