Code of Conduct
In order to ensure the provision of quality health care necessary to attain or maintain residents’ highest practicable physical, mental and psychosocial well-being, in full compliance with all applicable laws, Westminster Commons has adopted a Facility Compliance Program. An important component of the Program is a Code of Conduct (referred to as the “Code”), which sets out basic principles that must be followed by the leadership team and employees (collectively referred to as “Personnel”) of Westminster Commons. This Code applies to all business operations and Personnel. Representatives of Westminster Commons who are not considered Personnel, such as any agents or external advisers and consultants, should also be directed to conduct themselves in a manner that is consistent with this Code at any time. The Code describes the values, standards, and expectations that apply to all parts of the operations of Westminster Commons. It defines the relationships that we strive to have with residents, employees, customers, contractors, and the communities in which we work.
A copy of the Code will be distributed to all Personnel. It sets forth general standards applicable to all business and operations. In addition, our Compliance Program maintains a number of more detailed and specific policies covering particular business units or subject matters. These specific policies will be communicated to the Personnel who are particularly affected and who must comply with them in the course of normal business. A current set of such policies is available at the office of Westminster Commons. If you wish to review those policies, please contact your supervisor.
The Code covers a wide variety of areas of conduct, but it is not possible to list all activities that could raise compliance concerns. In many instances, the policies and procedures included in the Facility Compliance Program manual provide detailed guidance on how to handle these “gray” areas. There may be some situations, however, where neither the Code nor the policies and procedures provide the guidance needed to act ethically or legally. In these situations, Personnel should consult a supervisor, manager, or the Compliance Officer to be sure decisions made reflect our values and commitment to compliance.
The Facility Compliance Program and this Code are not intended to and shall not be deemed or construed to provide any rights, contractual or otherwise, to any Personnel or any third parties. Violating the Code is a serious matter that can lead to disciplinary action, up to and including discharge.
Standards of Conduct
- A reputation for integrity and honesty in our business operations is one of our strongest and most valuable assets. A fundamental principle upon which we will operate is full compliance with applicable laws. All business shall be conducted in conformance with sound ethical standards. It is not acceptable to attempt to achieve business goals or results by illegal acts or unethical conduct. To that end, all Personnel shall act in compliance with the requirements of applicable law and this Code and in a sound, ethical manner. All Personnel shall perform their duties in good faith and to the best of their abilities.
- All Personnel shall refrain from any illegal conduct. It is the responsibility of each supervisor and manager to ensure that the Personnel within their supervision are acting ethically and in compliance with applicable law and the Code. All Personnel are responsible for acquiring sufficient knowledge to recognize potential compliance issues applicable to their duties and for appropriately seeking advice regarding such issues. If you are uncertain of the meaning or application of any statute, regulation, or policy, or the legality of a certain practice or activity, seek guidance from your immediate supervisor or the Compliance Officer.
- Westminster Commons is subject to many federal and state laws regarding quality of care. We are committed to providing quality care in the most appropriate setting. All Personnel should strive to provide the best possible care, based on the identified needs of the residents and in the most cost-efficient manner.
- The Compliance Program policies and procedures refer to resident rights. Many residents have impaired or limited decision-making ability. Personnel must be familiar with and inform residents and their families of the rights that residents of long term care facilities are guaranteed under federal and state law and regulations. Personnel should always respect the rights of residents and their families to participate in health care decisions, including the right to consent to or refuse treatment. In certain instances, a resident’s decision may conflict with established policies. In such cases, the issue should be reviewed under the applicable policies and procedures and law.
- Each resident is an individual entitled to dignity, consideration, and respect. Resident abuse or neglect is not tolerated. Personnel are responsible for promptly reporting any instances of observed or suspected abuse, neglect, or exploitation of a resident to a supervisor or to the Compliance Officer, and to otherwise comply with our Elder Abuse Reporting policy.
- We will respond to resident concerns or complaints concerning admission, discharge, and the quality of care. Personnel are responsible for identifying and responding to such complaints or concerns. Any complaints or concerns should be brought to the attention of your immediate supervisor or the Compliance Officer. Complaints and concerns shall be reviewed, investigated, and responded to in a timely manner.
- Personnel shall not use or disclose confidential health or personal information pertaining to residents in any manner that is inconsistent with our Notice of Privacy Practices. Health and personal information shall be maintained and protected in accordance with applicable laws and established policies and procedures.
- Personnel shall not engage in any business practice intended to unlawfully obtain favorable treatment or business from any government entity, physician, resident, vendor, or any other party in a position to provide such treatment or business. The solicitation of tips, gifts, or personal gratuities from residents or vendors is prohibited. The acceptance of small tokens of appreciation, such as candy or flowers, is permitted when given to a unit or department. If you have any doubt as to the appropriateness of a gift, seek the guidance of the Compliance Officer.
- Personnel shall disclose any financial interest, ownership interest, or any other relationship that they (or a member of their immediate family) have with residents, customers, vendors, or competitors.
- Personnel shall not participate in any false billing of residents, government entities, or any other party. All claims submitted to government or third-party payers must be accurate. All business transactions shall be carried out in accordance with management’s general or specific directives. All of the books and records shall be kept in accordance with generally accepted accounting standards or other applicable standards. All transactions, payments, receipts, accounts, and assets shall be completely and accurately recorded on the applicable books and records on a consistent basis. No payment shall be approved or made with the intention or understanding that it will be used for any purpose other than that described in the supporting documentation for the payment. All information recorded and submitted to other persons must not be used to mislead those who receive the information or to conceal anything that is improper.
- Personnel shall not engage in any financial, business, or other activity that competes with the facility business and that may interfere or appear to interfere with the performance of duties or that involves the use of property, facilities, or resources. Personnel shall not use any confidential or proprietary information for their own personal benefit or for the benefit of any other person or entity during or after their time of employment.
- Books and records shall be created, maintained, retained, or destroyed in accordance with established records management policies.
- 13. Personnel shall be completely honest in all dealings with government agencies and representatives. No misrepresentations shall be made, and no false bills or requests for payment or other documents shall be submitted to government agencies or representatives. Personnel certifying the correctness of records submitted to government agencies, including bills or requests for payment, shall have knowledge that the information is accurate and complete before giving such certification. Personnel shall not destroy or alter any information or documents in anticipation of, or in response to, a request for documents by any applicable government agency or from a court of competent jurisdiction.
- All Personnel shall cooperate fully and promptly with appropriate government investigations into possible civil and criminal violations of the law. It is important, however, that in this process we are able to protect the legal rights of the businesses and any personnel. To accomplish these objectives, any governmental inquiries or requests for information, documents, or interviews should be promptly referred to the Compliance Officer. Personnel who participate in government interviews shall give answers that are truthful, complete, and unambiguous.
- Personnel shall not participate in any agreement or understanding (including agreements based upon a course of conduct) with a competitor to illegally fix prices, agree to labor costs, allocate markets, or engage in group boycotts. Before considering any agreements or entering into any discussions with a competitor concerning any of these issues, Personnel shall first speak with their immediate supervisor regarding the matter or obtain the advice of the Compliance Officer.
- 16. All political activities shall be conducted in full compliance with applicable law. No funds or property shall be used for any political contribution or purpose unless first approved by an authorized political action committee. Personnel may make direct contributions of their own money to political candidates and activities, but these contributions will not be reimbursed.
- All Personnel are responsible for ensuring that the work environment is free of discrimination or harassment due to age, race, gender, color, religion, national origin, disability, sexual orientation, or covered veteran status. Any form of sexual harassment, including the creation of a hostile working environment, is completely prohibited.
- The possession, use, transfer, distribution, dispensing, manufacture, or sale of illegal drugs, legal drugs without a valid prescription, drug-related paraphernalia, or alcohol on the premises of Westminster Commons is prohibited. To the extent that any such activity impairs the ability of Personnel to perform their job or adversely affects our reputation or integrity, the activities are prohibited during working and non-working hours, whether on or off-site. We reserve the right to implement drug-testing, searches, and inspections to enforce this policy. Personnel entering the premises of Westminster Commons, for any purpose, are deemed to consent to such searches and inspections.
- Personnel shall participate in scheduled training on the Facility Compliance Program and applicable state and federal laws, regulations, and standards.
Reporting Of Violations
- Illegal acts or improper conduct may subject Westminster Commons to severe civil and criminal penalties, including large fines and being barred from certain types of business. It is therefore very important that any illegal activity or violations of the Code or Compliance Program policies be promptly brought to the attention of the Compliance Officer. In many cases, if illegal acts are discovered and reported to the appropriate governmental authorities, such reporting may result in the imposition of lesser penalties.
- Any Personnel who believes or becomes aware of any violation of this Code or any illegal activity shall promptly report the violation or illegal activity by using the Compliance Hotline (1-866-954-4722) or in person, by phone, or in writing to the Compliance Officer. Information regarding the Compliance Hotline and the Compliance Officer’s contact information is set forth on the Compliance Officer Contact Information Sheet.
- It is a violation of this Code for Personnel not to report a violation of the Code or any illegal activity. If you have a question about whether particular acts or conduct may be illegal or violate the Code, you should contact the Compliance Officer. It is a violation of this Code for Personnel to whom a potential illegal act or violation of the Code is reported not to ensure that the illegal act or violation of the Code comes to the attention of the Compliance Officer.
- Reports of illegal activity or violations of this Code shall be promptly and thoroughly investigated. Personnel must cooperate with these investigations. You must not take any actions to prevent, hinder, or delay discovery and full investigation of illegal acts or violations of this Code. It is a violation of this Code for Personnel to prevent, hinder, or delay discovery and full investigation of illegal acts or violations of this Code.
- No reprisals or disciplinary action will be taken or permitted against Personnel for the good faith reporting of, or cooperating in the investigation of, illegal acts or violations of this Code. It is a violation of this Code for Personnel to punish or conduct reprisals in regard to Personnel who have made a good faith report of, or cooperated in the investigation of, illegal acts or violations of this Code.
- Personnel who violate the Code or commit illegal acts are subject to discipline up to and including dismissal. Personnel who report their own illegal acts or improper conduct, however, will have such self-reporting taken into account in determining the appropriate disciplinary action.
WHAT IF YOU REPORT A CONCERN AND IT TURNS OUT TO BE APPROPRIATE AND LEGAL?
As long as you honestly have a concern, compliance policy prohibits you from being reprimanded or disciplined. As Personnel, you have a responsibility to report suspected problems. In fact, Personnel may be subject to discipline if they are aware of or witness potential misconduct, but do not report it. The only time someone will be disciplined solely for reporting misconduct is if he or she knowingly and intentionally reports something that is false or misleading in order to harm someone else.
WHAT IF SOMEONE ASKS YOU TO DO SOMETHING THAT YOU KNOW IS WRONG?
DO NOT DO IT! No matter who asks you, if you know something is wrong, you must refuse to do it. You must immediately report the request to the Compliance Officer.
DISCIPLINARY ACTIONS FOR FAILURE TO FOLLOW COMPLIANCE POLICIES
An effective compliance program depends upon Personnel fulfilling their duties and responsibilities with respect to the Facility Compliance Program. Periodic job performance evaluations, eligibility for merit salary increases and/or bonuses, and promotional opportunities may take into account contributions toward meeting Facility Compliance Program objectives.
Intentional or reckless non-compliance will subject Personnel to significant disciplinary action. Appropriate disciplinary action in accordance with the Employee Handbook will be commensurate with the specifics of the individual’s failure to follow policies, standards, and applicable statutes and regulations. Disciplinary action will depend upon: (a) the nature of the activity; (b) whether Personnel could reasonably be expected to identify the activity as non-compliant; (c) whether Personnel was in a position to take appropriate corrective action; and/or (d) whether Personnel was unduly influenced to participate in the activity. Disciplinary action may include remedial training, oral warnings, written reprimands, suspension, or even termination.
Consistent with federal law, any Personnel convicted of a crime related to the provision of healthcare will be subject to termination. All Personnel, including new hires prior to employment, will be screened periodically against the Office of Inspector General’s Exclusion Database. Any Personnel who has been excluded from participation in a government healthcare program will be subject to immediate termination.
All Personnel are required to express their compliance concerns. Failure to communicate a known compliance concern through the established reporting mechanism will be considered a failure to comply with the Facility Compliance Program.
It is the intent of this Code to ensure that disciplinary actions will be taken on a fair and equitable basis. To ensure consistency and to monitor the effectiveness of the Facility Compliance Program, every proposed disciplinary action related to the Facility Compliance Program must be reported to the Compliance Officer. Based upon such report, the Compliance Officer will make a recommendation as to the appropriateness of the disciplinary action(s).