Highlands at Brighton and Highlands Living Center Health Care Compliance Code of Conduct

Purpose of the Code of Ethical Conduct (Code):

The purpose of the Code of Highlands at Brighton and Highlands Living Center (individually and collectively referred to herein as LTC) is to serve as a foundational document describing fundamental principles, values and commitment to conduct its business in an ethical manner. The Code is part of LTC’s Compliance Program (Program) that also includes the written Compliance Plan, and Compliance Policies and Procedures.

Scope:

This code is applicable to all LTC’s Affected Individuals (Individuals) including employees, board members, contractors, subcontractors, independent contractors (contractors), volunteers and agents. It is the expectation that all Individuals:

• Conduct themselves in accord to the highest ethical standards.
• Comply with applicable state and federal laws, rules and regulations (regulations) as per LTC’s Program.
• Report any real or suspected violations of the LTC Program to the LTC Compliance & Privacy Officer.
• Read all policies/procedures/standards applicable to an individual’s job or service responsibilities and seek out answers from a direct supervisor or HAB or HLC Senior Leader (as applicable) if clarity is needed.
• Sign an acknowledgement confirming commitment to and understanding of LTC’s Program Documents.

Certain sections of the Code may refer to specific policies to provide additional guidance. These policies may be within LTC’s Compliance and Privacy Policies and Procedures on Policy Stat or applicable written guidance from the University of Rochester Medical Center (URMC) and/or URMC Office of Integrity and Compliance (OIC).

Additional Responsibilities of LTC Management:

LTC’s Senior Leadership, directors, managers and department heads (“management”) must lead by example and take steps to promote the LTC Program by fulfilling the following responsibilities:

• Serve as a positive role model in fostering a culture of compliance and ethical behavior. Don’t give others the impression that it is okay to ignore policies or skip steps. Don’t create or tolerate an environment where workforce members feel pressured to bend the rules.
• Guide individuals on completing all required training on time and regularly review applicable policies and make sure they know how to act in a manner consistent with the program.
• Prevent problems before they happen. Respond to individuals who raise concerns in a way that makes them feel at ease and secure.
• Prevent program violations by reporting violations and/or concerns promptly. Any individual who fails to report program violations will be subject to HAB’s or HLC’s Disciplinary Standards Policy (as applicable) up to and including termination of employment, to the extent permitted by law.
• Disciplinary procedures may also be taken when management ignore misconduct, or fail to take action to correct it.

Reporting a Potential Violation:

It is LTC’s expectation that all individuals immediately report any suspected or actual violations (whether or not based on personal knowledge) of the Program (“Program”) to the LTC Compliance & Privacy Officer at (585) 275-1609. Once an issue is reported, the individual has an obligation to provide all applicable updates and/or additional information that may be learned. All information reported to the Compliance and Privacy Officer will be kept confidential to the full extent possible in completing a thorough investigation of the reported violations.

Additional options to discuss or report a concern:

• Speak with your direct supervisor or anyone in a leadership role at HAB or HLC (as applicable)
• Contact the URMC Office of Integrity and Compliance (OIC) at 585-275-1609 or by sending an email to compliance@urmc.rochester.edu; or,
• Report concerns anonymously in good faith and without fear of retaliation by calling the URMC Integrity Helpline at 585-756-8888.

Non-Retaliation and Non-Intimidation:

Individuals are protected from retaliation when reporting in good faith an actual or potential violation of the LTC Program including instances of intimidation and retaliation. 

Disciplinary Standards:

LTC has established disciplinary standards and procedures that fairly and consistently enforce disciplinary action relative to violations of the LTC Program.

Medical Records

All medical records must be accurate and complete to ensure patient safety, quality of care and accurate billing. Individuals must ensure all information documented in a medical record is truthful and complete. Documentation must never be deleted from a medical record or edited except through an approved amendment process.

HIPAA Privacy and Security/Patient Confidentiality

LTC is committed to protecting a patient’s confidentiality, and to following HIPAA Privacy and Security Policies. The LTC Compliance Committee is responsible for adopting applicable URMC and Affiliates HIPAA and Information Security Policies and creating HIPAA Privacy and Security procedures pertinent to LTC operations.

Excluded Individuals and Entities

LTC is committed to complying with applicable federal and state laws and regulations governing the exclusion, sanction, restriction, debarment, and/or ineligibility of individuals from participating in Federal and State Health Care Programs (i.e., Ineligible Persons).

Deficit Reduction Act – Fraud, Waste and Abuse

In compliance with the Deficit Reduction Act of 2005 and OMIG ‘Compliance Programs’, LTC provides all required information and compliance education to all workforce members (employees, temporary employees, contracted entities and/or individuals, volunteers) involved in providing or furnishing health care items or services.