TIFTREGIONALMEDICALCENTER
COMPLIANCE PROGRAM
Adopted: March 1999
Amended: August 21, 2000
Amended: February 19, 2001
Amended: May 21, 2001
Amended: June 16, 2003
VISION
TiftRegionalMedicalCenter will develop an organizational culture in which systems fulfill and support our mission as evidenced by:
- Becoming clearly recognized as a provider of compassionate individualized care for the citizens of TiftCounty and our surrounding communities.
- Consistently measuring, assessing and improving patient satisfaction.
- Remaining cognizant of the evolving status of healthcare changes and maintaining a proactive response.
- Becoming clearly recognized as a leader in information management and integration of services of the hospital and the physicians' practices, and other identified partners in healthcare management.
- Maintaining status as a major regional leader in providing the most comprehensive participation in healthcare delivery and utilization management across the continuum of care.
- Becoming clearly recognized as the highest quality healthcare system in the region.
- Cooperating with and supporting other healthcare providers so as to provide for the continuum of healthcare services.
- Serving as a major leading resource for information and education within our areas of service with particular emphasis on preventative and others as needed.
- Providing comprehensive, accessible inpatient and outpatient healthcare services.
- Assist neighboring counties as requested in the provision of accessible local healthcare.
- Maintaining constant vigilance of corporate compliance by in-depth surveillance, monitoring, auditing, and education of the Tift Regional Medical Center Compliance Program.
- Developing systems to proactively identify and manage potential risk to patient safety by promoting an environment of reporting and prevention.
MISSION
The philosophy of TiftRegionalMedicalCenter is based on the belief that the primary and fundamental purpose of the MedicalCenter’s existence is to serve the health needs of the patient as well as those of the community. The Tift County Hospital Authority has the complete legal and moral duty and responsibility to see that TiftRegionalMedicalCenter renders an adequate range of services that include preventive, inpatient, and outpatient services; to see that these services are delivered with a consistent, high level of quality; and, to ensure the hospital’s financial viability and cost effectiveness. The MedicalCenter also strives to assist in the provision of an adequate number of primary care and specialty physicians in the region in order to facilitate access to healthcare services. Insofar as TiftRegionalMedicalCenter is a regional referral facility serving the healthcare needs of the many citizens in South Central Georgia, the Hospital Authority recognizes its responsibility in a multi-county region. In this role, the MedicalCenter strongly supports the development and accreditation of quality continuing medical education programs. The MedicalCenter is expected to adopt new and innovative methods of healthcare delivery consistent with the identified needs of the region.
SECTION ONE TABLE OF CONTENTS
TIFTREGIONALMEDICALCENTER
COMPLIANCE PROGRAM CODE OF CONDUCT
I.INTRODUCTION...... 1
II.ADDRESSING ISSUES AND CONCERNS...... 1
III.HELPLINE...... 1
IV.REPORTING...... 1
V.COMPLIANCE AS AN ELEMENT OF PERFORMANCE...... 2
VI.PRINCIPLES AND STANDARDS...... 2
PRINCIPLE 1 - PATIENT CARE...... 2
1.1. Treatment of Patients...... 2
1.2. Privacy of Patients...... 2
1.3. Appropriate Care...... 2
1.4. Standards of Professional Practice...... 2
PRINCIPLE 2 - HUMAN RESOURCES...... 2
2.1. Equal Employment Opportunities...... 2
2.2. Drugs, Narcotics, and Alcohol...... 3
PRINCIPLE 3 - ENVIRONMENTAL HEALTH AND SAFETY...... 3
3.1. Workplace Violence...... 3
3.2. Environmental...... 3
PRINCIPLE 4 - CORPORATE INTEGRITY...... 4
4.1. Conflict of Interest...... 5
4.2. Market Practices...... 5
4.3. Protection of Assets...... 5
4.4. Lobbying/Political Activity...... 6
PRINCIPLE 5 - REGULATORY COMPLIANCE...... 6
5.1. Regulatory Requirements...... 6
5.2. TiftRegionalMedicalCenter Policies and Procedures...... 6
5.3. Tax...... 6
5.4. Antitrust...... 7
5.5. Physicians...... 7
PRINCIPLE 6 - REFERRALS...... 7
6.1. Referrals...... 7
6.2. Admissions...... 7
PRINCIPLE 7 - REIMBURSEMENT CLAIMS...... 7
7.1. Billing Fraud & Abuse...... 7
7.2. Cost Reports...... 8
7.3. Medical Necessity...... 8
PRINCIPLE 8 - CONFIDENTIALITY...... 9
8.1. Patient Information...... 9
8.2. Proprietary Information...... 9
PRINCIPLE 9 - GOVERNMENT INVESTIGATIONS...... 9 9.1. Responding to Inquiries 9
9.2. Responding to Subpoenas...... 10
PRINCIPLE 10 - DOCUMENT RETENTION...... 10
10.1. Requirements of Government Programs and Other Third-Party Payors....10
10.2. Tift Regional Document Retention Policies...... 10
SECTION TWO TABLE OF CONTENTS
TIFTREGIONALMEDICALCENTER COMPLIANCE PROGRAM
I.PURPOSE...... 1
II.PROGRAM STRUCTURE...... 1
III.IMPLEMENTATION...... 2
IV.EMPLOYEE AND CONTRACTOR DISCLOSURE...... 2
A.Applicants for Employment...... 2
B.Current Employees and Contractors...... 3
C.Employee Departures...... 3
D.Annual Disclosure...... 3
V.TRAINING AND EDUCATION...... 3
A.Responsibility...... 3
B.Subject Matter...... 4
C.Methods...... 4
D.Managers and Supervisors...... 4
E.Performance of Education/Training Requirements...... 4
VI.REPORTING AND INVESTIGATING...... 4
A.Compliance Helpline...... 4
B.Employee Reporting...... 5
C.Investigation...... 5
D.Compliance Committee Reports...... 5
VII.AUDITING AND MONITORING...... 5
A. Audits...... 5
B.Monitoring...... 6
VIII.RESPONSE TO REPORT OF VIOLATIONS...... 6
IX.DISCIPLINARY PROCEDURES...... 6
A.Disciplinary Policy...... 6
X.MODIFYING AND AMENDING THE COMPLIANCE PROGRAM...... 7
1
SECTION ONE
TIFTREGIONALMEDICALCENTER
COMPLIANCE PROGRAM
CODE OF CONDUCT
June 16, 2003
TiftRegionalMedicalCenter (“Tift Regional”) is committed to providing quality healthcare services in accordance with the law. To achieve this objective, Tift Regional developed this Code of Conduct to be followed by employees and others who work with Tift Regional. The development and implementation of a Compliance Program and this Code of Conduct should not be interpreted as a concern that present management systems are inadequate. The development of a Compliance Program and this Code of Conduct is simply another element in our continuing efforts to improve quality and performance.
Although this Code of Conduct cannot, nor was it intended to, cover every situation you may encounter, this Code of Conduct does provide guidance to the complex legal and business ethics issues we face and provides alternatives for resolution of issues or concerns you may have about Tift Regional operations.
We are committed to the ideals reflected in our Vision, our Mission and in this Code of Conduct and ask you to assist us and all our colleagues at Tift Regional in supporting the values and principles which are critical to achieving our Vision and our Mission.
/s/
William T. Richardson, FACHE
President-CEO
1
I.INTRODUCTION
Adherence to this Code of Conduct is a condition of employment and will be an important factor in each employee’s performance evaluation. Conduct in violation of the Principles and Standards set forth below is beyond the scope of an employee’s job and may lead to serious sanctions, including termination. However, the Principles and Standards cannot, nor were they intended to, cover every situation.
II.ADDRESSING ISSUES AND CONCERNS
The numerous, ever-changing regulations and rules that govern each department of Tift Regional can create areas of uncertainty for employees, professional staff members and agents who carry out daily operations. When such questions or uncertainty exists, it is each person’s obligation to seek guidance. Employees with issues or concerns regarding this Code of Conduct or any of the Principles or Standards should contact any member of the Compliance Committee or the Helpline.
III.HELPLINE: 386-6250
Employees, professional staff members and agents may anonymously call the Helpline to report ethical or legal concerns or to report any potentially improper action on the part of any Tift Regional officer, agent, employee, contractor or representative. A person who makes a report to the Helpline has a continuing obligation to update the report as additional information is available. Callers will be given a number so that they can call for an update at a later date. The Compliance Committee, assisted by the appropriate department, will investigate all calls.
Although information reported to the Compliance Committee or Helpline in accordance with the Compliance Program shall be kept confidential to the extent that confidentiality is possible, there may be a point where a person’s identity may become known or have to be revealed to further the investigation. No adverse action will be taken against a Helpline caller on the basis of a call, if the call is made in good faith. Any person who deliberately makes a false accusation with the purpose of harming or retaliating against another person will be subject to discipline, up to termination.
IV.REPORTING
Tift Regional employees, professional staff members and agents are expected to promptly report any perceived or alleged violation of the Compliance Program, Code of Conduct and/or Tift Regional policies and procedures to someone in their chain of command, the Compliance Committee or the Helpline. Managers and supervisors shall report to the Compliance Committee all compliance issues received from members of their department which require investigation or corrective action. Any employee, professional staff member or agent who is instructed, directed, or requested to engage in conduct prohibited by the Compliance Program, the Code of Conduct and/or Tift Regional policies and procedures shall promptly report such information to the Compliance Committee or the Helpline.
V.COMPLIANCE AS AN ELEMENT OF PERFORMANCE
The promotion of and adherence to the Compliance Program is the job responsibility of all employees and is a factor in evaluating the performance of employees, agents and contractors. Adherence to the Compliance Program includes reporting problems or noncompliance with applicable policies or legal requirements to someone in the employee’s chain of command, the Compliance Committee or the Helpline.
Violations of the Compliance Program, the Code of Conduct, Tift Regional policies or procedures or applicable laws or regulations will be grounds for disciplinary action up to privilege revocation (subject to applicable peer review procedure), discharge or contract termination, depending on the circumstances of each violation. Disciplinary action for noncompliance shall be taken consistently on a fair and equitable basis. Disciplinary action will be taken not only against employees, professional staff members and agents who authorize or participate directly in a violation but also against such persons who deliberately fail to report a violation or any responsible employee whose failure to detect a violation is attributable to his or her negligence or reckless conduct. Managers and supervisors will be sanctioned for failure to adequately instruct members of their department or for failure to detect noncompliance with applicable policies and legal requirements where reasonable diligence on the part of the manager or supervisor would have led to an avoidance of or an earlier discovery of a problem or violation.
VI.PRINCIPLES AND STANDARDS
PRINCIPLE 1 - PATIENT CARE
Compassionately deliver appropriate, effective, quality care to our patients.
Standard 1.1Treatment of Patients. Patients deserve to be treated at all times with dignity, respect and professionalism.
Standard 1.2Privacy of Patients. Patients’ privacy will be respected.
Standard 1.3Appropriate Care. Patient care must be appropriate and designed to meet the intended outcome of the patient’s treatment plan.
Standard 1.4Standards of Professional Practice. Tift Regional employees shall observe all applicable standards of professional practice in all Tift Regional facilities and programs.
PRINCIPLE 2 - HUMAN RESOURCES
Tift Regional is a drug-free work place and an equal opportunity employer. Tift Regional will comply with applicable laws concerning employment, promotion, transfers, demotions and wages.
Standard 2.1Equal Employment Opportunities. Harassment or abuse of any kind is prohibited in the Tift Regional workplace. Tift Regional prohibits discrimination in any work-related decision on the basis of sex, race, age, color, religious beliefs, disability status, national origin or any other illegal basis. Tift Regional expects everyone associated with Tift Regional to treat co-workers and patients with respect and courtesy and to respect and protect the privacy of Tift Regional employees and patients. Tift Regional does not tolerate discrimination or harassment on Tift Regional property by or against any person and will discipline or discharge those who violate this Standard. Freedom from harassment specifically includes freedom from sexual advances, requests for sexual favors, sexual innuendo, jokes of a sexual nature, or other verbal, graphic or physical forms of a sexual nature.
If an employee, contractor or agent perceives that inequitable or unfair conduct is occurring in the workplace, he/she should utilize Tift Regional’s existing grievance process already available. If the employee, contractor or agent feels that use of these resources does not resolve the matter, he/she may contact the Human Resources Director, the Compliance Committee or the Helpline.
Standard 2.2Drugs, Narcotics, and Alcohol. All employees, agents and contractors must report for work free of the influence of alcohol and illegal drugs. Reporting to work under the influence of any illegal drug or alcohol, having an illegal drug in your system, or using, possessing or selling drugs while on Tift Regional work time or property may result in immediate discharge or termination of contract. Any person reporting to work or discovered at work in a condition that suggests he or she is under the influence of narcotics, drugs or alcohol will not be permitted to report to or remain on the job. Drug testing may be used as a means of enforcing this Standard.
In order to ensure the safety of all Tift Regional employees and patients, any employee who has been directed by a physician to take a prescription drug that may adversely affect or impair performance on the job must report that circumstance to his/her immediate supervisor. Reasonable accommodation will be made for employees suffering from any disability, so long as the accommodation does not create an undue risk of harm to the employee, patients or others.
If an employee, professional staff member, agent or contractor has concerns regarding possible violations of this Standard, he/she should contact someone in his/her chain of command, the Compliance Committee or the Helpline.
PRINCIPLE 3 - ENVIRONMENTAL HEALTH AND SAFETY
Standard 3.1Workplace Violence. Tift Regional is committed to maintaining a work environment free from workplace violence. Workplace violence includes threats of violence or violent acts such as robbery, stalking, violence directed at employees or Tift Regional, terrorism, and hate crimes committed by current or former employees. Tift Regional prohibits the possession of firearms, other weapons, explosive devices, or other dangerous materials on Tift Regional premises. Persons who experience or observe any form of violence should report the incident to someone in their chain of command, the Director of Security, the Compliance Committee or the Helpline.
Standard 3.2Environmental. Tift Regional strives to manage and operate its business in a manner which respects our environment and conserves natural resources. In Tift Regional operations, employees, professional staff members and agents shall strive to utilize resources appropriately and efficiently, to recycle where possible and otherwise dispose of all waste in accordance with applicable laws and regulations, and to work cooperatively with appropriate authorities to remedy any environmental contamination for which Tift Regional may be responsible.
PRINCIPLE 4 - CORPORATE INTEGRITY
Standard 4.1Conflict of Interest. Each Tift Regional employee has a duty of loyalty to Tift Regional. Employees must avoid conflicts of interest and the appearance of conflicts of interest.
a.Outside Financial Interests. A conflict of interest occurs if an outside activity or personal interest may influence or appear to influence your ability to make objective decisions or meet your job responsibilities for Tift Regional. A conflict of interest may also occur if the demands of any outside activities hinder or distract you from the performance of your job responsibilities or cause you to use Tift Regional resources for any purpose other than Tift Regional purposes. Participation in activities that conflict with your employment responsibilities at Tift Regional is not acceptable. While not inclusive, the following will serve as a guide to the types of activities by an employee which might cause a conflict of interest:
1.Ownership. Tift Regional employees should not own stock in, serve as a director or officer of, receive compensation from, or provide consulting or other services to hospitals or firms in competition with Tift Regional without the written consent of the Director of Human Resources. However, Tift Regional employees may own less than one percent of the outstanding shares of any class of equity security of a competitor or supplier listed on a national securities exchange or regularly traded in the over-the-counter market.
2.Suppliers. Tift Regional employees who deal with suppliers must do so in a professional and legal manner. Tift Regional employees should not conduct any business not on behalf of Tift Regional with any vendor, supplier, contractor, or agency, or any of their officers or directors. To avoid even the appearance of impropriety, Tift Regional employees should decline gifts of more than nominal value, including discounts, of which the acceptance would raise even the slightest doubt of improper influence. Discounts that are available to all Tift Regional employees and employees of other companies may be accepted.
3.Business Information. Tift Regional employees may not use for their personal benefit any information about Tift Regional or information acquired as a result of the employee’s relationship with Tift Regional. Employees should disclose business information only as required in the performance of their job or as expressly authorized by Tift Regional. Violation of this policy may result in personal liability to the employee for any benefit gained from improper use of such information or any damages sustained by Tift Regional as a result of improper disclosure of such information.
b.Disclosure of Possible Conflict of Interest. Employees must disclose possible conflicts of interest involving themselves or their immediate families to the Director of Human Resources. The Director of Human Resources will investigate and report possible conflicts to the Compliance Committee. All employees will be required to annually affirm, in writing, that they have disclosed possible conflicts of interest. The Compliance Committee will determine whether significant conflicts of interest do occur and take the necessary steps to protect Tift Regional.
If a Tift Regional employee has concerns about possible conflicts of interest, the employee should contact the Director of Human Resources, the Compliance Committee or the Helpline.
Standard 4.2Market Practices. Tift Regional will comply with applicable laws concerning advertising and will forgo any business which can only be obtained by improper or illegal means.
a.Compliance with state and federal requirements. Employees must submit all advertising and marketing materials to the Director of Physician and Marketing Services for approval before use.
b.Tift Regional advertising must be truthful and not misleading. Specific claims about the quality of Tift Regional’s services must be supported by evidence to substantiate the claims made. All price advertising must accurately reflect the true charge for services provided.
If an employee has concerns regarding possible unethical or unlawful marketing practices, the employee should contact the Director of Physician and Marketing Services, the Compliance Committee or the Helpline.