CODE OF CONDUCT
Individually and as an organization, the Clinic and its officers, employees and independent contractors (collectively referred to as “Clinic Staff”) share in a commitment to legal, ethical and professional conduct in everything we do. As Clinic Staff, we support these commitments in our work each day, whether we care for patients, order supplies, prepare meals, keep records, pay bills or make decisions about the future of our organization. The Clinic’s success as a provider of healthcare services depends on us - our personal and professional integrity, our responsibility to act in good faith, and our obligation to do the right things for the right reasons.
The Compliance Plan was created as a structure to teach, support and monitor these commitments, and helps to apply the Clinic’s standards of excellence to a specific job. It provides principles, standards, training and tools to guide us in meeting our legal, ethical and professional obligations.
As Clinic Staff we are responsible for supporting the Compliance Plan in every aspect of our workplace behavior. Our regular performance reviews include understanding and adhering to the Compliance Plan as it applies to our jobs.
The Clinic Code of Conduct
The Code of Conduct is the foundation of the Compliance Plan. The Code of Conduct is a guide to appropriate workplace behavior. It will help us to make the right decisions if we are not sure how to respond to a situation. The Code of Conduct applies to everyone at the Clinic from entry-level employees, to contractors and to top management. I understand that the Code of Conduct supplements our employee handbook and the specific policies and procedures that apply to my job. The Code of Conduct discusses the importance of:
• Care Excellence: providing quality, compassionate, respectful and clinically appropriate care to patients.
• Professional Excellence: maintain ethical standards of healthcare and business practices.
• Regulatory Excellence: complying with federal and state laws, regulations and guidelines that govern the healthcare services that we provide.
To confirm that each of us understands and accepts responsibility for abiding by the Clinic’s Code of Conduct, every Clinic Staff member is required to read this Policy, and sign and return the Commitment to Compliance on the last page. The signed Commitment to Compliance will become part of our permanent employment record.
Of course, no single resource can answer every question or cover every concern one may encounter at work. We all should be guided by our own good judgment and professional pride as well. If we have concerns about the Code of Conduct or any moral, legal or ethical issue, I understand that I can talk with the Compliance Officer.
A Shared Responsibility
Because we're in the business of providing care to others, it is critical that each of us adheres to appropriate standards of behavior. As individuals and as an organization, we are responsible to many different groups. We must act ethically and responsibly in our relations with:
• Our patients and their families
• Our colleagues and co-workers
• Nonaffiliated colleagues and customers
• Healthcare payers, including federal and state governments
• Regulators, surveyors and monitors
• Physicians
• Vendors and suppliers
• The community we serve
Any compromise in our standards could harm our patients, our coworkers and our organization. Like every healthcare organization, we must do business under very strict regulations and oversight. Fraud and abuse are serious issues. Sometimes even an innocent mistake can have significant penalties to our organization and to us.
Because the Compliance Plan affects every Clinic Staff member and every job we do, it is critical that we all know and understand our responsibilities. Clinic Staff members participate in education and training about the Code of Conduct, the Compliance Plan and the compliance responsibilities of their jobs. In addition, written policies and procedures define specific tasks so employees understand the Clinic’s performance standards. Supervisors and managers must consistently reinforce these policies and procedures and make sure that Clinic Staff comply with the state and federal laws.
As we each are responsible for following the Code of Conduct on our daily work, we are also responsible for enforcing it. This means that we are expected to report any problems we observe.
I understand that if I observe or suspect a situation that you believe may be unethical, illegal, unprofessional or wrong, or if you have any clinical, ethical or financial concern, I MUST report it. In fact, if I suspect a violation and do not report it I understand that I could face disciplinary action.
The Clinic has a specific communication and reporting process for compliance issues.
1. Talk to a supervisor, he or she is most familiar with the laws, regulations and policies that relate to your work.
2. If I am not comfortable talking with your supervisor or are not satisfied with the response you receive, talk to another member of the management team. 3. If Istill have a concern, contact the Chief Compliance Officer.
4. If none of the above steps resolves your questions or concerns contact the Chief Executive Officer directly.
Care Excellence - Our First Priority
At the Clinic, our most important job is providing quality care to our patients. This means offering compassionate support to our patients and working towards the best possible outcomes, while following all healthcare rules and regulations. We care for people who are especially vulnerable; they may have a language barrier, legal status issues, financial inabilities, physical restrictions because of illness, injury or disease or many other vulnerabilities. It is our responsibility to respect, protect and care for them with compassion and skill.
1. Patients Rights
Patients receiving healthcare services have clearly defined rights. To honor these rights, we must:
• Provide the same quality care to everyone regardless of race, color, age, religion, national origin, gender, sexual orientation or disability.
• Treat all patients with compassion, courtesy, professionalism and respect.
• Protect all aspects of the patient's privacy and confidentiality.
• Obtain written permission from the patient or their legal representative before releasing personal, financial or medical information to anyone outside the Clinic.
• Limit access to medical and other records only to the employees, physicians or other healthcare professionals who need the information to do their job.
• Respect the rights of patients to participate in decisions about their care.
• Respect the right of patients to access their medical records as requested.
• Recognize that patients have the right to consent to or refuse care. 2. Providing Quality Care
As employees and as an organization, our primary commitment is to provide the care, services and products necessary to help the patient reach or maintain his or her highest possible level of physical, mental and psychological well-being. To meet this standard of care, we:
• Develop interdisciplinary plans of care for all patients.
• Constantly assess goals to ensure that the ongoing needs of our patients are being met.
• Provide only medically necessary services and products.
• Confirm that services and products are within accepted standards of practice for the patient's medical condition.
• Ensure that services and products are reasonable in terms of frequency, amount and duration.
• Measure clinical outcomes and patient satisfaction to confirm that quality care goals are met.
• Provide accurate and timely clinical and financial documentation and record keeping.
• Ensure that only properly licensed and credentialed providers with the appropriate background, experience and expertise give patient care.
3. Gifts from Patients
Sometimes grateful patients and their families offer gifts to employees. However, accepting a gift, gratuity or tip could give the impression that we are favoring a patient or giving him or her special care. Or, a patient with dementia might try to give away a precious heirloom without understanding what he or she is doing. Therefore, it is the Clinic’s policy that Clinic Staff should refuse all personal monetary gifts, gratuities or tips from patients and return them if they are given. It is acceptable to receive food, gift baskets, flowers, etc. Monetary donations in the form of cash, check, money order, or gift card are acceptable to the organization but not as an individual gift to any one member of the Clinic Staff.
4. Hiring and Employment Practices
As an organization, the Clinic is committed to fair employment practices. When hiring and evaluating Clinic Staff, the Clinic:
• Complies with federal and local Equal Employment Opportunity laws, hiring the best qualified individuals regardless of race, color, age, religion, national origin, gender, sexual orientation or disability. All promotions, transfers, evaluations, compensation and disciplinary actions also follow this same policy.
• Conducts employment screenings to protect the integrity of our workforce and the welfare of our patients and employees.
• Requires all Clinic Staff who need licenses or certificates to maintain their credentials in compliance with state and federal laws; these employees must show documentation of their current license or certifications.
• Confirms that no Clinic Staff has ever been convicted of Medicare or Medi-Cal fraud or abuse, a violent crime or criminal offense related to healthcare.
5. Staff Relations
To maintain an ethical, comfortable work environment, all Clinic Staff must:
• Treat all colleagues and coworkers with equal respect, regardless of their national origin, race, color, religion, sexual orientation, age, gender or disability.
• Protect the privacy of other employees by keeping personal information confidential and allowing only authorized individuals access to the information.
6. Drug and Alcohol Abuse
Clinic Staff may never use, sell or bring on Clinic property alcohol, illegal drugs and/or narcotics or report to work under the influence of alcohol, illegal drugs and/or narcotics. For Clinic Staff who appear to have work-performance problems related to drug or alcohol use, the Clinic will conduct an alcohol and drug screening and take appropriate action if necessary.
7. Use of Clinic Property
Clinic property - everything from office supplies and computers to Clinic vehicles - represent a significant expense to the Clinic and should only be used for legitimate business purposes. We all must make sure that we:
• Use Clinic property only for Clinic business, not personal use.
• Exercise good judgment and care using Clinic supplies, equipment and other property.
• Limit use of computers and Internet connections to legitimate Clinic use only.
• Respect copyright and intellectual property laws; never copy or download software. 8. Billing Practices
The Clinic is committed to ethical, honest billing practices, and we expect every Clinic Staff to be vigilant in maintaining these standards at all times. The Clinic will not tolerate any
deliberately false or inaccurate billing. Any Clinic Staff who knowingly submits a false claim, or provides information that may contribute to submitting a false claim, to any payer - public or private - is subject to dismissal. In addition, legal or criminal action may be taken.
But, even an innocent misunderstanding, careless mistake or accidental error can have serious consequences for the organization. Therefore, we must always be extra careful when we prepare billing documentation, and follow all procedures and instructions from regulatory agencies, fiscal intermediaries and insurance carriers. For Clinic Staff who are not directly involved in billing activities, maintaining regulatory compliance includes providing accurate, timely and complete documentation of the services provided so that claims are based on the correct information.
False or fraudulent claims may include:
• Billing for services that were not provided or costs that were not incurred.
• Duplicate billing - that is, billing for the same item or service more than once.
• Billing for items or services that are not medically necessary.
• Changing a code to increase reimbursement.
• Providing false or misleading information to Medicare about a patient's condition or eligibility.
• Failing to identify and refund credit balances.
I understand that if I suspect or observe that false claims are being submitted, I must immediately report the situation to a supervisor.
9. Referrals and Kickbacks
Clinic Staff often have close associations with other local healthcare providers and referral sources. To demonstrate ethical business practices, we must make sure that all relationships with these professionals are open, honest and legal.
The Clinic accepts patient referrals based solely on clinical needs and our ability to provide the services required by the patient. The Clinic makes referrals based solely on the clinical needs. We never solicit, accept or offer kickbacks of any kind.
A kickback is an item or service of value that is received in exchange for a business decision, such as a patient referral. Kickbacks can include any item or service of value, including cash, goods, supplies, gifts, freebies or bribes. Accepting kickbacks is against the law, as well as prohibited by the Clinic’s own policies and procedures.
* Clinic Staff cannot request, accept, offer, or give any item or service that is intended to influence - or even appears to influence - a healthcare service paid for by any private or commercial healthcare payer, or federal or state healthcare program, including Medicare, MediCal, Champus and the VA.
*There are select legal exceptions to this rule, please consult your supervisor.
10. Government Investigations
It is the Clinic’s policy to cooperate with all government investigations, surveys and evaluations. These investigations are part of the healthcare environment today, and the procedures for cooperating with these investigations can be complicated.
In complying with Clinic policy, I must not:
• Lie or make false or misleading statements to any government investigator, surveyor or evaluator.
• Destroy or alter any record or document in anticipation of a request from the government or court.
• Attempt to persuade another employee or any person to give false or misleading information to a government investigator, surveyor, or evaluator.
11. Commitment to Compliance
I have received a copy of the Clinic’s Code of Conduct. I understand that I have an obligation to read it and understand it, and I agree to abide by its principles. I further agree to conduct myself in an ethical, legal and responsible manner at all times.
I also agree to keep this booklet for future reference. I understand that if I have questions or concerns about its content or other Clinic policies, I will ask for clarification from my supervisor, Compliance Officer or a member of the human resource department.
Signature:___________________________________
Printed Name:________________________________ Date: ______________________
Please sign and return this form to your Compliance Officer. It will be included in your personnel records.
CODE OF CONDUCT FOR BOARD MEMBERS, OFFICERS, EMPLOYEES, CONTRACTORS AND AGENTS OF THE CLINIC
1. PURPOSE
The purposes of these standards are to provide safeguards to ensure the Clinic’s compliance with laws and regulations relating to the operation of the Clinic’s activities as well as to prevent members of the Board of Directors, officers, employees, contractors and agents of the Clinic (collectively referred to as “Clinic Staff”) from (1) using their positions for purposes that are, or giving the appearance of being, motivated by a desire for private financial gain for themselves or others such as those with whom they have family, business or other ties, and, (2) from violating their duty to the Clinic by inappropriately disclosing confidential information about the Clinic. 2. COMPLIANCE WITH LAWS AND REGULATIONS
(a) Accurate Claims for Reimbursement
All claims for reimbursement to third party payers, including but not limited to Medicaid and Medicare that are submitted on behalf of the Clinic, must contain accurate and true information and must only reflect services provided as supported by the patient's medical record.
(b) Medical Necessity
No supplies or services will be billed by the Clinic unless they are reasonable and medically necessary, as evidenced by a fully and accurately documented medical record.
(c) Accurate Business Records
All business records completed by the Clinic Staff must accurately reflect the matter to which it pertains. No entry in a Clinic record should disguise any material fact regarding the business transaction.
(d) Cost Reports
All cost report data, schedules and work sheets must be truthful, accurate and complete. Clinic will only report properly allowable costs that were absolutely and reasonably occurred by the Clinic.
(e) Refunds
If the Clinic determines that it has been overpaid by a government program, third party payor or patient, it will promptly refund the payment to the proper party in accordance with Clinic policies and procedures.
(f) Kickback Prohibition
No Clinic Staff will offer, provide, solicit of except anything of value from any person in return for the referral of Medicare/Medicaid or other government sponsored patients to the Clinic, or in return for influencing or engaging in any related business transaction, directly or indirectly,
(g) Co-payments/Discounts
The Clinic must not waive the collection of co-payment obligations unless it establishes that the patient meets the Clinic's sliding fee scale requirements. A record of the patient's financial indigence should be kept by the Clinic.
(h) Certifications of Physicians
A staff member will not misrepresent the evaluations of a patient's medical condition and qualification for home health care.
(i) Honest Dealing with Government Officials
No Clinic Staff will attempt to improperly influence actions or decisions made by government bodies, officials, employees or contractors.
(j) Cooperation and Government Audit and Investigation
The Clinic will be cooperative and truthful in its dealings with any governmental inquiries or request, including audits, surveys and certifications reviews.
3. PRIVATE FINANCIAL GAIN (a) Financial Interests
No Clinic Staff may participate in the selection, award or administration of a contract in which federal funds are used, in which he/she or his/her immediate family or partner has a financial interest or with whom he/she is negotiating or has any arrangement concerning employment. The Clinic requires that all Clinic Staff disclose in writing (and update at least annually) all business and family relationships which might potentially create a conflict of interest. In addition, Clinic Staff must disclose to the Executive Director (and the Executive Director must disclose to the Board President) in writing the specifics of any plans to accept supplemental outside
employment so that the Clinic may determine whether such outside employment has the potential for conflicting with the interests of the Clinic.
If an Clinic Staff member believes that he/she, a member of his/her immediate family or partner has a financial interest in a federally funded contract of the Clinic, he/she must immediately disclose this in writing to the Executive Director. Disclosures by officers or members of the Board of Directors must also be made to the President (and if it is the President who has such a financial interest, he or she must make disclosure to the Vice-President).
No member of the Board of Directors may vote on any matter which may directly or indirectly result in financial gain to that member, or which may conflict with that member's obligations to another organization's Board of Directors or to his/her employer. Provided that the member of the Board of Directors has first disclosed a conflict or potential conflict, and abstains from voting in that regard, he/she may participate in discussions relating to that matter.
(b) Compensation to Members of the Board of Directors
Within the limits of available funds, the Clinic may reimburse members of the Board of Directors for reasonable expenses actually incurred by reason of their participation in Board activities, e.g., travel expenses, meals and incidentals.
The Clinic will not compensate members of the Board of Directors for services rendered in the ordinary course of service as members of the Board of Directors. However, if a member of the Board of Directors who is not an officer is uniquely qualified to perform professional services for the Clinic, the Clinic may consider contracting with that member of the Board of Directors for such professional services, provided that the affected member of the Board of Directors does not participate in Board discussions or vote on his/her selection, the contract is in all respects "arms'-length," consistent with federal procurement standards if federal funds will be used, and in the best interests of the Clinic.
(c) Gifts/Gratuities
The Clinic Staff may not solicit or accept gratuities, favors or anything of value from contractors or potential contractors of the Clinic.
A gift means anything offered directly by or on behalf of a contractor other than promotional materials of little or nominal value such as pens, calendars and other items intended for wide distribution. Gifts include (but are not limited to): personal gifts, such as sporting goods, household furnishings and liquor, social entertainment or tickets to sporting events, personal loans or privileges to obtain discounted merchandise, and the like.
Any Clinic Staff member shall decline or return any gift and notify the Executive Director of such gift.
(d) Competition
It is the policy of the Clinic to conduct all procurement transactions in a manner to provide, to the maximum extent practical, open and free competition. The Clinic will be sensitive to, and seek to avoid, organizational conflicts of interest or non-competitive practices among
contractors. Consultants who want to bid for a contract from the Clinic are prohibited from drafting the contract's specifications, request for proposals and the like. Awards will be made to the bidder whose bid is responsive to the solicitation and most advantageous to the Clinic, price and other factors considered.
The Clinic always retains the right to reject any and all bids when it is in the Clinic's best interest to do so.
The Clinic retains the right to determine with respect to any particular procurement that a sole source procurement is justified.
(e) Bribery
The Clinic will immediately dismiss any employee, remove any officer, or member of the Board of Directors, and terminate the contract of any Clinic Staff member found to have offered or accepted a bribe to secure funding from the Clinic.
4. CONFIDENTIAL INFORMATION
Clinic Staff may gain access to confidential (i.e., non-public) information by virtue of his/her position within the Clinic. Employees are required to sign a Confidentiality Agreement that specifically limits the context in which, and persons to whom, confidential information may be communicated.
Officers and members of the Board may not communicate confidential information about the Clinic to anyone who is not also an officer or member of the Board, respectively, absent the explicit authorization of the full Board of Directors. If, as a result of negotiations in which the Clinic is engaged, an officer or member of the Board gains access to confidential information of another entity, the officer or member of the Board may not communicate this information about the other entity to anyone who is not also an officer or member of the Board, respectively, without the authorization of the full Board. If the Clinic executes an agreement with another entity which agreement includes provisions governing confidentiality of information, all officers and members of the Board are bound by those provisions and required to comply with them. 5. OTHER
(a) Political Activities
No Clinic Staff member may engage in political activities during business hours. No Clinic Staff may use the Clinic's name, facility, or resources in connection with political activities. In
particular, no federal grant or related funds may be used to support the costs, if any are incurred, of prohibited lobbying activities as defined variously in OMB Circular A-122,
Department of Health and Human Services ("HHS") rules implementing the Byrd Amendment and HHS appropriations riders.
Clinic Staff may not solicit political support in any manner, which might suggest that the Clinic supports any political party or candidate. No Clinic Staff member shall, in any manner, solicit financial assistance or subscription for any political party, candidate, fund, publication, or for any other political purpose from other Clinic Staff or patients in the workplace or otherwise in an employment-related setting.
(b) Nepotism
The Clinic will not hire any individual who is related to a Clinic Staff member of the Clinic if, in the position being applied for, the applicant will supervise, or be supervised by, the related Clinic Staff member without prior approval from the Board of Director's. Every applicant for
employment with the Corporation must disclose any and all family and business relationships with Clinic Staff on annual basis.
6. VIOLATIONS OF STANDARDS OF CONDUCT
Violations of the Clinic's standards of conduct must be reported promptly to the Compliance Officer and Executive Director. If the Executive Director has violated the standards, notice must be given to the Board Chair.
Clinic Staff members who violate these standards may, depending on the severity of the violation, be subject to oral admonishment, written reprimand, reassignment, demotion, suspension or separation, in addition to legal penalties which might apply. Officers and
members of the Board of Directors who violate these standards may, depending on the severity of the violation, be subject to oral admonishment or removal from the Board.
