100 Lincoln Avenue
Carbondale, PA
Tel: (570) 281-1000


| Carbondale Area Physician Hospital Organization (CAPHO) |
| Complete PharmacyMaxis Foundation | Maxis Medical Services, Inc. | 
| Mission Statement | Standard of Conduct | Tri-County Human Services, Inc. |

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STANDARD OF CONDUCT

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Maxis Health System 
Standard of Conduct

Maxis Health System
Corporate Compliance Program

September, 2000


Letter from the President and Chief Executive Officer

      “I have come that all may have life”, the Mission of Jesus Christ, is at the heart of the Mission of the Sisters, Servants of the Immaculate Heart of Mary which inspires the Maxis Health System.  The Maxis Health System commits itself to this end by integrating the resources of the entities for the total care of those we serve.  This Mission requires of us close and faithful attention to the establishment and maintenance of right relationships within and among all entities of the System as well as right relationship with clients, patients, physicians, colleagues, volunteers, students, family members, vendors, and payors.

     We understand that right relationships begin with a commitment on the part of each individual working within our System to personal and professional integrity.  The hallmark of our relationships with all those associated with Maxis Health System is honesty, compassion, competence and a focus on service.  The relationships between members of the Maxis Health System are those of support and challenge to further the System’s ability to bring life to those we serve and to the members of the Maxis Health System Family.

     The Mission, Vision and Values of the Maxis Health System compel us to foster and maintain an ethical culture, to engage in competent and compassionate clinical practices, to adhere to appropriate and just business practices.  This Standard of Conduct reflects the commitment of the Maxis Health System to bring life to those we serve and with whom we serve within an ethical culture that is consistent with our Catholic tradition and in compliance with applicable laws, regulations, standards, policies and procedures. These Standards apply to all who participate in the works of the Maxis Health System - employees and Medical Staff from all entities, members of the Maxis Health Board, the Health and Human Service Board and the Foundation Board, and volunteers.

     Mandated by the Maxis Health System Board of Trustees, the Compliance Program has my full support.  In addition, this process to enhance the ethical culture of the entities of the Maxis Health System has been endorsed by the Sponsor of the System, the Sisters, Servants of the Immaculate Heart of Mary

Sister Jean Coughlin, IHM
President
Maxis Health System  


Maxis Health System Compliance Program 


Introduction 

      Maxis Health System’s mission is to respond to the health and human service needs of the community by integrating available resources of each entity (Marian Community Hospital, Tri-County Human Services, Inc., Maxis Medical, Complete Pharmacy, Carbondale Area Physician Hospital Organization, Maxis Foundation) into a network of care.  It is the intent of the System to create and support a network that promotes the total health of the individuals and communities it serves.  In order to achieve this mission and vision, we intentionally commit ourselves to the Core Values of respect for human dignity, compassion, hospitality, service, stewardship, competent care and a special concern for the poor.

     In response to Maxis Health System Board of Trustee’s mandate to create a program that provides guidelines and education aimed at helping us to enhance and maintain our personal and corporate integrity, a Compliance Program was developed.  The intent of this program is to provide broad based as well as department-specific information to all employees through an education program. In addition, the program details a process for employees to report compliance-related concerns and questions through the use of a Hotline.

     The Standard of Conduct manual reflects the work of the Compliance  Committees:  Compliance Oversight, Anti-trust, Environment, General Laws, Labor, and Medicare/Medicaid.  The Oversight Committee provides direction and coordination of all compliance efforts.  Each of the other committees have assessed our current status relative to the global risks associated with their committees, evaluated current policies for relevance and timeliness, and proposed the development of new policies as appropriate.  The untiring work of these committees has added much to the development of our Compliance Program and will continue to provide support and guidance in an on-going way.

     This Standard of Conduct for the System challenges each of us and all of us together to engage in ethical business and clinical practice.  It is critical that we understand compliance as making intentional decisions to do the right thing for the right reason. In addition to keeping us focused on ethical behavior, the Compliance Program is intended to facilitate a structure that helps to reduces the prospect of criminal behavior.  This structure includes strategies that allow us to prevent infractions as well as to detect and correct infractions if they occur. 

      Compliance is also about the many types of relationships in which we engage.  It is critical for us to appreciate the relationship with those we serve as a sacred trust which we take seriously.  Right relationships with our coworkers are key to fidelity to the mission of each entity and the mission of the Maxis Health System. In addition, honest and just relationships with payors and vendors are essential to ethical business practice.

      Dilemmas are part and parcel of life.  These challenging times can become defining moments when we explore the dilemmas with an open mind and focus on making the right choice for the right reason.   Included in this document is one suggested model for approaching the decision-making process.  

     Our on-going ability to provide for the health and human service needs of our community depends on our faithfulness to what is fair and true.  Acceptance of our duty to know and to comply with Federal, state, and local rules and Church-related ethical standards is essential to fidelity to our mission. 

     This Standard articulates basic principles which apply to employees, medical staff members, Board Members, volunteers, and students.  The principles include the following: 

1.    We understand compliance as doing the “right thing for the right reason” and therefore commit ourselves to:

·     conducting our business and clinical practice in a way that respects the dignity of     each person and reduces the prospect of criminal behavior through prevention, detection and correction of misconduct,

·     adhering to the Ethical and Religious Directives for Catholic Health Care Services

·     complying with the rules, regulations, and  laws relevant to business and clinical practice.  

2.    Our relationships with the public and those we serve (patients/ clients) are a sacred trust.  We are committed to serving those who entrust their care to us with respect, compassion and competence. 

3.   Right relationships with our coworkers are key to fidelity to the Mission of each entity and to the Mission of the Maxis Health System.  We are committed to fostering environments in the workplace that foster trust, respect and compliance with all relevant rules regulations, and laws. 

4.   Compliance is the responsibility of each employee, medical staff member, Board Member, volunteer and student. We are committed to knowing and adhering to prevailing rules, regulations and laws.  Compliance with these rules, regulations and laws is a condition of employment. 

Understanding of and adherence to sound business ethics is essential to compliance.  We are committed to conduct ourselves with justice and honesty in our relationships with payors and vendors.

Notes   Questions   Comments

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We Understand Compliance as 
Doing the Right Thing
For the Right Reason

     As collaborators in Catholic Health Care ministry our “right reason” is founded on the gospel imperative to share in God’s life giving and healing work.  The Ethical and Religious Directives for Catholic Health Care Services guide our decision-making processes.  As noted in these directives, it is the responsibility of all employees to respect and uphold the religious mission of the Maxis Health System and to promote the commitment to human dignity and the common good. 

     The internal and external communication of the entities of Maxis Health System are governed by honesty, accuracy, and respect for coworkers, patients, clients, and those with whom we interact.  Managers and directors have a responsibility to ensure that staff is educated on ethical behavioral practices as they apply to clinical work and business dealings and to monitor their compliance.   

     It is the practice of the entities of Maxis Health System to employ staff who are competent, qualified, appropriately credentialed, and who are willing to share the mission, vision, and values of the Maxis Health System.  We do not engage in business with nor do we hire persons who have been convicted of health care-related crimes or are currently excluded from participation in government-subsidized programs.  

We expect all staff and employees to:

¨   understand and comply with the requirements of the relevant rules, regulations, laws, and policies that apply to their areas of responsibility.  This includes maintaining copies of current licenses and credentials in their Human Resources files;

¨   contact their department director or the Corporate Compliance Officer regarding issues that may be unclear, suggest inappropriate behavior, and/or have legal implications; 

¨   follow the reporting policy and procedures when knowledgeable of compliance-related infractions.

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Notes  Questions  Comments

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Our relationships with the Patients 
and Clients are a Sacred Trust

     Honesty, competence, and compassion are the hallmarks of our service and relationships with patients/clients and others with whom we come in contact.  We are committed to treating patients/clients in a dignified manner, with courtesy, respect and professional competence, without regard to race, color, religion, ethnic origin, gender, marital status, public assistance, disability, age or any other category prohibited by law, with respect for confidentiality and privacy of the individual. 

   Patients/clients are informed of their rights.  Employees are aware of these rights and act in accord with them as outlined in the “Patients’ Bill of Rights” (Marian Community Hospital) and the “Client’s Rights and Responsibilities” and “Grievance Procedure” (Tri-County Human Services Center, Inc.)

     Patients/clients receive professional, clinically appropriate, and compassionate treatment and care.  Confidentiality and privacy regarding patient and client information is maintained according to each entity’s standards. 

      In an on-going effort to foster and maintain an environment in which the trust of patients/ clients are held sacred, we expect employees, medical staff members, Board members, volunteers and students to take appropriate action to:  

  • preserve the confidentiality and privacy of each client and patient,

  • involve patients and clients in decision making processes regarding their care,

  • obtain informed consent for treatment when applicable, 

  • inform patients and clients of their options and their right to   choose to accept or refuse treatment

Notes   Questions   Comments

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Right Relationships with Our Coworkers Are Key
to Fidelity to the Mission of Each Entity and
to the Mission of the Maxis Health System

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     Each employee, medical staff member, Board member, volunteer, and student must follow the Standard of Conduct as well as the regulations, standards and expectations of their particular area. Compliance is required as a condition of continued association or employment within Maxis Health System.  Together we enhance the integrity of our working environment, conditions and the service we render to patients/clients and payors as we commit ourselves to compliance in the following areas:

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Engaging in Responsible and Respectful Personal Interactions

     The manner in which we treat each other has the potential to impact the way we perform our work-related tasks.  It is the responsibility of all employees, medical staff members, volunteers, and students to be aware of the ways their behavior affect their patients/ clients, coworkers, and the ability of each entity to convey a trustworthy image to those we serve.  Respectful and professional behavior is expected of all those who participate in the Mission of each entity of the Maxis Health System. 

     Behavior reflecting discrimination of any form will not be tolerated and will be dealt with in an appropriate disciplinary manner after investigation.  

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Creating a Safe Working Environment
     All persons associated with Maxis Health System must obey all laws and regulations that apply to their area of work.  These include environmental laws and rules in the operation of each entity, proper disposal of waste and protection from exposure.  Accepted procedures will be followed for the safety of employees and staff members and the safety of all associates and patients/clients.
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Maintaining Fair Working Conditions
     Employment practices are in accord with the non-discrimination policies of each entity. Qualified employees are sought to fulfill our mission.  Laws governing wages, employment, and employment termination are followed.  The workplace fosters, supports and affirms excellence, professional development and the health, safety, privacy and comfort of all associated with it.  As outlined in the Policy Against Sexual and Other Harassment, harassment of any type is not tolerated.

     References are sought for those who are hired.  Upon employment all employees are expected to present appropriate licenses and credentials.  In addition, employees will provide copies of updated licenses and credentials prior to expiration . This information will be maintained by the Human Resources department.
Preserving the Confidentiality of Coworkers
     Confidential information (professional activity, peer review, evaluations, appointments, etc.) regarding employees and the medical staff is protected.   Each entity of the Maxis Health System is required to comply with the security and safety policies that are detailed in the entity’s Confidentiality policy.  

     Employees, medical staff members, Board members, volunteers and students are protected from retaliation when they, in good faith, report to their directors/supervisors or to the Compliance Officer any compliance-related infraction.
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Notes   Questions   Comments

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We Are Responsible for Promoting Corporate Integrity 
Through Compliance. Compliance is a condition of employment.

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     Each employee, medical staff member, Board Member, volunteer, and student has a duty to comply with all standards as well as to report promptly and in good faith any procedures, regulations or the Standard of Conduct.  Employees are required to use the existing systems or processes that are in place to comply with policies and procedures.

     If there is a question regarding compliance, employees, medical staff members, Board Members, volunteers, and students are encouraged to talk first with their supervisors or contact the Corporate Compliance Officer.  Reports can be made anonymously, in a confidential manner and without fear of retaliation.

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Hotline Policy - The Maxis Health System Reporting Process

     The Hotline is one of the means available to report non-compliance with all applicable standards. Reportable actions are those related to provider, supplier, and practitioner practices that are inconsistent with our Standard of Conduct, Federal, State, Local regulations, sound fiscal, business, or medical practices.  The Hotline is not the vehicle for reporting Human Resource related grievances, unless they are violations of the regulations with which we are obliged to comply.  Grievances should be reported using the existing format as stated in the Personnel Policy Manual. 

      All employees and Medical Staff throughout the Maxis Health System have a duty to report suspected incidents of non-compliance to the Corporate Compliance Officer.  Open communication with the Compliance Officer is encouraged.  Concerns can be communicated in a number of ways: use of e-mail, memo, hotline, and direct oral communication.  The Hotline can be reached by calling      .  This line is in the office of the Compliance Officer and is available 24 hours a day, 365 days a year. This line is not equipped with any type of caller identification devise.  The identification of the caller remains anonymous.  In addition, The Health and Human Services – Office of the Inspector General Hotline is 1 – 800 – HHS – TIPS.   

      The duty to report is not limited to internal control in the reimbursement and payment areas (regarding claims and billing operations).  It encompasses each entity and all departments within the Maxis Health System, and is incumbent upon corporate officers, managers, physicians, other health care professionals, all employees as well as independent contractors to facilitate ethical and legal conduct.            

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Confidentiality of the Hotline
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     ALL CALLS ARE CONFIDENTIAL.  Reports and e-mail can be made on an anonymous basis.  Those calling to report using any format will not be required to disclose their names.  The Hotline phone is not equipped with any form of Caller-ID technology.  Callers will be informed that their identity may need to be revealed in the event of a governmental investigation or may become known during the process of investigation.  Callers will be asked if they are willing to disclose their names for the purpose of responding to their report but this will not be required.  Callers will be given a code number and a date to call the Compliance Officer back to receive a response.  The substance of the reports, not the names of the callers, will be reported to the governing body of the System, the CEO, and the Compliance Oversight Committee.

     If a caller is involved in alleged misconduct, he/she needs to be aware, however, that not withstanding that fact, there may be legal implications for him or her.  As a legal matter, voluntary disclosure can benefit the caller when prior misdeeds are taken into consideration.

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Non-retaliation Policy
     Truthful reporting of a concern in good faith is our duty and such reporting will not put the reporting employee’s job at risk.  Retaliation or harassment violates Maxis Health System Mission and policies and it will not be tolerated.  Incidents of any retaliation or harassment are to be reported immediately to the Compliance Officer.  Each report will be investigated and the person(s) responsible will be subject to immediate discipline.  In addition, frivolous or bad faith reporting can be the subject of disciplinary action.
Assessment and Investigation of Reports Made through the Hotline or Other Forms of Communication
     Compliance-related calls will be assessed and investigated for validity.
  • Confidentiality of the employee’s or individual’s identity will be maintained, however, the individual will be informed that his/her identity may become known or need to be revealed in certain instances if or when governmental authorities become involved.  
  • Each call will be assessed and a determination will be made as to the follow-up (e.g., investigation, referral, or immediate resolution.)  
  • The investigation process and its outcome will be documented on the Hotline Assessment and Investigation Form.  All documents will be reviewed and notes taken.
      
  • Appropriate action will be taken based on the results (e.g., change in procedure, education of staff, rebilling, returning funds, etc.) (Reference:  OIG Compliance Plan for Hospitals)  
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Disciplinary Guidelines
  • Disciplinary action will be imposed for failing to comply with each entity’s standards, policies, and applicable statutes and regulations.  Action will be taken on a fair and equitable basis.  Managers, supervisors and administration have a responsibility to discipline employees in an appropriate and consistent manner. Managers, supervisors and supervisors are subject to discipline for failing to recognize, respond to, and remediate any form of non-compliance.  
  • Human Resource policies or Medical Staff bylaws, rules and regulations outline how employees or Medical Staff members may be disciplined for violating the Standard of Conduct or Compliance Policies and Procedures. This includes all levels of employees and Medical Staff.
Education and Training

     Leaders, Managers, and Supervisors must ensure by training, teaching, leading and monitoring that the people they direct or supervise follow the Standard of Conduct, adhere to laws, standards, regulations, policies, and procedures and do so in an ethical manner. 

     Members of the Boards of Trustees across the Maxis Health System will be apprised of their responsibilities through on-going Board Education.   Each Board Member will sign a yearly Conflict of Interest statement.               

     Each employee of the Maxis Health System member, Medical Staff member, Board of Trustees member, and volunteer will acknowledge that the Standard of Conduct was received, reviewed, and complied with by signing a statement of acknowledgement upon initial affiliation with the organization.  A copy of the signed statement will be kept on file.  

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Notes   Questions   Comments

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We Are Committed to Conduct Ourselves with Justice 
and Honesty in Our Relationships with Payors

     All employees, medical staff members, Boards members, volunteers, and students within the Maxis Health System are obligated to comply with Federal and State laws, regulations regarding the Medicare/ Medicaid Programs, and Managed Care Plans, as well as regulations concerning private payors.

     It is our responsibility to code and bill accurately for services and/or treatments rendered, and to maintain proper billing practices, which include following special billing requirements for government- sponsored programs and other payors.  We will take appropriate and necessary measures to avoid instances of deliberately misleading any government agency or other payors.  It is also our responsibility to ensure compliance with facility and operating standards for licensing and certification of the entities within the Maxis Health System.

     Employees within each entity will attend appropriate mandatory education and training programs regarding Medicare/Medicaid and other payors as necessary.

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Notes   Questions   Comments

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We Are Committed to Right Relationships with 
the Vendors with Whom We Conduct Business

     The vendors with whom we conduct business are informed by the Director of Materials Management of our Standard of Conduct and our expectation of them to comply with the practices and policies of the entities with whom they engage.   

     All business transactions of Maxis Health System entities are conducted in compliance with applicable anti-trust laws.  These complex laws are an effort to encourage competitive and fair operating practices between organizations.  Price sharing is prohibited.

     Providers of contracted services who are in violation of standards or who have been sanctioned or excluded from any governmental program that provides coverage for service rendered will have their contracts cancelled.

     Maxis Health System has a policy regarding the reception of gifts from vendors.  Vendors will be apprized of this policy.  Employees and staff will be aware of and conform to this policy.   

     All employees, medical staff members, Board members, volunteers, and students are to avoid any behaviors that would engage in conflict of interest.  For example:  

  • No person should be involved in any transactions with persons or organizations unless approved according to existing procedures. All sales representatives are to report to Materials Management before meeting with Department Directors. 

  • Resources of any entity of the Maxis Health System may not be used for personal benefit

  • Those associated with the Maxis Health System cannot solicit or accept gifts or gratuities of more than the nominal value stipulated in Materials Management policies.   

  • The name or reputation of Maxis Health System or any of the entities may not be used for private businesses.

Notes   Questions   Comments

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A Model for Decision Making

     The following model can be use to help us think through and make ethical and professional
business and clinical decisions:

  • Collect accurate and appropriate information. Know the real issues, the relevant regulations, and understand the situation. 

  • Think things through.  Look at all the possible actions you can take.
  • Don’t isolate yourself.  Speak with your supervisor or the Compliance Officer about the situation.
  • Use the “Six O’clock news” rule as you consider the  consequences of your actions: 
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    How would you feel if your action was the focus of the Six
             O’clock News? 
           - Consider the outcome of your decision on you, your patients
             or clients, the entity, and your family. 
  • Follow through on your decision after your have spent quality time reflecting on the information you have gathered and the possible consequences of your behavior. Do the right thing for the right reason.
  • Be accountable for your decision.

Notes   Questions   Comments

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Standard of Conduct

1.      We understand compliance as doing the “right thing for the right reason” and therefore
         commit  ourselves 

  • to conducting our business and clinical practice in a way that respects  the dignity of  each person, and reduces the prospect of criminal behavior, 

  • adhering to the Ethical and Religious Directives for Catholic Health Care Services  

  • complying with the rules, regulations, and laws relevant to business and clinical practice.

2.      Our relationships with the public and those we serve (patients/
    clients) are a sacred trust.  We are committed to serving those who
    entrust their care to us with respect, compassion and competence.

3.      Right relationships with our coworkers are key to fidelity to the
    Mission of each entity and to the Mission of the Maxis Health
    System.  We are committed to fostering environments in the
    workplace that foster trust, respect and compliance with all relevant
    rules regulations and law.

4.      Compliance is the responsibility of each employee, medical staff
    member, Board member, volunteer, and student. We are 
    committed to knowing and adhering to prevailing rules, regulations
    and laws. Compliance with these rules, regulations and laws is a
    condition of
employment

5.      Understanding of and adherence to sound business ethics is
    essential to compliance.  We are committed to conduct ourselves
    with justice and honesty in our relationships with payors and
    vendors.

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Employee Response to the Standard of Conduct

        I have received and read the Maxis Health System Standard of Conduct.  I will conduct myself according the principles set forth in this document and according to the expectations that are included in the relevant and appropriate accreditation bodies, professional organizations, licensing bodies, regulations of payers with whom the entities of the Maxis Health System are related.  By signing this document, I also agree to abide by the Ethical and Religious Directives for Catholic Health Care Services, the Sexual and Other Harassment Policy, the Patients’ Bill of Rights (MCH), the Client’s Rights and Responsibilities and Grievance Procedure (Tri-County Human Services), the Confidentiality and Security policy relevant to the entity of which I am an employee.

       I will attend the required educational programs regarding. Compliance as they are scheduled.  I understand that I have a duty to report any violations of this policy.

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