Hosparus Code of Conduct - Kentucky Association of Hospice

Code of Conduct
Strive for Excellence
✦
Commitment to Integrity
Patient’s granddaughter and Hosparus volunteer shares her story
On the heels of an 11-day hospital stay, Bennie
Martinez knew he wanted to spend his final days
at home with his family. Thanks to Hosparus,
Bennie, a World War II veteran, got his wish. His
granddaughter, Cortney Hersch, says her family was
grateful to have Hosparus’ support at the end of his
life.
“We had lots of questions and concerns about
how to care for my grandfather and Hosparus guided
us throughout the process. His nurse explained
everything to us so we knew what to expect as his
disease progressed,” says Cortney.
She adds, “The Hosparus chaplain made a huge
Tara Zigler (left), Bennie’s granddaughter; Peggy Abbott, his
difference in our lives. She came in and listened to us
daughter; granddaughter, Cortney Hersch and Bennie Martinez
tell stories about my grandfather. She was so genuine
and caring; it meant a lot to us.”
The care and compassion that Bennie, Cortney and their family
received throughout his final stages of life was something that Cortney
will never forget. Because of that, her Hosparus experience didn’t stop
there.
To cope with the loss of her grandfather, Cortney took advantage of
the free counseling sessions offered at the Grief Counseling Center, “It
really helped to talk about my feelings with someone besides family.”
Cortney then took the next step to become a patient care volunteer.
Along with visiting patients in their homes and at the Hosparus
Inpatient Care Center, Cortney is an 11th hour volunteer. In that role,
she spends final hours with patients who don’t have loved ones close by.
“Hosparus plays such a crucial role in the journey of life,” she says.
“The staff, volunteers and programs are second to none. The Hosparus
experience not only provides support and compassion in the loss of a
loved one, it also teaches us to celebrate life and seize each moment.”
Bennie served his country in World War II
Table of Contents
Hosparus Code of Conduct – Strive for Excellence
Letter from Phil Marshall............................................................................................ 2
Hosparus Code of Coduct Overview........................................................................... 3
What is Hosparus’ Commitment to Integrity?
Hosparus Name Origin............................................................................................... 4
Mission....................................................................................................................... 4
Vision......................................................................................................................... 4
CARES Values............................................................................................................. 5
Our Commitments..................................................................................................... 5
Standards of Behavior.................................................................................................. 6
Integrity Inside the Workplace
Rights of Those We Serve (Patients, Clients and Caregivers)........................................ 8
Rights of Those Who Serve (Staff, Volunteers and Vendors)........................................ 9
Compliance with Laws and Regulations.................................................................... 10
Protecting Corporate Resources................................................................................. 12
Integrity Outside the Workplace
Gifts, Gratuities......................................................................................................... 13
Conflicts of Interest................................................................................................... 13
Social and Electronic Media...................................................................................... 14
Certificate of Compliance
Please acknowledge and return signed Certificate of Compliance............................. 19
Hosparus Code of Conduct | 1
Hosparus Code of Conduct –
Strive for Excellence
A message from our
President and Chief Executive Officer
The Hosparus Code of Conduct outlines various practices and standards that govern our
organization, staff and volunteers. As we strive to become the premier model for end-of-life care,
abiding by the law is more than just following the rules – it’s our commitment to providing the type of
care we would want for our own families. Patients and families trust us to provide care that is second
to none and our community has come to expect this level of service from Hosparus.
I ask each of you to review our Code of Conduct to gain a thorough understanding and apply its
principles daily as a representative of Hosparus. Within this document, you’ll find our Standards of
Behavior, CARES Values and valuable information such as how we protect our patients’ privacy and
real life examples of ethical behavior in action. The Hosparus Code of Conduct ensures our practices
are ethical and fair. It is a roadmap that guides us just as we guide our patients and families.
If you have questions regarding this document, we want to hear from you. Please contact the
senior director of compliance, at seniordirectorofcompliance@hosparus.org or 502-719-4194.
Thank you for your commitment to serving our patients and families with integrity.
Phil Marshall
President & Chief Executive Officer
2 | Hosparus Code of Conduct
Code of Conduct Overview
Hosparus is a dynamic organization that demonstrates compassion and provides
quality care for our patients and their families. As employees, volunteers, board members
and contractors/vendors, we embrace the Standards of Behavior and CARES values. The
Hosparus Code of Conduct further illustrates our commitment to strive for excellence
and maintain integrity in all environments.
As a healthcare organization, Hosparus is governed by an abundance of laws,
regulations and statutes. As integral parts of our organization, we are each individually
responsible for ensuring our actions are both legal and ethical. It is our responsibility
to act with integrity at all times. Integrity is characterized as honorable, pure, sincere,
honest, virtuous and reliable. It is our obligation to exemplify our CARES values and act
with integrity in all settings. By doing so, our vision to be the premier model for end-oflife care becomes our reality.
While it is not possible to identify all situations that may arise at any given point, the
Hosparus Code of Conduct is the foundation for ethical decision making and behavior.
The Hosparus policies and procedures will serve to provide more detailed guidelines
regarding our operational processes. To ensure all decisions are made to reflect Hosparus’
values and commitment to compliance, you may seek additional guidance from your
manager, director, vice president, or the senior director of compliance. You also may call
The Compliance Line at 866-842-7172.
Hosparus Code of Conduct | 3
What is Hosparus’
Commitment to Integrity?
Hosp: host, guest
Name Origin
Par: guide, prepare
Us: We
We guide our guests.
Mission
Improving the Quality of Life.
Vision
To be the premier model for end-of-life care.
4 | Hosparus Code of Conduct
CARES Values
Compassion
• Accountability
• Respect
• Empowerment
• Service Above and Beyond
•
Our Commitments
Honor Differences
• Open to Coaching and Learning
• Service Excellence that is Patient Centered
• Provide Quality Care, Comfort and Counseling
• A Work Community that Sustains and Enriches
• Respect Boundaries
• Understand and Respond to Unique Needs of Families
• Strive to Exceed Expectations
•
Hosparus Code of Conduct | 5
Standards of Behavior
Accountability/Integrity
I will…
• be honest, sincere and take responsibility for my actions
• give excellent care/service at all times to patients, families, referral sources and community partners
• follow Hosparus’ confidentiality and security policies
• demonstrate open communication to build trust
• meet established deadlines or follow-up with appropriate individuals, prior to the deadline, when
the time frame cannot be met
• be on time, maintain regular attendance and be flexible to meet the needs of my department and team
Attitude
I will…
• have a friendly attitude, make eye contact and respond with sensitivity and understanding
• cultivate an attitude of support and encouragement for my team, department and organization
• be solutions oriented
• avoid gossip and spreading negativity to others
• give support and encouragement to others
• be flexible, open to change and maintain a wholesome sense of humor
Communications
I will…
• acknowledge patients and families, introduce myself, explain my purpose, planned duration of visit and
express appreciation as appropriate
• provide clear financial and medical information to patients and families
• make sure patients and their families understand the medical terminology used when providing information
• provide direct, respectful and accurate information to clients and co-workers
• end each conversation with a recap of visit details and a plan of future visits
• communicate with all appropriate personnel when visiting another facility and document those contacts
• answer all questions directed to me and, when unable, clearly explain what follow-up may be anticipated
• allow each person to make his/her point or express frustration without interruptions, distractions
or taking things personally
• not hesitate to ask questions when in doubt
• wear my ID badge where it is clearly visible
• answer calls from our published lines within 3 rings in a professional manner,
e.g., “Hosparus, this is ______, how may I help you?”
• check email and voice mail at the beginning and end of each workday
• take responsibility for reviewing all communicated information
• provide timely and accurate documentation
6 | Hosparus Code of Conduct
Professionalism
I will…
• respond to referrals or the needs of patients
without regard to the time of day or location of
the individual
• promote the qualifications of other staff and
volunteers
• avoid distracting or disrupting others while they
are working
• communicate with my supervisor/team leader
when a delay occurs or if I am going to be late
• set priorities and organize my work in a manner
that promotes good stewardship
• take responsibility to grow professionally and
personally
• dress in a clean and neat manner according to Hosparus’ policy
• not wear perfumes or cologne
• maintain healthy boundaries
Respect
I will…
• use language that is not demeaning to anyone’s race, color, religion, sex, national origin, age, disability,
veteran status, sexual orientation, and gender identity
• demonstrate respect for co-workers by actively listening, avoiding assumptions and premature conclusions
• maintain a healthy balance between work and home life for the benefit of those I serve and myself
• ask permission of patients and families, with regard to touch, time and space
• be respectful of co-workers and our community partners by asking permission to access resources
• practice the principle of “treating others as you want to be treated” in relationships within the organization
and with those we serve
• actively involve others in decisions that impact them
Hosparus Code of Conduct | 7
Integrity
Inside the Workplace
Rights of Those We Serve
(Patients, Clients and Caregivers)
One of the ways we can exemplify integrity while performing duties on behalf of Hosparus is by observing
and protecting the rights of those we serve. As advocates, we must ensure individuals have the right to:

Access care, regardless of race, color, religion, sex, national origin, age, disability, veteran status, sexual
orientation, and gender identity

Be treated with dignity, consideration and respect

Be fully informed of the care and services that will be provided by Hosparus and be given the opportunity
to choose or refuse such care and services

Receive information and assistance with advance directives

Be free to complain or recommend changes in Hosparus’ policies and services without fear of negative
consequences

Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of an
unknown source and misappropriation of property
Q: I am a CNA and I noticed one of my nursing facility patients
has an unexplained bruise. I notified the nursing facility staff. Is
there anything else I need to do?
A: Hosparus has an obligation to promote the safety and welfare of its
patients. Anytime you suspect a patient could be the victim of abuse,
work with your immediate supervisor and the senior director of quality
and patient safety to ensure the patient’s safety needs are met.
Q: I am a nurse and one of my patients is questioning whether he
wants to revoke his hospice benefit and seek aggressive treatment of
his terminal illness. It is my professional opinion that he is going
to die and would have better quality of life if he stays in hospice
care but he continues to ask about revocation. What should I do?
A: The patient always has the right to accept or reject treatment,
including hospice care. Always provide the patient with the requested
information so he or she can make an informed decision. Respect the
patient’s decision, even if you disagree with it.
8 | Hosparus Code of Conduct
Rights of Those
Who Serve (Staff,
Volunteers and Vendors)
Our actions affect our co-workers, colleagues
and the overall quality of services provided by
Hosparus. We can have a positive effect on the
Hosparus continuum of services by always treating
others with respect, being accountable for our actions
and confidentially reporting inappropriate behavior.
Being mindful of the diversity of our workforce and
that of our vendors is one of the simplest ways to
contribute to Hosparus’ commitment to fairness and
equity. Other ways to have a positive effect include:

Observing others’ privacy

Refraining from offensive language and activities,
retaliation and harassment

Respecting others’ religious beliefs and cultural
differences

Maintaining boundaries of personal space and
refraining from wearing perfumes, colognes and
items that others might find offensive
Q: I volunteer in a Hosparus department where a vendor
regularly flirts with one of the Hosparus employees. She
seems very uncomfortable but I don’t think she’s brought
it to her supervisor’s attention. Should I do anything?
A: Yes. You should encourage fellow volunteers and
Hosparus employees to report inappropriate behavior
from anyone, including Hosparus employees, volunteers,
vendors, patients, clients and families. In addition, you
should report the behavior to your volunteer supervisor and
the department supervisor. You may be held responsible if
you witness inappropriate behavior and do nothing about it.
Q: A staff member who reports to me regularly “tattles”
that his co-workers do not follow department procedures.
Most of the time, I am able to verify that his suspicions are
valid but I do not think his behavior fosters a teamwork
environment and I find myself constantly investigating
his complaints. Can I ask him to stop focusing on
everyone else and let them do their jobs?
A: All concerns that departmental procedures are not
being followed must be investigated by the department
supervisor(s). An employee or volunteer who comes forward
and reports non-compliance should never be disciplined
for “tattling” or otherwise made to feel they are not being
supported.
Hosparus Code of Conduct | 9
Compliance with
Laws and Regulations
Q: Our team was working to discharge a
patient because we determined he was no
longer eligible for hospice care. The discharge
planning took a little longer than anticipated.
The patient is now due for recertification of
his eligibility. Can our medical director go
ahead and recertify? We will then discharge
once all the plans are completed.
A: No. The medical director cannot recertify
a patient who is no longer eligible. In this
particular instance, we will be reimbursed
only for those days up to the recertification.
Discharge planning should be completed timely
and the patient discharged as soon as possible.
Q: I’m working with a potential patient
who has insurance coverage. However, the
deductible they would have to pay for our
services is quite large. Her spouse lost his
job a few months ago, and they are helping
to support their son who was in a recent
accident and unable to work. I was hoping
we could help this patient by writing off
her deductible but I was told this would be
illegal. Is this true?
A: The Anti-Kickback Statute prevents any
healthcare provider from adjusting off any
balance due because this could be seen as an
arrangement to help increase our referrals.
Healthcare providers may not adjust off
co‑pays, deductibles, co-insurance or any
balance due as a means to assist the patient,
unless the patient qualifies through a financial
assistance process. Hosparus has a financial
assistance policy where patients can apply for
assistance towards their financial responsibility.
For additional information, please contact the
senior director of reimbursement.
10 | Hosparus Code of Conduct
Hosparus, its staff, volunteer, and vendors are all required
to follow certain laws and regulations. Violations of laws and
regulations due to non-compliance can result in penalties assessed
not only to Hosparus, but to YOU as an individual. This could
occur because you either engaged in the activity or you allowed it to
continue by not reporting it.
Just a few of the laws and regulations we must follow are
described below.
False Claims Act
The False Claims Act prohibits knowingly making a false
claim against the government or knowingly using a false record
or statement to obtain payment on a false claim, or conspiring to
defraud the government by getting a false claim paid. Compliance
with this Act requires billing only for services actually rendered that
are medically necessary and properly coded and documented.
Anti-Kickback Statute
The Anti-Kickback Statute governs the referral of patients or
services paid for by the federal government. We are prohibited
from giving, receiving, soliciting or helping to arrange anything of
value as part of the process of obtaining or making referrals.
It is our responsibility to ensure we are compliant with our referral
sources and also to report any concern we may have which illegally
promotes referrals. It is important to know violation of the
Anti‑Kickback Statue can result in a criminal and/or civil offense.
Conditions of Participation
As a participant in the Medicare and Medicaid programs,
Hosparus is responsible for complying with the Conditions of
Participation for Hospices (CoPs). They set forth the standards
for delivering and arranging care for hospice patients and affect
the organization’s ability to fund it services to the community. By
following Hosparus’ policies and procedures, you help ensure we are
in compliance with the CoPs.
HIPAA and HITECH
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) and portions of the Health
Information Technology for Economic and Clinical Health Act (HITECH) require health care providers and
their business associates to safeguard protected health information (PHI), whether paper, electronic or verbal.
It is vital that all individuals authorized to access PHI take appropriate measures to maintain the integrity and
confidentiality of PHI. Appropriate precautions should be taken whenever PHI is being discussed, accessed,
or disclosed, in or outside Hosparus facilities, to avoid a violation that could result in fines, penalties, or
imprisonment. Precautions include but are not limited to keeping your passwords confidential, logging off
systems when you are not using your computer and only disclosing PHI for purposes of treatment, payment,
health care operations or to individuals who have been authorized by the patient, the patient’s legal representative
or the law to receive it.
Q: I accidentally faxed a patient’s
medical records to the wrong
number. What should I do?
A: Contact the recipient of the fax
right away (send a follow-up fax if
you do not know the phone number)
and request that they immediately
shred the documents and send you a
fax confirming the documents were
shredded. Then, notify the senior director of compliance.
Q: I encouraged someone to seek Hosparus’ services and I am curious to see whether they decided to
do so. Is it permissible to query our electronic documentation system or look at other Hosparus records
to see if the person is a patient?
A: No, it is never permissible to verify whether someone is a Hosparus patient unless your role at Hosparus
requires you to do so.
Q: I found a list of patient names in the parking lot at Hosparus. Should I throw it away?
A: No. If you find patient information in an unsecured area of Hosparus, you should promptly deliver it to the
senior director of compliance so we can determine where it came from, how long it was in the unsecured area
and whether anyone else might have seen it. Also, it is never appropriate to throw away any patient information.
If the documentation belongs to you and you no longer need it, you must dispose of it in a shredding receptacle.
Hosparus Code of Conduct | 11
Protecting Corporate Resources
As a 501(c)(3) nonprofit organization, Hosparus often provides much needed, unreimbursed care to patients,
clients and their families. To continue its mission to support the needs of the community, it is essential that we
protect corporate resources, including but not limited to time, supplies and money. We are all stewards of these
resources and must act responsibly to ensure they are safeguarded appropriately.
Q: One of my co-workers often finishes
her duties early and visits with friends in
other departments or shops online. Is
this allowed during her shift since she has
all her work done?
A: When Hosparus employees are on
duty, they are expected to contribute to the
organization in a positive manner. While it
is permissible to engage in certain personal
activities during breaks and lunch, it is not
permissible to spend work hours doing
so, even if the employee’s regular tasks are
complete. The employee should look for
other ways to contribute to Hosparus and
his or her co-workers should discuss any
misuse of work time with a supervisor.
Q: I noticed a volunteer who was using the copier to print flyers for his personal business. Is this
allowed since he is a volunteer? He does so much to promote Hosparus’ mission and I don’t want to get
him in trouble.
A: Hosparus equipment and supplies are not to be used for purposes that do not benefit Hosparus. If you see
an employee or volunteer misusing equipment or supplies, you should notify the senior director of compliance.
12 | Hosparus Code of Conduct
Integrity
Outside the Workplace
As representatives of Hosparus, we are mirror images of the standards, values and principles that
embody the mission of our organization. At all times, even when we’re not at work, we must operate
with integrity.
Gifts
There may be occasions where you are offered a gift, tip,
or gratuity from patients, families, caregivers or others. In
circumstances of this nature, it is appropriate to show sincere
appreciation for their acts of kindness and suggest they use the
Shining Star Program. The Shining Star Program is a means by
which they can make a donation to our organization on behalf of
their care provider. Because of ethical dilemmas that may arise,
Hosparus’ policy prohibits the acceptance of gratuities by its
representatives. Non-monetary gifts valued at less than $50 per
individual may be accepted if it would be offensive to decline the
gift.
There also may be occasions where you feel inclined to provide
a gift to a patient, family, or vendor. This could be misinterpreted
as an inducement to seek our services or to do business with
Hosparus. Gifts should not be made to our patients, family, or
vendors, without the approval of Hosparus management.
Conflicts of Interest
In a society of developing business ventures and social networking, we may find ourselves in
association with a person or entity other than Hosparus that could cause a conflict of interest. This
occurs when you have the ability to significantly influence management or policies at Hosparus and
your outside relationship prevents you from fully pursuing the interests of Hosparus due to separate or
related-party interests. A conflict of interest may relate to you, your spouse, family members, business
interests and/or other associates.
It is not unethical or illegal to have a conflict of interest. Disclosure of a potential conflict will
assist Hosparus in managing it and promoting compliance. We must complete the Conflict of Interest
Questionnaire accurately and completely each year and as new conflicts arise or old conflicts are
resolved.
Hosparus Code of Conduct | 13
Social and Electronic Media
Our affiliation with Hosparus requires us to maintain its integrity
outside our scope of work, including but not limited to our use of
social media, such as Facebook, Twitter or Pinterest. We ask that you
use caution when discussing Hosparus through social media. Please do
not use social media to communicate about or with Hosparus patients
and families. Only secured Hosparus communication channels should
be used for this purpose. If you are unsure about the use of social
media, contact your supervisor or the director of communications at
502-719-8925 or directorofcommunications@hosparus.org.
Q: My parents operate a company
which provides supplies to Hosparus
for our patients. Would this be
considered a conflict of interest? Is
there anything I need to do?
A: A conflict of interest may arise by
an indirect financial interest in another
entity which Hosparus secures goods or
services. The indirect financial interest
could be through your spouse or other
family members, including your parents.
Each year, Hosparus ask its employees
to complete a questionnaire identifying
potential situations which could be a
conflict of interest. You should complete
the questionnaire and explain in detail
the relationship. If any further action is
necessary, your manager or a representative
from the Human Resources Department
will work with you.
14 | Hosparus Code of Conduct
As a staff member, volunteer or vendor of Hosparus, it is your responsibility
to report inappropriate or suspicious activity to your Hosparus supervisor,
senior director of compliance, president and chief executive officer, and/or
The Compliance Line at 866-842-7172, which is operated by an independent,
third-party administrator.
While it is helpful if you identify yourself
when calling The Compliance Line in case there are follow-up questions
about your concern, you do have the option of remaining anonymous.
You
also
may
contact
the
senior
director
of
compliance
at
seniordirectorofcompliance@hosparus.org or 502-719-4194. No matter
what notification method you use, please rest assured that Hosparus strictly
prohibits retaliation against or the harassment of individuals who notify it
of compliance concerns.
Hosparus Code of Conduct | 15
Photo courtesy of The Daily News. Reprinted with permission.
16 | Hosparus Code of Conduct
Notes
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18 | Hosparus Code of Conduct
Certificate of Compliance
Hosparus Code of Conduct
I have read and understand the content, requirements and expectations of the Hosparus Code of Conduct.
I have received a copy of the Code of Conduct and agree to abide by the guidelines while employed at Hosparus.
I understand that failure to abide by the Code of Conduct may lead to disciplinary actions.
I understand that if I have questions, at any time, regarding the Code of Conduct I will consult with my
immediate supervisor or the senior director of compliance.
________________________________________________________________________________________
Employee SignatureDate
________________________________________________________________________________________
Printed NameTitle/Position within the Company
The employee retains the first copy. Employee submits the second copy to Hosparus.
Certificate of Compliance
Hosparus Code of Conduct
I have read and understand the content, requirements and expectations of the Hosparus Code of Conduct.
I have received a copy of the Code of Conduct and agree to abide by the guidelines while employed at Hosparus.
I understand that failure to abide by the Code of Conduct may lead to disciplinary actions.
I understand that if I have questions, at any time, regarding the Code of Conduct I will consult with my
immediate supervisor or the senior director of compliance.
________________________________________________________________________________________
Employee SignatureDate
________________________________________________________________________________________
Printed NameTitle/Position within the Company
The employee retains the first copy. Employee submits the second copy to Hosparus.
18 | Hosparus Code of Conduct
Hosparus Code of Conduct | 1 9