|
policy:
President's Message to All Employees. 2
CCMC Mission: 3
CCMC Vision: 3
CCMC Core Values: 3
I. Medical Compliance and Ethics Standards. 3
Standard 1.1 - Professional Standards. 3
Standard 1.2 - Quality Patient Careviii. 3
Standard 1.3 - Emergency Care. 3
Standard 1.4 - Patient Rights. 3
Standard 1.5 - Patient Confidentiality. 3
Standard 1.6 - Admission, Transfer, and Discharge Practices. 3
II. Business Compliance and Ethics Standards. 3
Standard 2.1 - Conflict of Interest. 3
Standard 2.2 - Medical Records Coding and Billing of Third Parties. 3
Standard 2.3 - Record Keeping. 3
Standard 2.4 - Affiliated Physicians and Other Referral Sources. 3
Standard 2.5 - Antitrust and Competition. 3
Standard 2.6 - Information Owned by Others. 3
Standard 2.7 - Lobbying/Political Activity. 3
Standard 2.8 - Tax Laws. 3
Standard 2.9 - Standards of Conduct for Vendors and Independent Consultants. 3
Standard 2.10 - Marketing and Public Relations Practices. 3
III. Employment Compliance and Ethics Standards. 3
Standard 3.1 - Fair and Equitable Treatment of Employees. 3
Standard 3.2 - Health and Safety Precautions. 3
Standard 3.3 - Use of Illegal Drugs or Alcohol 3
Standard 3.4 - Pharmaceuticals, Prescription Drugs, Controlled Substances. 3
Standard 3.5 - Harassment and Workplace Violence. 3
IV. Environmental Compliance and Ethics Standards. 3
Standard 4.1 - Environmental Standards. 3
V. Basic Workplace Compliance and Ethics Standards. 3
Standard 5.1 - Confidentiality and Proprietary Information. 3
Standard 5.2 - Electronic Media. 3
Standard 5.3 - Travel and Entertainment. 3
Standard 5.4 - Receiving Business Courtesies From Non-referral Sources. 3
Standard 5.5 - Extending Business Courtesies to Non-referral Sources. 3
Standard 5.6 - Extending Business Courtesies to Possible Referral Sources. 3
Standard 5.7 - Proper Use of Corporate Assets. 3
VI. Doing Business With the Government. 3
Standard 6.1 - Medicare and Medicaid Requirements. 3
Standard 6.2 - Responding to Government Inquiries. 3
Standard 6.3 - Hiring of Former Government Employees. 3
Standard 6.4 - Offering Gifts, Meals or Gratuities to Government Personnel 3
VII. Communicating Legal and Ethical Issues. 3
Standard 7.1 - Adherence to Standards of Conduct Required/Responsibility to. 3
Report Violation. 3
Standard 7.2 - No Retaliation for Reporting Problems or Concerns. 3
VIII. Compliance Education. 3
IX. Sanctions for Code Violations. 3
X. How to Report Problems or Concerns. 3
Camden Clark Medical Center Corporation is committed to providing high-quality health care to our patients and their families through excellent customer service, sensitivity to customer needs, and professionalism. Camden Clark is committed to providing high-quality health care to our patients and their families through excellent customer service, sensitivity to customer needs, and professionalism. Camden Clark is equally committed to conducting business with the highest integrity and in compliance with all federal, state and local laws and regulations applicable to our operations. To reflect our commitments and help us achieve them, Camden Clark has adopted this Code of Ethics and Business Conduct, which is an integral part of our Corporate Compliance Program.
You are Camden Clark's most important asset. The way in which you perform your job affects not only your own success, but the performance and success of your fellow employees and, ultimately, the success of our organization. Therefore, it is essential that each of us understands and upholds certain principles and values that reflect our commitment to conducting business honestly, prudently, and in full compliance with our significant regulatory, as well as other legal responsibilities. This information is intended to convey to you the standard of ethical and legal behavior that is expected of all Camden Clark employees and to assist you in doing what is right, appropriate, and proper in the conduct of our doing business.
It is not possible, however, to include in this Code specific direction for all business activities. In many instances, Camden Clark's policies, procedures and guidelines will provide detailed guidance to you regarding how to conduct the organization's business ethically and legally. For these policies, procedures, and guidelines, you should refer to the Hospital Policy Manual, Hospital Safety and Security Manual, and all departmental procedure and guideline manuals. If you find yourself in a situation that neither this Code nor Camden Clark's policies, procedures and guidelines address, you should consult with a member of management, the Hospital's General Counsel or Corporate Compliance Officer to ensure that decisions made and actions taken reflect Camden Clark's values and commitment to legal compliance.
All employees are expected to abide by the standards in this Code of Ethics and Business Conduct and to comply with all organizational policies, procedures and guidelines. No one, regardless of his/her position, will be allowed to compromise adherence to our standards and policies.
Camden Clark maintains an open-door policy and management is committed to listening to and addressing employee concerns and questions. If you have any questions about the Code or Camden Clark’s policies, procedures and guidelines, or if you have concerns about a situation you are facing, you may seek assistance by:
talking with your supervisor, manager, Department Head, or Vice President; or
contacting the General Counsel and/or Corporate Compliance Officer.
- Talking with your supervisor, manager, department head, or vice president; or
- Contacting the General Counsel and/or Corporate Compliance Officer.
Simply put, Camden Clark is committed to doing the right thing in all matters at all times. If you are ever in doubt as to what the right thing to do is in a given situation, consult this Code and/or seek advice.
Finally, Camden Clark's ability to uphold its commitment to ethical behavior is dependent upon your commitment to us to report all instances of known or suspected noncompliant or illegal behavior. You should report immediately any behavior you detect or suspect on the part of an employee or agent of Camden Clark, or any person with whom Camden Clark deals, which you believe is or may be improper or inconsistent with the guidelines in this Code or in violation of applicable laws or regulations. You may do so in person, in writing, or by using our anonymous Compliance Line. It is essential that all team members abide by the standards outlined within this Code in order for Camden Clark to fulfill its commitment to compliance. I must ask that you please take your responsibilities seriously, and, at all times, conduct yourselves with the utmost honesty and integrity.
Michael A. King
President and CEO
To meet the health care needs of our community for a lifetime.
Camden Clark will be the leading regional medical center, known for high quality, comprehensive, state-of-the-art health care.
The core values of Camden Clark Medical Center represent the beliefs of our organization, guiding our process and decision making at all levels.
Integrity…
We will maintain the highest standards of behavior through honesty and stewardship of natural, human, and financial resources.
Commitment…
We are committed to making our hospital and our community a better place to work and live. Our employees must find meaning in their work and be supported in their efforts to provide high-quality patient care. We will act in the best interest of those we serve.
Accountability…
We are willing to accept responsibility for our actions and attitudes. We do whatever we can to make Camden Clark Medical Center a clean, safe, and service oriented hospital.
Respect…
We respect the value and worth of each person and treat each other the way we would like to be treated. We will create and sustain a culture in which our employees are valued.
Excellence…
We will achieve optimal outcomes by being innovative and working together to exceed expectations with both clinical quality and customer service. We endeavor to be the best in all we do.
Camden Clark will comply with all applicable federal, state and local laws and regulations, as well as all standards and requirement imposed upon us by licensing and accrediting bodies and by the various health professions represented by our team members.
Camden Clark prides itself in providing high quality patient care with the utmost degree of professionalism. Employees must display a high degree of professionalism and integrity while engaged in the organization's business. Additionally, licensed and certified employees are expected to abide by the ethical standards set forth by their professional organizations. Employees should respond honestly and in good faith, striving for excellence in performing job duties, observing all laws and regulations and using Camden Clark's assets only for legitimate business purposes.
Patient care at Camden Clark occurs through organized and systematic processes designed to ensure the delivery of safe, effective and timely care and treatment. The delivery of quality patient care services requires specialized knowledge, judgment and skill derived from the principles of biological, physical, behavioral, psychosocial, medical and nursing sciences. Patient services must be planned, coordinated, provided, delegated and supervised by professional health care providers who access and recognize the unique physical, emotional and spiritual needs of each person. Patient care encompasses not only the recognition of disease and health, but also patient education and patient advocacy. The medical staff, registered nurses and allied health care professionals must function collaboratively as part of an interdisciplinary team to achieve positive patient outcomes.
Each Camden Clark employee should strive to provide appropriate services and to achieve the best attainable outcome for our patients. Camden Clark employees are expected to adhere to all applicable patient care procedures and guidelines, including requirements of accreditation bodies; federal, state and local laws and regulations; organizational policies; and all other standards related to patient care.
Camden Clark is required by the Emergency Medical Treatment and Active Labor Act (EMTALA) to provide appropriate medical screening examinations to all patients seeking emergency services and stabilizing treatment when necessary, regardless of the patient's ability to pay. This medical screening and treatment will be provided within the capacity and capabilities of Camden Clark and within current standards of medical care.
Patients will be transferred to another facility only if Camden Clark is unable to meet the patient's medical needs or if the patient/family requests the transfer. Camden Clark will complete the medical screening examination and provide any treatment necessary to stabilize the patient prior to transfer or, in the case of an unstable patient, provide an appropriate transfer which is in accordance with hospital policies and federal regulations.
Medical screening examinations and treatment of emergency medical conditions will not be delayed for the purposes of obtaining pre-authorization for these services, for the purpose of requiring a patient to complete a financial responsibility statement or for the purpose of requiring the patient to make a co-payment for the services to be provided. Camden Clark may follow reasonable registration processes such as asking whether the patient is insured and for the name of the insurance company, as long as this inquiry does not delay the screening and treatment process. Under no circumstance will Camden Clark follow registration processes that are designed to influence the patient's decision to voluntarily seek a screening examination and necessary treatment.
Patients have a fundamental right to compassionate care that safeguards their personal dignity and respects their cultural and spiritual values. All Camden Clark employees involved in the care of a patient shall respect and support the patient's right to competent, considerate, and courteous treatment or service within our capacity without discrimination as to race, age, religion, gender, national origin, disability, or source of payment.
Upon admission to an inpatient unit, same day surgery, or observation bed, each patient is provided with a written statement of patient rights. Camden Clark is committed to the observance of a patient's rights, personal preferences, and individual values as much as reasonably possible. As applicable, each patient or patient representative is provided with a clear explanation of care including, but not limited to, diagnosis, treatment plan, right to refuse or accept care, advance directive options, and an explanation of the risks and benefits associated with available treatment options. Patients and representatives will be accorded appropriate confidentiality, privacy, security, opportunity for resolution of complaints, and pastoral counseling.
It is the right of every patient and the responsibility of all Camden Clark employees to maintain the confidentiality of patient information. Patient case discussions, consultations, examinations and treatments are private and should be conducted discreetly.
Patients have the right to review information contained in their medical record at any time while under care at any Camden Clark facility. Only patients or, in some cases, their properly designated decision makers, may review this information and should be accompanied by a health care professional to ensure accurate interpretation of the information.
In order to maintain patient confidentiality, employees should release patient information and medical record contents only in accordance with Camden Clark policies, procedures and guidelines.
In all cases, employees shall maintain patient confidentiality with respect to any information obtained by them consistent with the requirements of state and local law, including the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and the Privacy and Security regulation of that Act to the extent they are enacted and are effective.
Camden Clark, through its employees and medical staff, is committed to enabling the patient to make informed decisions and choices regarding treatments and procedures. Patients will be provided with accurate and timely information regarding their health status, diagnoses, prognosis, and other necessary information. Physicians are required to obtain the informed consent of patients when applicable.
When patients are asked to participate in an investigational study or clinical trial, they are to receive information upon which to base their decision. Camden Clark, through its staff, will protect and respect patients and their rights during research, investigation and clinical trials involving human subjects.
Camden Clark will serve as an advocate for the suspected or known victims of abuse and will support their right to access the protective services of outside agencies. Camden Clark will not withhold information regarding these outside advocacy agencies when requested. The name, address and telephone number of pertinent state client advocacy agencies will be provided upon request of the patient or legal representative of the patient when applicable. These advocacy agencies may include the West Virginia State Licensure Office, Medicaid Fraud Unit, Ombudsman Program, and the West Virginia Medical Institute.
The patients of Camden Clark have the right to ask and to be informed of the existence of business relationships among the hospital, educational institutions, other health care providers, payers, or networks that may influence the patient's treatment and care.
If known by the caregiver and permissible by law/regulations, the patient should be informed that a proposed or requested medical procedure may not be covered by his third party payer.
It is the right of every patient and the responsibility of all Camden Clark employees to maintain the confidentiality of patient information. Patient case discussions, consultations, examinations and treatments are private and should be conducted discreetly.
Patients have the right to review information contained in their medical record at any time while under care at any Camden Clark facility. Only patients or, in some cases, their properly designated decision makers, may review this information and should be accompanied by a health care professional to ensure accurate interpretation of the information.
In order to maintain patient confidentiality, employees should release patient information and medical record contents only in accordance with Camden Clark policies, procedures and guidelines.
In all cases, employees shall maintain patient confidentiality with respect to any information obtained by them consistent with the requirements of state and local law, including the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and the Privacy and Security regulation of that Act to the extent they are enacted and are effective.
Admission, transfer and discharge policies, procedures and guidelines are based on medical necessity, not current hospital fiscal conditions. We do not admit, transfer, or discharge patients based on their ability to pay. Patients whose specific condition or disease cannot be safely treated are transferred to an accepting organization only under such circumstances and/or in accordance with Camden Clark policies, procedures and guidelines.
Admission, transfer, and discharge are conducted in an ethical manner and in accordance with applicable local, state, and federal laws, rules, and regulations and Camden Clark policies, procedures and guidelines.
All officers, directors and employees of Camden Clark must make business decisions that are in the best interests of the Hospital and the patients we serve. In general, a conflict of interest may occur when any outside work you perform or any outside interest you may have influences your ability to do this. Extreme care must be taken when, in the course of your job responsibilities, you contemplate entering into a transaction, activity or other arrangement that might benefit your own private interest or the private interest of an officer, director or other employee of Camden Clark.
Specifically, possible conflicts of interest must be disclosed to a member of management, General Counsel or the Corporate Compliance Officer. Board members, Senior Management and selected other individuals are required to complete a Conflict of Interest Disclosure Statement annually.
Also, to avoid compromising the quality of patient care, the integrity of clinical decisions (including tests, treatments, and other interventions) cannot be compromised by any financial arrangements made by the Hospital's leaders, irregardless of how Camden Clark compensates or shares financial risk with its leaders, managers, clinical staff, and licensed independent practitioners.
If you have questions as to what constitutes a conflict of interest, a member of management, General Counsel or the Corporate Compliance Officer can help determine if a conflict of interest exists and can help take whatever action is necessary to solve the problem.
There are strict federal and state laws and regulations governing third party billing of our insured patients. Camden Clark employees are required to ensure that all patient records, documents, reports, and bills are prepared and maintained accurately and completely. To achieve this, employees must:
- Ensure that accurate, complete, truthful, and timely documentation is made in the patient medical record for all services performed;
- Use appropriate procedure, diagnosis, and billing codes that are supported by adequate documentation in the medical record;
- Ensure that services were actually rendered and are appropriately documented before bills or claims are submitted for payment; and
- Take necessary steps to verify the accuracy of the information and, if necessary, contact other employees or physicians to obtain additional information.
Affected employees must be familiar with all Camden Clark policies, procedures and guidelines and federal and state laws and regulations, third-party requirements, etc. that govern documentation, coding, and billing for services rendered. Further, employees are required to abide by these policies, procedures and guidelines and regulations in carrying out their duties.
Camden Clark will not knowingly submit claims for payment or reimbursement of any kind that are false, fraudulent, inaccurate, incomplete, or fictitious. Camden Clark employees are obligated to notify appropriate supervisory staff or the Corporate Compliance Officer of any requests or directives to deviate from accepted billing and coding practices. Camden Clark employees are further obligated to notify the Corporate Compliance Officer if they are aware or suspicious of any billing and coding practices that may deviate from this policy.
Of particular importance to employees is the Hospital's False Claims Act Policy. The Federal False Claims Act, among other things, applies to the submission of claims by health care providers for payment by Medicare, Medicaid and other federal and state health care programs. The False Claims Act is the federal government's primary civil remedy for improper or fraudulent claims. It applies to all government programs, from military procurement contracts to welfare benefits to health care benefits.
The False Claims Act prohibits, among other things:
(a) knowingly presenting or causing to be presented to the federal government a false or fraudulent claim for payment or approval;
(b) knowingly making or using or causing to be made or used, a false record or statement in order to have a false or fraudulent claim paid or approved by the government;
(c) conspiring to defraud the government by getting a false or fraudulent claim allowed or paid; or
(d) knowingly making or using, or causing to be made or used, a false record or statement to conceal, avoid or decrease an obligation to pay or transmit money or property to the government.
If any employee has knowledge or information that any such activity may have taken place, the employee should notify his or her supervisor or call the Camden Clark ComplianceLine at (888) 616-2473. Information may be reported to the ComplianceLine anonymously.
Federal and state law and Hospital policies prohibit any retaliation or retribution against any person who reports suspected violations of these laws to law enforcement officials or who file "whistleblower" lawsuits on behalf of the government. Anyone who believes he or she has been subject to any such retaliation or retribution should also report this to the ComplianceLine.
The procedures and guidelines of the Business Office reflects mechanisms which ensure that patients are billed only for those services and care provided to the patient.
All initial patient accounts are itemized and include dates of service. Detail billing will be provided at the patient's request.
When a patient or payer has a question about a charge, that inquiry is reviewed expeditiously and related conflict or complaints are handled through mechanisms without real or perceived harassment.
General collection procedures are conducted in an atmosphere of fairness and cooperation between the patient and Camden Clark.
Camden Clark expects that the medical staff will invoice patients and third party reimbursement programs only for services actually provided to patients and will provide assistance to patients seeking to understand the cost relative to their care.
All Camden Clark records (financial, clinical, and employee) must be accurate, timely, reliable, and properly stored. Camden Clark is required by law to maintain certain types of medical and business records for specified time periods. Camden Clark employees must familiarize themselves with the specific policies, procedures and guidelines applicable to the documents they work with and to fully comply with the applicable record retention and destruction policies, procedures and schedules.
The following standards govern all record keeping:
- Camden Clark does not misrepresent facts or falsify records;
- Camden Clark maintains those documents required by law and necessary to do business;
- Camden Clark preserves the confidentiality of patients' records;
- Camden Clark keeps records in accordance with legal requirements;
- Camden Clark destroys records only in accordance with its hospital policies, procedures and guidelines and federal and state regulations; and
- As required by regulatory agencies, Camden Clark makes records available for periodic inspection by authorized persons.
Any business arrangement with a physician or other referral source must be structured to ensure precise compliance with legal requirements. Such arrangements must be in writing and approved by the Corporate Legal Department.
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 or entities – for referral of patients. Violation of this policy may have grave consequences for the organization and the individuals involved, including civil and criminal penalties, and possible exclusion from participation in federally funded health care programs.
- We do not accept payments for referrals that we make. No Camden Clark 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 health care provider, we do not take into account the volume or value of referrals that the provider has made (or may make) to us.
All employees must comply with applicable antitrust and similar laws that regulate competition. These laws are designed to foster free and open competition in the marketplace and generally forbid any kind of understanding or agreement between competitors to fix or control fees for services, terms, conditions of treatment, patients, divide markets, boycotts, or to engage in any other conduct that restrains competition.
Camden Clark employees will not participate in any discussion, understanding, agreement, plan or scheme with any competitor or potential competitor which restricts competition. For Camden Clark, a "competitor" may be another hospital or, depending on the circumstances, any other health care provider. You should not have discussions or other communications with competitors about the division of either patients, geographic areas, or services; the circumstances under which business will be conducted with suppliers, insurance companies, patients or customers (including boycotts); or specific marketing efforts. Further, you should avoid discussions with competitors regarding the future business plans of Camden Clark. Finally, you should not have discussions with competitors regarding prices, reimbursement, or salary levels.
Camden Clark will compete fairly in the market.
Like Camden Clark, other organizations and individuals have intellectual property that they strive to protect, but are sometimes willing to disclose for a particular business purpose. If you are on the receiving end of another party's confidential information, you must proceed with caution to prevent any accusations that you or Camden Clark misappropriated or misused such information. Once another party's confidential or restricted information is properly in your hands, you must not use, copy, distribute or disclose that information, unless done so in accordance with the terms of any applicable agreement.
Camden Clark employees, contractors, and consultants should not duplicate copyrighted materials in any form without written permission of the license holder for use on Camden Clark premises or elsewhere.
Special care should be taken in acquiring software from others. As intellectual property, software is protected by copyright laws and may also be protected by patent, trade secret laws or as confidential information. Such software includes computer programs, databases and related documentation owned by the party with whom you are dealing or by another party. The terms and conditions of software license agreements - such as provisions not to copy or distribute programs - must be strictly followed. Also, if you acquire software for your personally-owned computer equipment, you should refrain from copying any part of such software in any work you do for Camden Clark or from placing such software on any Camden Clark-owned computer system.
As a tax-exempt, not-for-profit corporation, laws prohibit Camden Clark from donating - either directly or indirectly - corporate funds, goods, or services (including employees' work time) to any individual who holds a political office or is a candidate for political office.
Therefore, employees must follow these general rules:
- Camden Clark employees may NOT contribute any of Camden Clark 's money or property, or the services of any employees, to any political candidate, party,organization, committee or individual, which would violate any applicable law.
- Camden Clark employees MAY personally participate in and contribute to political organizations or campaigns as private individuals – not as representatives of Camden Clark – using their own personal time and funds. Employees will at all times let it be known that the views expressed are theirs as individuals and not those of Camden Clark.
- No political signs or literature may be displayed or distributed on Camden Clark premises.
- No political events are permitted on Camden Clark premises.
Where its experience may be helpful, Camden Clark may publicly offer recommendations concerning legislation or regulations being considered. Additionally, Camden Clark may analyze and take public positions on issues that have a relationship to the operations of the organization. These recommendations and positions may be made only by individuals officially appointed by Administration. This is not political activity.
As a not-for-profit organization, Camden Clark has a legal and ethical obligation to comply with applicable tax laws, to engage in activities to further its charitable purpose, and to ensure that its resources are used to further the public good. In order to maintain this tax exemption, which is critical to the organization's survival, Camden Clark must avoid what the tax laws refer to as "private inurement" and "private benefit". This means that all non-exempt individuals or entities must pay fair market value for the use of Camden Clark's services, supplies, equipment, properties or other assets. Also, Camden Clark must not pay others more than fair market value for their services, supplies, equipment, properties or other assets. Accordingly, competitive bidding will be used whenever required by the Hospital's Competitive Bidding Policy. Camden Clark will also properly observe all conflict of interest disclosure rules. Personal items should not be purchased through Camden Clark, even if the purchaser reimburses the organization. Additionally, we must file all tax and information returns according to applicable laws.
Camden Clark will enter into business relationships only with those vendors and independent contractors who agree to abide by the Standards contained within this Code. Prior to entering into a business relationship with any vendor or independent contractor, each authorized employee shall provide a current copy of this Code to the prospective vendor or independent contractor, obtain the appropriate signature on the Vendor/Contractor Acknowledgement contained in this booklet, and forward the completed acknowledgement to the Corporate Legal Department. In addition, all vendors will be screened against the OIG's List of Excluded Individuals/Entities and the General Service Administration's List of Parties Excluded from Federal Procurement Programs.
Our aim is to conduct ourselves professionally with truth, accuracy, fairness, and accountability to the public which we serve, holding to the fundamental values and dignity of the individual, and the freedom of speech, assembly and the press.
Camden Clark, being dependent upon community confidence and support, is accountable to the public. Therefore, its communications and disclosure of information and data related to the organization will be clear, accurate and sufficiently complete so that it is not misleading. Such disclosure will be aimed primarily at better public understanding of health issues, the services available to prevent and treat illness, and patient rights and responsibilities relating to health care decisions.
Advertising may be used to advance Camden Clark’s Mission Statement and its goals and objectives. It may also be used to educate the public, to increase awareness of available services, to increase support for the Hospital, and to recruit employees. Health care advertising should be truthful, fair, accurate, complete, and sensitive to the health needs of the community. False or misleading statements, or statements that might lead the uninformed to draw false conclusions about the Hospital are unacceptable and unethical.
Marketing material will reflect only those services available, the current level of licensure and accreditation, and comply with applicable laws and regulations of truth-in-advertising and non-discrimination.
Marketing shall not provide services for any individual or entity that may result in private inurement or private benefit and shall at all times be in accordance with all applicable standards of this Code.
Camden Clark is an equal opportunity employer and we ensure that employees are afforded non-discriminatory terms, conditions and privileges of employment in accordance with law, regardless of race, color, sex, religion, age, disability, national origin, veteran's status, or any other factor protected by applicable law.
Consistent with Camden Clark's respect for the rights and dignity of each employee, harassment based on race, color, sex, religion, age, disability, national origin, veteran's status, or any other factor protected by law will not be sanctioned or tolerated. CCMC expects that all employees will demonstrate proper respect and consideration for each other, regardless of their position and in accordance with Standard 3.5-Harassment and Workplace Violence of this Code.
It is Camden Clark's policy to comply fully with all applicable wage and hour laws and other statutes regulating the employer-employee relationship in the workplace environment.
Camden Clark supervisors and managers are available to discuss and resolve any concerns employees may have as to any aspect of their employment. Human Resources representatives may also be contacted to assist in resolving any employment issues that arise.
Camden Clark's employment policies are set forth in detail in the Employee Handbook and Hospital Policy Book. Employees should consult these resources for detailed information on these policies. Camden Clark's employment policies are set forth in detail in the Employee Handbook, the Hospital Policy Book and the Human Resources policy cabinet in the Meditech computer system.
Camden Clark is committed to complying with applicable federal, state, and local health and safety laws and standards. Camden Clark employees are expected to know about and follow all safety-related standards and regulations that apply to their positions. Additionally, employees should be aware of and effectively perform their duties during disasters and code situations. For specific policies, procedures and guidelines, employees should refer to the Hospital Policy Book, Hospital Safety and Security Manual and individual department procedure and guideline manuals.
Camden Clark requires employees to report to their supervisor, Safety Officer, or a member of the Environment of Care Committee any existing or potentially dangerous condition that is a threat to the health or well-being of individuals or that is a violation of policy. Camden Clark is committed to maintaining a safe workplace for our employees, patients and customers.
Camden Clark requires employees to report to their supervisor, Safety Officer, or a member of the Environment of Care Committee any existing or potentially dangerous condition that is a threat to the health or well-being of individuals or that is a violation of policy. The Camden Clark Safety Hotline is also available for the purpose of reporting such events. Camden Clark is committed to maintaining a safe workplace for our employees, patients and customers.
Camden Clark maintains a safe working environment without the presence of illegal drugs or alcohol. Unlawful use of controlled substances is inconsistent with the behavior expected of Camden Clark employees, subjects them and our patients and visitors to unacceptable safety risks, and undermines our ability to operate effectively and efficiently. Therefore, Camden Clark employees are prohibited from the use, sale, possession, manufacture, or purchase of illegal drugs or alcohol while at work or while on Camden Clark premises. Additionally, employees are not allowed to report to work while under the influence of illegal drugs, legal drugs improperly used, or alcohol.
Standard 3.4 - Pharmaceuticals, Prescription Drugs, Controlled Substances
Many of Camden Clark's employees have responsibility for or access to prescription drugs, controlled substances, hypodermic needles, drug samples and other regulated pharmaceuticals. Camden Clark is legally responsible for the proper distribution and handling of these pharmaceutical products. Federal, state and local laws covering prescription drugs and controlled substances are intended to maintain the integrity of our national drug distribution system and protect consumers by assuring that prescription drugs are safe and properly labeled.
Employees of Camden Clark are strictly prohibited from diverting any prescription drug or controlled substance, including a drug sample, in any amount for any reason to an unauthorized individual or entity. The distribution of adulterated, misbranded, mislabeled, expired or diverted pharmaceuticals is a violation of federal and state law for which severe criminal penalties may be imposed on individual violators, as well as on their employer.
It is Camden Clark's policy that all employees be both diligent and vigilant in carrying out their obligations to handle and dispense prescription drugs and controlled substances in accordance with all applicable laws, regulations and internal policies, procedures and guidelines.
Each Camden Clark employee has the right to work in an environment free of harassment.
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 or permitted 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 and will not be tolerated at Camden Clark.
Incidents or threats of workplace violence are also strictly prohibited. Workplace violence includes robbery and other commercial crimes, stalking cases, violence or threats of violence directed at the employer or other employees, terrorism, and hate crimes committed or threatened 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 on Camden Clark premises. 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, the Corporate Legal Department, or the Corporate Compliance Officer.
Camden Clark is committed to observing and complying with all federal, state and local health, safety and environmental laws. Employees are required to ensure that:
Medical waste, environmentally sensitive materials and hazardous materials are properly disposed of;
- Infectious materials and medical equipment are properly handled and stored;
- Personal protective equipment is used appropriately; and
- Spills or accidents involving infectious or hazardous materials are promptly reported and handled.
Additionally, Camden Clark respects the environment and strives to conserve natural resources in managing and operating its business affairs. Camden Clark employees are charged with using resources appropriately and efficiently, recycling where feasible, reporting instances of noncompliance with this Standard to their supervisor, the Safety Officer, or a member of the Safety Committee, and working cooperatively with appropriate authorities to remedy any environmental contamination for which Camden Clark may be responsible.
For detailed guidance in this regard, employees should refer to the Hospital Policy Book, Hospital Safety and Security Manual, Infection Control Manual, and departmental procedure and guideline manuals.
Throughout the course of employment, Camden Clark employees will have access to and become knowledgeable about information that is confidential, private or proprietary and which is very valuable to the organization. Camden Clark employees are required to maintain the confidentiality of such information during and subsequent to their employment with Camden Clark.
Examples of confidential proprietary information include, but are not limited to, the following:
- Medical information pertaining to patients and beneficiaries;
- Payment and reimbursement information;
- Hospital financial records;
- Computer programming and processing information;
- Business plans or business strategies;
- Product and pricing strategies; and
- Negotiations with employees or organizations.
Employees possessing proprietary information must handle the information in a manner so as to protect against improper access or use. Any confidential proprietary information may not be used directly or indirectly for personal gain, nor can it be disclosed to anyone without due authorization. Employees must return all confidential and proprietary information in their possession to Camden Clark upon termination of their employment with the organization.
All communications systems, electronic mail, intranet (Meditech), Internet access, or voice mail are the property of the organization and are to be primarily used for business purposes. Highly limited reasonable personal use of Camden Clark communications systems is permitted; however, you should assume that these communications are not private. Patient or confidential information should not be sent through the Internet until such time that its confidentiality can be assured.
Camden Clark reserves the right to periodically access, monitor, and disclose the contents of Meditech, e-mail, Internet activity and voice mail messages. Access and disclosure of individual employee messages may only be done with the approval of the Corporate Legal Department.
Employees may not use internal communication channels or access to the Internet at work to post, store, transmit, download, or distribute any threatening; knowingly, recklessly, or maliciously false; 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 a job search or open misaddressed 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.
Travel and entertainment expenses should be consistent with the employee's job responsibilities and Camden Clark's needs and resources. Employees should not have a financial gain or loss as a result of business travel and entertainment. Employees are expected to exercise reasonable judgment in using Camden Clark's financial resources and to spend them as carefully as they would their own.
Employees are expected to comply with Camden Clark's Travel Policy and any departmental travel and entertainment requirements.
When gifts or items of value are offered from a vendor, patient, or anyone outside Camden Clark, there may be a concern that the donor's motivation is improper, such as expecting to receive some special treatment in exchange for the gift. Therefore, employees may not accept gifts, entertainment, or other favors from any supplier, potential supplier, patient, or competitor of Camden Clark if it may be reasonably inferred that the gift is intended to influence, or possibly will influence, the employee in performing his/her duties at Camden Clark.
If a vendor or someone seeking to do business with Camden Clark offers an employee a gift, including entertainment, approval must be obtained by the employee's Director or Vice President before it can be accepted. Typically, gifts with a value over fifty dollars ($50) cannot be accepted. You may never accept cash or cash equivalents, such as gift certificates. Moreover, such gifts with respect to any particular vendor or individual must be infrequent, which, as a general rule, means not more than quarterly, and preferably less often.
If a patient offers an employee a gift, if it is perishable like flowers or candies, the employee may accept it on behalf of his/her Department. If it is anything else, the employee must inform the patient and/or his/her family members that employees are not permitted to accept gifts.
Under certain circumstances, acceptance of items, such as equipment, supplies, grants, or other monetary donations, intended for the benefit of a specific department or the Hospital, may be allowed when coordinated through the Camden Clark Foundation.
Also, there may be times when a business associate will extend training and educational opportunities which may include travel and over night accommodations at no cost to you or Camden Clark. Similarly, there may be circumstances where you are invited at a vendor's expense to receive information about new products or services. Prior to accepting any such invitation, you must receive approval to do so consistent with the Camden Clark policy on this subject.
No portion of this Standard 5.5 - Extending Business Courtesies to Non-referral Sources applies to any individual who makes, or is in a position to make, referrals to Camden Clark.
It is critical to avoid the appearance of impropriety when giving gifts to individuals who do business or are seeking to do business with Camden Clark. We will never use gifts or other incentives to improperly influence relationships or business outcomes. Gifts to business associates must be approved by the employee's Vice President, not exceed $50.00 per year per recipient and must not be offered in an attempt to influence business activity or transactions. You may never give cash or cash equivalents, such as gift certificates.
Camden Clark recognizes that there may be times when you may 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 in order to further 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 a privately owned vehicle) or lodging. The cost associated with such an event must be reasonable and appropriate. As a general rule, this will mean that 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 general rule, means not more than quarterly, and preferably less often. Camden Clark will under no circumstances sanction participation in any business entertainment that might be considered lavish.
Also, Camden Clark will occasionally sponsor events with a legitimate business purpose. Provided that such events are for business purposes, reasonable and appropriate meals and entertainment may be offered. In addition, transportation and lodging can be paid for. However, all elements of such events, including these courtesy elements, must be consistent with the Camden Clark policy on such events.
There are many complex rules governing the provision of anything of value to possible referral sources.
Therefore, any entertainment or gift involving physicians, their family members, or other persons or entities who are in a position to refer patients to Camden Clark must be undertaken upon the approval of the Corporate Legal Department only. We will comply with all federal laws, regulations and rules regarding these practices.
Camden Clark assets made available to employees are to be used only for authorized business purposes and should not be used for non-business or personal purposes. Camden Clark employees are personally responsible and accountable for the proper use of hospital property and proper expenditure of hospital funds. Employees are expected to protect Camden Clark's assets, property, facilities, equipment and supplies against loss, theft, damage and misuse by ensuring that appropriate internal controls exist and are adhered to.
Improper use of assets, including the outright theft or embezzlement of money or other property belonging to Camden Clark or its customers for anything other than an authorized purpose is a serious violation and will lead to appropriate disciplinary action.
Camden Clark is a participant in the Medicare and Medicaid programs, both of which are governed by complicated laws and regulations which impose strict requirements that are significantly different from, and more extensive than, those encountered in non-government commercial contracts. For example, Medicare and Medicaid have very complex payment guidelines that identify not only the circumstances under which, but also how much, those programs will reimburse hospitals for goods and services rendered to patients covered under those programs. These guidelines are often times different than directives received from other third party payers. Violations of these laws and regulations can result in criminal sanctions being imposed, not only on the persons actively involved, but also on the organization on whose behalf those persons act. Moreover, Camden Clark could be precluded from further participation in federally funded programs. It is essential, therefore, that there be strict compliance with all Medicare and Medicaid laws and regulations.
Camden Clark’s policy is to comply with every reasonable and lawful request by federal, state and local government officials for information and documents relating to the organization's operations. Government requests might include information related to patient care, billing and financial practices, or various operational issues. Where possible, Camden Clark employees should seek to obtain government requests/inquiries in writing; if this is not possible or appropriate, Camden Clark employees should independently document the specific request(s) for information.
Camden Clark employees are expected to provide only truthful and accurate information in a timely manner in response to a government request for information/inquiry. Camden Clark will not tolerate false statements made by employees to government agencies and will take appropriate action against employees violating this policy.
While employees are expected to comply with such requests, Camden Clark is entitled to the safeguards provided by law against disclosure of certain information to the government. Examples of information that might not be subject to disclosure include, but are not limited to:
- Certain patient information that might be protected by medical record privacy laws;
- Certain quality assurance information compiled by Camden Clark to comply with federal and state requirements; and
- Certain information collected as part of Camden Clark's peer review process to review and evaluate the credentials of health care providers furnishing services within our organization.
Employees should consult with the Corporate Legal Department if there is any question concerning whether information or documents requested by a government official are subject to disclosure. Employees should maintain copies of, or a list identifying, all information disclosed to the government in response to an audit.
Any employee receiving a subpoena from a government agency must notify the Corporate Legal Department immediately. Employees are not permitted to respond to subpoenas for Camden Clark information without the express permission and direction of the Corporate Legal Department. This measure is required to ensure that Camden Clark retains backup copies of the information submitted to the government so that Camden Clark’s delivery of health care services and business operations are not compromised as a result of responding to a government subpoena.
Any Camden Clark employee who is requested to provide information regarding Camden Clark operations or confidential information to a government official or investigator, regardless of where the request for information is made (i.e., on Camden Clark premises or at the employee's home), should report the existence of the communication to the Corporate Legal Department. All employees have the right to not respond to such inquiries before consulting with legal counsel.
Very specific rules exist to eliminate even the appearance of a conflict of interest by former government employees who, upon termination of their government service, seek employment with those who do business with the government. You should obtain clearance from the Corporate Legal Department prior to discussing the employment or possible retention of any current or former government employee.
You may not provide or pay for meals, gifts, travel or lodging expenses, or other business courtesies for government employees. Very strict guidelines prohibit any type of gratuity, with very few exceptions, and your strict compliance is required. Unlike in other circumstances, the laws regarding this issue could be violated if anything of value is given to a government employee, even if there is no intent to influence an official action or decision.
The Standards in Camden Clark's Code of Ethics and Business Conduct are designed to promote honesty and fairness in all of our dealings and to ensure compliance with all regulatory requirements. It is every employee's responsibility to ensure that all interactions and associations with patients, co-workers, community members, and businesses are honest and law-abiding. All employees are required to be familiar with and adhere to these Standards, all hospital policies, procedures and guidelines, and all laws and regulations applicable to the operations of our business. This imposes on each and every employee an affirmative obligation to know the hospital's policies, procedures and guidelines and laws and regulations that relate to their employment responsibilities.
Camden Clark's reputation depends upon each employee doing his/her part to report any questionable behavior, unethical conduct or suspected violation of policies or laws. Every employee is responsible for making the appropriate persons within the organization aware of potential problems, so that the problems may be resolved. It is not acceptable to overlook an actual or potential wrongdoing.
Camden Clark encourages employees to discuss legal and ethical issues that arise while performing their jobs and requires employees to report any concerns to appropriate persons within the organization for investigation or follow-up. In order to protect those employees coming forth in good faith to relate these issues, Camden Clark has implemented a non-retaliation and retribution policy. Camden Clark will not tolerate retaliation against any employee who, in good faith, reports a legal or ethical concern.
Camden Clark is committed to providing appropriate compliance related education and training to all employees, and employees are expected to attend compliance program training when requested to do so by their supervisors or managers. Satisfactory completion of all such required education and training will be a factor in each employee's annual evaluation.
All Camden Clark employees are expected to abide by the Standards in this Code of Ethics and Business Conduct, all Camden Clark policies, procedures and guidelines, and all laws and regulations that affect the operations of our business. Camden Clark maintains a policy of zero tolerance for violations of our standards, policies, procedures and guidelines, and regulatory requirements.
Disciplinary actions will be taken for:
- Authorization of or participation in actions that violate the Code;
- Failure to report a violation of the Code or to cooperate in an investigation;
- Failure by a violator's supervisor(s) or manager(s) to detect and report a violation of the Code, if such failure reflects inadequate supervision or lack of oversight;
- Retaliation against an individual for reporting a violation or possible violation of the Code.
Disciplinary action may result in verbal or written warnings, corrective action programs, or employment termination. Disciplinary action will be determined on a case-by-case basis in accordance with Camden Clark administrative policies, procedures and guidelines.
1) Talk to your supervisor about your concerns. Your supervisor is in a good position to listen to you and understand the concerns you have. Give your supervisor an opportunity to resolve the issue. Your supervisor is responsible for using resources throughout the organization to assist in upholding the standards of the Code of Ethics and Business Conduct, the organization's policies, procedures and guidelines, and all regulatory requirements.
2) If you have raised an issue and you do not think it is receiving appropriate attention, or if your supervisor does not provide an acceptable answer, you should relate your concerns to the next management level and/or to your Department Director.
3) If your supervisor, next level manager, or Department Director is unable to resolve the issue satisfactorily, you should contact your Vice President or the Corporate Compliance Officer.
If you do not feel comfortable discussing your issue(s) with a member of management or the Corporate Compliance Officer, or otherwise wish to report a concern anonymously, you may call the Camden Clark Compliance Line. The Compliance Line is designed to permit any employee to call and report a compliance-related concern or to obtain clarification on compliance issues. Calls to the Compliance Line are answered confidentially by trained operators from an outside agency twenty-four hours a day, seven days a week. There is no caller ID function on the Compliance Line, and callers are not required to identify themselves. If you desire to remain anonymous, you will be given a follow-up code to use if you wish to call back and check the status of Camden Clark's response to the problems or concerns you report. Additionally, there are many resources available throughout Camden Clark to answer questions and guide you on various matters. The following contacts within the organization are available for questions you may have in the identified areas:
|