Daybreak Venture, LLC Compliance Information

COMPLIANCE: Doing the right thing when no one is looking

Daybreak Venture, LLC and the nursing facilities it manages (collectively “Daybreak”) are committed to conducting operations in an ethical and lawful manner. Daybreak has developed and implemented a Compliance Program that applies to all employees and associates who provide services on behalf of Daybreak. Daybreak intends to detect and correct violations of applicable law, regulations, Daybreak’s policies, the Ethics Code of Conduct, and other applicable standards. Adhering to the law and the highest ethical standards of integrity is the foundation of everything we do. Meeting this standard and complying with all applicable laws, regulations, and Daybreak’s policies requires a commitment from each of us.

Report Concerns

Everyone is encouraged to report any incident that appears to violate the Daybreak Ethics Code of Conduct or the Federal and state regulations and laws.

Reports can be made to:

  • Facility Administrator – who is the Compliance Liaison and Abuse Coordinator
  • Chief Compliance Officer, Jackie Stephens, R.N. (888) 983-4310
  • Compliance Hotline (888) 983-4310
  • Email address: compliance@daybreakventure.com
  • Mail reporting form to attention:
    Chief Compliance Officer – Jackie Stephens R.N.
    Daybreak Venture, LLC
    419 South Elm Street
    Denton, Texas 76201
  • Call Texas Health and Human Services (THHS) Abuse Hotline (800) 252-5400

The Compliance Program

Daybreak’s Compliance Program Principles, Standards, and Guidance

As a long-term care company, we recognize that healthcare operations involve significant legal and ethical responsibilities. These responsibilities extend not only to the residents of the homes, but also to the many companies and agencies with whom we work, individuals employed by the homes in which Daybreak serves as a management consultant, and the public at large.

Daybreak’s Compliance Program is intended to help employees and other representatives understand and meet the legal and ethical standards that govern our business of providing care to our residents. The Compliance Program contains standards applicable to healthcare services that Daybreak either currently provides or may provide in the future. The Compliance Program has been carefully designed to help everyone associated with Daybreak to act in accordance with known legal duties and to detect and prevent violations of the law.

The Compliance Program is designed based on the recommendations made in the Compliance Program Guidance for Nursing Facilities and the Supplemental Compliance Program Guidance for Nursing Facilities issued by the OIG (the “OIG Compliance Guidance”), while also taking into account the standards established in the Federal Sentencing Guidelines for Organizational Defendants and the compliance guidelines established in the Affordable Care Act.

The Compliance Program consists of the Chief Compliance Officer, the Compliance Committee, the Compliance Department, Daybreak’s Compliance Plan, and the Ethics Code of Conduct.

Daybreak’s Compliance Committee addresses general compliance issues related to ethics, abuse and neglect, Quality Indicators and Quality Measures, staffing, billing and reimbursement compliance, privacy, and corporate compliance. In addition, the Compliance Department responds to reported compliance concerns and those identified through ongoing auditing and monitoring activities. The Compliance Department maintains a telephone hotline (888) 983-4310 that team members may use to report compliance concerns confidentially and anonymously. Confidentiality and anonymity will be maintained to the limits of the law.

In order for Daybreak to maintain a Culture of Compliance all team members will receive regularly scheduled and annual trainings on Federal and state legal and regulatory matters, as well as Daybreak’s policies and procedures. The promotion of and adherence to the Ethics Code of Conduct will be an element in evaluation of the performance of employees.

7 ELEMENTS OF DAYBREAK’S COMPLIANCE PROGRAM

  1. Compliance Officer and Compliance Committee
    The Compliance Officer’s duty is to oversee the hotline program and policies and procedures, and to investigate noncompliance. The Compliance Committee supports the Compliance Officer and oversees the day to day operations of Daybreak.
  2. Policies, Procedures, Practices, and the Ethics Code of Conduct
    These are the commitments to adhere to compliance and provide quality care and ethical behavior within the regulatory and legal requirements.
  3. Sanctioned Individuals – SAM / LEIE Programs
    This is a list of excluded individuals and organizations not allowed to work in nursing homes who receive Medicare and Medicaid funding.
  4. Education and Training
    This is the development and implementation of regular, effective education and training programs for all affected employees and associates.
  5. Communication and Hotlines
    This is the process to allow individuals to reach out to Compliance to express concerns and report suspected violations of the Ethics Code of Conduct. Reports may be made anonymously and confidentially. Anonymity and confidentiality will be maintained to the limits of the law.
  6. Auditing and Monitoring
    This is the use of audits and/or other evaluation techniques to monitor compliance and assist in the reduction of identified problem areas.
  7. Corrective Action
    This is the development of a system to respond to allegations of improper or illegal activities and the enforcement of appropriate disciplinary actions against individuals who have violated internal compliance policies and applicable statutes regulating Federal healthcare program requirements.

Daybreak’s Policies and Procedures are located at: https://daybreakemployee.sharefile.com

Daybreak’s Compliance Hotline: (888) 983-4310
Email: compliance@daybreakvenuture.com

Corporate Integrity Agreement – CIA

The Office of Inspector General (OIG), along with the Department of Justice (DOJ) and Daybreak Venture, LLC and subsidiary settled an investigation. A negotiated agreement was reached. Daybreak accepts no liability, but did agree to implement a plan of supervised corrective actions.

Daybreak entered into a Corporate Integrity Agreement (CIA) with the Office of Inspector General (OIG) of the United States Department of Health and Human Services (HHS) to promote compliance with the statutes, regulations and written directives of Medicare, Medicaid and all other Federal healthcare programs (as defined in 42 U.S.C. § 1320a-7b(f)) (Federal healthcare program requirements). Daybreak will ensure that during the term of the CIA it shall comply with the obligations set forth in the CIA.

Strategic Healthcare Solutions (SHS) will be the Independent Reviewer Organization (IRO) assessing the effectiveness, reliability, and thoroughness of systems, quality of care, and professionally recognized standards in addition to other areas. Since all parties involved have signed off on the “Settlement Agreement”, Daybreak voluntarily entered into a Corporate Integrity Agreement (CIA) effective September 30, 2016.

The compliance obligation assumed by Daybreak under the CIA shall be five years from the effective date of the CIA. Daybreak’s Compliance Program consists of a Chief Compliance Officer, Compliance Committee, Compliance Department and Compliance Hotline (888) 983-4310.

Our Obligation
Job responsibilities include ensuring compliance with regard to the department you work in and with all applicable Federal healthcare program requirements, obligations of the Corporate Integrity Agreement, professionally recognized standards of healthcare, and Daybreak’s policies and procedures. Employees are to take steps to promote such compliance.

To the best of your knowledge, the department you work in is in compliance with all applicable Federal healthcare program requirements, the obligations of the Corporate Integrity Agreement, and professionally recognized standards of healthcare. If an employee is unable to provide such a proclamation they must notify the Compliance Department with the reasons at (888) 983-4310 or compliance@daybreakventure.com.

Ethics Code of Conduct Principles:

A. Quality Resident Care: Daybreak will provide high quality resident care, in a compassionate manner, and in a safe environment.
B. Reporting: it’s every employee’s duty to report abuse, fraud, neglect, violations of the Code of Conduct, and violations of Federal and/or State standards.
C. Reporting Concerns: Employees are urged to contact the Chief Compliance Officer/designee using the Compliance Hotline (888) 983-4310, mail or fax the compliance reporting form, email at Compliance@DaybreakVenture.com, and/or call Texas Health and Human Services (THHS) Abuse Hotline at (800) 252-5400.
D. Workplace Conduct – Safe, professional, cooperative, creative
E. Non-Discrimination – Equal opportunity and non-discrimination
F. Non-Retaliation – No retaliation or harassment for reporting violations
G. Compliance with Federal, State and Local Laws and Regulations, and Daybreak’s Policies and Procedures – Obey the laws
H. Healthcare Fraud and Abuse Prevention – if you suspect it, REPORT IT
I. Coding and Reimbursement Truthfulness – Code and bill accurately
J. Accurate and Truthful Documentation – Do not falsify documents
K. Records, Retention, and Destruction – Keep records according to the law
L. Confidentially and Privacy – HIPAA: keep health information private
M. Conflict of Interest – No bribes or inappropriate behavior for self-gain – maintain the image of Daybreak
N. Business Relationships, Referrals, and Marketing – Stark Law – Do not allow physician self-referrals; Anti-kickback laws – Do not “Pay” for referrals
O. Protection of Daybreak’s Assets – Protect items from loss, damage, theft, misuse, and waste
P. Gifts, Gratuities, and Solicitation – Anti-kickback laws – prohibits giving or receiving money or gifts in exchange for referrals or services
Q. Political/Lobbying Activity – Do not use Daybreak for self-political or self-lobbying activity
R. Fair Competition – Anti-trust laws – bribery, unfair trade practices, etc.
S. Prescriptions, Drugs, Controlled Substances, and Administration – Report medication errors or misuse of prescriptions
T. Environmental Health and Safety – Provide a habitable environment
U. Government Investigations, Accreditations, and Surveys – Cooperate with investigations and surveys
V. Enforcement of the Ethics Code of Conduct – EVERYONE is expected to uphold and enforce
W. False Claims Act, Texas Laws, and Whistleblower Provisions – Prevent fraud, waste, and abuse

Fraud, Waste, and Abuse

Vendor Policy

Organizations who have a relationship or contract with Daybreak are responsible for incorporating certain, specific Compliance Program requirements in their day to day operations in order to ensure compliance with applicable Federal and state laws and regulations and Daybreak’s Ethics Code of Conduct.

The Compliance Department has provided you with this presentation to use as a tool to assist you in communicating to your employees Daybreak’s expectations of promotion and adherence to the standards and principles outlined within the Ethics Code of Conduct.

By reviewing the presentation and completing the online Vendor Compliance Form you are certifying that your organization agrees to:

  • Promote and adhere to the standards specified in the foregoing material
  • Adopt and follow a Code of Conduct, compliance program, and compliance policies particular to your own organization that reflects a commitment to detecting, preventing, and correcting noncompliance, fraud, waste, and abuse
  • Distribute the Ethics Code of Conduct to all employees that participate in the delivery of care and services with Daybreak Venture, LLC

After reviewing the presentation, vendors are required to complete the online Vendor Compliance Form certifying that your organization has received, read, and understands the Ethics Code of Conduct, and that your organization agrees to promote and adhere to the standards and principles within.

Having all of your organization’s employees sign an acknowledgement is not required, however, the Compliance Department recommends that you review the material and expectations with them, as they will be required to adhere to the standards and principles of the Ethics Code of Conduct while delivering care or services in our homes.


Vendor Compliance Form

Now that you have completed the Daybreak Venture Ethics Code of Conduct training, please fill out the form below.




By checking the TRAINING CONFIRMATION box and clicking SEND, you are certifying that your organization agrees to:

  • Promote and adhere to the standards specified in the Universal Ethics Code of Conduct
  • Adopt and follow a Code of Conduct, compliance program, and compliance policies particular to your own organization that reflects a commitment to detecting, preventing, and correcting noncompliance, fraud, waste, and abuse
  • Distribute the Ethics Code of Conduct to all employees that participate in the delivery of care and services with Daybreak Venture, LLC