Code of Conduct
Click Here for a copy of the Code of Conduct and Employee Acknowledgement
Dear Pinckneyville Community Hospital Team Member:As a board member, medical staff member, employee, volunteer, student, contracted agent or other agent conducting business with Pinckneyville Community Hospital, you are considered a “Team Member” of the Hospital. Pinckneyville Community Hospital is committed to delivering quality healthcare services. It is our intent to provide these services in alignment with our mission, vision, values and standards while complying with legal and regulatory requirements. The Hospital has designed a corporate responsibility program which is designed to help all Team Members make good decisions in patient care, particularly those decisions related to legal and regulatory requirements. The principles involved apply to all Team Members of Pinckneyville Community Hospital. Every Team Member is encouraged to raise questions about any part of their job if/when they feel that any work processes or actions are not in line with our Code of Conduct.
The intent of the Corporate Responsibility Program at Pinckneyville Community Hospital is to develop policies, procedures, staff education and internal controls that promote adherence to applicable federal and state laws and the program requirements of federal, state and private health plans. Our compliance efforts are designed to establish a culture within our hospital that promotes prevention, detection and resolution of instances that do not conform with regulations, including the HIPAA (Health Insurance Portability and Accountability Act) Privacy and Security Rules, as well as this Code of Conduct.
Each person is responsible for acting in a manner which reduces the risk to the Hospital of noncompliance in any legal area. Work processes put in place for any activity are designed to help you do your job. However, you are responsible for the results of the decisions you make and you have a personal obligation to report conduct that does not conform with this Code of Conduct. If you are concerned about an issue involving compliance or code of conduct:
1.Refer to the Hospital’s Compliance Manual, available to you on the Hospital Policy Server, which includes the Code of Conduct, detailed policy guidance and employee training materials. Also refer to your Department Policy Manual and any reference guides/software available in your department.
2. Report issues using the Chain of Command:
a. Ask your Department Manager
b. Ask your Director
c. Ask the CEO/Administrator
d. Ask the Human Resource (HR) Director
e. Ask the Compliance Officer
3.Report anonymously through one of the following options:
a.Online reporting through Pinckneyville Community Hospital’s Compliance website at www.pvillehosp.ethicspoint.com and click on the “Make a Report” tab.
b.Call the Pinckneyville Community Hospital Compliance Hotline (toll free) at (844)-643-2197.
c.The Comment Box, located at the employee entrance near the main employee time clock.
No bad consequences will happen to you for raising questions or issues or for reporting any known or suspected violations in good faith. However, filing false, groundless, or malicious complaints is an abuse of this code of conduct and will be treated as a violation.
This Code of Conduct is not intended to be all-inclusive. It provides general ethical guidance and is intended to serve as a resource to help resolve questions about appropriate work place conduct. For employees, a separate Employee Handbook provides additional guidance on employment policies that employed staff are also expected to abide by. No code is a substitute for each person’s internal sense of values including fairness, honesty, and integrity. Noncompliance with the Hospital’s Code of Conduct and policies, including failing to report non-compliant actions, will subject a Team Member to disciplinary action or termination of contractual/business relationship.
Before you make any decision, you should ask yourself the following questions:
1. Is this activity in line with our Code of Conduct?
2. Is this decision in compliance with the policies of Pinckneyville Community Hospital?
3. Is this activity in conformity with legal or ethical requirements as you understand them?
4. If this decision were to become public, would you be comfortable with the decision you have made?
5. Do you need further advice or assistance in understanding how you carry on your duties?
We believe that individuals that comprise the Pinckneyville Community Hospital team each contribute value, and each member’s support helps to assure that our Hospital fulfills it mission and provides quality care, services and employment. Mistakes are going to happen. An effective compliance program: finds these mistakes or creates an environment encouraging staff to report mistakes; fixes them; provides staff education; provides disclosure when necessary; and uses the experience to improve hospital operations and compliance. Working together on compliance is the key to our success!
Randall W. Dauby, CEO
Brad Futrell, MHA, Compliance Officer
MISSION, VISION, VALUES & STANDARDS OF ETHICAL CONDUCT
A. Mission StatementLeading the way to a healthier tomorrow through local access to quality care, delivered with compassion by a team of skilled healthcare professionals.
B. Vision StatementTo be recognized as the provider of choice for quality, compassionate healthcare services centered around the needs of our community.
C. Values & Standards of Behavior (REACH)Respect: Integrity. Concern for the wellbeing of others. Ethical behavior. Truthfulness. Doing the right thing.
Excellence: Strive for the highest quality in everything we do.
Accountability: through ownership Reliable. Self-motivated. Everyone's actions contribute to the overall success of the Hospital.
Compassion: Serve with understanding, sympathy and care.
Help Support Others: Work as a team. Each team member participates to find new and creative solutions.
D. Standards of Ethical Conduct1. Commitment to our patients, their families and the community. Everything we do is designed to provide quality care for the patients that we treat, their families, and the communities we serve.
2. Business ethics. All employees/agents must represent Pinckneyville Community Hospital accurately and honestly and must not engage in any activity intended to defraud anyone of money, property, services, or excellent quality care. No individual may use his/her position to profit personally or to assist others in profiting in any way at the expense of the Hospital. Each individual is responsible for using Hospital resources wisely and for the sole benefit of the Hospital’s mission and values and should not accept personal gifts from patients.
3. Legal & regulatory compliance. Pinckneyville Community Hospital is committed to conducting all its activities in compliance with all applicable federal, state and local laws
4. Confidentiality. All employees and agents must maintain the confidentiality of patient, employee and proprietary information.
5. Conflicts of interest. A conflict of interest is any situation where an employee/agent has a financial or business interest that might be in conflict with the financial or business interests of Pinckneyville Community Hospital when making decisions.
6. Vendor relationships. Employees must remain free from offers or solicitations for personal benefit of gifts, favors or other improper inducements and from performing their work in a particular fashion which benefits outside parties at the Hospital’s expense.
7. Harassment. Pinckneyville Community Hospital will not tolerate any behavior which an employee feels is harassing or any behavior that creates a hostile work environment for them. Employees who feel they are being treated unfairly or being harassed should report such behaviors immediately through the chain of command for immediate investigation and action.
Additional details on standards of ethical conduct are provided later in the Code of Conduct.
II. LEADERSHIP RESPONSIBILITIESBoard Members, CEO/Administrator, Directors, Managers, Supervisors and Coordinators are expected to set the example and to model adherence to this Code of Conduct. Leaders must assure their Team Members have sufficient information to comply with laws, regulations, funding requirements, and policies; as well as the resources to resolve ethical dilemmas. Our Leaders will promote the highest standards of ethics and compliance. Our cultural environment must encourage everyone to raise concerns as they arise.
III. COMMITMENT TO OUR PATIENTS, THEIR FAMILIES AND THE COMMUNITYA. Patient Care and Rights
All individuals will be treated with professionalism, respect, and dignity. The Hospital adheres to its Affirmative Action Plan and will not discriminate against any individual. At admission, each patient is provided with a copy of Patient Rights & Responsibilities.
Patient Responsibilities: As a patient here at Pinckneyville Community Hospital, patients have the responsibility to: Give accurate and complete health information concerning past illnesses, hospitalization, medications, allergies, and other pertinent items. To request further information concerning anything the patient does not understand. To follow the plan of care provided by the physician. To verbalize concerns regarding patient care to the physician and/or nurse. To report any change in condition to the physician or nursing staff. To understand that failure to comply with the plan of care or refusal to follow physician recommendations could result in an undesirable outcome that the patient would accept full responsibility for. To be considerate of other patient needs by limiting the number of visitors and amount of noise.
Patient Rights: As a patient here at Pinckneyville Community Hospital, patients have the right to: The highest quality of professional care. Respect and consideration of values and beliefs. Be informed about condition and treatment. Provide informed consent and to participate in decisions. Support and respect in pain management. Refuse treatment and to be informed of any consequences. Information about Advance Directives. Personal Privacy and Confidentiality. Available treatment or appropriate referral. Information, acceptance or refusal of experimental treatment. Continuity of Care. Participate in Ethical Decisions. Protective Services. Organ Donation. Billing Information. Affiliation Information. We are committed to supporting the communities we serve. Our Hospital and Team members will promote education and prevention programs in an effort to improve the quality of life for individuals in our communities.
Emergency Treatment: We follow the Emergency Medical Treatment and Active Labor Act (EMTALA) in providing emergency services. This means that we provide an emergency medical screening examination and stabilize all patients, whether or not they can pay. Within our capacity and our capability, we treat anyone with an emergency medical condition. In an emergency situation, we will not put off the medical screening and stabilizing treatment to find out patient financial and other information. We do not admit, discharge, or transfer patients with emergency medical conditions simply based on their ability to pay or any other discriminating factor.
B. Confidentiality of Patient Information
Patients can expect their privacy to be protected and that confidential information will only be released to persons involved with their treatment or payment thereof, as necessary for operational purposes, where it is authorized by law or per the patient’s written consent. No Team Member has a right to any patient information other than that necessary to perform his/her job. Team Members cannot use the access rights associated with their job to access their own health information or that of relatives or friends. Team Members shall follow the same procedures for accessing and requesting information as all other patients.
The Health Insurance Portability and Accountability Act (HIPAA is a federal program of regulations set forth to aid health care facilities in protecting the patient’s protected health information (PHI). Team Members are provided general HIPAA training and new employees receive department specific HIPAA training. Every Team Member has a responsibility to abide by the HIPAA policies and to report any known or suspected violations to the Privacy Officer. Requests for patient location should be forwarded to the Registration Office or the applicable nurses’ station. Requests for information on a patient’s condition are to be referred to the charge nurse, the patient’s physician or the patient’s relatives (if available). The CEO/Administrator or Marketing Director must approve any news releases, articles and publicity concerning the Hospital. Refer to the policy on “Patient Directory and Media Releases” for detailed guidance. Information required by public officials for official duties should be provided in full cooperation with the requesting authorities. Refer to the policies on “Release of Information” and “Response to Searches by Government Agents” for detailed guidance.
Use two patient identifiers such as asking the patient his/her full name and date of birth before providing treatment to a patient and before discussion of test results via the phone.
HITECH Act and Breach Notification: If a patient’s information is misdirected to a wrong individual, or a laptop or other type of mobile device or media containing or having access to PHI is lost/stolen, staff must promptly report the occurrence within 5 days from discovery to the Hospital’s Privacy Officer.
Team Members will not take patient health information (PHI) home. If documents containing PHI must be transported off Hospital premises for business purposes, the files will be password protected or encrypted, or otherwise properly safeguarded.
IV. LEGAL AND REGULATORY COMPLIANCEA. Legal and Regulatory Compliance
Team Members must provide services pursuant to appropriate Federal, State, and local laws and regulations, and funding source requirements. Were applicable, written policies and procedures have been established to assure compliance. The Hospital will provide appropriate, complete, factual, and accurate information in response to billing inquiries. The Hospital and its Team Members will cooperate with and be respectful of all government inspectors and provide these inspectors with the information to which they are entitled during an inspection. Team Members must never conceal, destroy, or alter any documents, lie, or make misleading statements to the investigator. Refer to the policies on “Release of Information” and “Response to Searches by Government Agents” for detailed guidance.
B. Accrediting & Survey Teams
The Hospital will deal with all accrediting and survey bodies in a direct, open, and honest manner and no action, either directly or indirectly, shall be taken to mislead accrediting or survey teams.
C. Affiliated Physicians/Providers, Stark Law and Anti-kickback Compliance
Business arrangements, including space rental agreements, with physicians and other providers will be in writing, will be based on fair market value rates and will be structured to meet all applicable legal requirements to ensure compliance with Stark, Anti-kickback and other applicable regulations. The Hospital or anyone acting on its behalf will comply with Anti-kickback regulations by not offering, paying or receiving monies, or anything of value, including free or discounted services, for patient referrals. Services provided are based solely on patient needs and the Hospital’s ability to offer appropriate services.
D. Third Party Payers
1. Coding and Billing for Services
The Hospital will bill and submit claims for services in an accurate and truthful manner. It is expressly prohibited to submit false, fictitious, or fraudulent claims. Claims will be submitted only for services actually provided. Documentation for services rendered shall be complete and accurate. Any Sub-Contractor or Contractor performing billing or coding services will be expected to adhere to this Code of Conduct and must have the necessary skills, quality assurance processes, systems, and appropriate procedures to assure that all claim submissions are accurate, complete, and timely. For billing or coding questions, review your department’s policies and procedures manuals, review reference guides/software available in your department or contact your manager.
2. Federal False Claims Act
The federal False Claims Act (FCA) exists to fight fraudulent, abusive or false claims, including those submitted to the Medicare and Medicaid programs. FCA prohibits any person from submitting a false claim for payment or approval under a federally funded contract or program. Fraudulent claims include overcharges, underpayments, charging for services not provided or charging for one product or service, but providing another. Innocent mistakes are not fraudulent claims. Fraud involves an intentional deception or misrepresentation that could result in an unauthorized benefit to someone or to an entity. Abusive claims include those claims with billing irregularities resulting from failure to follow sound business and/or medical practices. Refer to the Hospital’s “Accurate Billing and Claims” policy in the Hospital’s Compliance Manual for further guidance. Anyone who knowingly submits or causes the submission of false claims to the government is liable for damages plus civil penalties per false claim.
3. Whistleblower Reward and Protection
A private individual, who possesses and comes forward with information regarding false claims, may bring an action in federal court on behalf of the government and sue those entities that engaged in the fraud. This is called a "qui tam" suit, and the individual who brings it to court is known as the “whistleblower". The false claims act in Illinois is entitled Whistleblower Reward and Protection Act. This Act covers fraud involving any state funded contract or program. Also, the Public Assistance Fraud Act makes it a Class A misdemeanor to make false statements "relating to health care delivery." Under the Whistleblower Reward and Protection Act, anyone who knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid is liable to the State for a civil penalty plus damages sustained by the State.
Under the Whistleblower Act, an employer may not make or enforce any rule or policy preventing an employee from disclosing information to a government or law enforcement agency if the employee has reasonable cause to believe that the information discloses a violation of a state or federal law, rule, or regulation. Retaliation for any disclosures is prohibited. Likewise, an
employer may not retaliate against an employee for his or her refusal to participate in an activity that would result in a violation of a state or federal law, rule, or regulation. Employees may bring a civil action against the employer “for all relief necessary to make the employee whole,” including reinstatement, back pay with interest, and litigation costs. Under the Illinois Whistleblower Reward and Protection Act, if the court finds a whistleblower was terminated or otherwise mistreated for filing a qui tam lawsuit, the employee is entitled to certain compensation and employment reinstatement awards.
4. Cost reports
Our business involves reimbursement under government programs that require the submission of certain reports of our operational costs. The Hospital will comply with Federal and State laws and funding source requirements relating to all cost reports, including allowable costs and appropriate methodologies to claim reimbursement for the cost of services provided to patients. Given their complexity, all issues related to completion and settlement of cost reports must be coordinated with the Chief Financial Officer or his/her designee and the independent auditing firm. At no time will the Hospital purposely misrepresent rates or designation of costs to improperly enhance reimbursement.
5. Commercial Insurance, Managed Medicare & Managed Medicaid Network Plans
a.Team Members, including health care providers and health care professionals, shall comply with federal Medicare Advantage rules and regulations.
b.Team Members shall ensure that services are provided in a culturally competent manner, recognizing those patients with limited English proficiency and/or reading skills, diverse cultural and ethnic backgrounds, physical disabilities, and mental disabilities.
c.Providers practicing at Pinckneyville Community Hospital shall discuss all treatment options with patients, including the option of no treatment, as well as related risks, benefits and consequences of such options. As applicable, Provider shall also provide instructions regarding follow-up care and training regarding self-care.
d.Pinckneyville Community Hospital, including any of its contracted agents, shall promptly investigate any potential and/or suspected incidents of non-compliance with laws, fraud, waste, or abuse and will report incidents to a patient’s network plan as soon as reasonably possible, but in no instance later than thirty (30) calendar days after becoming aware of a reportable incident. Such notice shall include a statement regarding efforts to conduct a timely, reasonable inquiry into the incident, proposed or implemented corrective actions, and any other information that may be relevant to making its decision regarding self-reporting of the incident.
e.Lobbying. No federal appropriated funds have been paid or will be paid by or on behalf of any Team Member, to any Person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any federal contract, the making of any federal loan or grant, the entering into of any cooperative agreement, or the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement. If any funds other than Federally appropriated funds have been paid or will be paid to any Person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with Federal contracts, grants, loans, or cooperative agreements, notification shall be given to the appropriate network plan. Managed Medicaid network plans utilize a “Disclosure Form to Report Lobbying,” that may be obtained by request from the Illinois Department of Healthcare and Family Services, Bureau of Fiscal Operations.
f.Hospital shall maintain a Medical Staff roster of providers credentialed at its facility and provide notification to network plans within thirty (30) days of changes to the provider list.
6.Illinois Rural Community Care Organization (IRCCO)
Pinckneyville Community Hospital is a participant in IRCCO and has developed an IRCCO Compliance policy in order to document adherence to the IRCCO compliance, quality and other program requirements. That policy, including IRCCO specific policies on Compliance; Code of Conduct; Administrative Operating Requirements; Governance & Leadership; False Claims Act; Kickbacks, Inducements and Referrals; Marketing; and Quality Measures Collection & Reporting, etc. are included as part of the Hospital’s Compliance Manual Section VII IRCCO Compliance.
E. Health and Safety
The Hospital has a Safety Committee and is committed to promoting a safe and healthy working environment in compliance with government, accreditation, and funding source regulations. It is important that managers and/or the Safety Committee are advised of any situation presenting a danger of injury so that timely corrective action may be taken.
Employees can complain directly to the Federal Government when they believe that a violation that threatens harm or imminent danger exists. This should be done after discussion through the Chain of Command and only if steps are not taken to correct the situation. Staff should maintain the cleanliness/orderliness of the work area(s) while sharing in the responsibility of keeping the Hospital in good repair and safe for all who reside or work here.
Per regulatory requirements, Team Members are responsible for reporting suspected or actual abuse, neglect or exploitation of patients. Team Members who, in good faith, report suspicious or alleged abuse, neglect, or exploitation to the appropriate authorities shall not be subject to any adverse employment or contract action as a result of such report.
Pinckneyville Community Hospital competes with other hospitals for the opportunity to provide health care services to consumers. Antitrust laws are designed to give consumers the opportunity to purchase health care and other goods and services at competitive prices in a free market. These laws could be violated by discussing confidential Hospital business with a competitor, price fixing, disclosing terms of supplier relationships, or agreeing with a competitor to refuse to deal with a supplier. Antitrust laws prohibit contracts, combinations and conspiracies between competitors or customers that promote such illegal activities. Violations of antitrust laws are punishable by personal and institutional civil and criminal fines and penalties. Refer to the Hospital’s “Antitrust Policy” maintained in the Compliance Manual for further guidance.
G. Obtaining Information Regarding Competitors
It is not unusual to obtain information about other organizations, including competitors, through legal and ethical means such as public documents, public presentations, magazine articles, and other published and spoken information. It is never acceptable to obtain proprietary or confidential information about a competitor through illegal means, such as violating a confidentiality agreement with a prior employer. It is acceptable for Administration to seek general salary and price survey information, that is otherwise unavailable, from an independent source as long as information is obtained by de-identified means (meaning, by position, not by name, or in the case of charges, by procedure without reference to the specific competitor), and confidentiality regarding the source of the information is appropriately maintained.
All Team Members will adhere to copyright law and may only make copies of such material based on obtained permission.
I. Non-discrimination, Diversity, Affirmative Action, and Equal Employment OpportunityPinckneyville Community Hospital does not discriminate against any person on the basis of race, color,
sex, national origin, disability (physical or mental), religion, age, sexual orientation, gender identity, sex stereotyping, pregnancy or status as a parent, in admission, treatment, or participation in its programs, services and activities, or in employment. The Hospital is committed to Affirmative Action and will comply with all laws, regulations and policies to assure accessibility and non-discrimination related to employment actions. Such actions include, but are not limited to, hiring, staff reductions, transfers, terminations, performance appraisals, recruiting, compensation, corrective action, discipline, promotions and eligibility for health insurance and other benefits. No one will discriminate against any individual with a disability with respect to any offer, or term or condition of employment. Reasonable accommodations will be made for qualified individuals with disabilities.
J. Environmental Compliance
The Hospital’s policy is to comply with all environmental laws and regulations as they relate to our operations, including the proper handling and disposal of hazardous and biohazardous waste. The Hospital will act to preserve our natural resources to the extent reasonably possible.
K. Identity Theft
Individuals who commit identify theft are subject to criminal fines and imprisonment. Steps taken by the Hospital in order to minimize risks include background checks being performed on all employees and on-going education regarding the privacy and security of information. Any documents containing private information such as social security numbers must be shredded or placed in the designated locked shred containers throughout the facility. Furthermore, documents placed in outgoing mail or delivered via fax should not include social security numbers unless it is required for the transaction. Emails should not include social security data unless it is only the last four digits of the number or the file is password protected or encrypted. Patient credit card information should be kept secure, including maintaining only the last four digits for receipting record retention purposes. Employee earnings data should not be released without a signed authorization from the employee.
L. Cellular Phone, Auto-Phone Messaging and Email Contact Compliance
The Federal Communications Commission (FCC) and Federal Trade Commission (FTC) have various regulatory requirements related to the use of prerecorded messages, automatic dialing devices, calls and texts placed to cellular phones and email communications. As an employee of Pinckneyville Community Hospital, when providing primary and secondary phone contact information for entry in the payroll system, employees acknowledge that Administration has the authority to utilize an Auto Messaging System to contact employees at those phone numbers for instances including but not limited to: emergency and disaster situations, requests for help in filling vacant shifts, mandatory in-service training and other important notifications. Any personal emails provided by employees to the Hospital may also be utilized for contact purposes. Employees also acknowledge that depending on the cellular plan, calls and texts placed to cellular phone numbers provided by the employee may result in charges. By completing and signing the Phone Contact Information & Auto-Phone Messaging Consent Form upon hire, when providing Payroll and Human Resources with updated phone contact information and by signing this Code of Conduct Acknowledgement form, employees authorize Pinckneyville Community hospital to use an auto & pre-recorded message to contact them and acknowledge responsibility to keep the phone number(s) listed in the Hospital’s Payroll system accurate and valid. Phone numbers provided for emergency contacts are not utilized for auto-phone messaging contact by the Hospital.
V. BUSINESS ETHICS & CONFIDENTIALITYA. Code of Ethics
All employees are expected to adhere by the standards of ethical conduct outlined in this Code of Conduct.
B. Entertainment, Gifts and Business Courtesies
Team Members may not receive any gift under circumstances that could be interpreted as an attempt to influence the organizations or the employee’s decisions or actions. Team Members may have business meals in conjunction with business dealings. However, offers of anything considered to be a Business Courtesy is prohibited. “Business Courtesy” can mean cash payments, an invitation to attend a social event to further or develop business relationships, an actual gift, entertainment, etc. Business courtesy does not include snacks/food, promotional items and other items of nominal value.
Team Members may not accept gifts from patients. However, patients and their families may offer consumable gifts, such as food/candy, to a department for consumption by all employees.
C. Accuracy, Retention, and Disposal of Documents and Records
Each Team Member is responsible for the timeliness, integrity, and accuracy of our Hospital’s documents and records. No one may alter or falsify information on any record or document. Patient and business documents and records, in any format, are to be retained in accordance with applicable laws and our retention policies. No one should tamper with records, move or destroy them prior to the specified timeline, nor destroy records in an effort to deny government or legal authorities access that may be relevant to an investigation.
As an adequate medical record serves as a basis for planning patient care, evaluating care and providing a means of communication between the physician and other professional groups in contributing to the patient’s care and to protect the legal interests of the Hospital and physician, it is therefore the policy of Pinckneyville Community Hospital to collect, organize, maintain and secure as complete and accurate a medical record as possible on each patient utilizing the services of the Hospital. The same applies to employment and time & attendance records of Hospital staff.
All incidents of alteration/falsification of information are to be promptly investigated and documented. One who suspects the alteration or falsification of medical chart information shall promptly complete an unusual occurrence report and submit it to the Hospital’s Chief Nurse Executive (CNE) or Risk Manager. Suspected patient record alterations are to be promptly investigated by the CNE and/or Risk Manager. Due to the serious nature of alteration of medical records and the possibility of legal ramifications on the Hospital, the CEO/Administrator is to be notified of any such occurrence. Incidents of altering time and attendance records should be reported to the CFO who is in charge of payroll functions. Alterations or falsifications of employment records are to be reported to the Human Resource Director.
D. Confidential/Proprietary Information
Team Members may use confidential/proprietary information about the Hospital’s strategies and operations to perform their jobs, but it must not be shared with others outside of those with a need to know within our Hospital, unless there is a legitimate need to know this information, approval is provided by the appropriate management staff to release the information, and agreement is made that the released information will be kept appropriately confidential. Confidential/proprietary information includes, but is not limited to, personnel data maintained by the Hospital, patient lists and clinical information, pricing and cost data, information pertaining to acquisitions, divestitures, affiliations and mergers, financial data, research data, strategic plans, marketing strategies, techniques, employee lists and data maintained by the organization, supplier and Sub-Contractor information, and proprietary computer software. This provision does not restrict the Team Member’s right to voluntarily disclose information about his/her own compensation, benefits, or terms and conditions of employment.
E. Electronic Media/Systems & Communications
Access to the Internet is provided to Team Members for the benefit of Pinckneyville Community Hospital and its customers. Other, limited use of systems, must be approved by the CEO/Administrator or the Security Officer over Information Systems. Pinckneyville Community Hospital reserves the right to access the contents of any messages sent or websites accessed from its facilities. All communications, including text and images, can be disclosed to law enforcement or other third parties without prior consent of the sender or the receiver. Team Members who violate policy are subject to appropriate disciplinary action pursuant to Hospital policies.
A. Internet & Email
Team Members are expected to follow established guidelines for using hospital-based Internet and e-mail access:
a.Internet and email should be used in an effective, ethical and lawful manner. Acceptable use includes conducting business, using e-mail for hospital-related business contact or limited browsing of acceptable nature during a Team Members lunch and/or break. Don’t put anything in your e-mail messages that you wouldn’t want to see on the front page of the newspaper or be required to explain in a court of law.
b.Internet and email should not be used for purposes that are illegal, unethical, harmful to the Hospital or non-productive. Unacceptable use includes sending or forwarding chain e-mail; browsing the Internet, conducting personal business or checking personal home e-mail accounts on hospital time outside of lunch or break times; transmitting any content that is copyrighted, offensive, harassing or fraudulent; accessing any sites that are offensive or fraudulent; use of streaming audio/video; viewing sites deemed unacceptable to Pinckneyville Community Hospital.
c.Team members should exercise precaution and common sense when using email:
a)Messages should be professional in nature and shall include the Hospital’s standard confidentiality statement.
b)Confidential information should not be sent via email without password protection or encryption.
c)Not protecting PHI in emails increases the risk for PHI to be misdirected to outside sources. This risk is increased when using personal mobile devices to check emails and those emails inappropriately contain PHI.
d)Highly sensitive patient health information should never be sent via email (e.g. HIV, substance abuse, mental health).
e)Emails are considered discoverable data. Pay particular attention not to include any content in emails that you would not wish to be disclosed to the public or to become an issue in a Hospital lawsuit. If there is a request for producing any and all communication staff had regarding a particular incident, email correspondence would be included. Thus, email correspondence should be factual, accurate, objective, and professional with no finger pointing, speculations, opinions, assumptions, conclusions or recommendations regarding the incident. If the email should not be forwarded to other individuals, then the subject and/or header should designate “confidential information”.
f)Before hitting “send” verify that your email is addressed to the correct individual(s).
d.Do not circumvent Internet security measures, firewalls or Internet filters to gain access to blocked sites.
e.Do not transmit confidential customer information unless it is through a secure web portal or the files are properly password protected or encrypted.
B. Social Networking and Personal Mobile Devices
a.Social Media includes and is not limited to blogs, podcasts, discussion forums, online collaboration sites, video sharing, and social networks like Facebook, Twitter, Instagram and Snapchat.
b.During work time, team members should not be visiting any social networking sites or sending instant messages via the Internet or cell phone. The hospital’s computers are not to be used for personal blogging or social networking activities.
c.At no point should a team member claim nor imply that they are speaking on behalf of the hospital.
d.Team members cannot use blogs or social networking sites to harass, threaten, discriminate or disparage against employees or anyone associated with the hospital. Postings of pictures/videos/comments related to hospital social and community events that include oneself and/or that of other Hospital Team Members shall not be of an inappropriate nature.
e.Physicians, hospital staff, vendors, and contracted personnel agree to use social media in an appropriate manner that does not violate patients PHI or HIPAA privacy laws. Online, personal and business personas are likely to intersect. Pinckneyville Community Hospital (PCH) respects the rights of free speech, but it is a violation to disclose or discuss PCH confidential information or to violate HIPAA privacy laws. Unprofessional behavior or language reflects poorly on PCH. It is important to be respectful and professional to fellow employees, physicians, staff, business partners, and patients. When taking a public opinion on an issue on social media, be cautious not to violate patient privacy, not to tarnish the image of the hospital, or express views that can be deemed harmful. A failure to do so may result in a violation to the Code of Conduct and Ethics.
f.Personal mobile devices shall not be used to record, video or take pictures of patients or PHI.
g.Discussion of a patient's healthcare services, physical condition, capabilities and treatment over a public social media site, even without mentioning the patient's name or other identifiable information, is inappropriate. We live in a rural community and there is the possibility that someone seeing the post could infer a possible patient identity. Public perception is also an issue. Other patients or community members may perceive the sharing of healthcare related details over public social media as being inappropriate even if a name or other identifiable information is not mentioned.
C. PC and Portable Device Use and Security
a.Team Members have a responsibility to protect Hospital systems from computer viruses and spyware. Employees shall not knowingly introduce a computer virus or spyware into hospital computers; shall not load portable media devices of unknown origin; should not use portable media devices without first scanning them for viruses; and shall immediately power off the workstation and call the IT Department if you suspect that your workstation has been infected with a virus or spyware.
b.Team Members are responsible for protecting access to the Hospital’s systems. Do not disclose your User ID or password to others and do not keep it written down where it can be found by others. You are responsible for all transactions that are made with your User ID and password. Do not use passwords that are easily guessed. Do change your passwords regularly. Do log out when leaving a workstation. Do use screensavers that are password protected. Do not attempt to access the accounts of other users. Do not post user names and passwords on or near the PC.
c.Managers are responsible for ensuring that Team Member access to computer systems is promptly revoked upon termination of employment or transfer to another job.
d.Team Members are responsible for the physical security of computer hardware, software and data from misuse, theft, unauthorized access and environmental hazards. Portable storage devices should be stored out of sight when not in use and must be locked up if they contain highly sensitive or confidential data. Files containing confidential data should be password protected when possible. Team Members should exercise care to safeguard the valuable electronic equipment assigned to them. Environmental hazards such as food, smoke, liquids, high or low humidity, extreme heat or cold, direct sunlight and magnetic fields should be avoided around diskettes, tapes and electronic equipment. Team Members should not take shared portable equipment such as laptop computers out of the facility without the informed consent of their department manager. Furthermore, while the portable device is used outside the facility, the Team Member agrees to abide by hospital policies governing the security and business-only use of such equipment. Flash drives must be pre-approved by the employee’s department manager before being used. Notification of such use should be forwarded to the IT Department.
e.Do not install, copy or download software unless authorized by authorized by IT. Do not install hardware from home (e.g. laptop, flash drive, zip drive) unless authorized by IT.
f.Portable Devices: Team Members utilizing personal portable devices such as smart phones or tablets to check hospital email for business purposes, shall ensure that the portable device utilizes a password to gain access to the device and that the portable device is protected by anti-virus software.
D.Cell phone use and phone decorum
a.Personal cell phones, including texting features, are not to be utilized during working hours. Staff may use their cell phones while on break or at mealtime. At all other times, the cell phone must be turned off unless being utilized for business purposes. The employee’s manager may grant approval for limited, temporary situations in which cell phones can be placed on vibrate during working hours when expecting important personal information.
b.In the event of phone system outage or declared Disaster event, personal cell phones may be utilized by staff to place business-related phone calls. Picture and texting features should never be used for conveying patient info. Refer to the Emergency Preparedness Communications Policy.
c.Frequent personal calls are discouraged and when necessary are requested to be made during break time. If a personal long distance call is necessary and is made via the Hospital’s phone system, the call must be reported to the accounting department. A call report will be generated and the employee will be expected to pay for the personal long distance phone call(s).
F. Financial Reporting and Records
The Hospital maintains a high standard of accuracy and completeness in the documentation and reporting of all financial records that serve as the basis for managing our business and meeting our obligations. Hospital financial records are externally audited on an annual basis as required for compliance with 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. Our Hospital maintains a system of internal controls to provide reasonable assurances that all transactions are executed in accordance with appropriate management authorization and are recorded in a proper manner to maintain accountability of the Hospital’s assets.
G. Controlled Substances/Drug & Alcohol Free Work Environment
Pinckneyville Community Hospital prohibits the workplace use, sale, attempted sale or purchase of alcohol or any illegal or controlled substances and their possession and/or use other than those prescribed by a licensed practitioner. This applies to reporting for duty while under the influence of alcohol or drugs. Individuals taking prescribed substances who are experiencing adverse side effects from the prescription will be relieved of duties. If any employee believes he/she needs professional help with a substance abuse program, referrals to local counseling and rehabilitation programs can be obtained by contacting the Pinckneyville Community Hospital’s Licensed Social Worker.
H. License, Credentials and Excluded Party Verification
Team Members employed in positions that require professional licenses, certifications, or other credentials are responsible for maintaining the current status of their credentials, and forwarding current documentation to Human Resources. These staff shall comply at all times with Federal and State requirements applicable to their respective disciplines. Documentation of credentials in applicable positions is a condition of employment. We do not contract with, employ, or bill for services provided by an individual or entity that is excluded or ineligible to participate in Federal healthcare programs. We routinely search federal and state published lists of such excluded and ineligible persons.
I. Personal Use of Agency Resources
Each Team Member is responsible for preserving the Hospital’s assets, including time, materials, supplies, equipment, and information for business purposes. As a general rule, personal use of Hospital
assets without appropriate approval by management personnel is prohibited. The CEO/Administrator must approve any community or charitable use of Hospital resources. Any use of Hospital resources for personal gain is prohibited.
J. Relationships Among Team Members
Team Members are expected to treat other Team Members with professionalism, respect, and courtesy. No one should feel compelled to give another Team Member a gift for any occasion or to participate in any fund-raising or similar effort.
K. Marketing, Advertising and Fundraising
Marketing and advertising activities may be used to educate the public, provide information to the community, increase awareness of our services, and to recruit staff. Only truthful, fully informative, and non-deceptive information will be presented in these materials and announcements. All Hospital marketing and advertising efforts shall first be approved by the Marketing Director and/or CEO/Administrator. The Hospital complies with all state laws and regulations with respect to fundraising activities. This includes record-keeping and reporting requirements. No employee or associate may make any false, deceptive, or misleading statements in connection with fundraising activities. In addition, no protected health information may be used for the purpose of raising funds.
L. Political Activities and Contributions
Hospital funds or resources are not to be used to contribute to political campaigns or for gifts or payments to any political party or any of their affiliated organizations. Hospital 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 Hospital property for use in political campaigns. Team Members should never give the impression they speak on behalf of or represent the Hospital. At times, the Hospital may ask Team Members to make personal contact with government officials or to write letters to present our position on specific issues. In addition, it is part of the role of some Hospital management to interface with government officials. If you are making these communications on behalf of the Hospital, be certain you are familiar with any regulatory constraints and observe them and that such communication has been approved by the CEO/Administrator.
Solicitations at Hospital facilities and/or during work hours for any business or individual that do not benefit service recipients or the Hospital are strictly prohibited. Posting, canvassing, or distributing literature or information that does not benefit the Hospital clients or programs shall not be permitted at Hospital facilities. Employees may not solicit or distribute merchandise, services or literature on the Hospital premises in patient care areas during the employee’s work time or that of the employee being solicited. Persons not employed by the Hospital may not solicit, sell or distribute merchandise or services without the express permission of the CEO/Administrator.
N. Training and Education
Training will be documented, reviewed, and revised as necessary, to include issues raised by compliance reporting data. The Code of Conduct and related training and education will be provided at orientation and on a periodic basis. The Hospital is committed to assuring that Team Members receive appropriate training and education based on job duties and responsibilities. Look to the Hospital Compliance Manual for helpful compliance-related information in the form of policies, handbooks and newsletters.
O. Meeting & Training Rules of Behavior
The following meeting and training rules of behavior are designed to outline expectations as to how employees are to conduct themselves during meetings and training:
a.Start and end on time.
b.Sign-in sheet will be picked up upon start of the session. Employees arriving late will not be counted as in attendance. If you know that you are going to be arriving late due to another commitment, please notify the presenter/organizer in advance. If subsequent sessions are held, employee will need to arrange for attendance at a later session.
c.Everyone’s opinion counts. Therefore, don’t be afraid to speak up.
d.We will be honest and will respect people’s opinions.
e.We will work as a team, sharing thoughts and dividing up responsibilities for action plans.
f.No side conversations. Only one person speaks at a time. No one dominates the discussion.
g.Do not interrupt when someone else is speaking.
h.We will stay focused on the topic being discussed and not get sidetracked.
i.Respect the presenter.
k.Give your undivided attention. Avoid bringing other work with you.
l.Refrain from actions/activities/behaviors that are distractive and give the appearance that you are not paying attention to the content being presented.
VI. Conflict of InterestA conflict of interest may occur if a Team Member’s outside activities or personal interests influence or appear to influence that person’s ability to make objective decisions in the course of the individual’s job responsibilities. A conflict of interest may also exist if the demands of any outside activities hinder or distract a Team Member from job performance or cause a Team Member to use Hospital resources for other than Hospital purposes. It is each individual’s obligation to assure that they remain free of conflicts of interest in performance of job duties and responsibilities.
While Pinckneyville Community Hospital does not prohibit its employees from accepting other employment (i.e. part-time, PRN, etc.), employees are reminded that the employment relationship with Pinckneyville Community Hospital should be of prime importance to the employee. Employees should not be involved in outside employment, business or personal activities that may interfere with their good and efficient performance of current job duties and work schedule. All regularly scheduled employees must be able to work their assigned work schedule without interference from outside employment, business or personal activities.
All conflicts of interest must be reported to the CEO/Administrator. Team Members should refer to the “Conflicts of Interest” policy or contact the Compliance Officer or CEO/Administrator if there is a question about whether an outside activity may constitute a conflict of interest.
VII. Harassment, Violence & DISRUPTIVE BEHAVIOR IN THE WORKPLACEAll employees are expected to act in a responsible and professional manner to establish a pleasant working environment free of discrimination, acts or threats of sexual or other harassment, physical violence, intimidation, and/or coercion. Possession or use of firearms or weapons on hospital premises is prohibited.
Harassment is the act of systematic and/or continued unwanted and annoying actions of one party or a group, including threats and demands. Types of harassment include:
A.Sexual Harassment: unwelcome sexual advances, requests for sexual favors, or verbal or physical activity through which submission to sexual advances is made an explicit or implicit condition of employment or future employment-related decisions; unwelcome conduct of a sexual nature which has the purpose of effect of unreasonably interfering with the employee’s work performance or which creates an offensive, intimidating or otherwise hostile work environment; includes single occurrences and repeated occurrences.
B.Workplace Harassment: belittling, condescending, threating, or malicious remarks or acts aimed at others within a workplace.
C.Quid Pro Quo Harassment: offering a subordinate employee some sort of reward in exchange for a demeaning, sexual, or illegal act.
D.Cyberbullying: repeatedly sending unwanted and unwarranted messages via any form of electronic media.
Disruptive behavior is behavior that interferes with the ability of everyone on the team to provide safe and effective care; undermines the confidence of any member of the healthcare team in effectively caring for patients or performing their job responsibilities; undermines patients’ confidence in the caregiver or organization as a whole; causes concern for anyone’s physical safety; or undermines effective teamwork. Examples of disruptive behavior include profane or disrespectful language; rudeness; negative gossip that is harmful to patients, team members and the organization as a whole; name-calling; sexual comments; racial or ethnic jokes; outbursts of anger; throwing objects; criticizing others or the organization in front of patients; failure to respond to concerns about safety; retaliation against another who raises concerns about safety, conduct or culture issues; intimidation that suppresses input from others; deliberate failure to adhere to organizational policies without adequate evidence to support actions; and patterns of unwillingness or outright refusal to perform as part of the organization’s healthcare team.
If any employee feels that (s)he has been subjected to conduct which may constitute sexual or any type of harassment, violent or disruptive behavior, that employee should immediately report any such incident using the Chain of Command or HR Director without fear of reprisal. Displays of harassment, violence or disruptive behavior will subject a Team Member to disciplinary action or termination of contractual/business relationship.
VIII. Vendor RelationshipsRelationships with Sub-Contractors and suppliers should be fair, reasonable, and consistent with all applicable laws and good business practices. Team Members must remain free from offers or solicitations for personal benefit of gifts, favors or other improper inducements when dealing with Sub-Contractors and suppliers. Consumable or perishable gifts may be accepted, as long as it conforms to any established Hospital practice or policy that may be in effect. Nominal items with vendor logos may also be accepted. Gift certificates and entertainment tickets should be declined. If received despite the decline to accept, the items should be reported and submitted to the Compliance Officer or CEO/Administrator. Purchasing decisions will be made based on the supplier’s ability to meet Hospital needs and not on personal relationships and friendships. Competitive procurement to the maximum extent practicable is expected. The Hospital will not communicate to a third-party confidential information, including contracted pricing, provided by our suppliers unless directed to do so in writing by the supplier or as otherwise required by law. Subcontracts and suppliers are expected to comply with this Code.
VIIII. THE HOSPITAL'S CORPORATE RESPONSIBILITY (Compliance) PROGRAMA. Program Structure& Staff Education
The Compliance Officer will be responsible for coordinating the Corporate Responsibility Program. The Hospital has a Corporate Compliance Committee that meets regularly to:
a.Review chart audits and determine what courses of action are necessary in response to the audit findings (for example, policy revisions, staff education, etc.).
b.Review the OIG (Office of Inspector General) fraud alerts and annual work plans which include high-risk compliance areas. The Hospital shall cease and correct any applicable conduct criticized in an OIG fraud alert or work plan and will take reasonable action to prevent the reoccurrence of such conduct.
c.Prepare policies and conduct staff education in order to ensure compliance with regulations, hospital policies and standards of ethical conduct.
B. Internal Investigation of Reports
The Hospital will appropriately investigate all concerns promptly and confidentially, to the extent possible. The Compliance Officer and/or designee will coordinate any findings from the investigations and immediately recommend corrective action, discipline or changes that need to be made based on those findings. The Hospital expects all Team Members to cooperate with investigation efforts. Each Department Manager will be responsible for coordinating any investigations and monitoring compliance within his/her departments. Upon completing an investigation and/or standard review of compliance, the Compliance Officer shall provide the Committee with a report outlining the investigation and/or review process and documenting the findings and any necessary remedial actions.
C. Corrective Action
When an internal investigation results in a substantiated finding, it is the policy of the Hospital to initiate corrective action, including, as appropriate, making prompt restitution of any overpayment amounts, notifying the appropriate governmental agency, instituting any disciplinary action warranted and administered according to policies and/or collective bargaining agreement, and implementing systemic changes to prevent a similar violation from recurring.
All violators of the Code of Conduct will be subject to appropriate additional education assignments as well as disciplinary action pursuant to the Hospital’s “Sanction-Disciplinary Action” policy. Discipline may include: Counseling, verbal reprimand, written reprimand, suspension, termination, restitution, referral for criminal investigation/prosecution, or civil litigation/action.
E. Internal Audit and Other Monitoring
The Hospital is committed to appropriate, consistent monitoring of compliance with its policies. The Corporate Compliance Committee and/or the appropriate departments will conduct monitoring of policies. The Hospital routinely seeks other means of assuring and demonstrating compliance with laws, regulations, funding requirements, and Hospital policy. The Hospital’s Board of Directors are kept informed of the Hospital’s Compliance program activities through regular reports.
F. Measuring Program Effectiveness
The Hospital conducts an annual Employee Compliance and Workplace Assessment Survey. Results are utilized to develop strategies and action plans for risk areas, education and implementation of other compliance program improvements. The Compliance Committee also conducts an annual assessment of the Hospital’s compliance program that includes analyzing adherence with the OIG standards of an effective compliance program and identifying opportunities for improvement that are placed on an annual compliance work plan.