OUR COMMITMENT TO YOU
Ethics and accountability are central to our core values and mission. Our patients and their families put their trust in us, as do our personnel, clinicians, vendors, business partners, investors and others, including the communities we serve. We share the important responsibility to continuously strive to achieve the highest standards of ethical conduct.
Senior management of our company is committed to compliance and ethical behavior. The Code of Conduct provides guidance on expectations for acceptable behavior for those who work on behalf of our community. It provides a broad overview of compliance concepts and builds on the Code of Business Conduct and Company Standards, the Compliance Manual, as well as the policies and procedures of our Compliance Program.
The Code of Conduct is one of the most important communications you will ever receive. It is the cornerstone of our organization’s practices. You will need to read it from cover to cover. We expect you to understand and follow the Code of Conduct and help to make sure others do as well. Although no single document can provide all the answers, the Code of Conduct is a valuable resource designed to give guidance on where to turn if you see any inappropriate or unethical conduct or decisions being made. Lead by example, ask questions if you don’t know the answer, and report any problems or concerns about inappropriate or unethical actions. You can go to your supervisor, to management, to our compliance officers, or use other avenues described in this document, including the toll-free Compliance Hotline 1.844.758.1922 or via email at email@example.com. We will not retaliate or tolerate any retaliation against you for reporting in good faith.
If we work together, we can achieve our goals — a work environment that puts patient care first and fosters service excellence, compassion, and the ethical and fair treatment of all.
We are dedicated to adhering to the highest ethical standards. Common sense, good business judgment, ethical personal behavior, as well as compliance with applicable laws, policies and procedures are what we expect from all of our personnel. The Code of Conduct details the fundamental principles, values and framework for action within the organization. It is intended to deter wrongdoing and promote:
- Honest and ethical conduct
- Compliance with all applicable governmental laws, rules and regulations
- Prompt internal reporting of violations and compliance concerns
The Code of Conduct is intended to provide a general overview of basic compliance concepts and to give guidance on acceptable behavior for personnel, including all those who work on behalf of our communities— our personnel, vendors, physicians, and others affiliated with us or doing business in our facilities or offices. The Code of Conduct is not intended to fully describe the laws that apply to personnel or to detail company policies and procedures. An expanded overview of the Compliance Program is provided in the Compliance Manual, available from your supervisor, human resources department, compliance officer, or the Compliance Office. Personnel are also required to follow the standards governing business conduct in the Code of Business Conduct and Company Standards.
Our mission is to enable residents to live life to its fullest, regardless of age or health, with compassion, understanding, respect, dignity, and caring support.
We will provide timely, professional, effective and efficient service to all or our customer groups.
CONTINUOUS IMPROVEMENT IN MEASURABLE WAYS
We will identify the key needs of our customers, assess how well we meet those needs, continuously improve our services, and measure our progress.
We understand that the professionalism and drive of our people are the most important factors in quality of service we provide. We will hire talented people, increase their skills through training and experience, and provide opportunities for personal and professional growth within the company.
ETHICAL AND FAIR TREATMENT OF ALL
We are committed to forming relationships of fairness and trust with our patients, the physicians, and our personnel. We will conduct our business according to the highest ethical standards.
We will work together to provide ever-improving customer service. This team approach to our work will supersede traditional departmental organization and create a true customer focus. People at all levels of the organization will participate in decision making and process improvement.
We will never lose sight of the fact that we provide care and comfort to people in need. The patients and families who rely upon us are fellow human beings, and they will receive respectful and dignified treatment from all of our people at all times.
INNOVATION IN SERVICE DELIVERY
We will invest in the development of new and better ways of delivering our services.
We are committed to providing high-quality patient care in the communities we serve, and advocate a responsive management style and patient-first philosophy based on integrity and competence. We treat our patients with respect and dignity, providing high quality, compassionate care in a clean, safe environment.
The Code of Conduct applies to all personnel, include those who work on behalf of our community—personnel, vendors, healthcare professionals, and all other personnel affiliated with our company or doing business in our facilities and offices.
The Code of Conduct applies to healthcare professionals who work with or are affiliated with our facilities. In addition to the guidelines set forth in the Code of Conduct, healthcare professionals are expected to carry all required licenses and follow the ethical and professional standards dictated by their respective professional organizations and licensing boards.
We expect our leaders to set the example—to be in every respect a role model. Our leaders should help to create a culture that promotes the highest standards of ethics and compliance. We must never sacrifice ethical and compliant behavior in the pursuit of business objectives.
We are committed to full compliance and expects its personnel to obey all applicable state, federal, and local laws, to comply with facility policies and procedures, and to follow the guidelines in this Code of Conduct. Compliance will be an important aspect of performance evaluations. A violation of this Code of Conduct, our company policies and procedures, or any law or regulation will be handled through normal disciplinary procedures, and may lead to serious disciplinary action, up to and including immediate termination.
FACILITY POLICIES AND PROCEDURES
Personnel are required to understand and follow all policies and procedures that apply to their work. If anyone has a question about the applicable legal, policy or procedural requirements, they should ask their supervisor. The Compliance Program policies and procedures are available on the web or by contacting the applicable facility or organization Compliance Officer.
CODE OF BUSINESS CONDUCT AND COMPANY STANDARDS
Personnel are expected to perform their duties in good faith to the best of their ability and not engage in any illegal, unfair or deceptive conduct relating to business practices, conforming with the standards for business conduct set for the in the Code of Business Conduct and Company Standards, available through the applicable human resources department or online.
LAWS AND REGULATIONS
Personnel are expected to fully comply with all applicable laws and regulations federal, state, and local. Failure to comply with legal requirements can lead to serious disciplinary action, up to and including immediate termination. Key healthcare compliance laws which are addressed in more detail in the Compliance manual include the following:
The physician self-referral law, known as the Stark Law, which prohibits providers from submitting any claim for certain services called designated health services if the referral comes from a physician with who the hospital has a prohibited financial relationship.
The federal anti-kickback statute and similar state statues, which prohibit payments (direct or indirect) made to induce or reward the referral or generation of government healthcare program business
Laws authorizing the Office of Inspector General (OIG) to exclude healthcare providers from participation in Federal healthcare programs that provide unnecessary or substandard items or services provided to any patient.
Privacy and security laws and regulations that protect patient information, including protected health information (PHI) under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Health Information Technology for Economic and Clinic Health (HITECH) Act of 2009.
Federal and state false claims statutes and whistleblower protections that service a key role in preventing and detecting fraud, waste, and abuse in the federal healthcare programs.
CODING AND BILLING INTEGRITY
All billing practices as well as the preparation and filing of cost reports must comply with all federal and state laws and regulations as well as company and facility policies and procedures. Personnel will identify and appropriately resolving any coding and billing issues or concerns, will refund overpayments made by a federal healthcare program or other payers in accordance with applicable law.
RELATIONSHIPS WITH FEDERAL HEALTHCARE BENEFICIARIES
Federal fraud and abuse laws prohibit offering or providing inducements to beneficiaries in government healthcare programs and authorize the OIG to impose civil money penalties (CMPs) for these violations. Government healthcare programs include Medicare, Medicaid, Veterans Administration and other programs. Personnel may not offer valuable items or services to these patients to attract their business (including gifts, gratuities, certain cost-sharing waivers, and other things of value).
FRAUD AND ABUSE, THE FALSE CLAIMS ACT AND WHISTLEBLOWER PROTECTIONS
Our company intends to fully comply with the federal False Claims Act (FCA) and any similar state laws that fight fraud and abuse in government healthcare programs. The FCA contains a qui tam or whistleblower provision, which permits a private person with knowledge of a false claim for reimbursement by a government agency to file a lawsuit on behalf of the U.S. government. In addition, there are individual state laws providing that person who report fraud and abuse by participating healthcare providers in the Medicaid Program may be entitled to a portion of the recovery.
INELIGIBLE PERSONS, EXCLUDED INDIVIDUAL AND ENTITIES
Our company does not do business with, hire, or bill for services rendered by excluded or debarred individuals or entities. Personnel must report to their supervisor or human resource department immediately if they become excluded, debarred or ineligible to participate in any government healthcare program, or become aware that anyone doing business with or providing services for the company has become excluded, debarred, or ineligible.
We are committed to monitoring and investigating compliance concerns relating to laws, regulation and/or facility policies. When a violation is substantiated, we will initiate corrective action including, as appropriate, resolving overpayments, making required notifications to government agencies, implementing systemic changes to prevent recurrences, and instituting disciplinary action.
Our company strives to ensure facility medical records are accurate and to provide information that documents the treatment provided and supports the claims submitted. Tampering with or falsifying medical records, financial documents or other business records of the company will not be tolerated. The confidentiality of patient records and information must be maintained in accordance with privacy and security laws and regulations that protect patient information, including protected health information (PHI) under HIPAA and HITECH and applicable state laws.
Our company promotes diversity and strives to provide a workplace environment that is in full compliance with all applicable employment-related laws as well as facility policies and procedures. It is company policy to provide equal employment opportunities to all personnel, prospective and current, without regard to race, color, religion, sex, age, national origin, marital status, disability, or veteran status, and our company will do its best to make reasonable accommodations for known disabilities. Personnel who have questions concerning or are aware of any breach of the Equal Employment Opportunity (EEO) guidelines, should contact the applicable human resources department. The company prohibits workplace violence, threats of harm, and harassment of its personnel of any kind.
ENVIRONMENT AND WORKPLACE SAFETY
Our company expects its personnel to obey all state, federal and local environmental and workplace safety laws, regulations and rules, including those promulgated by the Environmental Protection Agency and the Occupational Safety and Health Administration (OSHA).
REPORTING SUSPECTED WRONGDOING
Our company is committed to complying with all applicable laws and regulations, including those designed to prevent and deter fraud, waste and abuse. Personnel with knowledge of or who in good faith, suspect any wrongdoing are expected to promptly report the matter, using one of the processes described below.
There are many ways to report suspected improper conduct. In many cases, concerns should be brought to the attention of a supervisor first. If this does not result in appropriate action, or if personnel are uncomfortable discussing these issues with their supervisors, they can use one or more of the other reporting methods described below:
- Report to an immediate supervisor, manager, company Compliance Officer, or applicable Human Resource Director
- Use the toll-free Compliance Hotline 1.844.758.1922 or via email at firstname.lastname@example.org — these reports may be made anonymously
Self-reporting is encouraged—anyone who reports their own wrongdoing or violation of law will be given due consideration in potential mitigation of any disciplinary action. Retaliation in any form against anyone who makes a good faith report of actual or suspected wrongdoing or cooperates in an investigation is strictly prohibited. Anyone who feels that they have been retaliated against should report this immediately, using any of the methods described above.
Our company’s commitment to compliance and ethical conduct depends on all personnel. Should you find yourself in an ethical dilemma or suspect inappropriate or illegal conduct, remember the internal processes that are available for guidance or reporting, including reporting to your supervisor or using the toll-free compliance hotline at 1.844.758.1922 or via email at email@example.com.