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Corporate Compliance

Touro Code of Conduct
Introduction

Touro Infirmary has a long tradition of providing health care services to New Orleans’ many communities based on the moral and ethical principals of Judaism, and is committed to integrity, ethical behavior, and the highest moral conduct from our employees and those who act on our behalf.

This Code of Conduct is intended to provide employees, physicians, volunteers, vendors, and other agents of Touro Infirmary specific guidelines for conducting business and their professional relationships. Each employee is expected to know, understand and abide by the guidelines outlined in this Code of Conduct, so that they are able to provide or support the provision of the highest levels of compassionate, quality health care while complying with all applicable laws, rules, and regulations.

As employees of Touro Infirmary, we understand that the responsibility for ethical behavior rests with each of us, in the decisions we make and the actions we take. We know that our relationships are expected to be professional, compassionate, and caring. We understand that we are expected to advance the best interests of Touro, by preserving its assets, avoiding conflicts of interest, acting in a manner that benefits the hospital, or never compromising its integrity or reputation.

This code provides general information about how Touro Infirmary expects its employees to conduct its business, and does not replace the policies, procedures, or practices of the medical center. However, any employee who may have questions regarding workplace activities and decisions should seek advice from his / her supervisor, a member of the Administrative staff, or the Compliance Officer at 504-897-8338.

Employees may also use Touro Infirmary’s Compliance Hotline at 888-684-3150 to confidentially submit questions or reports related to any issue.

Principles of Conducting Business at Touro Infirmary

Touro Infirmary's patient and business activities number in the thousands each day. While there are strict rules to guard against fraud or dishonesty, the broad values articulated by Touro also serve as guidelines for addressing possible problems that may arise. Therefore at Touro it is understood that:

We Obey the Law

Integrity

At Touro Infirmary, we know that laws may change, but also know we are all expected to be aware of and follow laws that affect the way we do our jobs. When we have any questions about legal issues affecting our jobs, we know we should refer them to our supervisor or to the Compliance Officer at 504-897-8338.

Although Touro Infirmary’s Compliance Officer has the responsibility to investigate all suspected violations of law and regulation and report any illegal actions to the government, every employee also may report suspected behavior directly to Health Services Administration’s Office of the Inspector General without fear of reprisal.

We Provide Quality Patient Care

Welcoming Spirit

We strive to assure that the services provided at Touro Infirmary meet or exceed acceptable standards of both quality and patient safety and are available to those who need them within the limits of Touro’s resources.

We are committed to providing quality healthcare to our patients. We treat our patients with respect and dignity and provide care that is both necessary and appropriate. We make no unlawful distinction in the admission, transfer or discharge of patients or in the care we provide based on race, color, religion or national origin. Clinical care is based on identified patient healthcare needs, not on patient or organization economics.

We also understand that many of us have responsibility for and access to prescription drugs, controlled substances, and other regulated pharmaceuticals, and that the law forbids the distribution of any drug, in any amount or for any reason, to an unauthorized individual or entity.

It is Touro Infirmary's policy that every employee is both diligent and vigilant in carrying out their obligations in regards to prescription drugs in accordance with all applicable laws, regulations and internal policies. Any violation of law or internal policy involving prescription drugs, controlled substances or other pharmaceuticals will constitute grounds for disciplinary action including possible termination.

We Provide Emergency Treatment to All

Welcoming Spirit

We understand that the Emergency Medical Treatment and Active Labor Act (EMTALA), requires us to provide emergency medical screening examination and necessary stabilization to all patients, regardless of their ability to pay, and we do so in a caring manner. We strive to ensure that all who present with an emergency medical condition is treated in an emergency situation or if the patient is in labor. We will not delay the medical screening and necessary stabilizing treatment in order to seek financial and demographic information. We do not admit, discharge or transfer patients with emergency medical conditions simply based on their ability or inability to pay or any other discriminatory factor.

Patients with emergency medical conditions are only transferred to another facility at the patient’s request or if the patient’s medical needs cannot be met at Touro (e.g., we do not have the capacity or capability) and appropriate care is knowingly available at another facility. Patients are only transferred in strict compliance with state and federal EMTALA regulatory and statutory requirements.

We Protect our Patients

Welcoming Spirit

We at Touro consider the care and safety of our patients to be our highest goal and in order to maintain the quality and safety of patient care we understand that suspected patient abuse is to be reported and investigated immediately. Further, we conduct background checks on all applicants and reserve the right to recheck the background of current employees. Each individual being considered for employment will have his / her background reviewed prior to a final employment offer. No individual with a history which endangers our patients, or who is found to be debarred or sanctioned by the Federal Government and therefore ineligible to participate in a federally funded health care program, shall be hired or continue in their employment.

In addition, all agency and temporary staff, together with physicians being considered for staff privileges are expected to adhere to the same standard.

We Are Honest In All Matters Related to Patient Referrals and Patient Billing

Integrity

Existing law specifically prohibits any form of kickback, bribe or rebate that is intended to induce the purchase or referral of any healthcare services or supplies paid for even in part by the Medicare or Medicaid programs. Because it is a crime, employees and other persons acting on behalf of Touro Infirmary, do not intentionally falsify a claim, understanding that such an act is never in our best interest, would tarnish our name and could result in severe sanctions.

No employee of agent of Touro Infirmary should offer or accept any improper payment, gift, or other remuneration, directly or indirectly that is intended to induce the referral of healthcare business or decisions regarding the use of products or services. Because there are strict limits on seemingly minor gifts, any questions related to this issue should be addressed to the Office of Compliance and Internal Audit Services

Thus, all employees involved in any aspect of billing are expected to know, understand and abide by Medicare, Medicaid and other third-party insurer billing rules and requirements. Each employee is expected must use his or her best efforts to prevent errors and report any situations that may violate this principle to the Compliance Officer at 504-897-8338 or to Touro Infirmary’s Compliance Hotline at 888-684-3150.

We Conduct our Business in Accordance with Antitrust Laws

Integrity

We do not engage in any behavior that might be interpreted as interfering with fair competition. We understand that Anti-trust laws are designed to preserve and foster fair and honest competition within our community and we do not seek to create any unfair advantage through dishonest or illegal means.

We are Honest in our Communications and Business Relationships

Integrity

Touro Employees are expected to be honest in your communication with patients and families, attorneys, staff members, auditors and with all of those with whom we do business. We do not make misleading statements about our services or products or those of our competitors, do not copy materials in violation of copyright laws or use any confidential business information obtained unfairly or illegally from a competitor. If you have any questions about whether a gift is appropriate, talk to your supervisor or the Compliance Officer at 504-897-8338.

We Treat our Employees Fairly

Respect, Professionalism and Teamwork

We understand that our employees are the face of Touro Infirmary and strive to treat our employees with fairness and courtesy. It is our policy to comply fully with all applicable wage and hour laws and other statutes regulating the employer-employee relationship and the workplace environment.

We at Touro do not discriminate on the basis of race, color, religion, national origin, age, disability, sexual orientation, or gender in providing services to patients or the public, nor in relation to employment practices. Furthermore, Touro Infirmary prohibits harassment or discrimination of its employees in any form by supervisors, coworkers, customers or vendors.

At Touro we also know that each employee has the duty to treat patients and their families, visitors and other employees with dignity, courtesy and respect.

If you have any questions about the laws governing labor and employee relations matters, please contact the Human Resources Department.


 

We do not engage in Reprisals and Retaliations

Professionalism, Integrity, Teamwork and Respect

Touro has implemented a clear policy related to protecting employees who in good faith report any violation of any federal or state law or any matter that impacts the safety and well being of a patient, visitor or other member of the staff. There will be no retribution for those who report misconduct in good faith, and the identity of the employee making the report will be kept confidential, to the extent possible.

In addition, Touro understands that employees who make such reports to an appropriate agency of the government have the right to be protected from reprisals and retaliations. In the event a Touro Employee makes a good faith report related improper or illegal submission of false or fraudulent claims to state or federal agencies, that individual will be afforded protection as a ‘whistle-blower’.

Any employee who believes that he or she has suffered a reprisal for a good faith claim should either report it to the Compliance Officer at 504-897-8338 or to Touro Infirmary’s Compliance Hotline at 888-684-3150. Any manager, supervisor or employee who is determined to have engaged in retaliatory behavior towards another employee, will be subject to disciplinary actions that may include termination.

We use Touro Infirmary’s Assets Properly

Integrity and Stewardship

We believe that Touro Infirmary’s assets are intended to support the hospital’s mission and must be protected from misuse. Therefore, we do not borrow or use hospital property, facilities or equipment for unapproved purposes.

We understand that information about the business activity of Touro Infirmary is also a valuable business asset, and do not share this information with inappropriate parties who might misunderstand or misuse the information. We recognize that maintaining business records accurately and reliably is as important as ensuring that medical equipment is well maintained and cared for, and therefore follow appropriate proper accounting policies and procedures.

We Strive to Ensure a Healthy and Safe Workplace

Professionalism, Integrity and Stewardship

We understand that it is essential we deal with hazardous materials and infectious waste in a manner that complies with environmental laws and regulations and follow the environmental safety procedures explained in our programs and manuals. Further, we believe that every employee should work in a safe environment and strive to follow the laws and regulations that govern workplace safety and job related hazards.


 

We Behave in a Manner that is Appropriate for a Charitable Organization

Integrity, Stewardship

As a charitable tax-exempt organization, we have a legal and ethical obligation to use our resources in a way that promotes the public good rather than the private or personal interests of any individual. Therefore, we avoid compensation arrangements in excess of fair market value, accurately report payments to appropriate taxing authorities, and file all tax and information returns consistent with applicable laws.

Because all of its assets are used exclusively to further Touro Infirmary’s charitable purposes, these assets may not be used to benefit any individual or person who is in a position to exercise influence over Touro Infirmary’s business concerns.

We Do not Try to Illegally Influence the Political Process

Integrity, Stewardship

At Touro Infirmary, we understand that participation in the political process is one of every American citizen’s most basic rights. Federal laws, however, limit the nature and extent of political participation on the part of organizations such as Touro, and while Touro Infirmary encourages its employees to participate in the political process, none of its resources or facilities is utilized in support of any candidate or position. Touro Infirmary employees who choose to run for political office are expected to do so on their personal time and with their own resources.

As a not-for profit organization Touro Infirmary may not contribute money, property or services to political parties or candidates. Further, while we, as individuals, may choose to make political contributions at our own expense, or decide to participate in political campaigns on our own time, no employee should attempt to influence legislation on behalf of Touro.

We Have Honest and Open Dealings with the Government

Integrity, Professionalism

Touro Infirmary is a participant in the Medicare and various Medicaid programs, all of which are governed by complicated laws and regulations. These laws are strict and much more extensive than those of non-governmental commercial contracts. Violations of these laws and regulations can result in criminal sanctions being imposed, not only on the employees actively involved, but also on the organization for which they work. We understand that it is essential, therefore, that there is strict compliance with all Medicare and Medicaid laws and regulations.

We understand that we have an obligation to report any violations or actions we reasonably believe may be violations of Federal and State laws to the Compliance Officer at 504-897-8338 or to Touro Infirmary’s Compliance Hotline at 888-684-3150. We also know that if we make such a report related to a violation of the Federal or State False Claims Acts, we may be protected as a ‘whistleblower’.


 

We Value Employee Loyalty and Avoid Conflicts Of Interest

Integrity, Teamwork, Professionalism

Touro Infirmary expects its employees to serve the organization with undivided loyalty, and requires that its interests be placed ahead of any individual business or commercial interests. Employees should avoid situations in which a conflict of interest, or the appearance of a conflict, could arise.

If an employee is considering an outside venture or position that might conflict with the interests of Touro Infirmary, the potential conflict must be submitted and approved by the administrative officer of the facility and reviewed by the Office of Compliance and Internal Audit.


 

Other Important Requirements of the Code

Safeguarding Patient Information

Safeguarding the Privacy of Our Patients

Taking care of patients requires Touro employees to gather and manage a great deal of personal information about our patients, and Touro is committed to protecting the privacy and security of the information created as a record of the care and services provided our patients. Touro Infirmary understands that these records are required to provide patients with quality care, and it has a responsibility to protect patients from the misuse of this information. Therefore, Touro expects its employees and business associates to comply with its responsibilities under the law. Employees who disclose, misuse or are careless with the Protected Health Information (PHI) of a patient are subject to disciplinary action, up to and including immediate termination.

How we may use and Disclose Medical Information

Touro employees, healthcare professionals and physicians, and business associates, are permitted to use and disclose Protected Health Information (PHI) in the following ways:

For Treatment: Medical and healthcare personnel may utilize patient information in the treatment of the patient.

For Payment: Patient medical information may be used to bill appropriate third parties for the treatment and services the patient received while a patient.

For Hospital Operations: Touro may use patient information for internal management purposes, such as: Quality Assurance; Utilization Review; and, Peer Review.

For Appointment Reminders: Touro may disclose information related to a scheduled appointment or medical care.

For Treatment Alternatives: Touro may release information in discussion of treatment alternatives with a patient and/or appropriate members of the patient’s family.

Individuals Involved in a Patient’s Care: Touro may release information regarding a patient to members of the patient’s family or friends previously identified as assisting a patient.

As Required by Law: Touro will disclose patient information to other parties as required by law.

In addition, it is recognized that special situations may exist that require the release of a patient’s PHI. Any questions whether the release of information is appropriate should be directed to the Privacy Officer.

Information Owned by Others

Other organizations and individuals have confidential information that they strive to protect, but sometimes disclose for a particular business purpose. If you have access to another party's confidential information, you must prevent the misuse of their information. Never use, copy, or distribute their information, unless you are doing so in accordance with the terms of their agreement with our organization.

This is especially true in acquiring software from others. The terms and conditions of software license agreements such as provisions not to copy or distribute programs, must be strictly followed. Employees should never, under any circumstances, bring in or install personal copies of software from their home or personal computer for use on any computer equipment owned or operated by Touro.

Record Retention/Destruction

Touro is required by law to keep certain types of medical and business records, for defined periods of time. Within your department, you will find a record retention and destruction schedule that you must strictly follow.

In addition, all records must be fully and accurately completed, and should never be falsified. Without accurate information, we can’t fulfill our obligations to our patients, co-workers and vendors, so it is every employee’s responsibility to take great care in dealing with our records.

Government Investigations

Touro has established guidelines on how and when to respond to government inquiries. Any information that an employee discloses without authorization jeopardizes the rights of our patients and puts our organization at risk. Therefore, we must follow prescribed procedures when responding to all government inquiries or investigations.

Employees who are approached in the workplace by any federal or state law enforcement agency or official seeking any information about our organization or any of its agents or employees should call the Compliance Officer before providing any information. In addition, please: (1) obtain the name and affiliation of the person asking for the information before supplying it, (2) maintain a written record of each and every document they are given access too; and (3) keep a detailed record of all telephone contacts made and any information requested and responses given.

Compliance with the Code


Questions and Concerns

The Director of Compliance and Internal Audit has been designated by the Governing Board of Touro as the Compliance Officer responsible for the implementation and ongoing operation of Touro’s Corporate Compliance Program, as well as making sure each employee abides by this Code of Conduct. Employees with questions about this Code should contact the Compliance Officer in person at 504-897-8338, in writing or by calling the compliance hotline at 888-684-3150.

Reporting of Violations

Touro expects all employees to report suspect or questionable conduct to the Compliance Officer or person designated by the Compliance Officer to handle such matters, these reports can be made to 504-897-8338. Employees may also wish to make anonymous reports by calling the compliance hotline at 888-684-3150.

Because failure to report misconduct can in itself be viewed as misconduct, we must strongly encourage the immediate reporting of any action that is questionable. Employees should understand that failure to make reports of illegal or unethical behavior on the part of others may result in disciplinary action against those who fail to report. Any manager or supervisor who receives a report of a potential Code violation must likewise immediately contact the Compliance Officer. There will be no retribution for those who report misconduct in good faith, and the identity of the employee making the report will be kept confidential, to the extent possible.

Investigation of Violations

At Touro, all reported violations of the Code of Conduct, hospital policies or applicable laws are expected to be investigated in a timely manner. Employees are required to cooperate in the investigation of an alleged violation and will be disciplined for not cooperating in any such investigation.

Discipline for Violations

Touro views compliance to the Code of Conduct and the law seriously, and may discipline employees for:

  • any involvement in actions that violate the Code of Conduct, hospital policies, or prevailing laws;
  • failure to report any violation or to cooperate in an investigation;
  • failure to detect, or purposefully overlooking violations of others; or retaliation against anyone who reports possible or actual violations

This disciplinary action may include dismissal, although principles of fairness will apply, including the availability of hearings and other appeal processes established in our policies.

Individual Judgment

Employees are often faced with making critical decisions based on activities in the workplace. Remember to always use good judgment and common sense. If anything within this Code of Conduct goes against your own good judgment, you are encouraged to discuss it with your supervisor or with the Compliance Officer.

Acknowledgment and Certification of Compliance

Touro requires that all employees be provided with their own copy of this Code of Conduct and that they read and sign an acknowledgment form, which states that they have received, read, and understand it. From time to time, this Code will be updated, and employees will receive revised versions and be asked to sign new acknowledgment forms.


 

Touro Infirmary

Compliance Program

CODE OF CONDUCT – EMPLOYEE ACKNOWLEDGMENT

I acknowledge that:

  • I have been advised of Touro Infirmary’s commitment to compliance with all laws, regulations, and guidelines governing federally funded programs.
  • I have received a copy of the compliance program code of conduct and compliance policies and procedures, and I am expected to read, understand, and comply with the code and policies and procedures.
  • The compliance program (compliance policies and legal requirements) has been reviewed and discussed with me, and I have had the opportunity to ask questions about same.
  • I have been informed that strict compliance with the policies and requirements of the compliance program is a condition of my continued employment.
  • I have been advised that I have an obligation to report any potential violation (by anyone) of the compliance program.
  • I have been advised that disciplinary action, up to and including termination, will be taken with me if I am found in violation of these policies or requirements.

The following statements apply to employees in supervisory and managerial positions:

I acknowledge that I have been advised that supervisors/managers may be sanctioned for:

  • Failure to adequately instruct subordinates regarding the compliance program
  • Failure to detect noncompliance with applicable policies and legal requirements, where reasonable diligence on the part of the supervisor/manager would have led to the discovery of any problems or violations
  • Any determination that I have engaged in any reprisal or retaliatory actions against an employee who, in good faith, reports any issue or matter to the Compliance Officer, the Touro Hotline, or any other appropriate individual or party.

_________________________________________ ______________________

Employee Signature Date

_________________________________________

Employee Name (print)

© 2014 Touro. All rights reserved.
Touro Infirmary, 1401 Foucher Street, New Orleans, Louisiana 70115
Phone: 504-897-7011 Pencil
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