Compliance and Business Ethics Program Overview
Compliance and Business Ethics Program Overview
Effective Date: January 1, 2026
Introduction
CNSCares operates in a highly regulated industry that is the focus of frequent regulatory changes at the federal, state and local levels. It is critical to our collective success that all personnel, which includes all officers, directors, general managers, field staff, support staff, contractors and anyone working on behalf of CNSCares, have the support and resources they need to ensure they are working in compliance with the law and consistent with CNSCares’ high integrity and ethical expectations. Our Compliance and Business Ethics Program (“Compliance Program”) is one of those resources. Through its promotion of written standards, policies, education, monitoring and other activities, the Compliance Program helps CNSCares and anyone working on behalf of our organization with preventing, detecting and remediating risk and misconduct. To be effective, the Compliance Program must be a significant part of CNSCares’ culture, mission and values. As such, CNSCares provides this overview of our Compliance Program to all personnel so that they are aware of the program, its activities and resources. Please contact the CNSCares Chief Compliance Officer, by calling (833) 827-4406 or emailing compliance@cnscares.com, for additional resources related to the Compliance Program.
Organizational Responsibility for the Compliance Program
In order to implement the Compliance Program, CNSCares, through its Governing Board, has designated a Chief Compliance Officer and authorized the formation of a Compliance Committee. Each is described below.
Chief Compliance Officer
The Chief Compliance Officer is responsible for coordinating and overseeing all aspects of the Compliance Program. The program is broad in scope and thus reaches numerous operational areas, often resulting in collaborative approaches among all personnel. Responsibilities of the Chief Compliance Officer include but are not limited to: Develop, revise, maintain, implement, and distribute compliance-related policies, procedures, systems, and other relevant materials for all personnel. Foster appropriate environment within the organization to promote participation in the Compliance Program by all personnel. CNSCares Compliance and If applicable, supervise assigned personnel to ensure compliance-related duties are satisfactorily carried out. Report periodically on compliance activities to the Governing Body. Develop, provide, coordinate and track compliance training and education for orientation and periodic training for all personnel. Investigate potential and actual compliance issues, including root cause analyses. Ensure prompt and thorough resolution of compliance issues, including implementation of policies, procedures, systems and necessary training of all personnel to reduce the potential for recurrence.
Compliance Committee
The Compliance Committee (Committee) assists with the oversight and implementation of the Compliance Program and supporting policies and activities. The Committee meets regularly to monitor Compliance Program activities and provide guidance and recommendations to the Chief Compliance Officer and other leaders with respect to compliance matters.
Written Standards
Written standards, policies and procedures are a central component of any effective compliance program. When followed, standards and procedures reduce the prospect of illegal, unethical, or other improper conduct by reasonably identifying risk areas for the organization and establishing internal controls to counter those risks. CNSCares’ Code of Conduct, our policies and procedures, and other written guidance documents are made available to all personnel upon hire or affiliation with CNSCares. Annual and periodic training and education regarding policies that address high-risk areas and new policies are provided to CNS personnel. Individuals are expected to comply with the standards set forth therein and to certify that they have received, read, understand, and will abide by them.
Compliance Training, Education and Communications
As part of its continued commitment to compliance with legal requirements, CNSCares maintains an effective training and education program and conducts orientation compliance training and education to all new personnel. Everyone is required to complete the training, including execution of the Code of Conduct certification, within 30 days of joining CNSCares. Compliance training and education is also provided annually on the Compliance Program, the Code of Conduct, and relevant compliance risk areas. Training is also a critical component of CNSCares’ response to substantiated compliance matters. Attendance and participation in training programs designated as mandatory are a condition of continued employment or association with CNSCares. Failure to comply with training requirements will result in disciplinary action, up to and including termination of employment or affiliation. CNSCares Compliance and The Chief Compliance Officer are responsible for the development of an effective compliance training program for all personnel that is tailored to CNSCares’ compliance risks. All personnel are actively encouraged to contact the Chief Compliance Officer with potential compliance risk areas for inclusion in training. The Chief Compliance Officer may rely upon internal or external subject matter experts. (Managers who coordinate department or team education or training activities outside the scope of the compliance training program should consult with the Chief Compliance Officer prior to inviting external speakers.) The Chief Compliance Officer (or designee) maintains records of participation in mandatory compliance training programs, as well as copies of such training program materials.
Monitoring and Auditing
CNSCares has a system of routine internal monitoring and auditing to ensure the organization is operating effectively, ethically, and in compliance with the law. These efforts occur in multiple operational areas of CNSCares and are selected based on organizational and industry risks, informed by compliance reports, prior compliance activities, changes in the law, industry activity, government enforcement priorities, and other key resources. These reviews are conducted independent of the influence of any Team Member and all individuals’ whose job responsibilities relate to the matter under review are required to cooperate fully and truthfully with reviewers. Through the coordination of the Committee, the Chief Compliance Officer and CNSCares leaders assess outcomes and develop action plans to address and mitigate risks. Action plans can include but are not limited to self-disclosure or referral of the matter to government regulators, changes in policies or the Compliance Program, remedial education for relevant personnel, and disciplinary action.
Reporting Compliance Matters
If anyone encounters a situation that may involve a violation of the Code of Conduct, CNSCares’ policies, or the law, the individual is encouraged to raise the concern as quickly as possible, and in some cases immediately. Personnel who act in a supervisory, managerial, or other administrative role have an additional obligation to promptly report any matters they become aware of or that are reported to them by subordinates or others. CNSCares offers several reporting avenues. These include an immediate supervisor, a member of CNSCares’ management team, Human Resources, our Compliance Department, including the Chief Compliance Officer, and the confidential CNSCares Compliance Hotline, which can be reached at (833) 761-5811 or cnscares.ethicspoint.com, 24 hours a day, seven days a week. Reporting parties can report anonymously via the Compliance Hotline. Reports of potential non-compliance or unethical conduct will be kept confidential to the fullest extent possible, consistent with the law and good business practices. Individuals may report anonymously unless prohibited by law. All personnel are encouraged to provide as much objective information as possible to facilitate the review but should not engage in their own ”investigation” CNSCares Compliance and of the matter. Regardless of the method used or whether the reporter remains anonymous, the same course of action will be taken to investigate the matter. While it is important to report a suspected violation of our Code of Conduct, policies, and/or the law, it is just as essential to do so honestly and ethically. CNSCares prohibits the filing of a report that is dishonest or for the purpose of retaliation, gaining an advantage in a personal conflict, or harassment. Knowingly filing a dishonest report or a report for an improper purpose is a violation of the Code of Conduct and subject to disciplinary action. CNSCares has a zero-tolerance policy on retaliation against anyone who reports a potential compliance matter or participates in the investigation of such a matter. Individuals who engage in retaliation will be subject to disciplinary action, up to and including, termination of employment or affiliation.
Investigating Potential Compliance Matters
CNSCares will promptly and impartially investigate all potential compliance matters and adverse audit findings in good faith. Upon receipt of a potential compliance matter, the Chief Compliance Officer will make a preliminary, good faith inquiry into the allegations to ensure necessary information is available to determine whether an investigation should commence. Should an internal investigation occur, the Chief Compliance Officer may conduct a preliminary assessment of the nature of the allegations, refer the matter to leadership in the relevant operational area or refer the matter to leadership for engagement of outside legal counsel. Whether the Chief Compliance Officer, legal counsel or other internal or external subject matter expert conducts the investigation is determined based on the nature, scope and details of the report. All personnel are required to cooperate truthfully and in good faith with investigation efforts. Failure to do so will result in disciplinary action, up to and including termination of employment or affiliation.
Responding to Misconduct
If an internal investigation substantiates a reported or suspected violation, corrective action to address the violation and mitigate against reoccurrence will be initiated. Appropriate actions may include, but are not limited to, instituting appropriate disciplinary action, terminating contractual relationships, conducting training and education for relevant personnel, revising relevant policies and the Compliance Program, self-disclosing conduct to relevant government authorities, and making restitution or repaying overpayments. Each event will be evaluated on a case-by-case basis. When appropriate, CNSCares may involve outside legal counsel to assist with recommending corrective action plans. For privacy and legal reasons, CNSCares does not typically report the outcome of internal investigations to individuals who report the matter. All personnel should know, however, that the Governing Body, the Committee, and Senior Leadership Team, as appropriate in each circumstance, monitor matters for a resolution that aligns with CNSCares’ commitment to integrity, honesty, and compliance. As such, before a potential compliance matter is considered resolved, the Chief Compliance Officer must confirm completion of the investigation and implementation of the corrective action plan, if any.
Disciplinary Actions
CNSCares’ standards are essential to a productive work environment. All personnel must familiarize themselves with the standards, as each individual will be held to them. Any individual who disregards or deviates from obligations imposed by law or CNSCares’ policies may be subject to disciplinary action, up to and including termination of employment or affiliation. While not intended to be an all-inclusive list, CNSCares’ disciplinary policy includes examples that the organization considers unacceptable in the workplace. The precise discipline utilized will depend on the nature, severity and frequency of the violation and may result in any of the disciplinary actions or a combination thereof. Disciplinary action will be administered on fair and equitable bases without regard to the position of the individual(s) involved. CNSCares also recognizes that certain types of behavior are serious enough to justify immediate termination of employment, without observing other disciplinary actions first.
Compliance Program Self-Assessment
CNSCares recognizes that compliance is always in a continual state of change and evolution. As such, it periodically assesses the effectiveness of the Compliance Program, utilizing internal and external subject matter experts. When opportunities for improvement are identified, the Chief Compliance Officer, Compliance Committee and relevant CNSCares leadership will review the recommendations and identify methods to incorporate appropriate recommendations, whether through the adoption of new policies or revisions to the Compliance Program.
Conclusion
The success of CNSCares and all personnel are tied to our joint effort to ensure we are upholding our commitment to honesty, integrity and compliance. CNSCares has an open-door policy. Personnel, including employees and independent contractors, are strongly encouraged to raise questions and bring new ideas to leadership that will help strengthen our compliance.