Catholic Health East System Office Code of Conduct
Letter
from the
President
and
Chief Executive Officer
Dear Catholic Health East System Office Colleagues: Our mission as a Catholic health system is inspired by our commitment to our Core Values and forms the basis for creating and maintaining an ethically and legally responsible corporate culture. For this reason, CHE’s board of directors has directed the development of the Compliance Program to ensure this mission continues to flourish. The purpose of the Compliance Program is to promote compliance with legal standards and System policies, support an organizational culture of compliance, foster ethical conduct and provide guidance to CHE colleagues. In support of the Compliance Program’s purpose, our Code of Conduct includes clear, concise statements of our commitment to follow applicable laws and our ethical responsibilities. Compliance means “doing the right thing.” CHE understands that working in a business context and in the heavily regulated health care industry is extremely challenging, and sometimes the right course of action can be unclear. The Code of Conduct is intended to help you respond to common questions and issues that may arise in your daily work. The Code of Conduct cannot describe every situation you may encounter, nor does it intend to do so. It does, however, provide guidance and reflects our deep commitment to our Core Values and Mission. You are expected to review and become familiar with the Code of Conduct, particularly those areas that apply to your everyday work activities. When faced with a difficult decision or uncertainty, I encourage you to seek guidance from your immediate supervisor, a member of management or the compliance department. You may also call the Compliance Hotline (1-877-424-3001) at any time to report your concerns anonymously. You have my personal guarantee that adverse action will not be taken against you for asking questions, raising a concern related to the Code of Conduct or reporting in good faith possible improper conduct. Thank you for your shared commitment to our Core Values and for supporting the delivery of high quality, safe and effective health care services, enhancing our ability to be a transforming, healing presence within the communities we serve. Sincerely,
Judith M. Persichilli President and Chief Executive Officer Catholic Health East
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TABLE
of
CONTENTS
Mission, Vision and Core Values
3
Our Mission: Why CHE Exists
3
Core Values: What We Believe In
3
Vision: What We Are Striving To Do
3
The Code of Conduct Leadership and Colleague Responsibilities Corporate Compliance Program
4 4 4
Oversight
5
Code of Conduct and Policies and Procedures
5
Education and Training
5
Auditing and Monitoring
5
Enforcement of Disciplinary Action
5
Corrective Action
6
Reporting Process (Open Lines of Communication)
6
Non-Retaliation
6
Patients Quality of Care Fiscal Responsibility
6 6 6
Financial Reporting and Records
6
Internal Control
7
Cost Reporting
7
Tax/Tax-Exempt Status
7
Personal Use of Corporate Assets
7
Information Security, Confidentiality and Retention
8
Electronic Media
8
Information Privacy and Security
8
Record Retention
8
Use of Proprietary Information
9
CHE Social Media Guidelines
9
Legal/Regulatory Compliance
9
Antitrust Laws
9
Documentation, Coding, Billing and Reporting
9
Fraud and Abuse
9
Federal False Claims Act, Program Fraud Civil Remedies Act of 1986, State False (Medicaid) Claims Acts
10
Response to Government Investigations
10
Marketing, Fundraising, Vendor and Political Activities
11
Fundraising and Contributions
11
Political and Legislative Activity
11
Marketing Our Services
11
Relationships with Vendors, Contractors and Third Parties
11
Workplace Conduct and Employment Practices
12
Equal Employment Opportunity
12
Colleague Rights and Responsibilities
12
Culture of Inclusion
12
Conflict of Interest
12
Outside Interests and Activities
12
Health and Safety
13
Alcohol and Drug Policy
13
Unlawful Discrimination and Harassment
13
Sanctioned/Excluded Individuals and Entities
13
Verification of Qualifications/Background Checks and Credentialing
13
Compliance Resources
14
Acknowledgment
15
Note: This document contains references to various CHE policies and procedures. Policies and procedures are available on the CHE portal or through a member of management.
“Associate
with men of good quality, if you esteem your own reputation; for it is better to be alone than in bad company.�
- President George Washington
Mission, Core Values
and
Vision
Catholic Health East’s (CHE) Code of Conduct, in word and deed, is one visible sign of alignment with our Mission, Core Values and Vision.
Our Mission: Why CHE Exists Catholic Health East is a community of persons committed to being a transforming, healing presence within the communities we serve. To effect this mission: • We treat all persons whom we serve and with whom we work with respect and compassion, calling forth their best human potential. • We provide a full range of services that support healthy communities, including quality medical care and holistic approaches to healing the body, spirit, and mind. • We collaborate with others who share a common mission and vision. • We continually seek ways to assure access to services to persons most in need. • We identify and develop leaders in the Catholic health ministry. • We advocate public policies and initiatives—particularly in the area of healthcare—that ensure quality of life for all.
Core Values: What We Believe In As a faith-based healthcare ministry, it is vitally important that we meet both our challenges and opportunities in the context of—and in accordance with—our Core Values: Reverence for Each Person We believe that each person is a manifestation of the sacredness of human life. Community We demonstrate our connectedness to each other through inclusive and compassionate relationships. Justice We advocate for a society in which all can realize their full potential and achieve the common good. Commitment to Those Who Are Poor We give priority to those whom society ignores. Stewardship We care for and strengthen the ministry and all resources entrusted to us. Courage We dare to take the risks our faith demands of us. Integrity We keep our word and are faithful to who we say we are.
Vision: What We Are Striving To Do Inspired by our Mission and committed to our Core Values, Catholic Health East strives to achieve excellence in all we do; creating a system that empowers communities and individuals to achieve optimal health and quality of life.
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The Code
of
Conduct
This Code of Conduct describes the expected behaviors of CHE System Office employees (“colleagues”) and its health care partners, i.e., physicians, students, other health professionals, volunteers, vendors and those with contractual relationships (“partners”) through the intentional use of the Mission and Core Values as the basis for these relationships. The Code of Conduct enables and directs colleagues to adhere to all system policies, management directives, guidelines and procedures; to comply with laws and governmental regulations; and to observe the Catholic moral tradition and the Ethical and Religious Directives for Catholic Health Care Services (ERDs) approved by the United States Conference of Catholic Bishops as applicable to all activities on behalf of or in relationship to CHE. CHE expects its partners to abide by the Code of Conduct which directs them to CHE’s standards and policies relevant to their engagement or services they provide. This Code of Conduct is not intended to be a comprehensive statement of colleague duties and obligations. CHE maintains numerous written policies and procedures that govern colleague activities. In some circumstances, subjects addressed in the Code of Conduct are of such complexity that additional guidance may be needed. In these circumstances, colleagues should consult the applicable policy or procedure for further clarification or contact a supervisor, the compliance or legal department for additional guidance. Separate Codes of Conduct are maintained at each of CHE’s Constituent Corporations. When at these locations, colleagues and partners are expected to be familiar with and abide by that Constituent Corporation’s Code of Conduct, policies and procedures. Questions can be directed to the Constituent Corporation’s compliance officer.
Leadership and Colleague Responsibilities At CHE, we rely on our leaders to promote a culture of trust, open communication and respect, and to reinforce our Mission, Core Values, the Compliance Program and the standards of behavior within our organization. Leaders must fulfill this commitment by serving as role models and by ensuring that their colleagues have the information they need to comply with all laws, regulations and policies applicable to their roles and responsibilities. It is expected that every colleague will adhere to the Code of Conduct and our Compliance Program as well as:
• Take responsibility for his/her own actions; • Know and comply with applicable laws and rules, including applicable federal health care program requirements, policies and procedures as they apply to his/her particular job responsibilities;
• Seek guidance as provided in the Code of Conduct and/or policies when in doubt about his/her responsibilities;
• Refrain from involvement in illegal, unethical or otherwise
improper acts;
• Promptly report any potential or suspected violation of
the CHE Compliance Program as provided in the Code of Conduct and policies and procedures; and
• When requested, assist authorized colleagues and
authorized outside advisors in investigating allegations of violations.
Leaders must encourage colleagues to report potential compliance matters. When leaders are approached with such issues, they are encouraged to contact the vice president, compliance and internal audit or the general counsel to proactively address the matter in an efficient and appropriate manner.
Corporate Compliance Program CHE’s Compliance Program (“Program”) demonstrates CHE’s commitment to maintaining high ethical standards and compliance with applicable laws, regulations, policies and procedures. The Program has been established to:
• promote compliance with legal requirements as well as policies and procedures;
• support an organizational culture of compliance; • foster ethical conduct; and • provide guidance to colleagues. The Compliance Program serves to educate generally CHE colleagues about the laws, regulations, policies and procedures governing CHE activities. By encouraging the identification, communication and correction of business and compliancerelated matters, the Program helps ensure that all our activities are aligned with CHE’s Mission, Core Values, policies and procedures, and are legally compliant. CHE’s Compliance Program is based on guidance issued by the U.S. Department of Health and Human Services (DHHS) Office of Inspector General (OIG) which, in turn, are based on the United States Sentencing Commission’s Federal Sentencing Guidelines.
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Code of Conduct and Policies and Procedures
The Program includes the following elements:
• Oversight (Structure and Organization)
The most tangible evidence of CHE’s commitment to compliance is the Code of Conduct. Representing overarching statements of principle, the Code of Conduct is designed to provide initial guidance to colleagues relating to business conduct. The Code of Conduct is designed to work with the CHE Colleague Handbook, Standards of Behavior and other policies and procedures.
• Code of Conduct/Policies and Procedures • Education and Training • Auditing and Monitoring • Enforcement of Disciplinary Action
Integral to the Program are policies and procedures that provide specific guidance to colleagues. These policies establish expected actions or work-related behaviors. Policies are updated from time to time as is necessary or warranted.
• Corrective Action (Response, Correction and Prevention) • Reporting Process (Open Lines of Communication) Oversight The CHE board of directors has primary oversight and accountability for the Program. This is accomplished through the board’s compliance and audit committee and management. The CHE risk assessment and monitoring council broadly monitors the execution of compliance and internal audit work plans relative to systemic risks. The CHE vice president, compliance and internal audit, under the leadership of CHE’s senior management team, is responsible for Program implementation and management. The director of corporate compliance assists with the day-to-day management of the Program. Additionally, management is required to oversee and direct departmental activities consistent with the Program. Similarly structured, each Constituent Corporation (i.e., Regional Health Corporation, Supportive Health Corporation, or Component Corporation) in the System has a comparable Code of Conduct and Corporate Compliance Program under the oversight of its respective board of directors and implemented under the leadership of its senior management team and compliance officer. Although CHE and its Constituent Corporation compliance officers collaborate on a number of initiatives, guidance about and concerns relating to Constituent Corporation compliance matters are addressed primarily at the Constituent Corporation level. Compliance concerns of CHE colleagues relating to a Constituent Corporation can be directed to either the Constituent Corporation compliance officer or CHE compliance department.
CHE colleagues can find the CHE Colleague Handbook, Standards of Behavior and related policies on CHE Connect (http://portal.che.org). Colleagues may also contact the human resources department or the compliance department for more information.
Education and Training CHE is committed to effectively communicating our standards, policies and procedures to our colleagues. As such, compliance education begins at New Colleague Orientation and is required at least annually for all colleagues. Certain colleagues may be required to complete additional training based on job function. Training may be provided through various means (i.e., inperson, online, newsletters, video, Code of Conduct, Colleague Handbook, etc.). For more information, see System Office Policy HR-041, Compliance Education.
Auditing and Monitoring Auditing is a formal, systematic and disciplined approach designed to evaluate and improve the effectiveness of processes and related controls. It is generally completed on a periodic basis by individuals independent of the process. Monitoring is an ongoing practice usually directed by management to ensure processes are working as intended. It is an effective detective control within a process and occurs on a routine or continuous basis. The vice president, compliance and internal audit is responsible for assuring that auditing and monitoring is conducted in accordance with CHE’s annual internal audit and/or compliance work plan. Additionally, each department manager or director is responsible for developing and maintaining appropriate ongoing, periodic monitoring to ensure compliance with the Code of Conduct, policies, procedures and regulatory requirements.
Enforcement of Disciplinary Action CHE promotes and enforces the compliance program through appropriate incentives. It also requires discipline for those who do not adhere to the Code of Conduct, follow policies and procedures, engage in misconduct, or who fail to take reasonable steps to prevent, detect or report misconduct. The level of
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Non-Retaliation
disciplinary action, including the potential for employment termination, will be determined by the seriousness of the violation without respect to the colleagues’ benefit to the System, and in accordance with System Office Policy HR-039, Corrective Action.
Consistent with our Core Values of Integrity and Justice, CHE seeks to promote an environment where colleagues’ concerns regarding real or perceived violations of CHE’s Code of Conduct, policies and procedures, and/or federal and state laws and regulations, are investigated and addressed without fear of retaliation, retribution or harassment for their good faith reporting of such concerns. However, making reckless or intentionally false accusations is strictly prohibited and offenders will be subject to disciplinary action. It must also be explicitly stated that the action of reporting a possible violation does not protect the individual from the consequences of their own involvement, misconduct or violation. Concerns about possible retaliation or harassment should be reported to the human resources department, the vice president, compliance and internal audit or by calling the Compliance Hotline at 877-4243001.
Corrective Action When a compliance issue is identified through monitoring, reporting of possible issues, investigations or otherwise, a corrective action plan is developed as warranted to respond to an identified compliance failure or other improper conduct and to prevent similar occurrences in the future.
Reporting Process (Open Lines of Communication) Questions and concerns about the appropriate way to handle various situations may and often do arise. CHE strives to promote an environment where all colleagues and partners can feel comfortable and confident in following the right course of action in their daily work. All members of management are expected to actively encourage and reward open communication within their areas of responsibility and throughout CHE.
For more information please refer to System Office Policy HR030, Non-Retaliation.
Individuals are obligated to report activities or practices that may violate law, regulation or policy. When faced with a question or possible concern, colleagues are encouraged to first report the matter to their supervisor, a member of management, or the compliance department, to give the organization a reasonable opportunity to conduct an appropriate investigation and take any needed corrective action.
Quality of Care
Colleagues and partners may also report their concerns anonymously through the Compliance Hotline (877-424-3001). The confidential hotline is available 24 hours a day, 7 days a week, 365 days a year and is operated through an outside company. The compliance department will investigate or direct the investigation and assist in determining the appropriate course of action. Regardless of the manner in which a report is made, any information supplied, including the reporter’s identity, will be kept in confidence to the fullest extent possible.
Patients
CHE is committed to providing high quality, safe, compassionate, person-centered health care to all. To achieve this, colleagues at the System Office assist our Constituent Corporations by:
• Initiating and supporting various processes to achieve
continuous improvements in the quality of care and services provided by our Constituent Corporations in their local communities;
• Supporting the Constituent Corporations with their clinical infrastructure; and
• Providing quality clinical data reporting. If a colleague has a question about whether these commitments are being fully met, that individual is obligated to raise this concern through appropriate channels as discussed in this document or to the vice president of clinical excellence.
Fiscal Responsibility Financial Reporting and Records CHE has established and maintains a high standard of accuracy and completeness in documenting, maintaining and reporting financial information. This information serves as a basis for managing our business and is important in meeting our obligations to provide accurate and complete financial information in reports to the government (e.g., IRS form 990),
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the investor community, and business partners. It is also necessary for compliance with tax and financial reporting requirements.
cost reports. These laws, regulations, and guidelines define what costs are allowable and outline the appropriate methodologies to claim reimbursement for the cost of services provided to program beneficiaries.
All financial information must reflect actual transactions and conform to generally accepted accounting principles. All funds or assets must be properly recorded in the books and records of the organization. CHE maintains a system of internal controls to provide reasonable assurance that all transactions are executed in accordance with management’s authorization and are recorded in a proper manner so as to maintain accountability of the organization’s assets.
Matters related to the preparation, submission and settlement of cost reports should be directed to or coordinated with the system financial services department through the system director of third party reimbursement or through the other reporting methods described in this document.
CHE diligently seeks to comply with all applicable auditing, accounting, and financial disclosure laws and regulations. Senior financial officers receive training and guidance regarding auditing, accounting and financial disclosure relevant to their job responsibilities. Questions or concerns regarding questionable accounting or auditing matters should report such matters to the vice president, chief accounting officer, the vice president, compliance and internal audit or by calling the Compliance Hotline at 877-424-3001.
Internal Control CHE has internal control standards and related procedures to ensure that assets are protected, properly used and that financial records and reports are accurate and reliable. All colleagues share responsibility for maintaining and complying with required internal controls, and for cooperating in all audits of internal controls. For more information, contact the vice president, compliance and internal audit.
Cost Reporting CHE is required by federal and state laws and regulations to submit certain reports of its operating costs and statistics (specifically the System Office cost report). CHE complies with federal and state laws, regulations and guidelines relating to all
Tax/Tax-Exempt Status The Internal Revenue Service (IRS) has designated CHE as a 501(c) (3) tax-exempt charitable organization. In order to maintain tax-exempt status, organizations are required to engage in activities in furtherance of charitable purposes, ensuring that resources are used in a manner that furthers the public good rather than the private or personal interest of any individual(s). Colleagues may not engage in activities that threaten the organization’s tax-exempt status or which involve the use of CHE resources or property for any private or political purpose or benefit. All transactions must be in the best interests of the organization and negotiated at fair market value. CHE will make available, as required, all necessary information to demonstrate the organization’s exemption, which shall include evidence of exempt status granted by the IRS. Questions or concerns related to tax exempt status should be directed to the vice president, chief accounting officer or the general counsel.
Personal Use of Corporate Assets Colleagues are responsible for preserving the organization’s assets including time, materials, supplies, equipment and information. Organizational assets are to be maintained for business-related purposes. As a general rule, the personal use of any CHE asset without prior supervisory approval is prohibited. The occasional use of items, such as copying machines or telephones, where the cost to CHE is insignificant, is permissible. Any community or charitable use of organizational resources must be approved in advance by a supervisor or manager. Any use of organizational resources for personal financial gain unrelated to the organization’s business is prohibited. Questions or concerns about personal use of corporate assets should be directed to the general counsel or the vice president, compliance and internal audit.
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Information Security, Confidentiality and Retention
personally identifiable information (PII), CHE proprietary and other sensitive information as required by applicable laws, regulations, policies and procedures. Colleagues and partners will maintain the security and integrity of such information through the administration of appropriate controls to protect CHE information from unauthorized disclosure, modification, or destruction.
Electronic Media All communication systems/devices provided by CHE, including but not limited to computers, electronic mail, intranet, Internet access, telephones, PDAs, cell phones and voice mail, are the property of CHE and are to be used in accordance with CHE Policy 408, Information Resources Acceptable Use Policy. CHE supports limited, incidental, ethical and respectful use of these CHE communication systems and devices; however, colleagues must accept that these communications are not private and should presume no expectation of privacy on anything they create, store, send or receive on systems or devices provided by CHE. In addition, CHE reserves the right to monitor and/or access communication usage consistent with CHE information security policies. Colleagues and partners must not distribute or store sensitive information unless approved by an authorized representative within CHE and the information is sent/stored on an approved CHE system or encrypted device. Sensitive information includes but is not limited to CHE proprietary and other protected information such as financial information and business practices, patient information including health and financial records, and any other information deemed non-public.
Information Privacy and Security
Any partners to whom CHE proposes to provide PHI or PII must execute a Business Associate Agreement (BAA). The director of compliance should be contacted in order to obtain such agreement. Colleagues and partners should immediately report any potential information breach to their manager, the ITSS Help Desk (610-492-3839) or the Compliance Hotline (877-424-3001). For more information, please see CHE Policy 400, Information Security Management Program or contact the information security officer or the vice president, compliance and internal audit.
Record Retention In the normal course of business, records are created and maintained to comply with legal, regulatory, accreditation and business requirements. CHE record retention polices are reviewed periodically to ensure continued compliance with applicable federal, state and local laws and regulations. Certain records are required to be maintained for specific periods of time. CHE requires adherence to the following guidelines on record retention:
• Records are prepared accurately, completely and in a timely
CHE is committed to the integrity, accuracy and confidentiality of information for the benefit of those we serve. CHE complies with federal and state laws and regulations, including HIPAA and HITECH, regarding the confidentiality of patients’ medical, financial and other personal information. Confidential patient information is not to be reviewed or disclosed without a legitimate business purpose, written authorization in accordance with CHE policies and procedures, or as otherwise required by applicable federal or state law. Information utilized in the course of business is considered a CHE asset, and all colleagues and partners will protect and maintain the confidentiality of all protected health information (PHI),
manner;
• Medical and other patient records are properly safeguarded and only accessible by authorized personnel;
• Records are maintained in a logical, systematic order to facilitate prompt recovery;
• Records are maintained minimally for the time periods
prescribed by federal, state or local laws and for such further periods as determined by business need pursuant to CHE record retention policies. Information on retention schedules for various types of records and legal holds can be found by colleagues on CHE Connect (http://portal.che.org) on the legal services homepage;
• Destruction of CHE records prior to expiration of the
prescribed time period for record retention is prohibited;
• Records are never destroyed in anticipation of a request or
if such records are subject to a “Legal Hold” notice issued by the general counsel; and
• Records should be periodically reviewed for destruction pursuant to policy.
For more information, please refer to System Office Policy HR038, System Office Record Retention & Destruction or contact general counsel.
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Use of Proprietary Information CHE business affairs are only discussed as required in the normal course of conducting business. Colleagues and partners are required to safeguard confidential information regarding CHE business affairs and are responsible for information security. Colleagues and partners are prohibited from attempting to obtain confidential information for which they have not received access authorization. Copyrighted information is used in accordance with applicable laws. Please refer to CHE Policy 401, Access to Information Resources, or contact the CHE information security office for more information.
CHE believes social networking is a valuable communication medium and advocates responsible involvement of all colleagues in this rapidly growing space of relationships, learning and collaboration. As a values-based organization, CHE trusts and expects colleagues to exercise personal responsibility whenever and wherever they participate in the use of social media. CHE recognizes that social media is an emerging online platform and has established guidelines for appropriate online conduct.
• Will not post any financial, confidential, sensitive or
proprietary information about CHE, any of its Constituent Corporations, business partners or other colleagues;
• Are personally responsible for the content they publish on blogs, wikis or any other form of user-generated media;
For more information please contact the communications department.
Legal/Regulatory Compliance Antitrust Laws
CHE Social Media Guidelines
Colleagues:
If any CHE colleague is contacted by the media, it is his/her responsibility to refer the inquiry directly to the communications department.
Antitrust laws are designed to create a level playing field in the marketplace and to protect and promote fair competition, protect against contracts, combinations or conspiracies in restraint of trade or commerce, prohibit price discrimination, prevent mergers and acquisitions that lessen competition and prohibit illegal tying arrangements which lessen competition or create monopoly power. In the health care industry, antitrust concerns may arise in activities such as health planning, shared services, supply chain contracting, utilization review, medical staff privileging, managed care contracting and mergers and consolidations among others. Violations of these laws can create criminal as well as substantial civil penalties for the organization and potentially the involved individuals. Colleagues and partners will not discuss CHE’s business with a competitor (such as what our prices are or how our prices are set), disclose the terms of supplier relationships, allocate markets among competitors or agree with a competitor to refuse to deal with a supplier. Questions related to these matters should be directed to the general counsel.
• Will not cite or reference CHE Constituent Corporations or business partners without their express approval;
• Will refrain from posting disparaging comments about CHE Constituent Corporations, its colleagues, or partners;
• Will not engage in behavior that is inconsistent with our Core Values and Standards of Behavior; and
• Will not post obscenities, slurs, personal attacks or infringe on copyrights or trademarks.
Documentation, Coding, Billing and Reporting With CHE’s support, our Constituent Corporations have implemented certain policies, procedures and systems to facilitate accurate documentation, coding, billing, financial and clinical (quality) reporting. Colleagues and partners involved in these processes are expected to be familiar with and to comply with applicable procedures to ensure all transactions are compliant with payer contracts and government regulations. Additionally, any subcontractors or consultants engaged to perform billing or coding services are expected to have the necessary skills, quality control processes, systems and appropriate procedures to ensure all transactions are compliant with payer contracts and government regulations. For more information, please contact the revenue management department.
Fraud and Abuse All health care providers that receive payments from Medicare and Medicaid and other state or federal health care payment programs have an obligation, under law, to conform to the requirements of federal health care programs including
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to, the judicial or court remedy for false claims provided by the False Claims Act. Penalties for violating the federal False Claims Act can be up to three times the value of the false claim, plus a fine of $5,500 to $11,000 per claim, and in certain situations, potential exclusion from participation in federally funded health care programs. Under federal laws, a person who knows a false claim was filed for payment can file a lawsuit on behalf of the federal government and, in some cases, receive a reward for bringing original information about a violation to the government’s attention.
program conditions of participation and billing and payment requirements. Fraud and abuse committed against federal health care programs may be prosecuted under various provisions of the United States Code and could result in the imposition of restitution obligations, civil or criminal fines and penalties and, in some instances, imprisonment. In addition, there is also a range of administrative sanctions (such as exclusion from participation in the program) and civil monetary penalties that may be imposed when facts and circumstances warrant such action. Fraud is defined as making false statements or representations of material facts in order to obtain some benefit or payment for which no entitlement would otherwise exist. These acts may be committed either for the person’s own benefit or for the benefit of some other party. In order to prove that fraud has been committed against the government, it is necessary to prove that fraudulent acts were performed knowingly, willfully and intentionally.
Federal and state laws protect anyone who advises their employer of a possible false claim (or who files a false claim lawsuit) against retaliation, such as being fired, demoted, threatened or harassed by their employer, for having taken such action. If a court finds that the employer retaliated against such an employee, the court can order the employer to re-hire and to compensate the employee. In addition to the federal law, several states in which CHE operates have adopted laws similar to these federal laws (state False Claims Acts) and which also allow individuals to file a lawsuit in state court for false claims that were filed with the state for payment, such as the Medicaid program. Concerns regarding federal/state False Claims Acts or PFCRA should be brought immediately to the attention of the general counsel or the vice president, compliance and internal audit. For more information related to fraud and abuse or any of the federal or state laws relating to false claims, please contact the general counsel or the vice president, compliance and internal audit.
Response to Government Investigations
Abuse describes practices that, either directly or indirectly, result in unnecessary costs to the federal health care programs. Many times abuse appears quite similar to fraud except that it is not possible to establish that abusive acts were committed knowingly, willfully and intentionally. CHE and each Constituent Corporation, through its respective compliance program are responsible for investigating suspected instances of fraud, waste and abuse and to mitigate such risks through organizational policies, appropriate education, auditing and monitoring, and remedial activities.
Federal False Claims Act, Program Fraud Civil Remedies Act of 1986 (PFCRA), State False (Medicaid) Claims Acts The federal False Claims Act prohibits a person or organization from knowingly submitting a false record or statement in order to secure payment of false or fraudulent claims with the government. “Knowing” can include deliberate or reckless ignorance of facts that make the claim false. The Program Fraud Civil Remedies Act of 1986 (PFCRA) creates administrative remedies for making false claims separate from and in addition
CHE expects colleagues to cooperate appropriately in government investigations. However, it is essential that the legal rights of CHE, our colleagues, our Constituent Corporations and our patients be protected. If a colleague receives a search warrant or subpoena, civil investigative demand, written demand, claim or personal contact from any government agency regarding CHE’s business, its Constituent Corporations or patients, whether at home or in the workplace, the general counsel should be notified immediately. If a colleague is aware of an imminent or ongoing investigation, audit or examination, he/she should retain all documents (including computer records) in his/her custody or control relating to the matter under review, and take immediate steps to preserve the same from destruction. Any questions regarding the government inquiries or investigations should be addressed to the general counsel.
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Marketing, Fundraising, Vendor Political Activities
At times, CHE may ask colleagues to make personal contact with government officials or to write letters to present CHE’s position on specific issues. If making these communications on behalf of CHE, individuals should be familiar with any regulatory constraints and observe them.
and
Fundraising and Contributions CHE preserves and protects its reputation for sound business practices and avoids the appearance of impropriety in all fundraising activities and in acceptance of contributions. Colleagues are prohibited from undertaking fundraising activities or accepting or providing contributions or other things of value that in any way influence the decision-making process with any purchaser, supplier, customer, government official or other person. For more information, please contact the vice president for advocacy, government relations and fund development.
Political and Legislative Activity CHE, including its Constituent Corporations, are exempt from federal income tax pursuant to Section 501(c) (3) of the Internal Revenue Code. In order to maintain this status, CHE may not participate in any political campaign on behalf of or in opposition to any candidate for public office. This is an absolute prohibition. Requests to utilize CHE or Constituent Corporation facilities by elected officials or political candidates should be reviewed in advance through the respective compliance department in consultation with the CHE vice president for advocacy, government relations and fund development. With regards to legislative and regulatory activities, it is understood that CHE representatives have many contacts and dealings with governmental bodies and officials. All such contacts and transactions shall be conducted in an honest and ethical manner. The organization and its representatives will be familiar with regulatory constraints and comply with federal, state and local laws governing participation in government relations and political activities. All such contacts should be reviewed with the CHE vice president for advocacy, government relations and fund development.
Colleagues are free to engage in political and legislative activities in their personal capacity on their personal time. CHE titles, letterhead and resources may not be used for political activities. They may be used for legislative activities only with the permission of a member of the CHE senior management team. For more information, please contact CHE’s vice president for advocacy, government relations and fund development.
Marketing Our Services CHE may use marketing and advertising activities to educate the public, provide information to the community and increase awareness of our services and to recruit colleagues. In all these circumstances, CHE will present only truthful, fully informative and non-deceptive information in these materials and announcements. All such materials and announcements should be reviewed by the communications or human resources departments, as appropriate. For more information, please see System Office Policy HR-035, Articles/Comments to Publications by CHE, or contact CHE’s vice president, communications or CHE’s vice president, human resources.
Relationships with Vendors, Contractors and Third Parties Colleagues have an obligation to act in the best interest of the organization. This means colleagues must avoid situations where relationships with partners could appear to influence decisions they make involving CHE. CHE recognizes there will be times when a current or potential business associate, including a potential referral source, may extend an invitation to attend a social event, offer gifts or entertainment in order to further develop a business relationship. CHE has established conditions for acceptance of gifts, meals, social and entertainment events, educational opportunities, charity events and honoraria and when disclosure is required. Colleagues may consider such invitations or offers, subject to the standards of CHE Policy 232, Relationships with Vendors, Contractors and Third Parties, or contact CHE’s vice president, supply chain management.
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Workplace Conduct Practices
and
Employment
Equal Employment Opportunity CHE is dedicated to living our Core Values in every facet of our work. As such, CHE is committed to equal opportunities for all our colleagues. CHE will not engage in or tolerate unlawful discrimination on account of a person’s sex, age, race, color, religion, creed, sexual preference or orientation, gender identification, genetic condition, marital status, national origin, ancestry, citizenship, military status, veteran status, handicap or disability, or any other protected group or status as defined by federal, state or local law. CHE fully complies with the requirements of the Americans with Disabilities Act (ADA). As such, reasonable accommodations are made available to colleagues and potential applicants for employment with a disability, as long as the accommodations do not create an undue hardship on CHE.
Culture of Inclusion
For more information, contact the human resources department or review System Office Policy HR-034, Anti-Discrimination.
Colleague Rights and Responsibilities Colleagues have a right to be treated in a fair and respectful manner, without regard to race, gender, creed, marital status, sexual orientation, age, national origin or disability. CHE promotes a positive, healthy work environment and encourages colleagues to learn, grow and develop. The following rights and responsibilities guide workplace conduct:
• Practice the Core Values of reverence for each person,
community, justice, commitment to those who are poor, stewardship, courage and integrity;
• Uphold professional standards, judgment and objectivity, even in difficult situations;
• Report events that are not aligned with our Core Values or
other organizational policies or laws to management, senior leadership, the compliance department or the Compliance Hotline at 877-424-3001;
• Address disrespectful or unfair treatment toward
As a Catholic health system that is committed to its Mission and Core Values, CHE calls upon all colleagues to develop a culture that welcomes, embraces and is enriched from individual differences and similarities. Our goal is to continually develop a system that integrates the principles of inclusion and diversity as essential elements of a mission centered, high performing organization. For more information, please contact the human resources department.
Conflict of Interest Conflicts of interest are those circumstances in which a colleague’s personal interest may actually or potentially conflict with those of CHE or may be perceived as actually or potentially conflicting with those of CHE. CHE has adopted a conflict of interest policy which establishes processes by which CHE identifies and addresses actual or potential conflicts of interest of those who hold fiduciary responsibilities to CHE. A potential, perceived or actual conflict of interest situation may arise at any time. CHE’s policy requires that such situations be disclosed promptly, as soon as the existence of the potential, perceived or actual conflict of interest is or should be known. This allows for an assessment by the colleague and CHE to address the facts and to obtain guidance about the situation to assure that CHE business decisions are made in a transparent fashion and in the best interests of CHE. If there is any doubt about a situation, it should be fully disclosed so that a determination can be made. Please refer to CHE Policy 103, Conflict of Interest, for more information. Questions can be addressed to the general counsel or the vice president, compliance and internal audit.
themselves or others in an appropriate and professional manner;
• Become familiar with System Office Policy HR-026,
Sexual and Other Harassment. Refrain from engaging in intimidating or harassing behavior and report any instances of harassment or intimidation; and
• Share the responsibility of maintaining an ethical corporate culture.
Outside Interests and Activities Colleagues are encouraged to actively participate in various charitable or civic organizations that benefit our communities. Before engaging in any activity, transaction or relationship that might give rise to a conflict of interest, colleagues must consult with their immediate manager or the vice president, compliance and internal audit.
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Health and Safety CHE is committed to providing our colleagues with a safe and healthy working environment. All colleagues are encouraged to maintain a safe and secure workplace by practicing good housekeeping, understanding responsibilities regarding safety issues and reporting to their immediate manager any accidents, injuries, incidents of workplace violence or any other suspicious visitors or activity. For more information, see System Office Policy HR-040, Reporting Work Related Injuries, or contact your manager or the human resources department.
Alcohol and Drug Policy In order to preserve a safe workplace, to promote high standards of colleague health and comply with law, CHE endeavors to maintain a work environment free from the adverse effects of drug use and alcohol abuse. Therefore, colleagues are prohibited from using, possessing, manufacturing, selling, distributing or dispensing illegal drugs at any time. Use or possession of alcohol during business hours, including meal periods and while engaged in job duties or on CHE premises, is also prohibited.
Unlawful Discrimination and Harassment Each CHE colleague has the right to work in an environment that is free from unlawful discrimination, harassment (including sexual harassment) and conduct that can be considered unprofessional and disrespectful. Unlawful discrimination and harassment (including sexual harassment) based on any protected trait, including sex or gender, age, race, color, religion, national origin, ancestry, sexual preference or orientation, gender identity, marital status, veteran status, genetic condition, handicap, disability, or any other protected status as defined by federal, state, and local law, is strictly prohibited. This prohibition includes: any unwanted physical, verbal, written or visual harassment based on any protected trait; sexual advances or requests for sexual favors; and other conduct based on or because of any protected trait which is offensive or objectionable to the recipient. This may include derogatory or
suggestive comments, jokes, slurs, gestures, cartoons, pictures and/or drawings based on any protected trait. Generally, any conduct that is not welcome, that is derogatory, demeaning or personally offensive, disrespectful, unprofessional, or that debilitates morale and interferes with a colleague’s work effectiveness, is prohibited and not tolerated at CHE. CHE strongly encourages all colleagues to report any and all incidents of harassment to their immediate manager, or the human resources department, in accordance with policy. No colleague will be adversely affected by making any such report. Retaliation for making any report is itself a violation of this Code of Conduct. All reports will be promptly and thoroughly investigated. For more information, see System Office Policy HR-026, Sexual and Other Harassment, or contact the human resources department.
Sanctioned/Excluded Individuals and Entities Applicable federal law prohibits health care organizations from seeking reimbursement from federal health care programs (i.e., Medicare, Medicaid, etc.) for services provided or ordered by individuals or companies excluded from participation in such government programs. Therefore, CHE seeks to avoid the employment of or business relations with individuals or companies deemed ineligible (or excluded) by the federal government to participate in federal health care programs. CHE reserves the right to deny employment or continued employment or work/contract for goods or services to any individual or company which is excluded from participation in these health care programs or otherwise becomes ineligible for continued employment or retention. CHE maintains a policy and process that reasonably ensures colleagues and partners have been screened against certain exclusion lists including, but not limited to the U.S. Department of Health & Human Services Office of Inspector General List of Excluded Individuals/Entities (LEIE) and the U.S. General Services Administration (GSA) Excluded Parties List System (EPLS). For more information, see System Office Policy HR-036, Sanction Screening and Protocols, or contact the human resources department or the vice president, compliance and internal audit.
Verification of Qualifications/Background Checks and Credentialing CHE, through its background screening and licensure verification processes, makes appropriate efforts to verify that colleagues are appropriately licensed, certified or otherwise qualified for their role with CHE. CHE endeavors to conduct formal background and credentialing checks on all colleagues, and certain vendors/ contractors. For more information, please contact the human resources department.
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Compliance Resources CHE Compliance Hotline (Toll Free, Confidential)
877-424-3001
CHE System Office
610-355-2000
CHE Compliance Department
610-355-2177
CHE Vice President, Compliance and Internal Audit
610-492-3720
CHE Director, Corporate Compliance
610-550-3200
CHE Website
www.che.org
Corporate Compliance
www.che.org/transparent/compliance.php
CHE System Office Policies & Procedures
http://portal.che.org/dept/hr
CHE System-wide Policies & Procedures
http://portal.che.org/CHE Policies
Centers for Medicare & Medicaid Services (CMS)
www.cms.gov
Office of Inspector General (OIG) / U.S. Department of Health & Human Services
www.oig.hhs.gov
Other Important Phone Numbers
“A man
does what he must
...
in spite of personal consequences,
in spite of obstacles and dangers, and pressures
and that is the basis of all human morality.�
- President John F. Kennedy
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Acknowledgment Affirmation Statement An integral part of the implementation of the Corporate Compliance Program is assuring that CHE Colleagues understand and are appropriately knowledgeable regarding the Corporate Compliance Program and applicable federal and state laws. CHE colleagues are held responsible and accountable for adhering to the Code of Conduct and as well as CHE policies and procedures. Colleagues are required to sign a statement as part of their compliance training affirming that they understand and agree to abide by the Code of Conduct and the requirements of the Corporate Compliance Program. Documenting Your Commitment Please read and sign this acknowledgment: • I certify that I have received a copy of CHE’s Code of Conduct and that I have read, understood and will abide by the content. • I understand that I am responsible for knowing and following the Code of Conduct as a condition of my continued employment with CHE. • I also understand that I am obligated to report any actual or perceived violations of the Code of Conduct, the Corporate Compliance Program, including policies or state or federal law, to a supervisor, member of management, the Corporate Compliance Department or the Compliance Hotline. By signing below, I acknowledge receipt of the CHE Code of Conduct. I understand that adherence to the Code of Conduct is a condition of my employment and, my failure to adhere to the Code of Conduct can result in disciplinary action up to and including termination of employment. Print Name (Legal Name): Signature: Department:
Date:
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Catholic Health East 3805 West Chester Pike, Suite 100 Newtown Square, PA 19073 Tel: 610.355.2000 E-mail: info@che.org Web: www.che.org