Code of Conduct
PURPOSE OF OUR CODE OF CONDUCT
Our Code of Conduct ("Code") provides guidance to all Community Memorial Healthcenter (hereafter "CMH") board members, officers, employees, physicians and auxiliary members and assists us in carrying out our daily activities within appropriate ethical and legal standards. These obligations apply to our relationships with patients, affiliated physicians, third-party payers, subcontractors, independent contractors, vendors, consultants, and one another.
The Code is a critical component of our overall Compliance Program. We have developed the Code to ensure we meet our compliance standards and comply with applicable laws and regulations.
While all CMH employees are obligated to follow our Code, we expect our leaders to set the example, to be in every respect, a model. They must ensure that those on their team have sufficient information to comply with laws, regulations, and policies; as well as the resources to resolve ethical dilemmas. They must help to create a culture within CMH, which promotes the highest standards of ethics and compliance. This culture must encourage everyone in the organization to share concerns when they arise. We must never sacrifice ethical and compliant behavior in the pursuit of business objectives.
TO OUR PATIENTS: We are committed to providing quality care that is sensitive, compassionate, promptly delivered, and cost-effective.
TO OUR CMH EMPLOYEES: We are committed to a work setting which treats all employees with fairness, dignity, and respect, and affords them an opportunity to grow, to develop professionally, and to work in a team environment in which all ideas are considered.
TO OUR AFFILIATED PHYSICIANS: We are committed to providing a work environment which has excellent facilities, modern equipment, and outstanding professional support.
TO OUR THIRD-PARTY PAYERS: We are committed to dealing with our third-party payers in a way that demonstrates our commitment to contractual obligations and reflects our shared concern for quality healthcare and bringing efficiency and cost effectiveness to healthcare. We encourage our private third-party payers to adopt their own set of comparable ethical principles to explicitly recognize their obligations to patients as well as the need for fairness in dealing with providers.
TO OUR REGULATORS: We are committed to an environment in which compliance with rules, regulations, and sound business practices is woven into the corporate culture. We accept the responsibility to aggressively self-govern and monitor adherence to the requirements of law and to our Code of Conduct.
TO THE COMMUNITIES WE SERVE: We are committed to understanding the particular needs of the communities we serve and providing these communities quality, cost-effective healthcare. We realize as an organization that we have a responsibility to help those in need. We proudly support charitable contributions and events in the communities we serve in an effort to promote good will and further good causes.
TO OUR SUPPLIERS: We are committed to fair competition among prospective suppliers and the sense of responsibility required of a good customer. We encourage our suppliers to adopt their own set of comparable ethical principles.
TO OUR VOLUNTEERS: The concept of voluntary assistance to the needs of patients and their families is an integral part of the fabric of healthcare. We are committed to ensuring that our volunteers feel a sense of meaningfulness from their volunteer work and receive recognition for their volunteer efforts.
PATIENT CARE AND RIGHTS
We treat all patients with warmth, respect and dignity and provide care that is both necessary and appropriate. We make no distinction in the admission, transfer or discharge of patients or in the care we provide based on age, gender, disability, race, color, religion, ability to pay or national origin. Clinical care is based on identified patient healthcare needs, not on patient or organization economics.
Upon admission, each patient is provided with a written statement of patient rights. This statement includes the rights of the patient to make decisions regarding medical care and conforms to all applicable state and Federal laws.
We seek to involve patients in all aspects of their care and obtain informed consent for treatment. As applicable, each patient or patient representative is provided with a clear explanation of care including, but not limited to, diagnosis, treatment plan, alternatives to proposed care, right to refuse or accept care, care decision dilemmas, advance directive options, estimates of treatment costs, organ donation and procurement, and an explanation of the risks and benefits associated with available treatment options. Patients have the right to request transfers to other facilities. In such cases, the patient will be given an explanation of the benefits, risks, and alternatives.
Patients are informed of their right to make advance directives. Patient advance directives will be honored within the limits of the law and capabilities. In the promotion and protection of each patient's rights, each patient and his or her representatives will be accorded appropriate confidentiality, privacy, security and protective services, opportunity for resolution of complaints, and pastoral care or spiritual care.
Patients are treated in a manner that preserves their dignity, autonomy, self-esteem, civil rights, and involvement in their own care. CMH maintain processes to support patient rights in a collaborative manner which involves the facility leaders and others. These structures are based on policies and procedures, which make up the framework addressing both patient care and organizational ethics issues. These structures shall include informing each patient, or when appropriate the patient's representative of the patient's rights, in advance of furnishing or discontinuing care. Additionally, the facility has established processes for prompt resolution of patient grievances, which include informing patients of whom to contact regarding grievances and informing patients regarding the grievance resolution. CMH employees will receive training about patient rights in order to clearly understand their role in supporting them.
Compassion and care are part of our commitment to the communities we serve. We strive to provide health education, health promotion, and illness-prevention programs as part of our efforts to improve the quality of life of our patients and our communities.
We follow the Emergency Medical Treatment and Active Labor Act ("EMTALA") in providing emergency medical treatment to all patients, regardless of ability to pay. Provided we have the capacity and capability, anyone with an emergency medical condition is treated and admitted based on medical necessity. In an emergency situation or if the patient is in labor, financial and demographic information will be obtained only after an appropriate medical screening examination and necessary stabilizing treatment (including treatment for an unborn child). We do not admit, discharge or transfer patients simply on their ability or inability to pay.
Patients will only be transferred to another facility at the patient's request or if the patient's medical needs cannot be met at the CMH (e.g., we do not have the capacity or capability) and appropriate care is knowingly available at another facility. Patients may only be transferred in strict compliance with the EMTALA guidelines.
We collect information about the patient's medical condition, history, medication, and family illnesses to provide quality care. We realize the sensitive nature of this information and follow the Health Insurance Portability and Accountability Act (HIPPA). We do not release or discuss patient-specific information with others unless it is necessary to serve the patient or required by law.
CMH employees must never disclose confidential information that violates the privacy rights of our patients. No CMH employee, affiliated physician, or other healthcare partner has a right to any patient information other than that necessary to perform his or her job.
Subject only to emergency exceptions, patients can expect their privacy will be protected and patient specific information will be released only to persons authorized by law or by the patient's written consent.
Any business arrangement with a physician must be structured to ensure precise compliance with legal requirements.
In order to ethically and legally meet all standards regarding referrals and admissions, we will adhere strictly to two primary rules:
We do not pay for referrals. We accept patient referrals and admissions based solely on the patient's clinical needs and our ability to render the needed services. We do not pay or offer to pay anyone -- employees, physicians, or other persons -- for referral of patients. Violation of this policy may have grave consequences for the organization and the individuals involved, including civil and criminal penalties.
We do not accept payments for referrals we make. No CMH employee or any other person acting on behalf of the organization is permitted to solicit or receive anything of value, directly or indirectly, in exchange for the referral of patients. Similarly, when making patient referrals to another healthcare provider, we do not take into account the volume or value of referrals that the provider has made (or may make) to us.
CODING AND BILLING FOR SERVICES
We will take great care to assure all billings to government payers, commercial insurance payers and patients are true and accurate and conform to all pertinent Federal and state laws and regulations. We prohibit any employee of CMH from knowingly presenting or causing to be presented claims for payment or approval, which are false, fictitious, or fraudulent.
Any subcontractors engaged to perform billing or coding services must have the necessary skills, quality control processes, systems, and appropriate procedures to ensure all billings for government and commercial insurance programs are accurate and complete, as will be documented in all contracts. CMH prefers to contract with such entities that have adopted their own ethics and compliance programs. Third-party billing entities, contractors, and preferred vendors under contract consideration must be approved consistent with the corporate policy on this subject.
We are required to submit certain reports of our costs of operation. We will comply with all applicable Federal and state laws relating to all cost reports. These laws and regulations define what costs are allowable and outline the appropriate methodologies to claim reimbursement for the cost of services provided to program beneficiaries. Given their complexity, all issues related to the completion and settlement of cost reports must be communicated through or coordinated with our Reimbursement Department.
LEGAL AND REGULATORY COMPLIANCE
CMH services may be provided only pursuant to appropriate Federal, state, and local laws, regulations and conditions of participation. Such laws, regulations and conditions of participation may include subjects such as certificates of need, licenses, permits, accreditation, access to treatment, consent to treatment, medical record-keeping, access to medical records and confidentiality, patients' rights, terminal care decision-making, medical staff membership and clinical privileges, practice of medicine restrictions, and Medicare and Medicaid program requirements. The organization is subject to numerous other laws in addition to these healthcare regulations and conditions of participation.
We will comply with all applicable laws and regulations. All employees, medical staff members, privileged practitioners, and contract service providers must be knowledgeable about and ensure compliance with all laws, regulations and conditions of participation; and should immediately report violations or suspected violations to a supervisor or member of management, the Corporate Compliance Officer, the Compliance Hotline, the Corporate Compliance Email, or Corporate Compliance PO Box.
CMH will be forthright in dealing with any billing inquiries. Requests for information will be answered with complete, factual, and accurate information. We will cooperate with all inspectors and surveyors and provide them with the information to which they are entitled during an inspection or survey.
During a survey or inspection, you must never conceal, destroy, or alter any documents; lie; or make misleading statements to the agency representative. You should not attempt to cause another employee to fail to provide accurate information or obstruct, mislead, or delay the communication of information or records relating to a possible violation of law.
In order to ensure we fully meet all regulatory obligations, CMH employees must be informed about stated areas of potential compliance concern. The Department of Health and Human Services, and particularly its Inspector General, have routinely notified healthcare providers of areas in which these government representatives believe insufficient attention is being accorded government regulations. We should be diligent in the face of such guidance about reviewing these elements of our system to ensure their correctness.
CMH will provide its employees with the information and education they need to comply fully with all applicable laws, regulations and conditions of participation.
DEALING WITH ACCREDITING BODIES
CMH will deal with all accrediting bodies in a direct, open and honest manner. No action should ever be taken in relationships with accrediting bodies that would mislead the accreditor or its survey teams, either directly or indirectly.
The scope of matters related to accreditation of various bodies is extremely significant and broader than the scope of this Code of Conduct. The purpose of our Code of Conduct is to provide general guidance on subjects of wide interest within the organization. Accrediting bodies may be focused on issues both of wide and somewhat more focused interest. In any case, where CMH determines to seek any form of accreditation, obviously all standards of the accrediting group are important and must be followed.
BUSINESS INFORMATION AND INFORMATION SYSTEMS
ACCURACY, RETENTION, AND DISPOSAL OF DOCUMENTS AND RECORDS
Each CMH employee is responsible for the integrity and accuracy of our organization's documents and records, not only to comply with regulatory and legal requirements but also to ensure records are available to support our business practices and actions. No one may alter or falsify information on any record or document.
Medical and business documents and records are retained in accordance with the law and our record retention policy. Medical and business documents include paper documents such as letters and memos, computer-based information such as e-mail or computer files on disk or tape, and any other medium that contains information about the organization or its business activities. It is important to retain and destroy records only according to our policy. You must not tamper with records, nor remove or destroy them prior to the specified date.
INFORMATION SECURITY AND CONFIDENTIALITY
Confidential information about our organization's strategies and operations is a valuable asset. Although you may use confidential information to perform your job, it must not be shared with others unless the individuals have a legitimate need to know this information and have agreed to maintain the confidentiality of the information. Confidential information includes personnel data maintained by the organization; patient lists and clinical information; patient financial information; passwords; pricing and cost data; information pertaining to acquisitions, divestitures, affiliations and mergers; financial data; details regarding federal, state and local tax examinations of the organization or its joint venture partners; research data; strategic plans; marketing strategies and techniques; supplier and subcontractor information; and proprietary computer software. If your relationship with CMH ends for any reason, you are still bound to maintain the confidentiality of information viewed during your employment. This provision does not restrict the right of a employee to disclose, if he or she wishes, information about his or her own compensation, benefits, or terms and conditions of employment.
Our clinical and business processes rely on timely access to accurate information from our computer systems. Your passwords act as individual keys to our network and to critical patient care and business applications, and they must be kept confidential. It is part of your job to learn about and practice the many ways you can help protect the confidentiality, integrity and availability of electronic information assets.
All communications systems, including electronic mail, Internet access, and voice mail, are the property of the organization and are to be primarily used for business purposes. Highly limited reasonable personal use of CMH communications systems is permitted; however, you should assume these communications are not private. Patient or confidential information should not be sent through Microsoft Outlook or the Internet until such time that its confidentiality can be assured.
CMH reserves the right to periodically access, monitor, and disclose the contents of e-mail and voice mail messages. Access or disclosure of individual employee messages may only be done with the approval of the Corporate Compliance Department.
Employees may not use internal communication channels or access to the Internet at work to post, store, transmit, download, or distribute any threatening materials; knowingly, recklessly, or maliciously false materials; or obscene materials including anything constituting or encouraging a criminal offense, giving rise to civil liability, or otherwise violating any laws. Additionally, these channels of communication may not be used to send chain letters, personal broadcast messages, or copyrighted documents that are not authorized for reproduction; nor are they to be used to conduct an external job search or open mis-addressed mail.
Employees who abuse our communications systems or use them excessively for non-business purposes may lose these privileges and be subject to disciplinary action, to include termination of employment.
FINANCIAL REPORTING AND RECORDS
We have established and maintain a high standard of accuracy and completeness in the documentation and reporting of all financial records. These records serve as a basis for managing our business and are important in meeting our obligations to patients, employees, suppliers, and others. They are also necessary for compliance with tax and financial reporting requirements.
All financial information must reflect actual transactions and conform to generally accepted accounting principles. No undisclosed or unrecorded funds or assets may be established. CMH maintains a system of internal controls to provide reasonable assurances 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.
WORKPLACE CONDUCT AND EMPLOYMENT PRACTICES
CONFLICT OF INTEREST
A conflict of interest may occur if your outside activities or personal interests influence or appear to influence your ability to make objective decisions in the course of your job responsibilities. A conflict of interest may also exist if the demands of any outside activities hinder or distract you from the performance of your job or cause you to use CMH resources for other than CMH purposes. It is your obligation to ensure you remain free of conflicts of interest in the performance of your responsibilities at CMH. If you have any question about whether an outside activity might constitute a conflict of interest, you must obtain the approval of your supervisor before pursuing the activity.
Some of our employees routinely have access to prescription drugs, controlled substances, and other medical supplies. Many of these substances are governed and monitored by specific regulatory organizations and must be administered by physician order only. It is extremely important these items be handled properly and only by authorized individuals to minimize risks to us and to patients. If you become aware of the diversion of drugs from the organization, you should report the incident immediately.
DIVERSITY AND EQUAL EMPLOYMENT OPPORTUNITY
Our employees provide us with a wide complement of talents, which contribute greatly to our success. We are committed to providing an equal opportunity work environment where everyone is treated with fairness, dignity, and respect. We will comply with all laws, regulations, and policies related to non-discrimination in all of our personnel actions. Such actions include hiring, staff reductions, transfers, terminations, evaluations, recruiting, compensation, corrective action, discipline, and promotions.
No one shall discriminate against any individual with a disability with respect to any offer, or term or condition, of employment. We will make reasonable accommodations to the known physical and mental limitations of otherwise qualified individuals with disabilities.
HARASSMENT AND WORKPLACE VIOLENCE
Each CMH employee has the right to work in an environment free of harassment and disruptive behavior. We will not tolerate harassment by anyone based on the diverse characteristics or cultural backgrounds of those who work with us. Degrading or humiliating jokes, slurs, intimidation, or other harassing conduct is not acceptable in our workplace.
Any form of sexual harassment is strictly prohibited. This prohibition includes unwelcome sexual advances or requests for sexual favors in conjunction with employment decisions. Moreover, verbal or physical conduct of a sexual nature that interferes with an individual's work performance or creates an intimidating, hostile, or offensive work environment has no place at CMH.
Harassment also includes incidents of workplace violence. Workplace violence includes robbery and other commercial crimes, stalking cases, violence directed at the employer, terrorism, and hate crimes committed by current or former employees. As part of our commitment to a safe workplace for our employees, we prohibit employees from possessing firearms, other weapons, explosive devices, or other dangerous materials at any CMH facility or any CMH sponsored activity wherever conducted. Employees who observe or experience any form of harassment or violence should report the incident to their supervisor, the Human Resources Department, a member of management, or the Compliance Officer.
HEALTH AND SAFETY
CMH must comply with all government regulations and rules, CMH policies, and required facility practices that promote the protection of workplace health and safety. Our policies have been developed to protect you from potential workplace hazards. You should become familiar with and understand how these policies apply to your specific job responsibilities and seek advice from your supervisor or the Safety Officer whenever you have a question or concern. It is important for you to advise your supervisor, Human Resources or the Safety Officer of any serious workplace injury or any situation presenting a danger of injury so timely corrective action may be taken to resolve the issue.
LICENSE AND CERTIFICATION RENEWAL
Employees and individuals having medical privileges as independent contractors in positions which require professional licenses, certifications, or other credentials are responsible for maintaining the current status of their credentials and shall comply at all times with Federal and state requirements applicable to their respective disciplines. To assure compliance, CMH may require evidence of the individual having a current license or credential status.
CMH will not allow any employee or independent contractor who is required by applicable law to be licensed or credentialed to work without valid current licenses or credentials.
PERSONAL USE OF CMH RESOURCES
It is the responsibility of each CMH employee to preserve our organizations assets including time, materials, supplies, equipment, and information. Organization assets are to be maintained for business related purposes. As a general rule, the personal use of any CMH asset without the prior approval of your supervisor is prohibited. Any community or charitable use of organization resources must be approved in advance by your supervisor. Any use of organization resources for personal financial gain unrelated to the organization's business is prohibited.
RELATIONSHIPS AMONG CMH EMPLOYEES
In the normal day-to-day functions of an organization like CMH, there are issues that arise which relate to how people in the organization deal with one another. It is impossible to foresee all of these, and many do not require explicit treatment in a document like this. A few routinely arise, however. One involves gift giving among employees for certain occasions. While we wish to avoid any strict rules, no one should ever feel compelled to give a gift to anyone, and any gifts offered or received should be appropriate to the circumstances.
RELATIONSHIPS W\ SUBCONTRACTORS, SUPPLIERS, AND EDUCATIONAL INSTITUTIONS
We must manage our subcontractor and supplier relationships in a fair and reasonable manner, consistent with all applicable laws and good business practices. We promote competitive procurement to the maximum extent practicable. Our selection of subcontractors, suppliers, and vendors will be made on the basis of objective criteria including quality, technical excellence, price, delivery, adherence to schedules, service, and maintenance of adequate sources of supply. Our purchasing decisions will be made on the supplier's ability to meet our needs, and not on personal relationships and friendships. We will always employ the highest ethical standards in business practices in source selection, negotiation, determination of contract awards, and the Administration of all purchasing activities. We will not communicate to a third-party confidential information given to us by our suppliers unless directed in writing to do so by the supplier. We will not disclose contract pricing and information to any outside parties. (The subject of Business Courtesies, which might be offered by or to subcontractors or suppliers, is discussed on pages 13 to 15 of this Code.)
The organization has policies and procedures in place to ensure we do not contract with, employ or bill for services rendered by an individual or entity that is excluded, suspended, debarred, or ineligible to participate in Federal health care programs; or has been convicted of a criminal offense related to the provision of health care items or services and has not been reinstated in a Federal health care program after a period of exclusion, suspension, debarment, or ineligibility, provided that we are aware of such criminal offense. We routinely search the Office of Inspector General lists of such excluded and ineligible persons.
SUBSTANCE ABUSE AND MENTAL ACUITY
To protect the interests of our employees and patients, we are committed to an alcohol and drug-free work environment. All employees must report for work free of the influence of alcohol and illegal drugs or the improper use of legal drugs. Reporting to work under the influence of any illegal drug, improper use of legal drugs or alcohol; having an illegal drug in your system; or using, possessing, or selling illegal drugs while on CMH work time or property may result in immediate termination. We may use drug testing as a means of enforcing this policy.
It is also recognized individuals may be taking prescription or over-the-counter drugs, which could impair judgment or other skills required in job performance. If you have questions about the effect of such medication on your performance, or you observe an individual who appears to be impaired in the performance of his or her job, consult your supervisor.
Antitrust laws are designed to create a level playing field in the marketplace and to promote fair competition. These laws could be violated by discussing CMH business with a competitor, such as how our prices are set, disclosing the terms of supplier relationships, allocating markets among competitors, or agreeing with a competitor to refuse to deal with a supplier. Our competitors are other health systems and facilities in markets where we operate.
At trade association meetings, be alert to potential situations where it may not be appropriate for you to participate in discussions regarding prohibited subjects with our competitors. Prohibited subjects include any aspect of pricing, our services in the market, key costs such as labor costs, and marketing plans. If a competitor raises a prohibited subject, end the conversation immediately. Document your refusal to participate in the conversation by requesting your objection be reflected in the meeting minutes and notify the Corporate Compliance Officer of the incident.
In general, avoid discussing sensitive topics with competitors or suppliers, unless you are proceeding with the advice of the Administration. You must also not provide any information in response to an oral or written inquiry concerning an antitrust matter without first consulting the Administration and/or Compliance Officer.
GATHERING INFORMATION ABOUT COMPETITORS
It is not unusual to obtain public information about other organizations, including our competitors, through legal and ethical means such as public documents, public presentations, journal and magazine articles, and other published and spoken information. However, you should avoid seeking or receiving information about a competitor throughout other non-public means if you know or have reason to believe the information is proprietary or confidential. For example, you should not seek proprietary or confidential information when doing so would require anyone to violate a contractual agreement, such as a confidentiality agreement with a prior employer.
MARKETING AND ADVERTISING
We may use marketing and advertising activities to educate the public, provide information to the community, increase awareness of our services, and to recruit employees. We will present only truthful, fully informative, and non-deceptive information in these materials and announcements.
It is our policy to comply with all environmental laws and regulations as they relate to our organization's operations. We will act to preserve our natural resources to the full extent reasonably possible. We will comply with all environmental laws and operate each of our facilities with the necessary permits, approvals, and controls. We will diligently employ the proper procedures with respect to handling and disposal of hazardous and biohazardous waste, including but not limited to medical waste.
In helping CMH comply with these laws and regulations, we must understand how job duties may impact the environment, adhere to all requirements for the proper handling of hazardous materials, and immediately alert our supervisors to any situation regarding the discharge of a hazardous substance, improper disposal of medical waste, or any situation which may be potentially damaging to the environment.
This part of the Code of Conduct should not be considered in any way as an encouragement to make, solicit, or receive any type of entertainment or gift. For clarity purposes, please note that these limitations govern activities with those outside CMH. This section does not pertain to actions between CMH and its employees or actions among CMH employees themselves. (See "Relationships Among CMH Employees" on page 13.)
RECEIVING BUSINESS COURTESIES
We recognize there will be times when a current or potential business associate may extend an invitation to attend a social event in order to further develop your business relationship. You may accept such invitations, provided: (1) the cost associated with such an event is reasonable and appropriate, which, as a general rule, means the cost will not exceed $100.00 per person; (2) no expense is incurred for any travel costs (other than in a vehicle owned privately or by the host company) or overnight lodging; and (3) such events are infrequent. The limitations of this section do not apply to business meetings at which food (including meals) may be provided. Sometimes a business associate will extend training and educational opportunities that include travel and overnight accommodations to you at no cost to you or CMH. Similarly, there are some circumstances where you are invited to an event at a vendor's expense to receive information about new products or services. Subsequent to accepting any such invitation, you must receive approval to do so.
As an CMH employee, you may accept gifts with a total value of $50.00 or less in any one year from any individual or organization who has a business relationship with CMH. For purposes of this paragraph, physicians practicing in CMH facilities are considered to have such a relationship. Perishable or consumable gifts given to a department or group are not subject to any specific limitation. You may accept gift certificates, but you may never accept cash or financial instruments. Finally, under no circumstances may you solicit a gift.
This section does not limit CMH from accepting gifts, provided they are used and accounted for appropriately.
EXTENDING BUSINESS COURTESIES TO NON-REFERRAL SOURCES
No portion of this section, "Extending Business Courtesies to Non-referral Sources," applies to any individual who makes, or is in a position to make, referrals to CMH.
There may be times when you wish to extend to a current or potential business associate (other than someone who may be in a position to make a patient referral) an invitation to attend a social event (e.g., reception, meal, sporting event or theatrical event) to further or develop your business relationship. The purpose of the entertainment must never be to induce any favorable business action. During these events, topics of a business nature must be discussed and the host must be present. These events must not include expenses paid for any travel costs (other than in a vehicle owned privately or by the host entity) or overnight lodging. The cost associated with such an event must be reasonable and appropriate. As a rule, this means the cost will not exceed $100.00 per person. Moreover, such business entertainment with respect to any particular individual must be infrequent, which, as a rule, means not more than four times per year. With regard to the $100.00 guideline, if circumstances arise where an entertainment event was contemplated prior to the event to meet the guideline but unforeseeably exceeded it, a report to that effect with the relevant details must be filed consistent with the corporate policy on this subject. If you anticipate an event will exceed the $100.00 guideline, you must obtain advance approval as required by corporate policy. That policy requires establishing the business necessity and appropriateness of the proposed entertainment. The organization will under no circumstances sanction participation in any business entertainment that might be considered lavish. Departures from the $100.00 guideline are highly discouraged.
It is critical to avoid the appearance of impropriety when giving gifts to individuals who do business or are seeking to do business with CMH. We will never use gifts or other incentives to improperly influence relationships or business outcomes. You may accept gift certificates, not to exceed $50, but you may never accept cash or financial instruments. The corporate policy on business courtesies may from time to time provide modest flexibility in order to permit appropriate recognition of the efforts of those who have spent meaningful amounts of volunteer time on behalf of CMH.
U.S. Federal and state governments have strict rules and laws regarding gifts, meals, and other business courtesies for their employees.
EXTENDING BUSINESS COURTESIES TO POSSIBLE REFERRAL SOURCES
Any entertainment or gift involving physicians or other persons who are in a position to refer patients to our healthcare facilities must be undertaken in accordance with corporate policies. We will comply with all Federal laws, regulations, and rules regarding these practices.
GOVERNMENT RELATIONS AND POLITICAL ACTIVITIES
The organization and its representatives will comply with all Federal, state and local laws governing participation in government relations and political activities. Additionally, CMH funds or resources will not be contributed directly to individual political campaigns, political parties or other organizations, which intend to use the funds primarily for political campaign objectives. Organization resources include financial and non-financial donations such as using work time and telephones to solicit for a political cause or candidate or the loaning of CMH property for use in the political campaign. The conduct of any political action committee is to be consistent with relevant laws and regulations. In addition, political action committees associated with the organization will select candidates to support based on the overall ability of the candidate to render meaningful public service. The organization will not select candidates to support as a reflection of expected support of the candidate on any specific issue.
The organization will engage in public policy debate only in a limited number of instances where it has special expertise that can inform the public policy formulation process. When the organization is directly impacted by public policy decisions, it may provide relevant, factual information about the impact of such decisions on the private sector. In articulating positions, the organization will only take positions that it believes can be shown to be in the larger public interest. The organization will encourage trade associations with which it is associated to do the same.
It is important to separate personal and corporate political activities in order to comply with the appropriate rules and regulations relating to lobbying or attempting to influence government officials. No use of corporate resources, including e-mail, is appropriate for personally engaging in political activity. You may, of course, participate in the political process on your own time and at your own expense. While you are doing so, it is important not to give the impression you are speaking on behalf of or representing CMH in these activities. You cannot seek to be reimbursed by CMH for any personal contributions for such purposes.
At times, CMH may ask employees to make personal contact with government officials or to write letters to present our position on specific issues. In addition, it is a part of the role of some CMH management to interface on a regular basis with government officials. If you are making these communications on behalf of the organization, be certain that you are familiar with any regulatory constraints and observe them. Guidance is always available from the Corporate Compliance Department as necessary.
THE CORPORATE COMPLIANCE PROGRAM
The Corporate Compliance Program is intended to demonstrate in the clearest possible terms the absolute commitment of the organization to the highest standards of ethics and compliance. The elements of the program include setting standards (the Code and Policies and Procedures), communicating the standards, providing a mechanism for reporting potential exceptions, monitoring and auditing, and maintaining an organizational structure that supports the furtherance of the program.
These elements are supported at all levels of the organization. There is oversight from the Board of the Trustees; Senior Management; to include CEO/President and Vice President of Finance, Corporate Compliance Officer and Corporate Legal Counsel. Collectively, these individuals are responsible for the development of the Compliance Program, including the creation and distribution of compliance standards; the development and delivery of compliance training; auditing and monitoring compliance with laws, regulations, conditions of participation and policies; and providing a mechanism for reporting exceptions.
All of these individuals are prepared to support you in meeting the standards set forth in this Code.
RESOURCES FOR GUIDANCE AND REPORTING VIOLATIONS
To obtain guidance on an ethics or compliance issue or to report a suspected violation, you may choose from several options. It is encouraged to utilize the human resources-related problem solving procedure to resolve such issues as payroll, fair treatment and disciplinary. It is an expected good practice, when you are comfortable with it and think it appropriate under the circumstances, to raise concerns first with your supervisor. If this is uncomfortable or inappropriate, another option is to discuss the situation with Compliance Officer or another member of management at CMH. You are always free to contact the Healthcare Ethics line at 1-800-340-5877.
CMH will make every effort to maintain, within the limits of the law, the confidentiality of the identity of any individual who reports possible misconduct. There will be no retribution or discipline for anyone who reports a possible violation in good faith. Any employee who deliberately makes a false accusation with the purpose of harming or retaliating against another employee will be subject to discipline.
PERSONAL OBLIGATION TO REPORT
We are committed to ethical and legal conduct that is compliant with all relevant laws and regulations and to correcting wrongdoing wherever it may occur in the organization. Each employee has an individual responsibility for reporting any activity by any employee, physician, subcontractor, or vendor that appears to violate applicable laws, rules, regulations, or this Code.
INTERNAL INVESTIGATIONS OF REPORTS
We are committed to investigating all reported concerns promptly and confidentially to the extent possible. The Corporate Compliance Officer will coordinate any findings from the investigations and immediately recommend corrective action or changes that need to be made. We expect all employees to cooperate with investigation efforts.
Where an internal investigation substantiates a reported violation, it is the policy of the organization to initiate corrective action, including, as appropriate, making prompt restitution of any overpayment amounts, notifying the appropriate governmental agency, instituting whatever disciplinary action is necessary, and implementing systemic changes to prevent a similar violation from recurring in the future at CMH.
All violators of the Code will be subject to disciplinary action. The precise discipline utilized will depend on the nature, severity, and frequency of the violation and may result in any or all of the following disciplinary actions:
* Oral warning
* Written warning
* Written reprimand
INTERNAL AUDITING AND OTHER MONITORING
CMH is committed to monitoring compliance with its policies. Internal and external audits will be conducted of issues that have regulatory or compliance implications. The organization also routinely seeks other means of ensuring and demonstrating compliance with laws, regulations, and CMH policies. Additionally, facilities regularly conduct self-audits pursuant to compliance policies and procedures.
CMH requires all employees to sign an acknowledgment confirming they have received the Code, understand it represents mandatory policies of CMH and agree to abide by it. New employees will be required to sign this acknowledgment as a condition of employment. Each CMH employee is also required to participate in annual Code of Conduct training, and records of such training must be retained by each facility.
Adherence to and support of CMH's Code of Conduct and participation in related activities and training will be considered in decisions regarding hiring, promotion, and compensation for all candidates and employees. New employees must receive Code of Conduct training within 30 days of employment.