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Code of Compliance
Larkin Community Hospital
Purpose
To promote ethical, legal behavior and standards to guide all job performance, decisions and actions.
Policy
The Compliance Code of Conduct is the core of the Compliance Program and defines Larkin Community Hospital's (Larkin) commitment to full compliance with the statutes, regulations, and written directives of Medicare, Medicaid, and all other Federal health care programs. The Code of Conduct provides guidance to carry out our daily activities within appropriate ethical and legal standards.
Larkin Community Hospital is committed to provide the highest quality primary care, to serve the medical needs of the community, to honor the patient's Bill of Rights and ensure patient safety. To accomplish this mission, Larkin believes our actions embody the following value statements:
- We affirm that each person is unique and deserves our concern, respect and compassion.
- We serve the well being of our community by offering the best possible care and services.
- We deliver high quality health services in a cost effective manner.
- We act with integrity and honesty and uphold ethical standards in the way we conduct business.
Definitions
- "Corporate Integrity Agreement" or CIA is an agreement with the Office of Inspector General (OIG) of the United States Department of Health and Human Services (HHS) to promote compliance with the statutes, regulations and written directives of Medicare, Medicaid and all other Federal health care programs.
- "Covered person"
- includes all owners, officers, directors, and employees of Larkin; and
- includes all contractors, subcontractors, agents, and other persons who provide patient care items or services or who perform billing or coding functions on behalf of Larkin; and
- includes all physicians with staff privileges at Larkin; but
- does not include part-time or per diem employees, contractors, subcontractors, agents, and other persons who are not reasonably expected to work more than 160 hours per year.
Code of Conduct
The Compliance Code of Conduct is designed to promote ethical and legal behavior in all aspects of Larkin's operations. A written Compliance Code of Conduct is distributed to all covered persons during initial orientation. The Code of Conduct may not deal with certain areas of concern but if additional guidance is necessary covered persons may refer to Larkin's Policies and Procedures.
The Code of Conduct provides guidance and assists in carrying out daily activities within appropriate ethical and legal standards. These standards apply to the relationship with patients, physicians, third party payers, suppliers, contractors and each other.
Leaders including directors, supervisors and managers have a special responsibility to set the right example and make sure that his or her work reflects Larkin's standards of ethics and compliance. Larkin expects leaders to exercise that responsibility in a manner that is kind, sensitive, thoughtful, and respectful and to create a culture where everyone feels free to raise concerns and propose ideas. Larkin also expects that leaders will ensure everyone has sufficient information to comply with laws, regulations, and policies.
Larkin is committed to quality care and patient safety and if there is ever a question about whether quality or patient safety is being fully met, that individual is obligated to raise this concern until it is satisfactorily addressed and resolved.
Larkin expects that as per HIPAA requirements, staff do not use, disclose or discuss patient health information with others unless it is necessary to perform his or her job or is required by law. Patient health information will be released only to persons authorized by law or by the patient's written authorization.
Larkin requires as per the Emergency Medical Treatment and Active Labor Act ("EMTALA") that patients who come to the Emergency Department be provided with an emergency medical screening examination and necessary stabilizing treatment within the capabilities of the emergency department, regardless of ability to pay. Patients are transferred to another facility at the patient's or legal representative's request or by a physician order with the appropriate physician certification.
Larkin is committed in its relationship with physicians who may refer patients to follow federal and state laws. The applicable Federal laws include the Anti-Kickback Law and the Stark Law. Larkin requires that covered persons involved in arrangements are aware of the requirements of the laws, regulations, and policies that address relationships between Larkin and physicians.
Larkin commits to maintain full compliance with all Federal health care program requirements, including its commitment to prepare and submit accurate claims consistent with such requirements, therefore Larkin expects covered persons to maintain full compliance with all Federal health care program requirements.
Larkin requires that all arrangements with physicians comply with laws, regulations and Larkin's policies and procedures.
Larkin requires that all of its Covered Persons comply with all Federal health care program requirements and with Larkin's own Policies and Procedure including the requirements of the Corporate Integrity Agreement (CIA).
Larkin expects that all covered persons provide quality care since quality should be the primary consideration behind decisions made and actions taken.
Larkin requires that all of its Covered Persons shall be expected to report immediately to the Compliance Officer, to the Ethics & Compliance Telephone Line, to a supervisor or director any violation or suspected violation of any laws, regulations, conditions of participation or of Larkin's own Policies and Procedures.
Larkin requires that the communication systems be used primarily for business practices, limited reasonable personal use is permitted; however, these communications are not private. Users who abuse the communication systems are subject to disciplinary action up to and including termination.
Larkin expects everyone to understand, identify, manage and appropriately disclose actual, potential or perceived conflicts of interest. An actual, potential or perceived conflict of interest occurs in those circumstances where a covered person or a member of his or her family stands to directly or indirectly gain as a result of a decision.
Larkin commits to never provide gifts or other incentives to improperly influence relationships or business outcomes, and staff will ensure that any gift Larkin extends meets the business conduct standards of the recipient's organization.
Larkin provides a work environment free of harassment, sexual harassment or violence. Larkin expects anyone who observes or experiences any form of harassment or violence to report to their supervisor/director, Human Resources, the Compliance Officer or the Ethics-Compliance Line.
Larkin promotes the protection of workplace health and safety and expects that all employees immediately report any serious workplace injury or danger of injury for timely correction of the issue.
Larkin is committed to comply with all environmental laws and regulations. Larkin employs proper procedures to provide a safe environment of care. All staff must understand how job duties impact the environment and must adhere to all requirements for the proper handling of hazardous materials, and immediately alert supervisors to any situation regarding the discharge of a hazardous substance, improper disposal of hazardous and medical waste, or any situation which may be potentially damaging to the environment.
Larkin requires that individuals disclose immediately any debarment, exclusion, suspension or other event that makes the person an Ineligible Person. All individuals shall disclose if he/she is an Ineligible Person at the time of the initial hiring, credentialing, or contracting process, or upon becoming an Ineligible Person in the future.
Larkin expects that everyone preserve the hospital's assets including time, materials, supplies, equipment, and information. The occasional use of items, such as copying facilities or telephones, where the cost is insignificant, is permissible. Any use of the hospital's resources for personal financial gain unrelated to the organization's business is prohibited.
Larkin informs its Covered Persons of their responsibility to be aware of policies and procedures that pertain to his or her work and to follow those policies and procedures and of the possible consequences for the failure to comply.
Larkin notifies its Covered Persons of the right of all individuals to use the Disclosure Program and Larkin's commitment to non retaliation and to maintain, as appropriate, confidentiality and anonymity with respect to such disclosures.
Larkin requires that the promotion of, and adherence to, the Compliance Code of Conduct be an element in evaluating the performance of all employees.
Larkin shall distribute any revised Compliance Code of Conduct within 30 days after any revisions are finalized and each Covered Person shall certify, in writing, that he or she has received, read, understood, and shall abide by the revised Compliance Code of Conduct within 30 days after the distribution of the revised version.
REFERENCES:
Office of Inspector General (OIG) of the United States Department of Health and Human Services (HHS)
This notice was published and becomes effective on April 14, 2003.
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