UR Medicine Home Care Health Care Compliance Code of Conduct

POLICY:

It is URMHC’s expectation of all individuals to do the following:

• Conduct themselves in accordance with the highest ethical standards and all applicable laws, regulations and legal requirements.
• Report any real or suspected violations of the URMHC Compliance Program to the URMHC 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 senior leader if clarity is needed.
• Violations of the Code of Ethical Conduct or any compliance policy must be reported promptly to the Office of Integrity and Compliance.
• No individual shall be subject to adverse action, retaliation, intimidation or discrimination in any way for reporting in good faith an actual or suspected violation of the Code of Ethical Conduct.
• Sanctions for violating the Code of Ethical Conduct or any URMHC compliance policy include disciplinary action up to and including termination of employment.

The Code of Ethical Conduct is part of mandatory compliance education and training implemented as follows:

• All new employees within 30 days of hire;
• All new board members upon election to the URMHC Board
• All URMHC employees and board members on an annual basis.

Purpose of the Code of Ethical Conduct (Code)

The purpose of URMHC’s Code is to serve as a foundational document describing its fundamental principles, values and commitment to conduct its business in an ethical manner. The Code is part of URMHC’s Compliance Program that also includes the written Corporate Compliance Plan, and Compliance Policies and Procedures.

Scope

This code is applicable to all URMHC’s Affected Individuals (“affected individuals” or “individuals”) and includes employees, board members, contractors, subcontractors, independent contractors, agents and volunteers.

URMHC Mission Statement and Values

It is URMHC’s mission to preserve and enhance the quality of life for the people and communities it serves by providing comprehensive high-quality health care at home delivered with compassion and integrity.

As an affiliate of the University of Rochester, URMHC is committed to Meliora – ever better. Embedded in this ideal are shared values of equity, leadership, integrity, openness, respect and accountability.

Additional Responsibilities of URMHC Management

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

• Serve as a positive role model in fostering a culture of compliance and ethical behavior. Do not give others the impression that it is okay to ignore policies or skip steps. Do not 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 URMHC’s Disciplinary Standards Policy 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 URMHC’s expectation that all individuals immediately report any suspected or actual violations (whether or not based on personal knowledge) of the Compliance Program to the URMHC Compliance and Privacy Officer at (585) 667-1175. 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 URMHC Senior Leadership
• 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 585-766-8888.
• (See URMHC Compliance Policy – ‘Effective Lines of Communication for Reporting’)
• Any individual failing to comply with the Compliance Program will be subjected to URMHC’s ‘Disciplinary Standards for Compliance Violations Policy’ up to and including termination.

Non-Retaliation and Non-Intimidation

Individuals are protected from retaliation when reporting in good faith an actual or potential violation of the URMHC Compliance Program including instances of intimidation and retaliation. (See URMHC Compliance Policy – ‘Non-Intimidation and Non-Retaliation’)

Disciplinary Standards

URMHC has established disciplinary standards and implemented procedures that fairly and consistently enforce disciplinary action relative to violations of the URMHC Compliance Program. Disciplinary standards apply to all individuals, up to and including termination to the extent allowed by law. (See URMHC Compliance Policy – ‘Disciplinary Standards for Compliance Violations Policy’)

Medical Records

All medical records must be accurate and complete to ensure patient safety, quality of care and accurate billing procedures. 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. (Reference to URMHC Policy- ‘Clinical Staff Performance Standards’)

HIPAA Privacy and Security/Patient Confidentiality

URMHC is committed to protecting a patient’s confidentiality, and to following HIPAA Privacy and Security Policies. The URMHC Compliance Committee is responsible for adopting applicable URMC and Affiliates HIPAA and Information Security Policies and creating HIPAA Privacy and Security procedures pertinent to URMHC operations. (See Policy Stat URMHC – ‘HIPAA Privacy and Security Policies’)