Corporate Compliance Program

The Corporate Compliance Program of Beth Sholom Lifecare Community (“Beth Sholom”) is a written and operational commitment to organization-wide compliance with all applicable laws. This includes laws governing quality of care, laws and regulations and state licensure laws, fraud and abuse-specific laws like the federal False Claims Act and Anti-Kickback Statute, HIPAA Omnibus, and a variety of other laws governing the delivery of care and claims for payment in nursing facilities.

The Corporate Compliance Program is concerned with the detection and prevention of fraud, waste and abuse in all areas. The government defines “fraud” as the intentional deception or misrepresentation when the individual knows it to be false (or does not believe it to be true), knowing that the deception could result in an unauthorized benefit to himself or another person. “Abuse” is defined as incidents or practices that are inconsistent with sound health care practice and may result in unnecessary costs, improper payment, or the payment for services that either fail to meet professional standards of care or are medically unnecessary.

The Corporate Compliance Program promotes doing business in a way that prevents intentional or unintentional violations of the laws regulating nursing homes. The Corporate Compliance Program includes policies and procedures, staff training and education and mechanisms to detect, investigate and report any potential conflicts or violations. A Corporate Compliance Program can protect the facility and its employees from civil damages and government sanctions.


Discrimination Complaint Proceduces
Handling, Tracking, Resolving, and Reporting Investigations/Complaints

Any individual may exercise his or her right to file a complaint with Beth Sholom Lifecare Community (hereafter referred to as “BSLCC”) if that person believes that s/he or any other program beneficiaries have been subjected to unequal treatment or discrimination in the receipt of benefits/services or prohibited by non-discrimination requirements. BSLCC will make a concerted effort to resolve complaints locally, using the agency’s Nondiscrimination Complaint Procedures, as described below. All Title VI complaints and their resolution will be logged as described under “Data collection” and reported immediately.

Should any Title VI investigations be initiated by any Federal Agency (e.g. FTA), or any Title VI lawsuits be filed against BSLCC, the agency will follow these procedures listed below.

These procedures apply to all complaints filed under Title VI of the Civil Rights Act of 1964 as amended, and the Civil Rights Restoration Act of 1987, relating to any program or activity administered by BSLCC as well as to sub-recipients, consultants, and/or contractors. Intimidation or retaliation of any kind is prohibited by law. These procedures do not deny the right of the complainant to file formal complaints with other state or federal agencies, or to seek private counsel for complaints alleging discrimination. These procedures are part of an administrative process that does not provide for remedies that include punitive damages or compensatory remuneration for the complainant. Every effort will be made to obtain early resolution of complaints at the lowest level possible. The option of informal mediation meeting(s) between the affected parties and the Title VI Compliance Officer may be utilized for resolution. The Title VI Compliance Officer will make every effort to pursue a resolution to the complaint. Initial interviews with the complainant and the respondent will request information regarding specifically requested relief and settlement opportunities.


  1. Any individual, group of individuals, or entity that believes they have been subjected to discrimination prohibited by Title VI nondiscrimination provisions may file a written complaint with BSLCC’s Title VI Program Compliance Officer. A formal complaint must be filed within 180 calendar days of the alleged occurrence or when the alleged discrimination became known to the complainant. The complaint must meet the following requirements:
    a. Complaint shall be in writing and signed by the complainant(s).
    b. Include the date of the alleged act of discrimination (date when the complainant(s) became aware of the alleged discrimination; or the date on   which that conduct was discontinued or the latest instance of the conduct).
    c. Present a detailed description of the issues, including names and job titles of those individuals perceived as parties in the complained-of incident.
    d. Allegations received by fax or e-mail will be acknowledged and processed, once the identity(ies) of the complainant(s) and the intent to proceed with the complaint have been established. The complainant is required to mail a signed, original copy of the fax or e-mail transmittal for BSLCC to process it.
    e. Allegations received by telephone will be reduced to writing and provided to complainant for confirmation or revision before processing.
    f. A complaint form will be forwarded to the complainant for him/her to complete, sign, and return to BSLCC for processing.
  2. Upon receipt of the complaint, the Title VI Compliance Officer will determine its jurisdiction, acceptability, and need for additional information, as well as investigate the merit of the complaint.
  3. In order to be accepted, a complaint must meet the following criteria:
    a. The complaint must be filed within 180 calendar days of the alleged occurrence or when the alleged discrimination became known to the complainant.
    b. The allegation(s) must involve a covered basis such as race, color, or national origin.
    c. The allegation(s) must involve a program or activity of a federal-aid recipient, subrecipient, or contractor.
  4. A complaint may be dismissed for the following reasons:
    a. The complainant requests the withdrawal of the complaint.
    b. The complainant fails to respond to repeated requests for addition information needed to process the complaint.
    c. The complainant cannot be located after reasonable attempts.
  5. Once BSLCC decides to accept the complaint for investigation, the complainant and the respondent will be notified in writing of such determination within seven calendar days. The complaint will receive a case number and will then be logged into BSLCC’s records identifying its basis and alleged harm.
  6. BLSCC’s final investigative report and a copy of the complaint will be forwarded to the appropriate Federal Agency (e.g. FTA) and affected parties within 60 calendar days of the acceptance of the complaint.
  7. BSLCC will notify the parties of its final decision.
  8. If complainant is not satisfied with the results of the investigation of the alleged discrimination and practices the complainant will be advised of their right file a complaint with the appropriate Federal Agency.

Please contact the following:

Sue Berinato, Compliance Officer
1600 John Rolfe Parkway
Richmond, VA 23238

Phone: (804) 421-5037


Discrimination is Against the Law

Beth Sholom Lifecare Community complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Beth Sholom does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Beth Sholom Lifecare Community:
Provides free aids and services to people with disabilities to communicate effectively with us, such as:

-Qualified sign language interpreters
-Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

-Qualified interpreters
-Information written in other languages

If you need these services, contact Sue Berinato, Civil Rights Coordinator (see below).

If you believe that Beth Sholom Lifecare Community has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Sue Berinato, Corporate Compliance Officer/Civil Rights Coordinator
c/o Beth Sholom Lifecare Community
1600 John Rolfe Parkway
Richmond, VA 23238
Phone: 804-421- 5037      TTY users dial “711”
Fax: 804-741-9813         email:

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,

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

Equal Employment Opportunity

Beth Sholom Lifecare Community (hereafter referred to as “BSLCC) is committed to providing equal opportunity for all applicants and employees regardless of race, color, religion, sex, age, marital status, national origin, citizenship status, disability, veteran status or political affiliation.

Equal Opportunity extends to all aspects of the employment relationship, including hiring, transfers, promotions, training, terminations, working conditions, compensation, benefits, and other terms and conditions of employment.

BSLCC complies with federal and state equal employment opportunity laws and strives to keep the workplace free from all forms of harassment, including sexual harassment. DRPT considers harassment in all forms to be a serious offense.

Any employee who believes he or she has been subjected to prohibited discrimination or harassment should report the alleged act immediately to his or her supervisor or the next level supervisor, the division/project director, or the Compliance Officer. If a complaint involves a manager or supervisor, the complaint should be filed directly with the next level of supervisor or the Department of Human Resources. The agency ensures that employees following this complaint procedure are protected against illegal retaliation.

Any reported violations of EEO law or this policy are investigated. Directors, managers, supervisors, employees, or agency appointed authorities found to have engaged in discriminatory conduct or harassment are subject to immediate disciplinary action, including possible termination of employment.

Fair Housing Act, Title VIII of the Civil Rights Act of 1968

In general, the Fair Housing Act prohibits discrimination in most housing and housing-related transactions with respect to the following: race, color, religion, sex, disability, familial status, national original, or elderliness. Under the Fair Housing Act, Beth Sholom does not:

  1. deny anyone the opportunity to apply to rent housing or deny to any qualified applicant the opportunity to lease housing suitable to his or her needs;
  2. provide anyone housing that is different from that provided to others;
  3. subject anyone to segregation, even if by floor or wing;
  4. restrict anyone’s access to benefits enjoyed by others in connecting with the housing program;
  5. treat anyone differently in determining eligibility or other requirements for admissions, in use of the housing amenities, facilities or programs;
  6. deny anyone access to the same level of services;
  7. deny anyone the opportunity to participate in a planning or advisory group that is an integral part of the program;
  8. publish or cause to be published an advertisement or notice indicating the availability of housing that prefers or excludes persons;
  9. discriminate against someone because of that person’s relation to or association with another individual; or
  10. retaliate against, threaten or act in any manner to intimidate someone because he or she has exercised rights under the Fair Housing Act.
Health Insurance Portability and Accountability Act (HIPAA)

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) required the Secretary of the U.S. Department of Health and Human Services (HHS) to develop regulations protecting the privacy and security of certain health information. To fulfill this requirement, HHS published what are commonly known as the HIPAA Privacy Rule and the HIPAA Security Rule.

The Privacy Rule, or Standards for Privacy of Individually Identifiable Health Information, establishes national standards for the protection of certain health information.

The Security Standards for the Protection of Electronic Protected Health Information (the Security Rule) establish a national set of security standards for protecting certain health information that is held or transferred in electronic form. The Security Rule operationalizes the protections contained in the Privacy Rule by addressing the technical and non-technical safeguards that organizations called “covered entities” must put in place to secure individuals’ “electronic protected health information” (e-PHI).

HIPAA applies to access of all Protected Healthcare Information (PHI). This includes patient names, addresses, health plan information, email addresses, social security numbers and other personal identifiers, health diagnosis and treatment information and other medical record information, payment information, and all other unique identifier numbers, characteristics or codes. Basically PHI is any information that could reveal the identity of a person. NOTE: The Privacy and Security Rules do not now protect the PHI of persons who have been deceased for fifty (50) years.

General Rules – Beth Sholom must obtain an individual’s written authorization for any use or disclosure of PHI that is NOT for treatment, payment or health care operations or otherwise permitted or required by the Privacy Rule.

Beth Sholom may disclose PHI to a) the resident b) as specifically permitted or required by the Privacy Rule, and c) pursuant to written permission by the resident or his/her personal representative. Permission may be granted to Beth Sholom through an authorization or after providing the resident the opportunity to agree or object to a course of action.

Beth Sholom may disclose PHI for the treatment, payment and certain health care operations of another entity without permission from the resident.

The following disclosures may be made without the resident’s authorization or opportunity to object:

  1. as required by law;
  2. for public health activities;
  3. about victims of abuse, neglect, or domestic violence;
  4. for health oversight activities;
  5. for judicial and administrative proceedings;
  6. for law enforcement purposes;
  7. about decedents;
  8. for cadaveric organ, eye or tissue donation purposes;
  9. for specialized government functions;
  10. for worker’s compensation.

Psychotherapy Notes – Psychotherapy notes are notes recorded (in any medium) by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, join, or family counseling session. The following are excluded from the definition: medication prescription and monitoring, counseling start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following: diagnosis, functional status, treatment plan, symptoms, prognosis and progress.

With few exceptions, Beth Sholom must obtain the resident’s authorization to use or disclose psychotherapy notes to carry out treatment, payment, or health care operation.

In order for psychotherapy notes to receive protection noted above, they must be kept in separate from the rest of a resident’s medical record. These authorizations should rarely be necessary since psychotherapy notes do not include information that Beth Sholom typically needs for treatment, payment or other types of health care operations.

Beth Sholom must obtain an authorization for any use or disclosure of psychotherapy notes EXCEPT:

  1. to carry out the following treatment, payment or health care operations consistent with the consent requirements of the Privacy Rules:
  • use by the originator of the psychotherapy notes for treatment;
  • use or disclosure by Beth Sholom in training programs in which students, trainees or
  • practitioners in mental health learn under supervision to practice or improve their skills
  • in group, join, family, or individual counseling; or
  • use or disclosure by Beth Sholom to defend a legal action or other proceeding brought
  • by the resident.
  1. The following uses or disclosures:
  • when required by DHHS to investigate or determine Beth Sholom’s compliance with the Privacy Rule;
  • when required by any other law;
  • when requested as part of the oversight of the originator of the psychotherapy notes;
  • release to coroners or medical examiners;
  • to avert a serious threat to health or safety.

HITECH – The Health Information Technology for Economic and Clinical Health (HITECH) Act enhances enforcement of HIPAA’s Privacy and Security requirements and creates new obligations for breach notification, information sharing and business associate relationships.

Most important are the increased sanctions for violations and explicit authority for state attorneys general to pursue private claims on behalf of individuals. Beth Sholom acknowledges the importance of this Act and is reviewing steps to ensure compliance and to minimize liability exposure.

Breach Notification Requirements – Any breach of unsecured PHI must be reported to the individual whose PHI has been, or reasonably believed to have been, accessed, acquired or disclosed. Notification must be made without unreasonable delay and at least within 60 days of the discovery of the breach. Notice of the breach must include as much of the following information as possible:

  • a brief description of what happened, including the dates of the breach and discovery
  • a brief description of the type of information
  • a brief description of the actions taken by Beth Sholom in response to the breach
  • and contact procedure for the individual to request more information.

If the individual is a minor or otherwise lacks legal capacity because of a physical and/or mental condition, Beth Sholom may provide notice to the individual’s parent or other personal representative.

If the individual knows that an affected individual is deceased and has the address of the individual’s next-of-kin or personal representative, Beth Sholom will send a written notice to the individual’s next-of-kin or personal representative at their last known address. If Beth Sholom does not have this information, it is not required to provide a substitute notice nor is it required to conduct any further investigation.

Beth Sholom is not obligated to explain the exact type of vulnerability in the security of its electronic record system that led to the access and how that vulnerability was exploited. Also Beth Sholom has the flexibility to describe what the facility is doing in response to the breach. If employee sanctions are relevant, Beth Sholom may determine to describe the sanctions in general and is not required to disclose the name(s) of the employee(s) involved.

In the event of a breach, Beth Sholom will send a first class mail to the last known address of the individual unless that person has specified that they prefer to be contacted through electronic mail. Telephone calls may be made but are not a substitute for written communication.

If the Beth Sholom does not have contact information for affected individuals or if notices are returned as undeliverable, substitute notice may be given to those individuals as follows:

  • Contact information unknown for less than ten (10) individuals: Beth Sholom may provide individuals notice through an alternate form of written communication, telephone, web posting, etc. Beth Sholom is required that the notice be reasonably calculated to reach the individual.
  • Contact information unknown for ten (10) or more individuals: Beth Sholom will place a substitute form of notice by either a posting it on the home page of Beth Sholom’s website or a notice in major print or broadcast media in the geographical area where persons affected by the breach would likely reside including a toll-free phone number where individuals can learn whether their information has been breached. Beth Sholom will keep the toll-free number active for 90 days.

If a breach potentially implicates the PHI of 500 or more individuals, the Secretary of Health and Human Services must be notified immediately. If 500 or more individuals from the state of Virginia are implicated in a breach, Beth Sholom will provide notice to major media outlets serving Virginia.

Required notification is not limited to individuals. All information breaches must be documented in a log and submitted annually to the Secretary of Health and Human Services.


Note: the above requirements apply to unsecured PHI. Secured PHI – information that is encrypted so that it is unusable, unreadable, or indecipherable to unauthorized individuals – is not subject to the new HIPAA requirements and remains subject to pre-existing HIPAA rules.

The encryption software or technology used to secure the PHI must be developed or endorsed by an organization that is accredited by the American National Standards Institute.

The Business Associates of Beth Sholom are responsible for adhering to HIPAA rules and regulations.


The federal HIPAA applies to all areas within Beth Sholom. Each employee and Business Associates are expected to follow this law. Violations of HIPAA can result in fines of $100 per violation (for knowing violations, the fines can be $50,000 or more and/or conviction and incarceration in prison).


Non-Discrimination Statement

Beth Sholom Lifecare Community (hereafter referred to “BSLCC”) gives public notice of its policy to assure full compliance with Title VI of the Civil Rights Act of 1964 and all related statutes. Title VI requires that no person in the United States of America shall, on the grounds of race, color, or national origin be excluded from the participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which (your agency) receives Federal financial assistance.

Please contact BSLCC to request a copy of their department’s Title VI program.

Any person who believes that he or she has, individually, or as a member of any specific class of persons, been excluded from the participation in, been denied the benefits of, or been otherwise subjected to discrimination under any program or activity for which BSLCC provides assistance, and believes the discrimination is based upon race, color, national origin, gender, age, economic status or limited English proficiency has the right to file a formal complaint.

If a complaint addresses a particular service provider, the complaint should be lodged with that provider. A complaint must be submitted within 180 days of the alleged discriminatory act. Complaints may also be filed with the appropriate Federal Agency (e.g. Federal Transit Administration). If a complaint addresses The Department of Rail and Transportation, he or she may file the complaint thru email via the link below, by phone or in writing.

For complainants who may be unable to file a written complaint, verbal information will be accepted by BSLCC as well as by the individual service providers.

To submit a formal complaint or to request additional information on Title VI obligations, please contact:

Sue Berinato, Compliance Officer
1600 John Rolfe Parkway
Richmond, VA 23238
Phone: (804) 421-5037

Notice Under the Americans with Disabilities Act

In accordance with the requirements of Title II of the Americans with Disabilities Act of 1990 (ADA), Beth Sholom Lifecare Community (hereafter referred to as “BSLCC”) will not discriminate against qualified individuals with disabilities on the basis of disability in its services, programs or activities.

Employment: BSLCC 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: BSLCC will generally, upon request, provide appropriate aids and services leading to effective communication for qualified persons with disabilities so they can participate equally in DRPT’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: BSLCC 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.

Anyone who requires an auxiliary aid or service for effective communication, or a modification of policies or procedures to participate in a BSLCC program, service or activity, should contact Sue Berinato, ADA Coordinator (804) 421-5037 or as soon as possible but no later than 48 hours before the scheduled event.

The ADA does not require BSLCC to take any action that would fundamentally alter the nature of its programs or services, or impose any undue financial or administrative burden.

Complaints that a BSLCC program, service or activity is not accessible to persons with disabilities should be directed to BSLCC’s ADA Coordinator Sue Berinato at phone (804) 421-5037 or

BSLCC 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.

ADA Grievance Procedure

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 (Agency Name). (Agency Name) Personnel Policy governs employment-related complaints of disability discrimination.

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 alleged discrimination. Alternative means of filing complaints, such as personal interviews or tape recording of the complaint, will be made available for persons with disabilities upon request.

The complaint should be submitted by the complainant and/or his/her designee as soon as possible but no later than 60 calendar days after the alleged violation to:

(your agency coordinator’s name)
ADA Coordinator
Your agency’s name, address, and phone number

TTY/TDD (for the deaf or hard-of-hearing),
1-800-828-1120, or 711


Within 15 calendar days after receipt of the complaint, (Your agency coordinator) or his/her designee will meet with the complainant to discuss the complaint and the possible resolution. Within 15 calendar days of the meeting, (your agency coordinator) or his/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 DRPT’s position and offer options for substantive resolution of the complaint.

If (your agency name) response 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 Department of Rail and Public Transportation or his/her designee.

Within 15 calendar days after receipt of the appeal, the Department of Rail and Public Transportation or his/her designee will meet with the complainant to discuss the complaint and possible resolutions. Within 15 calendar days after the meeting, the Department of Rail and Public Transportation 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 (your agency coordinator) or his/her designee, appeals to the Department of Rail and Public Transportation or his/her designee, and responses from these two offices will be retained by (your agency) for at least three years.

Title VI Complaint Form

TITLE VI Plan Transportation