Code of Conduct
The Corporate Compliance Program
Questions and How to Report Violations of the Standards
Saint Raphael Healthcare System’s Commitment to Compliance
Gifts and Gratuities from Physicians or their Staff
Giving gifts to patients and vendors
Also see:
The Saint Raphael Healthcare System (SRHS) Code of Conduct – RVSD 1-2011
In response to its mission and vision, the Saint Raphael Healthcare System is committed to core values which include justice, service, stewardship, dignity, charity, excellence and integrity. For these reasons we are committed to conducting all our operations in an ethical, honest manner and in accordance with the Ethical and Religious Directives for Catholic Health Care Services and all applicable laws and regulations.
SRHS is committed to full compliance with all Federal and state healthcare program requirements, including a commitment to prepare and submit accurate claims and to protect the privacy and security of personal health information collected and used by SRHS. This Code of Conduct (“Code”) is intended to provide employees, physicians, volunteers, vendors, and independent contractors (“any individual or entity covered under this policy”) with guidelines for conducting business in a manner that fulfills this commitment. The Code is consistent with the mission, vision and values of SRHS, and applies to all individuals or entities that provide services under the auspices of SRHS or its affiliates. All trustees, employees, contracted individuals, and agents who provide patient care items or services or who perform billing or coding functions on behalf of Saint Raphael are required to comply with all Federal and state healthcare program requirements and all policies and procedures in place to support full compliance with all applicable laws and regulations.
The standards contained in this Code are important, and therefore, any violation of the Code shall be handled in accordance with the Discipline and Termination Policy (F:1), as outlined in the Personnel Policies and Procedures Manual, and/or other applicable policies and procedures of SRHS and its Medical Staff. In addition, referral of certain matters may be made to government and regulatory agencies, as appropriate. The offender may also be responsible in a civil suit or criminal action for losses or other damages caused by his/her inappropriate conduct.
The Corporate Compliance Program
SRHS has adopted a Corporate Compliance Program to prevent and detect the occurrence of illegal or unethical behavior, to stop any such behavior as soon as reasonably possible after it has been discovered, to discipline the individuals involved (including those who know of violations but fail to report them), and to recommend and implement changes in policy and procedure necessary to avoid a recurrence of any prior violation. Additional information on the Corporate Compliance program and efforts to prevent illegal or unethical activities may be found on the SRHS Intranet, in SRHS Administrative Policy F-10 Prevention of Fraud, Waste and Abuse, or by contacting the Corporate Compliance Officer at 789-4228.
Questions and How to Report Violations of the Standards
It is important that each individual associated with SRHS, including employees, contractors, subcontractors, officers and members of the medical staff recognize their obligation to resolve any questions they have about their jobs. It is also important for any individual or entity covered under this policy to report any instance of a known or suspected violation of this Code.
In the event that any individual or entity covered under this policy has a question, concern, believes that someone is conducting business in an illegal, unethical, or otherwise questionable manner, or is violating SRHS’s policies, the individual should first contact his/her supervisor to discuss the matter. There are times, however, when either the response the employee receives may be inadequate, or the employee may feel uncomfortable discussing the matter with his/her supervisor. In those situations, the employee should contact the Corporate Compliance Officer (CCO) at 789-4228 or call the toll -free Healthcare ValuesLine at 1-800-273-8452. This line may also be used to report any unresolved concerns related to auditing, financial reporting matters, confidentiality or other real or perceived violations of law or SRHS policy. All calls to the Healthcare ValuesLine are treated as confidential to the greatest extent possible. The caller is not required to provide his or her name. To ensure confidentiality, the Healthcare ValuesLine is operated by an organization not affiliated with SRHS. Calls are answered 24 hours a day, seven days a week. Employees and others may call back to the Healthcare ValuesLine to receive responses to their calls.
If you have any concerns or questions regarding the privacy or security of information you may also contact:
– Privacy Officer at 203-789-4305
– Security Officer at 203-789-3589
There is no retaliation against an individual who reports a compliance concern as long as the individual making the report believes the information is truthful and made in good faith.
It is expected that all SRHS personnel will report any suspected violations of any Federal or state healthcare program requirements or SRHS policies or procedures. SRHS and its employees could face significant consequences, including fines and/or civil or criminal prosecution for failure to comply with Federal and state healthcare program requirements and with SRHS policies and procedures. All employees have a duty to report instances of non-compliance.
All employees, officers, directors, contractors, subcontractors, agents who provide patient care items or services, and/or who perform billing and coding functions, and all compensated members of the medical staff must certify in writing that they have received the Code of Conduct, have read and understand it, and will abide by it.
Saint Raphael Healthcare System’s Commitment to Compliance
Saint Raphael Healthcare System employees will:
1. Provide excellent patient care. SRHS employees shall strive to treat all patients with respect and compassion. Each patient is an individual and should be treated honestly and with kindness. Patients shall be respected, with their needs and desires considered as health care decisions are made. Each patient should understand treatment needs, treatment options, methods utilized, and potential treatment outcomes. SRHS provides services in a manner that does not discriminate against any person because of age, race, religion, gender, sexual orientation, disability, national origin, or for any other reason prohibited by applicable state and Federal law. At all times, competent, qualified individuals will provide appropriate care, while ensuring the patient’s safety and well being.
Patients with an emergency medical condition will only be transferred in compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA).
2. Comply with the law. SRHS is subject to numerous local, state and Federal laws pertaining to all aspects of its operation. All individuals and entities covered under this policy are required to understand and abide by those laws applicable to the performance of their jobs, duties, and responsibilities.
3. Prepare and submit accurate claims in full compliance with local, state and Federal laws pertaining to all aspects of its operation.
4. Protect confidential information. SRHS is committed to maintaining the confidentiality of patient, personnel, and other proprietary information in accordance with applicable legal and ethical standards. Patient privacy is everyone’s responsibility. Employees shall access only the minimum necessary information in the performance of their job. SRHS employees may not discuss private patient information, access electronic or written information such as computerized or paper medical records, unless these actions are specifically required to do their job. Confidential information may not be shared, either verbally or in written or electronic form, without authorization, or as specifically required or allowed. This includes your own medical information as well as that of friends and family.
5. Compliance with anti-referral and health care fraud and abuse laws. All individuals and entities covered under this policy are required to comply with laws that prohibit health care fraud and abuse. Activities that are prohibited include, but are not limited to:
– Intentionally or knowingly making false or fraudulent claims for payment or approval including billing for services at a higher level or without adequate documentation to support the service;
– Paying or giving something of value in exchange for referrals or accepting payment or other inducement to make a referral;
– Submitting false information for the purpose of gaining or retaining the right to obtain reimbursement for services; and,
– Referrals by a physician of Medicare or Medicaid patients to any entity for “designated health services” when the physician or an immediate family member has a financial relationship with the entity (unless the arrangement complies with applicable legal exceptions).
6. Refuse inappropriate gifts or gratuities. The following standards apply to the giving or receiving of gifts and gratuities. For additional information, refer to SRHS Administrative Policy; Gratuities and Gifts.
Receiving Gifts from Patients and Vendors
Employees are prohibited from soliciting tips, personal gratuities or gifts from patients. Employees may, however, accept non-monetary gratuities or gifts of a nominal value ($50 or less), such as cookies, flowers or candy, if the gift would not influence, or reasonably appear to others to be capable of influencing, the employee’s business judgment in conducting affairs with the patient. Gifts of intoxicating beverages, money, or loans of monies are prohibited. Employees must decline any favor, gift, hospitality or entertainment offer that could influence or be suspected of influencing purchasing, referrals, the awarding of contracts or other decisions.
Gifts and Gratuities from Physicians or their Staff
Employees are prohibited from soliciting tips, personal gratuities or gifts from a physician. Gifts of a personal nature offered to employees by physicians are to be discouraged. However, inexpensive tokens of appreciation ($50.00 or less) such as flowers or candy may be accepted. Gifts of intoxicating beverages, money, or loans of monies are prohibited. If the value of the gift is substantial, or if there is any question regarding whether the gift meets this standard of reasonableness, the employee shall seek prior approval from the CCO (who may take the request to the Compliance Committee for review), or refuse the gift, promptly returning the gift to the physician or staff member. Substantial gifts to the Hospital or System may be made by contacting the Saint Raphael Foundation.
Giving gifts to patients and vendors
Employees shall not offer or give money, services or other things of value with the expectation of influencing the judgment or decision-making process of any purchaser, vendor, patient, governmental official, or any other person. An employee who is in doubt about whether a situation involving the giving or receiving of something of value is acceptable should ask his/her supervisor or the CCO. Refer to Conflict of Interest Policy (C:100), as outlined in the Administrative Policies and Procedures.
7. Avoid conflicts of interest
It is the policy of SRHS to prohibit its employees and others from engaging in any activity, practice, or act which conflicts with, or appears to conflict with, the interests of SRHS, its patients, or its vendors. Therefore, any individual or entity covered under this policy should refer to the SRHS Conflict of Interest Policy (C:100) and Human Resources Policy (E:14), Outside Employment.
8. Keep accurate and complete records. It is essential that SRHS maintain accurate, complete and legible records. In order to meet this obligation, it is equally essential that every employee accurately and clearly report the relevant facts or the true nature of a transaction. No employee should knowingly, or with reckless disregard for the truth, make any false or misleading statement on any form or to any other officer, employee, government official or auditor of SRHS. All patient records shall meet the documentation standards required for quality care, and otherwise comply with all laws, rules, and regulations. Legibility is a key component of record documentation.
Employee travel and entertainment related expenses shall be accurately documented and supported when seeking reimbursement from SRHS entities.
All records shall be maintained in accordance with SRHS Record Retention and Management policy
9. Conduct political activities according to the law: SRHS does not participate or intervene in (including the publishing or distributing of statements), any political campaign on behalf of, or in opposition to, any candidate for public office. Please refer to Political Candidates Policy (P:110).
While SRHS supports employee participation in the political process, employees are not permitted to use their positions in SRHS to try to influence the personal decisions of others to contribute, or otherwise support, political parties or candidates, except as lawfully permitted through political action committees.
SRHS may participate in lobbying activities or advocating for the passage or defeat of certain legislation that pertains to issues that affect the healthcare community. Lobbying activities, or advocating for the passage or defeat of certain legislation, shall not constitute a substantial part of the activities of SRHS. All lobbying activity shall be approved in advance by the Chief Executive Officer.
10. Protect the environment. It is the policy of SRHS to comply with all State and Federal laws protecting the environment. Employees shall dispose of all waste and other materials as required by law. All chemicals and hazardous substances shall be stored in accordance with applicable laws and regulations. All required environmental reports shall be filed accurately and on time. SRHS shall cooperate fully with governmental authorities in the event of an environmental incident.
11. Provide a safe workplace. It is the policy of SRHS to comply with all applicable State and Federal laws designed to ensure workplace safety. SRHS is committed to training employees to carry out their work in a manner that is safe for them, their coworkers, and the patients they serve.
12. Not tolerate harassment or discrimination. It is SRHS’s policy not to discriminate on the basis of race, color, religion, national origin, age, disability, sexual orientation, or gender in providing services to patients or the public, or in relation to its employment practices. Furthermore, SRHS prohibits harassment of its employees in any form by any individual or entity covered under this policy.
13. Appropriate use of assets. All employees are responsible for protecting and preserving SRHS’s assets and resources by following procedures to prevent their waste, loss, theft or unauthorized use. No part of the net earnings of SRHS shall inure to the benefit of, or be distributed to its trustees, executive staff, employees or other private persons having, directly or indirectly, any personal or private interest in the activities of SRHS, except to the extent that such payments constitute reasonable compensation for services rendered in the ordinary and necessary course of SRHS’s business.
14. Protect access to information systems. SRHS is committed to protecting all aspects of its information systems. All employees, and others with access to SRHS’s computerized information system, shall sign and abide by the Information Security Policy (I:20), as outlined in the Administration Policies and Procedures, including the protection of confidential passwords and other access information.
15. Adhere to intellectual property laws. SRHS is committed to adhering to all applicable intellectual property laws. All software used in connection with SRHS business shall be properly licensed and used in accordance with that license. Additionally, SRHS shall respect the intellectual property and copyright laws regarding books, trade journals, magazines, and other applicable resources.
This SRHS Code of Conduct carries with it the obligation to abide by it. It is a condition of employment as well as SRHS willingness to work with vendors, contractors or other partners. All members of SRHS’ workforce are expected to support the Code in spirit and to ask questions to resolve areas of uncertainty. The members of the management team, Corporate Compliance Officer and Healthcare Values Line are avenues available for that purpose.
Page last updated on Feb. 09, 2011