Privacy Policy

Code of Conduct

Departments Affected: All YCH Departments	Effective Date: 04/23/2020
Approved By: YCH Governing Board	Revision Date(s):
Governing Board Secretary: Danny Bell	Page 1 of 12

PURPOSE

To establish and adopt a Code of Conduct as part of the broader Compliance Plan of Hospital.

POLICY

Yoakum County Hospital (“Hospital”) is committed to the highest standards of regulatory and ethical compliance in all business, operations, and clinical aspects of Hospital. It is the policy of Hospital to adopt a Compliance Plan which meets the requirements of the Compliance Guidance for Hospitals promulgated by the Department of Health and Human Services Office of the Inspector General. The Code of Conduct is to be an integral part of this broader Compliance Plan. The Code of Conduct is drafted to be a basic statement of Hospital’s commitment to regulatory compliance which is easily understood by Hospital employees, promotes basic awareness of ethical and unethical activities, and communicates to employees the responsibility to adhere to ethical principles.

PROCEDURE

1. The Board of Directors of Hospital shall adopt the Code of Conduct on an annual basis. It shall be the responsibility of the Compliance Committee to provide updates and revisions to the Code of Conduct to the Board on an annual basis for consideration and adoption.

1. The Code of Conduct shall be provided to each new employee and a signed acknowledgement of its receipt and review shall be obtained and maintained in the employment file.
2. A review of the Code of Conduct shall be incorporated into the annual training and update session required to be attended by each employee.

1. The Code of Conduct for the current year is attached to this Policy.

Code of Conduct Page 1

CEO/Administrator Welcome

Yoakum County Hospital (“Hospital”) is committed to the highest standards of business ethics and integrity. Therefore, we have adopted the following Code of Conduct to provide our employees with a guide to proper workplace behavior. Included are guidelines for ethical behavior and business conduct that are consistent with the law and the Hospital’s vision, mission, and core values. We are all responsible for making sure our actions adhere to the laws governing health care as well as our own high standards.

This Code of Conduct outlines our pledges to the many people that we serve and who surround us. It establishes the standards that we expect each one of our employees to meet. Compliance with the Code of Conduct and all of its provisions is a perfect way for us to maintain a warm and caring team and accomplish our mission.

A Pledge to Our Patients

Quality of Care

We will treat all patients with respect and dignity and provide care that is both necessary and appropriate. We strive to deliver high quality care by utilizing technological advancements, techniques proven to ensure patient safety and an overall culture of service. As a general principle, we promote excellence from all of our employees, medical staff members, and business associates. The commitment to quality of care is a responsibility of every Hospital employee. Each employee has an obligation to report any inappropriate care or treatment of patients and question any possible activities that may appear to be in violation of our values by using the available channels of communication.

Patient Rights

We will treat patients in a manner that preserves their dignity, autonomy, self-esteem, civil rights, and involvement in their own care. We do not discriminate among patients based on race, ethnicity, religion, gender, sexual orientation, national origin, age, disability or veteran status. Patients will receive a statement of patient rights, which notifies them of, among other things, the right to make decisions regarding medical care, the right to refuse or accept treatment, and the right to informed decision-making. We will obtain patient consent for treatment or participation in research, and we will explain available options. We do not conduct medical procedures unless doing so is in accordance with good medical practices. In the promotion and protection of each patient’s rights, each patient and his or her representatives are provided with appropriate confidentiality, privacy, security, advocacy, and protective services, an opportunity for resolution of complaints, and pastoral or spiritual care.

Confidentiality of Patient Information

We understand that the information we obtain from a patient is sensitive and personal information. We strive to maintain the confidentiality of patients in accordance with applicable legal and ethical standards, including state law and the Health Insurance Portability and

Accountability Act, known as “HIPAA.” Every patient will be provided with a Notice of Privacy Practices. This Notice establishes the patient’s rights related to his or her health information maintained by the Hospital. We will refrain from accessing or revealing any personal, confidential or protected health information concerning patients unless authorized to do so; as required to perform treatment, payment or healthcare operations; or as required by law. We will release information to business associates only in accordance with legal standards and internal policies. All employees have an obligation to actively protect and safeguard confidential and sensitive information in a manner designed to prevent unauthorized disclosure of information. If an unauthorized disclosure occurs, an employee must immediately report this issue to his or her Director or Manager, the Privacy Officer, or the Compliance Officer to remedy the disclosure.

Emergency Treatment

We follow the Emergency Medical Treatment and Labor Act, (commonly called “EMTALA”), which requires an emergency medical screening examination and necessary stabilization of all patients, prior to obtaining financial information and regardless of the ability to pay. We do not admit, discharge, or transfer patients with emergency medical conditions based on their ability or inability to pay or any other discriminatory factor. Patients are only transferred in compliance with federal and state EMTALA statutory and regulatory provisions. Any intentional failure or refusal to comply with the regulations will result in disciplinary action.

A Pledge to Our Business Associates

The modern healthcare system is comprised of many components that work in collaboration to provide the highest quality benefit to those we serve. Each party in the process serves important roles and responsibilities. As we select business associates to partner with for necessary services and materials, we will be very careful to ensure that they continually embrace and demonstrate high standards of ethical business behavior. Our business associates, whether they are members of our medical staff or third parties, are encouraged to work in a respectful and supportive manner. We appreciate this caring attitude and we will expect it to continue.

Competition

As the focus on healthcare increases in importance nationally, it is imperative that we compete fairly in the marketplace. We will comply with applicable antitrust and similar laws that encourage fair competition and prevent monopolies. The antitrust laws were founded on the belief that the public interest is best served by vigorous competition that is free from collusive agreements among competitors on both price and service terms. Examples of conduct prohibited by the law include but are not limited to: agreement to fix prices; bid rigging; collusion (including price sharing) with competitors; boycotts; and bribery. We do not illegally obtain or use proprietary or confidential information concerning competitors, nor do we use deceptive means to gain such information. When confronted with business decisions involving risk of anti- trust violations, employees will seek advice from the Compliance Officer and legal counsel to ensure fair competition.

Marketing and Advertising

Consistent with laws and regulations that govern such activities, we may use marketing and advertising activities to educate the public, provide information to the community, increase awareness of our services, and to recruit business associates. We present only truthful, fully informative and non-deceptive information in these materials and announcements.

Gifts and Entertainment

Business transactions, whether offered, provided or received from vendors, contractors, other healthcare providers, physicians and other third parties, shall be conducted free from offers or solicitations of gifts and favors or other improper inducements in exchange for influence or assistance in a transaction.

Receiving Gifts and Entertainment

Employees shall not solicit tips, personal gratuities or gifts from patients, their family members, or any other business associate. Employees may not accept cash or its equivalent (checks, gift certificates, stocks, coupons, etc.). Employees will not accept gifts, favors, services, entertainment or other items of value to the extent that the Hospital’s decision-making or actions might be influenced. Knowledge of any such conduct must be reported immediately to Administration or the Compliance Officer. If a gift is received that exceeds our guidelines, the person who received the gift will return it with an explanatory note. Examples of gifts that would be inappropriate include, but are not limited to, the following: tickets to sporting events with a face value over $50.00; multiple gifts from a single giver that create more than a nominal aggregate total; and gifts to an employee’s family members because of the employee’s position.

Employees may accept non-monetary gifts of nominal value (defined as a value up to $50.00), upon a Director or Manager’s approval (e.g., perishable items, free samples, training sessions, coffee mugs, etc.). Employees may accept an invitation to attend a vendor-sponsored meal, workshop, seminar or training session, which is geographically close to the Hospital. Attendance at out-of-town workshops, seminars, and training sessions is permitted only with Director or Manager and Administrative approval. If there is any concern whether a gift or invitation should be accepted, consult your Director or Manager, Administration, or the Compliance Officer.

Providing Gifts and Entertainment

Federal and state laws and regulations, including the Stark Law and the Anti-Kickback Law, govern the relationship between the Hospital and its referral sources. Referral sources include physicians or other entities that are in a position to refer patients to our facility. Any arrangement with a referral source must be structured to ensure compliance with the legal requirements, our policies and procedures, and with any applicable guidelines. Most arrangements must be in writing and approved by the proper approval process. We do not pay or offer items or services of value in order to induce referrals or as a reward for referrals. Any entertainment, gifts or tokens of appreciation involving a referral source must be undertaken in accordance with federal laws, regulations, and rules regarding these practices.

We may provide gifts, entertainment, and meals of nominal value to non-referral sources, such as Hospital customers, current or prospective business associates and other persons, when such activities have a legitimate business purpose and are reasonable and consistent with applicable laws. It is imperative to avoid the appearance of impropriety when giving gifts to individuals who have a relationship with the facility. An effort will be made to ensure that any gift we extend meets the business conduct standards of the recipient’s organization. If there is any concern whether a gift, entertainment, or meal should be provided, consult the Compliance Officer or Administration.

A Pledge to Our Community

Community Involvement

We serve our community by providing quality cost-effective healthcare and recognize our specific responsibility to help those in need. We encourage volunteerism for charitable activities, but do not pressure others to do so. We sponsor activities that benefit the community and aim to fulfill our ultimate purpose.

Governmental Relations

Yoakum County Hospital will not provide funds or resources directly to an individual’s political campaign, political party, or other organization, which intends to use the funds or resources primarily for political campaign objectives. This includes the use of the Hospital’s facilities as an open forum for making political speeches. On limited occasions, the Hospital may engage in public policy debates where it has special expertise that can inform the public policy formation process. During these events, the Hospital may provide relevant factual information about the impact of decisions on the health care sector. An employee may personally participate in and contribute to political organizations or campaigns, but they must do so as an individual, not as representatives of the Hospital and they must use their own funds and time. Use of the facility’s resources, such as telephone, fax, copiers or email, is not appropriate for personal engagement in political activities. Any activity that relates to political campaigns, such as ticket sales for political fund-raising or advertising for political candidates, is not allowed on the Hospital’s campus.

Environmental Obligations

We will strive to comply with the laws and regulations relating to our environment. We utilize all resources appropriately and efficiently and dispose of all waste in accordance with applicable law. The Hospital will assist appropriate authorities to remedy any environmental contamination for which the Hospital may be held responsible.

A Pledge to Our Fellow Employees

Diversity and Equal Employment Opportunity

We ensure that all employment decisions are made on a non-discriminating basis, and without regard to an employee’s or applicant’s race, ethnicity, religion, gender, national origin, veteran status, age, or disability. We will make reasonable accommodations to the known physical and mental limitations of qualified individuals with disabilities. Employee information is confidential and will only be accessed as part of our job and when necessary to complete our work.

Positive Work Environment

We strive to create an environment that supports working in teams and respecting other people, regardless of their position in the organization. We will make ourselves accountable to one another for the manner in which we treat one another and for the manner in which people around us are treated. Undesirable and disruptive behaviors that intimidate coworkers, patients, and/or visitors, decrease morale, or increase staff turnover may threaten the safety and quality of services provided and will not be tolerated. These undesirable and disruptive behaviors may be verbal, non-verbal or written and may include, but not be limited to, the following:

• rude, abusive language – in person, on the phone or via email;
• making fun of or mocking someone – alone or around others;
• public embarrassment;
• threatening mannerisms/intimidating body language – clenched fists, a raised voice, obscene gestures, snapping fingers, pointing, staring;
• physical abuse;
• blaming others for your actions, reactions, problems; and
• gossiping or spreading rumors.

No form of harassment or discrimination on the basis of sex, race, color, disability, age, religion, or ethnic origin, in addition to sexual harassment or any other protected classification prohibited by law, will be permitted. Each allegation of harassment or discrimination will be promptly investigated in accordance with applicable personnel policies.

Health and Safety

We promote a safe and healthy workplace by complying with the governmental health and safety rules and regulations. Employees will follow policies and procedures when handling hazardous materials or dangerous instruments and are informed of their properties. When a situation arises that may cause an injury or accident, employees should immediately report it to the employee’s Director or Manager, Administration or the Safety Officer.

We are committed to a safe, drug-free workplace. Reporting to work under the influence of any illegal drug or alcohol; having an illegal drug in your system; or using, possessing, or selling illegal drugs while on work time or property may result in termination. Prescription and

controlled substances must be handled properly and by authorized individuals to minimize risks. Any appearance of mental impairment or drug diversion will be reported to Management, te Compliance Officer, or Human Resources for follow-up actions.

Legal Employment

We endeavor to provide the highest quality care and service to our patrons. Employees will maintain all professional credentials, licenses, and certifications that are necessary to perform their jobs. At all times, employees will comply with federal and state requirements applicable to our respective disciplines. We do not knowingly contract with, employ, or bill for services rendered by an individual or entity that is: excluded or ineligible to participate in federal healthcare programs; suspended or debarred from federal government contracts; or who has been convicted of a criminal offense related to the provision of healthcare items or services and has not been reinstated in a federal healthcare program after a period of exclusion, suspension, debarment, or ineligibility. A thorough search of the Department of Health and Human Services’ Office of Inspector General and the U.S General Services Administration’s exclusion list is conducted to ensure compliance with this standard. If an employee becomes aware of an ineligibility action, he or she shall report the issue to the Compliance Officer, Legal Services, or Human Resources. If an employee joins our staff from the federal government or a Fiscal Intermediary, we will ensure the person is not impacted by regulations restricting his or her recruitment and hiring.

A Pledge to Be Professionally Responsible

Physical Assets

We strive to make prudent, effective use of the Hospital’s resources, including time, materials, supplies, equipment, capital, space, and information. As a general rule, the personal use of Hospital resources is prohibited without prior Management approval. Everyone is responsible to ensure that we do not improperly and unreasonably use documents, telephones, computers, copiers, equipment, or Hospital licensed computer programs (e.g., access to inappropriate websites) for personal purposes. Employees may not use supplies or equipment for personal purposes or remove them from the premises, even just to “borrow” them. Occasional use of facilities and telephones, where the cost is insignificant, is permissible, but limited. To ensure compliance with duties regarding the use of Hospital assets, periodic audits will be conducted, sometimes without notice, and may result in disciplinary action, up to and including termination.

We strive to protect the organization’s assets from loss, damage, carelessness, misuse, and theft. Our computers and sensitive documents are password protected and/or protected behind physical barriers. Employees will not discuss sensitive, confidential matters over cellular phones or in public areas. Employees will screen files and downloads to ensure that they are free from viruses and hackers’ intentions. Employees will secure assets when they are not in use to prevent any misappropriation.

Travel and entertainment expenses should be consistent with the employee’s job responsibilities and the Hospital’s needs and resources. Employees may not have an interest in or speculate in

products or real estate, the value of which may be affected by the Hospital’s business. Employees may not divulge the Hospital’s confidential information such as financial data, payer information, computer programs, and patient information, for their own personal or business purposes.

Financial Information

Accuracy, Retention and Disposal of Documents and Records

We are responsible for the accuracy of, and keep complete, clear documents and records. We maintain and comply with internal controls, regulatory and legal requirements, and our policies and procedures. All financial reports, accounting records, research reports, expense accounts, timesheets and other documents must accurately and clearly represent the facts or the true nature of the transaction. All information will be retained according to the law and our records retention policy.

Coding and Billing for Services

We will prepare and submit accurate claims for payment from government payers, commercial insurance payers and patients. Employees will comply with all federal and state laws and regulations concerning proper billing and reimbursement of medical claims. We make every attempt to present claims for payment or approval that are not false, fictitious, exaggerated or fraudulent. We make every effort to ensure that entries in patient records are clear, complete, and accurately reflect the item or service that was provided to the patient. No one may alter or falsify information on any record or document. We strive to ensure that our records do not include guesswork, exaggerations, or miscoding. If an employee changes a record, he or she will note the change as required by our internal policies. If an employee discovers a claim, bill or code that contains a possible error, he or she has an obligation to investigate the potential error and, if possible, correct the error prior to the bill or claim being submitted. If the issue cannot be resolved, employees should report the issue to the proper authority, including Administration or the Compliance Officer.

Financial Reporting and Records

All financial information must reflect actual transactions and conform to generally accepted accounting principles (“GAAP”). We do not hide expenditures, funds, assets or liabilities. All funds and assets must be properly recorded in the books and records of the Hospital. If an employee ever becomes aware of or suspects any potential improprieties regarding accounting, internal controls, or auditing, he or she should report it immediately.

Fraud and Abuse

We must refrain from conduct that may violate the fraud and abuse laws. Abuse is defined as payment for items or services when there is no legal entitlement to that payment and the Hospital, physician, or supplier has not knowingly and/or intentionally misrepresented facts to obtain the payment. Fraud is defined as an intentional deception or misrepresentation, which an individual or entity makes, knowing it to be false, and the deception could result in some, unauthorized benefit.

The Federal False Claims law protects government programs, including Medicare, Medicaid and Tri-Care, from fraud and abuse. These laws prohibit: 1) direct, indirect or disguised payments in exchange for referral of patients; 2) submission of false, fraudulent or misleading claims to any government entity or third party payer, including claims for services not rendered or claims which do not otherwise comply with applicable program or contractual requirements; and 3) making false representations to any person or entity in order to gain or retain participation in a program or to obtain payment for any service. The Federal Deficit Reduction Act of 2005 (“DRA”) provides states with financial incentives for enacting State False Claims laws to protect the individual state’s Medicaid Program from fraud and abuse. Provisions in the DRA specifically provide protection from retaliation to employees who initiate lawful actions under the False Claims and DRA laws. If any possible fraud or abuse situations arise, employees should report the issue to Administration or the Compliance Officer.

Confidential Information

The term “confidential information” refers to proprietary information about the Hospital’s strategies and operations, as well as patient information and third-party information. Improper use or disclosure of confidential information could violate legal and ethical obligations. Employees may use confidential information only as required to perform their job duties and shall not share this information with others unless they have a legitimate need to know the information. Employees must protect the organization’s confidential information, even if they leave the organization. Employees shall not use confidential business information obtained from competitors, including customer lists, price lists, contracts, or other information, in violation of a covenant not to compete, prior employment agreements, or in any other manner likely to provide an unfair advantage to the Hospital. Salary, benefits, and other personal information relating to employees shall be treated as confidential.

Conflict of Interest

A conflict of interest is a situation when outside activities, personal financial interests, or other personal interests hinder, distract, influence, or appear to influence the ability to make objective decisions in the course of employment. Employees have a duty of loyalty to the Hospital and must avoid conflicts of interest. Employees will act to protect the Hospital and its interests by acting in a way that positively represents our endeavors. When a conflict of interest or the appearance of a conflict of interest develops, an employee will immediately disclose the conflict to Management. Written approval by Administration must be acquired before pursuing the activity or obtaining or retaining the interest. Types of activities that might cause conflicts of interest include, but are not limited to: ownership in or employment by an outside concern that does business with or competes with the Hospital; conduct of any business, not on behalf of the Hospital, with any vendor, supplier, contractor or agency or any of their officers or employees; and disclosure or use of confidential, special or inside information of or about the Hospital, particularly for personal profit or advantage.

A Pledge to be Honorable in All That We Do

Yoakum County Hospital is committed to the highest standards of business ethics and integrity and to providing services in compliance with all state and federal laws governing our operations. We will accurately and honestly represent the Hospital and will not engage in any activity or scheme intended to defraud anyone of money, property, or honest services. Employees shall not make false or misleading statements to any patient, person or entity doing business with the Hospital about other patients, persons, entities doing business or competing with the Hospital, or about products or services of the Hospital or its competitors.

Leadership Responsibilities

All employees have the obligation to follow the code of conduct, but the leaders of the Hospital are held to a higher standard and have a special responsibility to set the right tone. We must not sacrifice ethical and compliant behavior for business objectives. We expect everyone with supervisory responsibility to exercise authority in a manner that is kind, sensitive, thoughtful, and respectful. We expect every supervisor to create an environment where all staff feel free to raise concerns and propose ideas, without any fear of retaliation. This includes situations where employees give criticism or raise an uncomfortable question. Management must remember that openness is essential to maintaining a healthy work environment.

No Retaliation

Retaliation is considered a serious violation and will not be tolerated. When an individual raises a good faith concern, calls the Compliance Reporting Line, or fully cooperates with an investigation, retaliation against that person is strictly prohibited. Appropriate steps will be taken to protect those who report retaliation. Allegations of retaliation will be promptly investigated and, if supported, will result in disciplinary action, up to and including termination of employment of the individual responsible for the retaliation.

Compliance Program

The Compliance Program is charged with the responsibility of reviewing our compliance policies and acting to resolve/investigate specific compliance situations that may arise. The Hospital’s Compliance Program is led by the designated Compliance Officer elected and supported by the Compliance Committee, which is comprised of senior management. Even though these individuals operate the Compliance Program, each one is part of the Compliance Program and has individual duties and responsibilities. The key elements of the Program include: setting written standards (the Code of Conduct and policies and procedures); conducting education and training to further the knowledge base of the organization; monitoring, auditing, investigating and resolution of compliance issues; providing a mechanism for reporting potential exceptions; ensuring the eligibility of employees and business associates; and maintaining an organizational structure that supports the furtherance of the Program.

Reporting Compliance Issues

When an employee becomes aware of an issue that appears inconsistent with the ethics and values of the Hospital, the employee is encouraged to call the Compliance Reporting Line. Calls to the Compliance Reporting Line allow individuals to confidentially disclose information to someone who is not part of the reporting structure of the Hospital. Any caller to the Compliance Reporting Line has the option to remain anonymous. However, sometimes the only way for an investigation to proceed is if the caller provides details specific to the incident, such as department, location, and in limited circumstances, the caller’s name. When requested, strict confidentiality of the caller’s identity will be maintained to the extent allowed by law. Access to the Compliance Reporting Line is available 24 hours a day, 7 days a week by calling the following number: (806) 592-0202

When the Compliance Reporting Line is not utilized, but you wish to contact the Compliance Officer, please contact him or her as follows:

Via Mail:

Compliance Officer Yoakum County Hospital 412 Mustang Avenue Denver City, TX 79323

Via Fax: (806) 592-2020

Any time an employee does not understand something or has a concern, the employee needs to question others for accurate answers. Often, the best person to contact when questions arise concerning appropriate actions is your department Director or Manager. If the Director or Manager is unavailable or is inappropriate to question, then turn to the other resources of the Hospital, such as Administration, the Compliance Officer, the Compliance Reporting Line, members of the Compliance Committee, or Human Resources. The important thing is not so much where you obtain help, but that you do seek help.

As misconduct or perceived misconduct is observed, it is each employee’s responsibility to report the issues to the proper members of the Hospital. Any violations of laws, regulations, or our policies and procedures will be disciplined in the proper manner with appropriate authorities. Discipline may also result for those who knew about the issue but failed to report it. The Hospital will use increasing levels of discipline, up to termination, depending on the severity of the violation. All reports of potential violations must be made in good faith. It is unacceptable to falsify facts or spread rumors to get someone else in trouble. This is a form of retaliation and will not be tolerated.

The Compliance Officer, the Compliance Committee, or proper designee, shall investigate all reported allegations. As part of the investigation, we will ensure that each situation shall be given a good faith inquiry into the allegations set forth and that all of the information necessary to 

determine the scope of the incident has been determined. For alleged improper practices, we will adopt corrective actions to prevent further misconduct. As necessary, the Compliance Officer

shall confer with third party legal counsel to determine if credible evidence of misconduct exists. Ongoing and specific-to-risk evaluations will be conducted on a regular and/or “as needed” basis in order to determine that corrective actions are effective and to uncover potential areas of non- compliance.

No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.