St. James Hospital Health Care Compliance Code Of Conduct

PURPOSE:

To set forth written standards of conduct that promote the St. James Hospital's commitment to compliance and that set forth general compliance expectations for all individuals involved directly or indirectly in the governance of St. James Hospital's or the delivery of health care services at St. James Hospital.

SCOPE:

Applies to all trustees, corporate officers, directors, employees, administrators, managers, medical staff members, residents, fellows, independent contractors, agents, subcontractors, vendors and volunteers ("Affected Individuals").

POLICY:

St. James Hospital ("SJH") shall adopt, maintain and distribute a Health Care Compliance Code of Conduct ("Code of Conduct") which describes its expectation that all Affected Individuals will conduct themselves in accordance with the highest ethical standards and all applicable laws, regulations and legal requirements.

DESCRIPTION:

1. SJH is committed to fully complying with all state and federal laws, regulations and policies that apply to the delivery of health care services and to the correct documentation, coding and billing for all health care services, including services covered by the Medicare and Medicaid programs. All Affected Individuals are expected to obey the law, report improper and illegal activity and conduct themselves with integrity.

2. To promote the highest standards of ethical behavior and integrity, SJH has adopted the Code of Conduct. While not intended to be all inclusive, the Code of Conduct describes general legal, ethical and regulatory requirements that affect the delivery of, and billing for, health care services. It also provides information on where Affected Individuals may obtain more information and assistance to ensure that they are following the law and abiding by the Code of Conduct.
3. All Affected Individuals are subject to and required to read and follow the Code of Conduct.
4. A current copy of the Code of Conduct is maintained on the Compliance Office website and may be accessed here. 
5. The Code of Conduct shall be distributed to:
   1. All new employees via the MyPath system within 90 days of hire;
   2. All new board members upon election to the St. James Hospital Board;
   3. All St. James employees, residents and fellows via the MyPath system on an annual basis;
   4. All medical students and volunteers;
   5. All St. James Hospital board members on an annual basis.
6. Violations of the Code of Conduct or any Compliance Policy must be reported promptly to the Office of Integrity & Compliance.
7. No individual shall be subject to adverse action, retaliation or discrimination in any way for reporting in good faith an actual or suspected violation of the Code of Conduct.
8. Sanctions for violating the Code of Conduct or any St. James Hospital Compliance Policy include disciplinary action up to and including termination of employment.