Code Of Conduct - Amazon S3 · Code Of Conduct We do not pay for referrals. We accept patient referrals and admissions based solely on the patientʼs clinical needs and our ability

Code Of Conduct

CATHOLICHEALTHSERVICESRevised 11/2018

CATHOLICHEALTHSERVICES

A Letter from the President and Chief Executive Officer

To the Employees of Catholic Health Services

and Affiliated Entities:

The subject of the following pages is corporate compliance, a subject about

which all of us should have strong and aligned views.

As employees of Catholic Health Services and Affiliated Entities ("CHS")

we must hold ourselves to high ethical and legal standards of conduct.

The CHS Corporate Compliance Program guides us on how to manage

specific business activities we engage in every day. It helps define what conduct

is allowed and what conduct is not allowed.

Further, to help steer our actions on a day-to-day basis, we have named a

Corporate Compliance Officer, Thomas J. Piszczatoski. Our Compliance Officer

must be notified as soon as an actual or potential compliance issue is identified

so that she can help answer questions, guide actions, and prevent

noncompliance. You may contact the Compliance Officer by completing and

submitting a Compliance Verification Form; or by contacting her directly at

954-484-1515 . You may also report your concerns anonymously by calling the

Catholic Health Services Corporate Compliance Hot Line at 1-800-785-1436.

Each of us wants to be a part of an organization with high ethical standards.

We can and should be proud of CHS, but we must recognize that it takes even

more effort to build and maintain a good corporate reputation than it does to

provide a good product or service. We need relentless attention to this most

critical task every day.

Joseph M. Catania

President and Chief Executive Officer

CATHOLIC HEALTH SERVICES

Code Of Conduct

TABLE OF CONTENTS

Purpose of Our Code of Conduct ......................................................................... 2

Leadership Responsibilities .................................................................................. 2

Our Fundamental Commitments........................................................................... 2

Relationship to Others .......................................................................................... 3Patients................................................................................................................. 3

Patient Care Rights, Patient InformationAffiliated Physicians.............................................................................................. 4Third-Party Payors................................................................................................ 5

Coding and Billing for Services, Cost ReportsRegulatory Compliance ........................................................................................ 5

Tax Compliance .................................................................................................... 6

Dealing with Accrediting Bodies............................................................................ 6

Business Information and Information Systems ................................................... 7 Accuracy, Retention, and Disposal of Documents and Records .......................... 7

Confidential Information, Electronic Media, Financial Reporting RecordsWorkplace Conduct and Employment Practices................................................... 8

Conflict of Interest, Controlled Substances, Intellectual Property/Copyrights,Diversity and Equal Employment Opportunity, Harassment and Workplace Violence,Health and Safety/Environmental Compliance, Hiring of Former and CurrentGovernment Employees, Ineligible Persons, License and Certification Renewals,Personal Use of CHS Resources, Relationships among CHS Staff, Relationships withSubcontractors, Suppliers, and Educational Institutions, Research Projects/Grants,Drug Free Workplace Program

Marketing Practices ........................................................................................... 13 Antitrust, Gathering Information about Competitors, Marketing and Advertising

Business Courtesies ........................................................................................... 14 General, Receiving Business Courtesies, Extending Business Courtesies to Non-referral Sources, Extending Business Courtesies to possible Referral Sources

Political Activities and Contributions ................................................................... 15

The Corporate Ethics and Compliance Program................................................ 16 Program Structure, Resources for Guidance and Reporting Violations, PersonalObligation to Report, Internal Investigation of Reports, Corrective Action,Discipline, Internal Audit and Other Monitoring, Acknowledgement Process

Questions and Answers ...................................................................................... 18The Corporate Compliance Program, Ethical Behavior Generally, Accuracy,Retention, and Disposal of Documents, Business Courtesies, Conflicts of Interest,Patient information, Personal Use of Organization Resources, Political Activitiesand Contributions

EMPLOYEE ACKNOWLEDGEMENT................................................................. 20

PURPOSE OF OUR CODE OF CONDUCT

Our Code of Conduct provides guidance to all CHS staff and those affiliated withCHS, and assists us in carrying out our daily activities within appropriate ethicaland legal standards. These obligations apply to our relationships with employees,patients, residents, physicians, third-party payors, subcontractors, independentcontractors, vendors, consultants, and one another.

The Code is a critical component of our overall Compliance Program. We havedeveloped the Code to ensure that we meet our ethical standards and comply withapplicable laws and regulations.

The Code is intended to be a statement that is comprehensive and easilyunderstood. In some instances, the Code deals fully with the subject covered. Inmany cases, however, the subject discussed has so much complexity thatadditional guidance is necessary for those directly involved with the particular areato have sufficient direction.

Though we promote the concept of management autonomy at facilities in order tomeet local needs, the policies set forth in this Code are mandatory and must befollowed.

LEADERSHIP RESPONSIBILITIES

While all CHS staff are obligated to follow our Code, we expect our leaders to setthe example, to be in every respect a model. They ensure that those on their teamhave sufficient information to comply with law, regulation, and policy; as well as theresources to resolve ethical dilemmas. They must help to create a culture withinCHS, which promotes the highest standards of ethics and compliance. This culturemust encourage everyone in the organization to raise concerns when they arise.We must never sacrifice ethical and compliant behavior in the pursuit of businessobjectives.

OUR FUNDAMENTAL COMMITMENTS

We affirm the following commitments:

To all: We are committed to adherence to the Ethical and Religious Directives forCatholic Health Care Services in all our endeavors.

To our patients: We are committed to providing quality care that is sensitive,compassionate, promptly delivered, and cost effective.

To our employees: We are committed to a work setting which treats all staff withfairness, dignity, and respect, and affords them an opportunity to grow, to developprofessionally, and to work in a team environment in which all ideas are considered.

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Code Of Conduct

To our third-party payors: We are committed to dealing with our third-party payorsin a way that demonstrates our commitment to contractual obligations and reflectsour shared concern for quality healthcare and bringing efficiency and costeffectiveness to healthcare. We encourage our private third-party payors to adopttheir own set of comparable ethical principles to explicitly recognize their obligationsto patients as well as the need for fairness in dealing with providers.

To our regulators: We are committed to an environment in which compliance rules,regulations, and sound business practices are woven into the organizational culture.We accept the responsibility to aggressively self-govern and monitor adherence tothe requirement of the law and our Code of Conduct.

To the communities we serve: We are committed to understanding the particularneeds of the communities we serve and providing these communities quality, cost-effective healthcare. We realize as an organization that we have a responsibilityto help those in need. We proudly support charitable events in the communitieswe serve in an effort to promote good will and further good causes.

To our suppliers: We are committed to fair competition among prospective suppliersand the sense of responsibility required of a good customer.

To our volunteers: The concept of voluntary assistance to the needs of patients,residents and their families is an integral part of the fabric of healthcare. We arecommitted to ensuring that our volunteers feel a sense of meaningfulness fromtheir volunteer work and receive recognition for their volunteer efforts.

RELATIONSHIP TO OTHERS

Patients

Patient Care RightsOur mission is to provide quality healthcare to all of our patients. We treat patientswith respect and dignity and provide care that is both necessary and appropriate.We make no distinction in the admission, transfer, or discharge of patients or in thecare we provide based on race, color, religion, sex, or national origin. Clinical careis based on identified patient healthcare needs, not on patient or organizationeconomics.

Upon admission, each patient is provided with a written statement of his or herrights. This statement includes the rights of the patient to make decisions regardingmedical care and conforms to all applicable state and Federal laws.

We assure patientsʼ involvement in all aspects of their care and obtain informedconsent for treatment. As applicable, each patient representative is provided witha clear explanation of care including, but not limited to, diagnosis, treatment plan,right to refuse or accept care, care dilemmas, advance directive options, estimatesof treatment costs, and an explanation of the risks and benefits associated with

available treatment options. Patients have the right to request transfers to otherfacilities. In such cases, the patients will be given an explanation of the benefits,risks, and alternatives.

Patients are informed of their right to make advance directives, Patient advancedirectives will be honored within the limits of the law and the organizationʼs missionphilosophy capabilities.

Patients and their representatives will be accorded appropriate confidentiality,privacy, security and protective services, opportunity for resolution of complaints,and pastoral counseling. Any restriction on patientʼs visitors, mail, telephone, orother communications must be evaluated for therapeutic effectiveness and fullyexplained to and agreed upon by the patient or patient representative. Duringprolonged stays in the facility, patients have the right to refuse to perform tasks inor for the facility.

Patients are treated in a manner that preserves their dignity, autonomy, self-esteem,civil rights, and involvement in their own care. CHS staff will receive training aboutpatient rights in order to clearly understand their role in supporting them.

Compassion and care are part of our communities we serve. We strive to providehealth education, health promotion, and illness-prevention programs as part of ourefforts to improve the quality of life of our patients and our communities.

Patient InformationWe collect information about the patientʼs medical condition, history, medication,and family illnesses to provide the best possible care. We realize the sensitivenature of this information and are committed to maintaining its confidentiality, andcomplying with the provisions of the Health Insurance Portability and AccountabilityAct (HIPAA). We do not release or discuss patient-specific information with othersunless to serve the patient or required by law.

CHS staff must never disclose confidential information that violates the privacyrights of our patients. No CHS staff, affiliated physician, or other healthcare partnerhas a right to any patient information other than that necessary to perform his orher job.

Affiliated Physicians

Any business arrangement with a physician must be structured to ensure precisecompliance with legal requirements. Such arrangement must be in writing, mustidentify the specific services to be provided, must contain defined timecommitments and include a compensation rate for the services which is at fairmarket value, and must be approved by CHS Legal Counsel.

In order to ethically and legally meet all standards regarding referrals andadmissions, we will adhere strictly to two primary rules:



Code Of Conduct

We do not pay for referrals. We accept patient referrals and admissions basedsolely on the patientʼs clinical needs and our ability to render the needed services.We do not pay or offer to pay anyone—staff, physicians, other persons—for referralof patients. Violation of this policy may have grave consequences for theorganization and the individuals involved, including civil and criminal penalties, andpossible exclusion from participation in federally funded healthcare programs.

We do not accept payments for referrals that we can make. No CHS staff or anyother person acting on behalf of the organization is permitted to solicit or receiveanything of value, directly or indirectly, in exchange for the referal of patients.Similarly, when making patient referrals to another healthcare provider, we do nottake into account the volume or value of referrals that the provider has made (ormay make) to us.

Third-Party Payors

Coding and Billing for ServicesWe will take great care to assure that all billings to government and to privateinsurance payors reflect truth and accuracy and conform to all pertinent Federaland state laws and regulations. We prohibit any staff or agent of CHS fromknowingly presenting or causing to be presented claims for payment or approval,which are false, fictious, or fraudulent.

Any subcontractors engaged to perform billing or coding services must have thenecessary skills, quality assurance processes, systems, and appropriateprocedures to ensure that all billings for government and commercial insuranceprograms are accurate and complete. CHS prefers to contract with such entitiesthat have adopted their own ethics and compliance programs. Third party billingentities, contractors, and preferred vendors that we consider must be approvedconsistent with the organizational policy on this subject.

Cost ReportsOur business involves reimbursement under government programs which requirethe submission of certain reports of our costs of operation. We will comply withFederal and state laws relating to all cost reports. These laws and regulationsdefine what costs are allowable and outline the appropriate methodologies to claimreimbursement for the cost of services provided to program beneficiaries. Giventheir complexity, all issues related to the completion and settlement of cost reportsmust be communicated through or coordinated with our Vice President of Finance.

REGULATORY COMPLIANCE

CHS provides varied healthcare services in several locations. These servicesgenerally may be provided only pursuant to appropriate Federal, state, and locallaws and regulations. Such laws and regulations may include subjects such ascertificates of need, licenses, permits, accreditation, access to treatment, medicalrecord-keeping, access to medical records and confidentiality, patients rights,

terminal care decision-making, medical staff membership and clinical privileges,and Medicare and Medicaid regulations. The organization is subject to numerousother laws in addition to these healthcare regulations.

We will comply with all applicable laws and regulations. All staff, privilegedpractitioners, and contract service providers must be knowledgeable about andensure compliance with all laws and regulations; and should immediately reportviolations or suspected violations to a supervisor or member of management, theCompliance Verification Line, or the Corporate Compliance Officer.

CHS will be forthright in dealing with any billing inquiries. Requests for informationwill be with complete, factual, and accurate information. We will cooperate with,and be courteous to all government inspectors providing them with the informationto which they are entitled during an inspection.

During a government inspection, you must never conceal, destroy, or alter anydocuments, lie or make misleading statements to the government representative.You should not attempt to cause another staff member to fail to provide accurateinformation or obstruct, mislead, or delay the communication of information orrecords relating to a possible violation of law. Any receipt of an inquiry, a subpoenaor other legal document regarding CHS or its staff from a governmental orregulatory agency should immediately be communicated and referred to yoursupervisor and the Corporate Compliance Officer before responding to the inquiry.

In order to ensure that we fully meet all regulatory obligations, CHS staff must beinformed about stated areas of potential compliance concern. We should be diligentregarding guidance about reviewing systems to ensure their correctness.

CHS will provide its staff with the information and education they need to complyfully with all applicable laws and regulations.

TAX COMPLIANCE

As a not-for-profit, tax-exempt entity, CHS is organized solely for religious,charitable and educational purposes, and has a legal and ethical obligation to actand engage in activities in furtherance of its charitable purpose, and ensure itsresources are used to further the public welfare rather than private interests. CHStherefore will avoid any compensation arrangements below or in excess of fairmarket value.

DEALING WITH ACCREDITING BODIES

CHS will deal with accrediting bodies in a direct, open and honest manner. Noaction should ever be taken in relationships with accrediting bodies that wouldmislead the accrediting agency or its survey teams, either directly or indirectly.



Code Of Conduct

The scope of matters related to accreditation of various bodies is extremelysignificant and broader than the scope of this Code of Conduct. The purpose ofour Code of Conduct is to provide general guidance on subjects of wide interestwithin the organization. Accrediting bodies may be focused on issues both of wideand somewhat more focused interest. In any case, where CHS determines to seekany form of accreditation, obviously all standards of accrediting group are importantand must be followed.

BUSINESS INFORMATION AND INFORMATION SYSTEMS

Accuracy, Retention, and Disposal of Documents and Records

Each CHS staff member is responsible for the integrity and accuracy of ourorganizationʼs documents and records, not only to comply with regulatory and legalrequirements but also to ensure that records are available to defend our businesspractices and actions. No one may alter or falsify information on any record ordocument.

Medical and business documents and records are retained in accordance with thelaw, (i.e.: HIPAA), and our record retention policy. Medical and business documentsinclude paper documents such as letters and memos, computer-based informationsuch as e-mail and stored documents (on sites such as iCloud), or computer fileson disk or tape, and any other medium that contains information about theorganization for its business activities. It is important to retain and destroy recordsappropriately according to our policy. You must not tamper with records, norremove them prior to specified date.

In the event you have received written notice from CHS legal counsel that a legalhold has been placed on certain records, then such records cannot be destroyedand must be retained regardless if the record is timely for destruction in accordancewith our policy, until legal counsel advises you in writing that the legal hold for suchrecords is withdrawn.

Confidential InformationConfidential information about our organizationʼs strategies and operations is avaluable asset. Although you may use confidential information to perform your job,it must not be shared with others outside of CHS or your department unless theindividuals have a legitimate need to know this information which includespersonnel data maintained by the organization, patient lists and clinical information,pricing and cost data, information pertaining to acquisitions, divestitures, affiliationsand mergers, financial data, research data, strategic plans, marketing strategies,techniques, employee lists and data maintained by the organization, supplier andsubcontractor information, and proprietary computer software.

Electronic MediaAll communication systems, electronic mail, internet access, or voice mail are theproperty of the organization and are to be primarily used for business purposes.

Highly limited reasonable personal use of the CHS communications systems ispermitted; however, you should assume that these communications are not private.Patient or confidential information should not be sent through the Internet until suchtime that its confidentiality could be assured.

CHS reserves the right to periodically access, monitor, and disclose the contentsof e-mail, and voicemail messages.

Staff may not use internal communication channels or access to the Internet atwork to post, store, transmit, download, or distribute any threatening; knowingly,recklessly, or maliciously false; or obscene materials including anything constitutingor encouraging a criminal offense, giving rise to civil liability, or otherwise violatingany laws. Additionally, these channels of communication may not be used to sendchain letters, personal broadcast messages, political campaign advocacy, orcopyrighted documents that are not authorized for reproduction; nor are they to beused to conduct a job search or open misaddressed mail.

Staff who abuse our communications systems or use them exclusively for non-business purposes may lose these privileges and be subject to disciplinary action.

Financial Reporting RecordsWe have established and maintained a high standard of accuracy andcompleteness in the documentation and reporting of all records. These recordsserve as a basis for managing our business and are important in meeting ourobligations to patients, staff, suppliers, and others. They are also necessary forcompliance with tax and financial reporting requirements.

All financial information must reflect actual transactions and conform to generallyaccepted accounting principles. No undisclosed or unrecorded funds or assetsmay be established. CHS maintains a system of internal controls to providereasonable assurances that all transactions are executed in accordance withmanagementʼs authorization and are recorded in a manner so as to maintainaccountability of the organizationʼs assets.

WORKPLACE CONDUCT AND EMPLOYMENT PRACTICES

Conflict of InterestA conflict of interest may occur if your outside activities or personal interests, orthose of your immediate family, influence or appear to influence your ability to makeobjective decisions in the course of your job responsibilities. A conflict of interestmay also exist if the demands of any outside activities hinder or distract you fromthe performance of your job or cause you to use CHS resources for other than CHSpurposes. It is your obligation to ensure that you remain free of conflicts of interestin the performance of your responsibilities at CHS. If you have any questions aboutwhether an outside activity might constitute a conflict of interest, you must obtainthe approval of your supervisor before pursuing the activity.



Code Of Conduct

Controlled SubstancesSome of our staff routinely have access to prescription drugs, controlledsubstances, and other medical supplies. Many of these substances are governedand monitored by specific regulatory organizations and must be administered byphysician order only. It is extremely important that these items be handled properlyand only by authorized individuals to minimize risks to us and to patients. If youbecome aware of the diversion of drugs from the organization, you should reportthe incident immediately.

Intellectual Property/CopyrightsAny works of authorship, invention, or other creation created by staff during thescope and course of his or her employment shall be considered the property ofCHS. If any such work created is copyrightable, it will be considered a “Work forHire” under the United States Copyright Act, with CHS being considered to be theauthor and owner of such work.

CHS staff may only make copies of copyrighted materials pursuant to theorganizationʼs policy on such matters.

Diversity and Equal Employment OpportunityOur staff provide us with a wide complement of talents, which contributes greatlyto our success. We are committed to providing an equal opportunity workenvironment where everyone is treated with fairness, dignity and respect. We willcomply with all laws, regulations, and policies related to non-discrimination in all ofour personnel actions. Such actions include hiring, staff reductions, transfers,terminations, evaluations, recruiting, compensation, corrective action, discipline,and promotions.

No one shall discriminate against any individual with respect to any offer, or termof condition of employment. Reasonable accommodations for qualified personswith disabilities will be implemented unless making the accommodation poses anundue hardship or the individual poses a direct threat to the health or safety ofothers in the workplace.

Harassment and Workplace ViolenceEach CHS staff member has the right to work in an environment free of harassment.We will not tolerate harassment by anyone based on the diverse characteristics orcultural backgrounds of those who work with us. Degrading or humiliating jokes,slurs, intimidation, or other harassing conduct is not acceptable in our workplace.

Any form of sexual harassment is strictly prohibited. This prohibition includesunwelcome sexual advances or requests for sexual favors in conjunction withemployment decisions. Moreover, verbal or physical conduct of a sexual naturethat interferes with an individualʼs work performance or creates an intimidating,hostile, or offensive work environment has no place at CHS.

CHS has a zero tolerance for workplace violence. Workplace violence includesrobbery and other commercial crimes, stalking cases, violence directed at others,

terrorism, and hate crimes. As part of our commitment to a safe workplace for ourstaff, we prohibit staff from possessing firearms, other weapons, explosive devices,or other dangerous materials on CHS premises.

Staff who observe or experience any form of harassment or violence must reportthe incident to their supervisor, the Human Resources Department, a member ofmanagement, the Compliance Officer, or the Compliance Verification Line.

Health and Safety/Environmental ComplianceCHS facilities provide its employees with a workplace in accordance with currentguidelines as established by the Occupational Safety and Health Administration(OSHA) and other federal, state and local standards. You should become familiarwith and understand how these policies apply to your specific job responsibilitiesand seek advice from your supervisor or the Safety Officer of any serious workplaceinjury or any situation presenting a danger of injury so that timely corrective actionmay be taken to resolve the issue.

We will comply with all environmental laws and operate each of our facilities withthe necessary permits, approvals, and controls. We will diligently employ the properprocedures with respect to handling and disposal of hazardous and biohazardouswaste, including but not limited to medical waste.

In helping CHS comply with these laws and regulations, employees receive training,(ie.: Hazardous Communication and Bloodborne Pathogens Programs).Immediately alert your supervisor to any situation regarding the discharge of ahazardous substance, improper disposal of medical waste, or any situation whichmay be potentially damaging to the environment or could result in injury.

Hiring of Former and Current Government EmployeesThe recruitment and employment of former or current U.S. government employeesis subject to complex rules which change frequently and vary by employee. Similarrules may apply to current or former state or local government employees orlegislators and members of their immediate families.

If a former government employee or consultant wishes to become employed by oras a consultant to CHS, care should be exercised to insure that the requirementsof conflict of interest laws are not violated. Each situation should be considered onan individual basis and you should consult with the Corporate Human ResourcesDepartment or legal counsel on issues related to recruitment and hiring of formeror current government employees.

Ineligible PersonsIt is the policy of CHS not to contract with, employ, or bill for services rendered byan individual or entity that is suspended, excluded or ineligible from participating infederal healthcare programs. These individuals and companies are not eligible todo business with or be employed by CHS. In order to ensure safeguards, CHSperforms General Service Administration checks and Office of Inspector Generalchecks upon contracting or hiring, and annually as per policy.



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Staff, vendors, contractors, and credentialed practitioners of CHS are required toreport to the Corporate Compliance Officer if he/she/they become suspended,excluded, or ineligible to participate in a federal healthcare program.

License and Certification RenewalsStaff and individuals retained as independent contractors in positions which requireprofessional licenses, certifications, other credentials are responsible formaintaining the current status of their credentials and shall comply at all times withFederal and state requirements applicable to their respective disciplines. To assurecompliance, CHS may require evidence of the individual having a current licenseor credential status.

CHS will not allow any staff or independent contractor to work without valid, currentlicenses or credentials.

Personal Use of CHS ResourcesIt is the responsibility of each CHS staff member to preserve our organizationʼsassets including time, materials, supplies, equipment, and information.Organization assets are to be maintained for business related purposes. As ageneral rule, the personal use of any CHS asset without the prior approval of yoursupervisor is prohibited. The occasional use of items, such as copying machinesor telephones, where the cost to CHS is insignificant, is permissible. Anycommunity or charitable use of organization resources for personal financial gainunrelated to CHS business is prohibited.

Relationships among CHS StaffIn the normal day-to-day functions of an organization like CHS there are issuesthat arise which relate to how people in the organization deal with one another andit is impossible to forsee all of these. If you have a question or concern speak toyour supervisor or department manager.

Relationships with Subcontractors, Suppliers, and Educational InstitutionsWe must manage our subcontractor and supplier relationships in a fair andreasonable manner, consistent with all applicable laws and good businesspractices. We promote competitive procurement to the maximum extentpracticable. Our selection of subcontractors, suppliers, and vendors will be madeon the basis of objective criteria including quality, technical excellence, price,delivery, and adherence to schedules, service, and maintenance of adequatesources of supply. Our purchasing decisions will be made on the suppliersʼ abilityto meet our needs, and not on personal relationships and friendships, or on anygifts or other remuneration offered by the supplier. We will always employ thehighest ethical standards in business practices in source selection, negotiation,determination of contract awards, and the administration of all purchasing activities.We will not communicate to a third-party confidential information given to us by oursuppliers unless directed in writing to do so by the supplier. We will not disclosecontract pricing and information to any outside parties.

CHS may be entitled to rebates, discounts and allowances from suppliers. All suchrebates, discounts and allowances must by approved by CHS management asbeing customary and acceptable, and not an illegal or unethical payment.

All facilities having relationships with an educational institution must have a writtenagreement, which defines both partiesʼ roles and the facilities retention of theresponsibility for the quality of patient care.

Research Projects/GrantsWe follow high ethical standards in any research conducted by our professionalstaff. We do not tolerate intentional research misconduct . Research misconductincludes making up or changing results or copying results from other studies withoutperforming the research.

Any CHS facility or staff engaging in research involving patients must do so withthe approval of an Institutional Review Board (IRB), and consistent with anyapproved protocols and CHS policy.

All patients asked to participate in a research project are given a full explanationof alternative services that might prove beneficial to them. They are also fullyinformed of potential discomforts and are given a full explanation of the risks,expected benefits, and alternatives. The patients are fully informed of theprocedures to be followed, especially those that are experimental in nature. Refusalof a patient to participate in a research study will not compromise their access toservices. Applicable acknowledgement and waivers should be completed.

All personnel applying for or performing research of any type are responsible formaintaining the highest ethical standards in any written or oral communicationsregarding their research projects as well as following appropriate researchguidelines. As in all accounting and financial record keeping, our policy is to submitonly true, accurate, and complete cost related to research grants.

Drug Free Workplace ProgramTo protect the interests of our staff and patients, we are committed to an alcoholand drug-free work environment. All staff must report for work free of the influenceof alcohol and illegal drugs. Reporting to work under the influence of any illegaldrug or alcohol, having an illegal drug in your system, or using, possessing, orselling illegal drugs while on CHS work time or property may result in immediatetermination. We may use drug testing as a means of enforcing this policy.

It is also recognized that individuals may be taking prescriptions drugs, which couldimpair judgement or other skills required in job performance. If you have questionsabout the effect of such medication on your performance, consult with yoursupervisor.

It is also your responsibility to report to the Corporate Compliance Officer any otherCHS staff or affiliated individual whom you believe may be impaired during thecourse of their job performance.



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MARKETING PRACTICES

AntitrustAntitrust laws are designed to create a level playing field in the marketplace and topromote fair competition. These laws could be violated by discussing CHS businesswith a competitor, such as how our prices are set, disclosing the terms of supplierrelationships, allocating markets among competitors, or agreeing with a competitorto refuse to deal with a supplier. Our competitors are other health systems andfacilities in markets where we operate.

At trade association meetings, be alert to potential situations where it may not beappropriate for you to participate in discussions regarding prohibited subjects withour competitors. Prohibited subjects include any aspects of pricing, our services inthe market, key cost such as labor costs, and marketing plans. If a competitor raisesa prohibited subject, end the conversation immediately. Document your refusal toparticipate in the conversation by requesting that your objection be reflected in themeeting minutes and notify your supervisor of the incident.

In general, avoid discussing sensitive topics with competitors or suppliers, unlessyou are proceeding with the advice of legal counsel. You must also not provide anyinformation in response to oral or written inquiry concerning an antitrust matter.

Gathering Information about CompetitorsIt is not unusual to obtain information about other organizations, including ourcompetitors, through legal and ethical means such as public documents, publicpresentations, journal and magazine articles, and other published and spokeninformation. However, it is not acceptable for you to obtain proprietary or confidentialinformation about a competitor through illegal means. It is also not acceptable toseek proprietary or confidential information when doing so would require anyoneto violate a contractual agreement, such as a confidentiality agreement with a prioremployer.

Marketing and AdvertisingWe may use marketing and advertising activities to educate the public, provideinformation to the community, increase awareness of our services, and to recruitstaff. We will present only truthful, fully informative, and non-deceptive informationin these materials and announcements. All marketing materials will reflect servicesavailable and the level of licensure and certification.

BUSINESS COURTESIES

General Nothing in this part of the Code of Conduct should be considered in any way as anencouragement to make, solicit, or receive any type of entertainment or gift. Forclarity purposes, please note that these limitations govern activities with thoseoutside of CHS. This section does not pertain to actions between the organizationand its staff nor actions among CHS staff themselves.

Receiving Business CourtesiesWe recognize that there will be times when you may wish to accept from a currentor potential business associate an invitation to attend a social event in order tofurther develop a business relationship. These events must not include expensespaid for any travel costs (other than in a vehicle owned privately or by the hostcompany) or overnight lodging. The cost associated with such an event must bereasonable and appropriate, and apply only to the staff member and not a spouseor other guest. As a general rule, this will mean that the cost will not exceed $100per person.

Sometimes a business associate will extend training and educational opportunitiesthat include travel and overnight accommodations to you at no cost to you or CHS.Similarly, there are some circumstances where you are invited to an event at avendorʼs expense to receive information about new products and services. Priorto accepting any such invitation, you must receive approval from your supervisorto do so consistent with the corporate policy on this subject.

As a CHS staff member, you may accept gifts with total value of $50.00 or less inany one year from any individual or organization who has a business relationshipwith CHS. For purposes of this paragraph, physicians practicing in CHS facilitiesare considered to have such a relationship. Perishable or consumable gifts givento a department or group are not subject to any specific limitation. You may neveraccept cash or cash equivalents, such as gift certificates or tickets to entertainmentevents. Finally, under no circumstances may you solicit a gift.

Extending Business Courtesies to Non-referral SourcesNo portions of this section, “Extending Business Courtesies to Non-referralSources,” applies to any individual who makes, or is in a position to make, referralsto CHS facility.

There may be times when you wish to extend to a current or potential businessassociate (other than someone who may be in a position to make a patient referral)an invitation to attend a social event in order to further or develop your businessrelationship. The purpose of the entertainment must never be to induce anyfavorable business action. During these events, topics of a business nature mustbe discussed and the host must be present. These events must not includeexpenses paid for any travel costs (other than in a vehicle owned privately or bythe host entity) or overnight lodging. The cost associated with such an event mustbe reasonable and appropriate. As a general rule, this will mean that the cost willnot exceed $100 per person. Moreover, such business entertainment with respectto any particular individual must be infrequent, which, as a rule, means not morethan quarterly, and preferably less often.

With regard to the $100 guideline, if circumstances arise where an entertainmentevent was contemplated prior to the event to meet the guideline but unforeseeablyexceeded it, a report to that effect with the relevant details must be filed consistentwith the corporate policy on this subject. If you anticipate an event will exceed $100guideline, you must obtain advance approval as required by corporate policy. That



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policy requires a showing as to the business necessity and appropriateness of theproposed entertainment. The organization will under no circumstances sanctionparticipation in any business entertainment that might be considered lavish.Departures from the $100 guideline are highly discouraged.

Also, CHS facilities will routinely sponsor events with a legitimate business purpose.Provided that such events are for business purposes, reasonable and appropriatemeals and entertainment may be offered. In addition, transportation and lodgingcan be paid for. However, all elements of such events, including these courtesyelements, must be consistent with the corporate policy on such events.

It is critical to avoid the appearance of impropriety when giving gifts to individualswho do business or are seeking to do business with CHS. We will never use giftsor other incentives to improperly influence relationships or business outcomes.Gifts to business associates who are not government employees must not exceed$50 per year per recipient. You may never give cash or cash equivalents, such asgift certificates. The organizational policy on business courtesies may from time totime provide more flexibility in order to permit appropriate recognition of the effortsof those who have spent meaningful amounts of volunteer time on behalf of CHS.

U.S. Federal and state governments have strict rules and laws regarding gifts,meals, and other business courtesies for their employees. CHS policy is to notprovide any gifts, entertainment, meals, or anything else of value to any employeeof the Executive Branch of the Federal government, except for minor refreshmentsin connection with business discussions or promotional items with the CHS orfacility logo valued at no more than $10. With regard to gifts, meals, and otherbusiness courtesies involving any other category of government official oremployee, you must determine the particular rules applying to any such personand carefully follow them.

Extending Business Courtesies to possible Referral SourcesAny entertainment or gift involving physicians or other persons who are in a positionto refer patients to our healthcare facilities must be undertaken in accordance withcorporate policies. We will comply with all Federal laws, regulations, and rulesregarding these practices.

POLITICAL ACTIVITIES AND CONTRIBUTIONS

Law limits the organizationʼs political participation. CHS funds or resources are notto be used to contribute to political campaigns or for gifts or payments to anypolitical party or their affiliated organization. Organization resources includefinancial and non-financial donations such as using work time and telephone tosolicit for a political cause or candidate or the loaning of CHS property for use inthe political campaign. The conduct of any political action committee is to beconsistent with relevant laws and regulations.

It is important to separate personal and corporate political activities in order tocomply with the appropriate rules and regulations relating to lobbying or attemptingto influence government officials. You may, of course, participate in the politicalprocess on your own time and at your own expense. While you are doing so, it isimportant not give the impression that you are speaking on behalf of or representingCHS in these activities. You cannot seek to be reimbursed by CHS for any personalcontribution for such purposes.

THE CORPORATE ETHICS AND COMPLIANCE PROGRAM

Program StructureThe Corporate Compliance Program is intended to demonstrate in the clearestpossible terms the absolute commitment of the organization to the higheststandards of ethics and compliance. That commitment permeates all levels of theorganization. There is an oversight committee of the Board of Directors; aCompliance Committee; and a Compliance Officer. This individual and group areprepared to support you in meeting the standards set forth in the Code.

Senior Management Corporate Compliance Responsibility:• Thomas J. Piszczatoski

CHS senior staff members serve as Corporate Compliance committeemembers and provide their expertise as applicable.

Resources for Guidance and Reporting ViolationsTo obtain guidance on ethics or compliance issues or to report a suspectedviolation, you may choose from several options. We encourage the resolution ofissues at a local level whenever possible. It is an expected good practice, whenyou are comfortable with it and think it appropriate under the circumstances, toraise concerns first with your supervisor.

If it is uncomfortable or inappropriate, another option is to discuss the situation withanother member of management at your facility or in your organization. You arealways free to contact the Compliance Verification Line anonymously at 1-800-785-1436 or complete and submit a Compliance Verification Request Form.

Personal Obligation to ReportWe are committed to ethical and legal conduct that is compliant with all relevantlaws and regulations and to correcting wrongdoing wherever it may occur in theorganization. Each staff member has the responsibility for reporting any activityby any staff, physician, subcontractor, or vendor that appears to violate applicablelaws, rules, regulations, or this Code.

Internal Investigation of ReportsWe are committed to investigate all reported concerns promptly and confidentially.The Corporate Compliance Officer will coordinate any findings from the



Code Of Conduct

investigations and immediately recommend corrective action or changes that needto be made. We expect all staff to cooperate with investigation efforts.

Corrective ActionWhere an internal investigation substantiates a reported violation, it is the policy ofthe organization to initiate corrective action, including, as appropriate, makingprompt restitution of any overpayment amounts, notifying the appropriategovernmental agency, instituting whatever disciplinary action is necessary, andimplementing systematic changes to prevent a similar violation from recurring inthe future at any CHS facility.

DisciplineStaff members violating the Code of Conduct will be subject to disciplinary action.The precise discipline utilized will depend on the nature, severity, and frequency ofthe violation and may result in any of the following disciplinary actions:

• Written Warning/Reprimand• Suspension• Termination• Restitution

Internal Audit and Other Monitoring CHS is committed to the aggressive monitoring of compliance with its policies.Much of this monitoring effort is provided by the CHS staff, which conducts internalreviews of issues that have regulatory or compliance implications. The organizationalso routinely seeks other means of ensuring and demonstrating compliance withlaws, regulations, and CHS policy.

Acknowledgement ProcessCHS requires all staff members to sign an acknowledgement confirming they havereceived the Code of Conduct and understand it represents mandatory policies ofCHS. New staff will be required to sign this acknowledgement as a condition ofemployment.

Adherence to and support of CHSʼ Code of Conduct and participation in relatedactivities and training will be considered in decisions regarding hiring, promotion,and compensation for all candidates and staff.

QUESTIONS AND ANSWERS

The Code of Conduct is not intended to provide answers to every question that you mayhave about CHS policies, laws, or regulations. The following questions and answers areintended to increase your understanding of how the specific guidelines must be applied.

The Corporate Compliance ProgramIf I have a question about workplace conduct or saw something that I thought was wrong,whom should I contact?We have provided several resources for you to turn to with such concerns. Weencourage you to talk to your supervisor first. However, if for any reason you donot feel comfortable talking to your supervisor, you do have other options. You maywish to try to speak with someone else in management at your facility, contact theCompliance Officer, or call the Compliance Verification Line at 1-800-785-1436, orcomplete and submit a Compliance Verification Request Form. We encourage ourstaff to try to resolve matters locally when possible and appropriate.

If I report something suspicious, will I get in trouble if my suspicion turns out to bewrong?As long as you honestly have a concern, our policy prohibits retaliation or yourbeing reprimanded or disciplined. As a CHS staff member, you have a responsibilityto report suspected problems. In fact, staff may be subject to discipline if theywitness something but do not report it to the company. The only time someone willbe disciplined for reporting misconduct is if he or she knowingly and intentionallyreports something that he or she knows to be false or misleading in order to harmsomeone else.

What should I do if my supervisor asks me to do something that I think violates the Codeof Conduct, CHS policy, or is illegal?Donʼt do it. No matter who asks you to do something, if you know it is wrong, youmust refuse to do it . You must also immediately report the request to a level ofmanagement above your supervisor or to the Compliance Verification Line.

Ethical Behavior GenerallyHow do I know if I am on ethical “thin ice?”If you are worried about whether your actions will be discovered, if you feel a senseof uneasiness about what you are doing, or if you are rationalizing your activitieson any basis (as perhaps the belief that “everyone does it”), you are probably onethical “thin ice.” Stop, step back, consider what you are doing, get advice, andredirect your actions to where you know you are doing the right thing.

Accuracy, Retention, and Disposal of DocumentsIn preparation for an accreditation visit, my supervisor has asked me to review medicalrecords and to fill in any missing signatures. May I do this?No. It is absolutely wrong to sign another healthcare providerʼs name in the medicalrecord. It is part of our basic integrity obligation to provide only complete and fullyaccurate information to accrediting groups.



Code Of Conduct

Business CourtesiesA patient with a chronic health condition is frequently admitted to our facility fortreatment. He routinely tips his primary nurse around $100. May the nurse accept it?No. Cash gifts must never be accepted from anyone with whom we have abusiness relationship.

May I accept a basket of fruit or flowers that a patient sent?Yes. Gifts to an entire department may be accepted if they are consumable orperishable.

Conflicts of InterestI am planning a dinner meeting at our facility. My daughter owns a catering service intown. May I pick her catering services if the prices are comparable to other restaurants?No. This may seem unfair, but you must avoid even the appearance of favoritism.

Do the conflict of interest policies apply to distant relatives, such as cousins or in-laws orfriends?The conflict of interest policies generally apply to members of your immediatefamily. However, if any relationship could influence your objectivity or create theappearance of impropriety, you must apply the policies.

Patient informationThere is a physician in our facility who sometimes requests medical records, whether heis taking care of the patient or not. Is he allowed to do this?No. Only the attending, covering, or consulting physicians may have access topatient medical records. We are responsible for protecting the confidentiality ofpatient information from interested third parties as well as our staff. Patients areentitled to expect confidentiality, the protection of their privacy, and the release ofinformation only to authorized parties.

Personal Use of Organization ResourcesCan I type my spouses’ resume on my computer?Possibly. If you use the computer during non-working hours, you may be permittedto type personal documents, Check with your supervisor.

I volunteer for Big Brothers. May I copy a fundraising leaflet?CHS encourages all staff to participate in volunteer activities. Organizationequipment, however, must not be used for charitable or other non-businesspurposes without prior approval from your supervisor.

Political Activities and ContributionsI do volunteer work for a local candidate for office. May I use the copy machine to makeflyers?No. You may not use CHS time or resources to support political activities that areundertaken on a personal basis, as is the case here.

EMPLOYEE ACKNOWLEDGEMENT

This confirms that:

I have received and will read the Catholic Health Services Corporate ComplianceCode of Conduct dated 8/2013 within five (5) working days. If I do not understandany section of the standards, it is my responsibility to receive clarification from mysupervisor, the Human Resources Department or the Corporate ComplianceOfficer.

I further understand that violation and/or non-confirmation with the Code of Conductmay result in disciplinary action up to and including employment termination.

______________________________________ ________________________Employee/Medical Staff member Signature Date of Signature

Please Print Name for Record Clarification

______________________________________
