Corporate Governance Policy

1. Purpose

The purpose of this policy is to establish the governance framework of HealthWorksPros (HWP) and its affiliated divisions, define organizational authority, establish accountability structures, support regulatory compliance, promote ethical operations, and ensure effective oversight of all clinical, administrative, operational, financial, and strategic activities.

This policy serves as the foundational governance policy for the organization and establishes the authority structure under which all other organizational policies operate.

2. Policy Statement

HealthWorksPros shall maintain a governance structure that promotes:

• Organizational accountability
• Ethical conduct
• Regulatory compliance
• Clinical excellence
• Financial integrity
• Risk management
• Strategic growth
• Operational effectiveness

The organization shall maintain clearly defined lines of authority, responsibility, oversight, and decision-making for all programs, departments, providers, employees, contractors, and consultants.

All organizational activities shall be conducted in accordance with applicable federal, state, and local laws, regulations, contractual requirements, and professional standards.

3. Scope

This policy applies to:

• Executive Leadership
• Medical Leadership
• Behavioral Health Leadership
• Clinical Operations
• Administrative Personnel
• Contractors
• Consultants
• Volunteers
• Students and Interns
• All Organizational Divisions

This policy applies to all locations, service lines, programs, and contracts operated by HealthWorksPros.

4. Organizational Governance Principles

HealthWorksPros shall operate according to the following governance principles:

5. Organizational Structure

The organization shall maintain a formal organizational structure documenting:

• Executive Leadership
• Clinical Leadership
• Administrative Leadership
• Operational Leadership
• Financial Leadership
• Program Leadership

The organizational chart shall be reviewed annually and updated as necessary.

6. Executive Leadership Authority

Executive Leadership shall serve as the highest operational authority within the organization. Executive Leadership responsibilities include:

• Strategic Planning
• Organizational Oversight
• Financial Oversight
• Contract Approval
• Risk Management Oversight
• Regulatory Oversight
• Policy Approval
• Program Development
• Organizational Growth

Executive Leadership retains final authority for organizational decisions unless otherwise delegated.

7. Medical Director Authority

The Medical Director shall serve as the senior clinical authority for medical services. Responsibilities include:

• Clinical Oversight
• Provider Supervision
• Clinical Policy Review
• Clinical Quality Assurance
• Medical Staff Consultation
• Clinical Risk Management
• Occupational Medicine Oversight
• Clinical Compliance

The Medical Director maintains independent authority regarding clinical standards and patient safety matters.

8. Director of Behavioral Health Authority

The Director of Behavioral Health shall serve as the senior behavioral health authority. Responsibilities include:

• Behavioral Health Oversight
• Behavioral Health Quality Assurance
• Clinical Supervision
• Behavioral Health Compliance
• Crisis Management Oversight
• Behavioral Health Program Development
• Behavioral Health Documentation Standards

9. Clinical Operations Authority

Clinical Operations Leadership shall oversee operational implementation of clinical programs. Responsibilities include:

• Workflow Management
• Staffing Coordination
• Operational Compliance
• Quality Monitoring
• Program Implementation
• Training Coordination

10. Financial Governance

The organization shall maintain financial oversight mechanisms designed to ensure:

• Accurate Financial Reporting
• Revenue Integrity
• Budget Oversight
• Internal Controls
• Fraud Prevention
• Contract Compliance
• Financial Sustainability

Financial records shall be maintained in accordance with applicable accounting standards and organizational requirements.

11. Quality Governance

The organization shall maintain a Quality Assurance Program. Quality governance shall include:

• Clinical Audits
• Performance Monitoring
• Incident Review
• Corrective Action Monitoring
• Regulatory Compliance Monitoring
• Quality Improvement Activities

Quality performance shall be reviewed at least quarterly by leadership.

12. Compliance Governance

The organization shall maintain an active compliance program. Compliance activities shall include:

• Regulatory Monitoring
• Policy Review
• Audit Activities
• Staff Training
• Documentation Review
• Corrective Action Planning

Known compliance concerns shall be investigated promptly.

13. Risk Management Governance

The organization shall maintain a risk management program designed to identify, evaluate, mitigate, and monitor organizational risks. Risk management activities shall include:

• Clinical Risk Assessment
• Operational Risk Assessment
• Financial Risk Assessment
• Legal Risk Assessment
• Cybersecurity Risk Assessment
• Contractual Risk Assessment

Risk reports shall be reviewed by leadership regularly.

14. Ethics & Professional Conduct

All workforce members shall:

• Act Professionally
• Act Ethically
• Maintain Confidentiality
• Avoid Conflicts of Interest
• Comply With Applicable Laws
• Report Suspected Misconduct

Unethical conduct may result in corrective action.

15. Authority Delegation

Executive Leadership may delegate operational authority as necessary. Delegations shall:

• Be Documented
• Clearly Define Responsibilities
• Define Reporting Relationships
• Define Limitations of Authority

Delegation does not eliminate accountability.

16. Policy Management Authority

Executive Leadership shall maintain ultimate responsibility for policy approval. Policy owners may:

• Draft Policies
• Recommend Revisions
• Conduct Reviews
• Monitor Compliance

All policies shall be approved through established organizational processes.

17. Regulatory Compliance Responsibilities

All workforce members are responsible for compliance with:

• Federal Laws
• State Laws
• Professional Standards
• Licensing Requirements
• Contract Requirements
• Organizational Policies

Failure to comply may result in corrective action.

18. Reporting Responsibilities

Personnel shall promptly report:

• Compliance Concerns
• Safety Concerns
• Ethical Concerns
• Privacy Concerns
• Fraud Concerns
• Significant Operational Risks

Reports may be made without fear of retaliation.

19. Non-Retaliation

The organization prohibits retaliation against any individual who, in good faith:

• Reports Concerns
• Participates in Investigations
• Raises Compliance Issues
• Reports Patient Safety Concerns

Retaliation is prohibited and may result in disciplinary action.

20. Policy Review

This policy shall be reviewed annually, or earlier if required due to:

• Regulatory changes
• Organizational changes
• Operational changes
• Compliance concerns

All revisions shall follow the organization's document control procedures.

21. References

Related Policies:

• Policy 101 – Organizational Authority & Delegation Policy
• Policy 105 – Quality Assurance Governance Policy
• Policy 203 – Confidentiality Policy
• Policy 500 – Quality Assurance Policy
• Policy 505 – Regulatory Compliance Policy
• Policy 508 – Document Control Policy

22. Approval

This policy becomes effective upon approval by Executive Leadership and shall remain in force until revised or rescinded.