Maxis Health System Standard of Conduct

Standard of Conduct

Letter from the President and Chief Executive Officer

The Mission, Vision and Core Values of the Maxis Health System are incorporated throughout the Standard of Conduct and Corporate Compliance Program. They guide our interactions and are the foundation for the expectations of the Maxis Health System in meeting the rules and regulations that govern the delivery of healthcare. It is important that you familiarize yourself with the content of these and commit to incorporating them into your interactions with all that we serve.

Mission Statement:  The Maxis Health System, a member of Catholic Health East, is a compassionate community of women and men committed to being a transforming, healing presence by providing quality care to those we serve. 

Vision:  Inspired by our Mission and guided by our Core Values, Maxis Health System will achieve excellence in all we do and empower individuals in our community to realize an optimal quality of life. 

Core Values:

• Reverence for Each Person-We believe that each person is a manifestation of the sacredness of human life.
• Community-We demonstrate our concern for each other through inclusive and compassionate relationships.
• Justice-We advocate for a society in which all can realize their full potential and achieve the common good.
• Commitment to Those Who Are Poor-We welcome those whom society ignores.
• Stewardship-We care for and strengthen the ministry and all resources entrusted to us.
• Courage-We dare to take the risks our faith demands of us.
• Integrity-We keep our word and are faithful to who we say we are.

I would like to reinforce the need to embrace these concepts that have been approved by the Maxis Health System Board of Directors, and endorsed by the Sisters, Servants of the Immaculate Heart of Mary.  As we work together to continue our identity as a Catholic Health System, please incorporate this standard of conduct into your daily behaviors and interactions with patients, families, colleagues and business partners.  Thank you.

Sincerely,

Mary Theresa Vautrinot

President and Chief Executive Officer

Maxis Health System

OVERVIEW

Core Values

The core values of Maxis Health System and Catholic Health East are a foundation for all of the work done within the Maxis Health System. These include: reverence for each person, community, justice, commitment, stewardship, courage, courage and integrity.

Purpose of the Code of Conduct

The Code of Conduct is provided to all employees as a foundation for the expectations of the Maxis Health System in meeting the rules and regulations that govern health care.

LEGAL COMPLIANCE

Antitrust

Antitrust laws are designed to create a level playing field in the marketplace and to promote fair competition. These laws could be violated by discussing Maxis Health System business with a competitor, such as how our prices are set, disclosing the terms of supplier relationships, allocating markets among competitors, or agreeing with a competitor to refuse to deal with a supplier. Our competitors are other health systems and facilities in markets where we operate.

At trade association meetings, colleagues must be alert to potential situations where it may not be appropriate to participate in discussions regarding prohibited subjects with competitors. Prohibited subjects include any aspect of pricing, our services in the market, key costs such as labor costs, and marketing plans. If a competitor raises a prohibited subject, colleagues must end the conversation immediately. Colleagues should notify the Compliance Officer and/or Administration of the incident.

In general, colleagues must avoid discussing sensitive topics with competitors or suppliers, unless they are proceeding with the advice of the Compliance Officer and/or legal counsel. Colleagues also must not provide any information in response to an oral or written inquiry concerning an antitrust matter without first consulting the Compliance Officer and/or legal counsel.

Tax

Several Maxis Health System affiliate entities are exempt from federal income tax, state sales tax and certain other taxes as prescribed by law. The Internal Revenue Service (IRS) has designated all entities of the Maxis Health System with the exception of Complete Pharmacy Services, as 501(c) (3) tax-exempt charitable organizations.

Maintenance of tax-exempt status requires that these entities engage in activities in furtherance of their charitable purposes, ensuring that their resources are used in a manner that furthers the public good rather than private or personal interest of any individual(s).  Therefore, you may not engage in any activities that threaten an entity’s tax-exempt status or which involve the use of the entity’s resources or property for any private or political purpose or benefit. All transactions must be in the best interest of the entity and negotiated at fair market value. Your adherence to the Maxis Health System Conflict of Interest Policy is essential to the maintenance of this tax-exempt status. Maxis Health System will make available, as required, all necessary information in support of an entity’s exemption to include, but not limited to, state sales tax exemption forms duly signed and authorized, evidence of exempt status granted by the IRS, etc.

Fraud and Abuse

Providers and suppliers have an obligation, under law, to conform to the requirements of the Medicare program. Fraud and abuse committed against the program may be prosecuted under various provisions of the United States Code and could result in the imposition of restitution, fines, and, in some instances, imprisonment. In addition, there is also a range of administrative sanctions (such as exclusion from participation in the program) and civil monetary penalties that may be imposed when facts and circumstances warrant such action.

Following are definitions and examples of fraud and abuse. These definitions and examples give a better understanding of the types of practices that are forbidden, under law, in the Medicare program.

Definition and Examples of Fraud

Fraud is defined as making false statements or representations of material facts in order to obtain some benefit or payment for which no entitlement would otherwise exist.  These acts may be committed either for the person's own benefit or for the benefit of some other party.  In order to prove that fraud has been committed against the government, it is necessary to prove that fraudulent acts were performed knowingly, willfully, and intentionally.

Examples of fraud include, but are not limited to the following:

Billing for services that were not furnished and/or supplies not provided. This includes billing Medicare for appointments that the patient failed to keep;

• Altering claims forms and/or receipts in order to receive a higher payment amount; Duplicating billings that includes billing both the Medicare program and the beneficiary, Medicaid, or some other insurer in an effort to receive payment greater than allowed; Offering, paying, soliciting, or receiving bribes, kickbacks, or rebates, directly or indirectly, in cash or in kind, in order to induce referrals of patients or the purchase of goods or services that may be paid for by the Medicare program;
• Falsely representing the nature of the services furnished. This encompasses describing a non-covered service in a misleading way that makes it appear as if a covered service was actually furnished;
• Billing a person who has Medicare coverage for services provided to another person not eligible for Medicare coverage;
• Repeatedly violating the participation agreement, assignment agreement, and the Maximum Allowable Actual Charge (MAAC) limits or limitation amount;
• Completing certificates of medical necessity (CMN) for patients not personally and professionally known by the provider;
• Using another person's Medicare card to obtain medical care;
• Giving false information about provider ownership in a clinical laboratory;
• Conspiring to submit or manipulate bills by a provider and a beneficiary, two or more providers and suppliers, or a provider and a carrier employee that results in higher costs or charges to the program;
• Billing procedures over a period of days when all treatment occurred during one visit (e.g., split billing schemes);
• Using the adjustment payment process to generate fraudulent payments; and
• Billing for "gang visits," (e.g., a physician visits a hospital, walks through the facility, and bills for 5 visits without rendering any specific service to the individual patients).

Definition and Examples of Abuse

Abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare program.  Many times abuse appears quite similar to fraud except that it is not possible to establish that abusive acts were committed knowingly, willfully, and intentionally.

Following are three standards that HCFA uses when judging whether abusive acts in billing were committed against the Medicare program:

• Medically necessary;
• Conform to professionally recognized standards; and
• Provided at a fair price.

Examples of abuse include, but are not limited to, the following:

• Charging in excess for services or supplies;
• Providing medically unnecessary services or services that do not meet professionally recognized standards;
• Billing Medicare based on a higher fee schedule than for non-Medicare patients;
• Submitting bills to Medicare that are the responsibility of other insurers under the Medicare secondary payer (MSP) regulation;
• Violating the participating physician/supplier agreement;
• Breaches in the assignment agreement.

Although these types of practices may initially be categorized as abusive in nature, under certain circumstances they may develop into fraud if there is evidence that the subject was knowingly and willfully conducting an abusive practice.

Responsibility for Combating Fraud, Waste, and Abuse

The OIG is responsible for investigating instances of fraud, waste, and abuse in the Medicare and Medicaid programs.  OIG concentrates its efforts in the following areas:

• Conducting investigations of specific providers suspected of fraud, waste, or abuse for purposes of determining whether criminal, civil, or administrative remedies are warranted;
• Conducting audits, special analyses and reviews for purposes of discovering and documenting Medicare and Medicaid policy and procedural weaknesses contributing to fraud, waste, or abuse, and making recommendations for corrections;
• Conducting reviews and special projects to determine the level of effort and performance in health provider fraud and abuse control;
• Participating in a program of external communications to inform the health care community, the Congress, other interested organizations, and the public of OIG's concerns and activities related to health care financing integrity;
• Collecting and analyzing Medicare contractor and State Medicaid agency produced information on resources and results; and
• Participating with other Government agencies and private health insurers in special programs to share techniques and knowledge on preventing health care provider fraud and abuse.

Cost Reports

We are required by Federal and state laws and regulations to submit certain reports of our operating costs and statistics.  We comply with Federal and state laws, regulations, and guidelines relating to all cost reports.  These laws, regulations, and guidelines define what costs are allowable and outline the appropriate methodologies to claim reimbursement for the cost of services provided to program beneficiaries.

The Maxis Health System policy regarding cost reports address cost report compliance and articulate our commitment to provide consistency in the preparation, organization, presentation, and review of cost reports; apply a uniform cost report review process; identify and exclude non-allowable costs; adhere to documentation standards; and use transmittal letters to report protested items and make other appropriate disclosures.  Also, we submit our cost report process to internal audits and maintain a peer review process.

All issues related to the preparation, submission and settlement of cost reports must be performed by or coordinated with our Finance Department.

Political Activity and Contribution

The organization and its representatives comply with all Federal, state, and local laws governing participation in government relations and political activities. Further, Maxis Health System funds or resources are not contributed directly to individual political campaigns, political parties, or other organizations which intend to use the funds primarily for political campaign objectives. Organization resources include financial and non-financial donations such as using work time and telephones to solicit for a political cause or candidate or the loaning of Maxis Health System property for use in the political campaign. The conduct of any political action committee is to be consistent with relevant laws and regulations. In addition, political action committees associated with the organization select candidates to support based on the overall ability of the candidate to render meaningful public service. The organization does not select candidates to support as a reflection of expected support of the candidate on any specific issue.

The organization engages in public policy debate only in a limited number of instances where it has special expertise that can inform the public policy formulation process. When the organization is directly impacted by public policy decisions, it may provide relevant, factual information about the impact of such decisions on the private sector. In articulating positions, the organization only takes positions that it believes can be shown to be in the larger public interest. The organization encourages trade associations with which it is associated to do the same.

It is important to separate personal and corporate political activities in order to comply with the appropriate rules and regulations relating to lobbying or attempting to influence government officials. No use of corporate resources, including e-mail, is appropriate for personally engaging in political activity. A colleague may, of course, participate in the political process on his or her own time and at his or her own expense. While doing so, it is important Maxis Health System colleagues not give the impression they are speaking on behalf of or representing Maxis Health System in these activities. Colleagues cannot seek to be reimbursed by Maxis Health System for any personal contributions for such purposes.  

At times, Maxis Health System may ask colleagues to make personal contact with government officials or to write letters to present our position on specific issues. In addition, it is a part of the role of some Maxis Health System management to interface on a regular basis with government officials. If a colleague is making these communications on behalf of the organization, he or she must be certain to be familiar with any regulatory constraints and observe them.

Guidance is always available from the Corporate Government Relations and Legal Departments of Catholic Health East Corporate Office as necessary.

Discrimination

Maxis Health System actively promotes diversity in its workforce at all levels of the organization. We are committed to providing an inclusive work environment where everyone is treated with fairness, dignity, and respect. We will make ourselves accountable to one another for the manner in which we treat one another and for the manner in which people around us are treated. We are committed to recruit and retain a diverse staff reflective of the patients and communities we serve. We regard laws, regulations and policies relating to diversity as a minimum standard.  We strive to create and maintain a setting in which we celebrate cultural and other differences and consider them strengths of the organization.

Maxis Health System is an equal opportunity workforce and no one shall discriminate against any individual with regard to race, color, religion, sex, national origin, age, disability, sexual orientation, or veteran status with respect to any offer, or term or condition, of employment. We make reasonable accommodations to the known physical and mental limitations of qualified individuals with disabilities.

Harassment and Workplace Violence

Each Maxis Health System colleague has the right to work in an environment free of harassment and disruptive behavior. We do not tolerate harassment by anyone based on the diverse characteristics or cultural backgrounds of those who work with us. Degrading or humiliating jokes, slurs, intimidation, or other harassing conduct is not acceptable in our workplace.

Sexual harassment is prohibited. This prohibition includes unwelcome sexual advances or requests for sexual favors in conjunction with employment decisions. Moreover, verbal or physical conduct of a sexual nature that interferes with an individual’s work performance or creates an intimidating, hostile, or offensive work environment has no place at Maxis Health System.

Health and Safety

All Maxis Health System facilities comply with all government regulations and rules, Maxis Health System policies, and required facility practices that promote the protection of workplace health and safety. Our policies have been developed to protect our colleagues from potential workplace hazards. Colleagues must become familiar with and understand how these policies apply to their specific job responsibilities and seek advice from their supervisor or the Safety Officer whenever they have a question or concern. It is important that each colleague immediately advise his or her supervisor or the Safety Officer of any serious workplace injury or any situation presenting a danger of injury so timely corrective action may be taken to resolve the issue.

Ineligible Persons

We do not contract with, employ, or bill for services rendered by an individual or entity that is excluded or ineligible to participate in Federal healthcare programs; suspended or debarred from Federal government contracts; or has been convicted of a criminal offense related to the provision of healthcare items or services and has not been reinstated in a Federal healthcare program after a period of exclusion, suspension, debarment, or ineligibility, provided that we are aware of such criminal offense. We routinely search the Department of Health and Human Services’ Office of Inspector General and General Services Administration’s lists of such excluded and ineligible persons. Human Resources, Medical Staff and Corporate Compliance policies address the procedures for timely and thorough review of such lists and appropriate enforcement actions.

Colleagues, vendors, and privileged practitioners at one or more Maxis Health System facilities are required to report to us if they become excluded, debarred, or ineligible to participate in Federal healthcare programs; or have been convicted of a criminal offense related to the provision of healthcare items or services.

BUSINESS ETHICS

Honest Communication/Integrity of Communication

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

Appropriation of Proprietary Information

Each Maxis Health System colleague is responsible for the integrity and accuracy of our organization’s documents and records, not only to comply with regulatory and legal requirements but also to ensure records are available to support our business practices and actions. No one may alter or falsify information on any record or document. Records must never be destroyed in an effort to deny governmental authorities that which may be relevant to a government investigation.

Medical and business documents and records are retained in accordance with the law and our record retention policy, which includes comprehensive retention schedules. Medical and business documents include paper documents such as letters and memos, computer-based information such as e-mail or computer files on disk or tape, and any other medium that contains information about the organization or its business activities.

It is important to retain and destroy records only according to our policy. Maxis Health System colleagues must not tamper with records. No one may remove or destroy records prior to the specified date without first obtaining permission as outlined in the Company records retention policy. Finally, under no circumstances may any Maxis Health System colleague use patient, colleague or any other individual’s or entity’s information to personally benefit (e.g., perpetrate identity theft).

CONFIDENTIALITY

Patients’ Information/HIPAA

We also respect our patients by maintaining their confidentiality.  When patients choose a Maxis Health System entity, they provide us with sensitive personal information.  This can include names, addresses, phone numbers, Social Security numbers, medical diagnoses, family illnesses, prescription histories and other personal information.  In accordance with the federal patient privacy law known as HIPAA (Health Insurance Portability and Accountability Act), we protect this trusted information.  We access and share it with co-workers only when authorized to do so and for the purpose of doing our jobs.  We release information to business partners only in accordance with proper procedures, which usually require the express written consent of the patient.

Patient Records

We make every effort to ensure that entries we make into patient records are clear and complete and reflect exactly the item or service that was provided to the patient. We strive to ensure that our records never include guesswork, exaggerations or miscoding. If we change a record, we note the change in the manner in which our internal policies for amending the medical record require.

 

Proprietary Information

The term “confidential information” refers to proprietary information about our organization’s strategies and operations as well as patient information and third party information. Improper use or disclosure of confidential information could violate legal and ethical obligations. Maxis Health System colleagues may use confidential information only to perform their job responsibilities and shall not share such information with others unless the individuals and/or entities have a legitimate need to know the information in order to perform their specific job duties or carry out a contractual business relationship, provided disclosure is not prohibited by law or regulation. Confidential information covers virtually anything related to Maxis Health System’s operations that is not publicly known, such as personnel data maintained by the organization; patient lists and clinical information; patient financial information; passwords; pricing and cost data; information pertaining to acquisitions, divestitures, affiliations and mergers; financial data; details regarding Federal, state, and local tax examinations of the organization or its joint venture partners; research data; strategic plans; marketing strategies and techniques; supplier and subcontractor information; and other proprietary information.

Because so much of our clinical and business information is generated and contained within our computer systems, it is essential that each Maxis Health System colleague protect our computer systems and the information contained in them by not sharing passwords and by reviewing and adhering to our information security policies and guidance.

Personnel Action/Decisions

If an individual’s employment or contractual relationship with Maxis Health System ends for any reason, the individual is still bound to maintain the confidentiality of information viewed, received or used during the employment or contractual business relationship with Maxis Health System. This provision does not restrict the right of a colleague to disclose, if he or she wishes, information about his or her own compensation, benefits, or terms and conditions of employment. Copies of confidential information in an employee’s or contractor’s possession shall be left with Maxis Health System at the end of the employment or contractual relationship.

Conflict of Interest

Your conduct should be in a manner that is free from unlawful or otherwise inappropriate offers or solicitations of gifts and favors or other improper inducements in exchange for influence or assistance. Refer to the corporate compliance policy “Relationships with Vendors, Contractors, and Third Parties” for guidance in this area.

Business Relationships - General

This part of the Code of Conduct should not be considered in any way as an encouragement to make, solicit, or receive any type of entertainment or gift.  For clarity purposes, please note that these limitations govern activities with those outside of Maxis Health System. This section does not pertain to actions between Maxis Health System and its colleagues or actions among Maxis Health System colleagues themselves.

Protection of Assets

We protect our assets and the assets of others entrusted to us, including physical and intellectual property, and protect information against loss, theft or misuse.

We establish policies, practices and educational mechanisms within our areas of responsibility to ensure the safeguarding of assets, the accuracy of financial statements and all other records and reports.

We use property appropriately, with approval and take measures to prevent any unexpected loss of equipment, supplies, materials or services and adhere to established policies regarding approval for disposing of properties.

We report time and attendance accurately.

Expenses are consistent with and justified by our job responsibilities and the organization’s policies, procedures and required needs.

We adhere to established policies and procedures governing record management and comply with the record retention and destruction policies/schedules for our departments.

Workshops, Seminars and Training Sessions

Payment for workshops, seminars, and training sessions may not violated the business courtesies policies.

PROTECTION OF ASSETS

Internal Controls

Internal controls with Finance and Human Resources are maintained to protect the monies of the Maxis Health System. This includes controls within payroll for receipt of blank checks for use and signatures of directors or vice presidents for reimbursements.

Financial Report

Financial reports are reviewed by an independent auditor according to regulations. There is an annual report from the independent auditor to the governing board at least annually.

Travel and Entertainment

Travel and entertainment will not violate the business courtesies policies.  Travel expenses will be paid only when receipts are provided and the expenses explained as indicated.

Personal Use of Corporate Assets

All materials, pharmaceuticals, medical supplies, office supplies and equipment are property of the Maxis Health System and are not for personal use by any employee

Corporate Theft

Corporate theft will be grounds for termination and legal action as deemed appropriate by the administration.

RELATIONSHIPS WITH PATIENTS, PHYSICIANS AND PAYORS

Patient’s Care Rights

Maxis Health System understands and respects the patients’ right to a reasonable response to request and needs for treatment or service, within Maxis Health System’s capacity, our stated mission, and applicable law and regulations. Employees are expected to abide by the current bill of rights that is distributed to any patient/client within the Maxis Health System.

Maxis Health System’s Patients/clients, or when appropriate the patient’s/client’s legally designated representative, have the right:

To considerate and respectful care:

Care of the patient includes consideration of the psychosocial, spiritual; and cultural variables that influence the perception of illness;

Care of dying patients optimizes the comfort and dignity of the patient;

In collaboration with their physician, to make decisions involving their health care including:

To accept medical care or to refuse treatment to the extent permitted by law and to be informed of the medical consequences of such refusal;

To formulate advance directives and appoint a surrogate to make health care decisions on their behalf to the extent permitted by law;

To the information necessary to enable them to make treatment decisions in accordance with their wishes;

To receive, at the time of admission, information about patient’s/client’s rights policy (ies) and the mechanism for initiation, review and, when possible, resolution of patient/client complaints concerning the quality of care;

To participate in the consideration of ethical issues that arise in the provision of care;

To be informed of any human experimentation, other research or education projects affecting their care;

To have personal privacy and confidentiality of information, within the limits of the law; and

To access the information contained in the patient’s/client’s medical records, within the limits of the law.

Conduct in Service to Patients/Client’s and Families

A patient’s/client’s guardian, next of kin, or legally authorized responsible person, to the extent permitted by law, has the right to exercise rights delineated on the patient’s behalf, if the patient:

Has been adjudicated incompetent in accordance with the law;

Is found by their physician to be medically incapable of understanding the proposed treatment or procedure;

Is unable to communicate their wishes regarding treatment;

Is a minor.

Communication with Patients

Patients/clients, families, and/or visitors sometimes seek medical advice or information from a staff member. Staff members should not offer information about possible cures, remedies, diagnoses, prognoses, or any other facts/options, which could be interpreted as medical advice.  Refer all such requests to the attending or consulting physician.

Patient/Client Care

Patient/client care activities occur throughout the Maxis Health System. These activities are carried out by a variety of staff members and licensed practitioners from various service areas including medical, nursing, pharmacy, dietetics, rehabilitation, and other care disciplines within the behavioral center. Patients/clients may only receive care that has been ordered by a physician or qualified practitioner with established clinical privileges or scope of practice. Given the scope and diversity of service offered by Maxis Health System, we must assure that patient/client care services are provided through the integration and coordination of the various delivery system disciplines. Quality assessment and performance improvement is the responsibility of everyone associated with Maxis health System.

Medical Staff Privileges

Medical staff membership and privileges in Maxis Health System entities are governed by the applicable medical staff bylaws. Individuals associated with the Maxis Health System may not offer or provide physicians with any benefits, compensation or other inducements with the intent of obtaining, or in exchange for, the referral of patients/clients. Maxis Health System shall not enter into any financial relationships with physicians that would violate the prohibitions of the federal Anti-Fraud and Abuse Statutes, physician self-referral prohibitions, Internal Revenue Service rules/regulations or any other related laws.

Patient Medical Records

Patient Medical Records are the only source of information upon which Maxis health System entities can rely for the proper billing of the services and care provided as ordered by the patient’s/client’s physician. Diagnostic or procedural codes and other pertinent medical information included in the chart must adequately support the “medical necessity” for the service and/or care being billed; regardless of whether billed to Medicare, Medicaid or other third party payors. It is essential that the physician consider “medical necessity” when ordering services and/or care for his/her patients/clients. Physicians and other practitioners are required to document medical indications when ordering ancillary services and other information such as secondary conditions being treated, comorbidities, and personal or family history that affects treatment decisions. Maxis Health System entities cannot and will not bill for services and/or care without proper documentation supporting “medical necessity.”

We make no distinction in the availability of services; the admission, transfer or discharge of patients/clients; or in the care we provide based on age, gender, disability, race, color, religion, or national origin. We recognize and respect the diverse backgrounds and cultures of our patients/clients and make every effort to equip our caregivers with the knowledge and resources to respect each patient’s/client’s cultural heritage and needs. We are mindful that the populations in those communities we serve are becoming even more diverse. Accordingly, we are structuring more formal programs to ensure that Maxis Health System colleagues are equipped to meet these articulated commitments for multi-cultural competency in patient care. The hospital respects the patient’s/client’s right to and need for effective communication.

Each patient/client is provided with a written statement of patient/client rights and a notice of privacy practices. These statements include the rights of a patient/client to make decisions regarding medical care, the right to refuse or accept treatment, the right to informed decision-making, and a patient’s/client’s rights related to his or world through her health information maintained by the facility. Such statements conform to all applicable state and Federal laws, including but not limited to the Health Insurance the other Portability and Accountability Act of 1996 (hereinafter referred to as HIPAA).

We seek to involve patients/clients in all aspects of their care, including giving consent for treatment and making healthcare decisions, which may include managing pain effectively, foregoing or withdrawing treatment, and, as appropriate, care at the end of life. The hospital addresses the wishes of the patient/client relating to end of life decisions.

As applicable, each patient/client or patient/client representative is provided with a clear explanation of care including, but not limited to, diagnosis, treatment plan, right to refuse or accept care, care decision dilemmas, advance directive options, estimates of treatment costs, organ donation and procurement, and an explanation of the risks, benefits, and alternatives associated with available treatment options. Patients/clients have the right to request transfers to other facilities. In such cases, the patient/client is given an explanation of the benefits, risks, and alternatives of the transfer.

Patients/clients are provided information regarding their right to make advance directives regarding treatment decisions, financial considerations and the designation of surrogate healthcare decision-makers. Patient/client advance directives or resuscitative measures are honored within the limits of the law and our organization’s policy.

In the promotion and protection of each patient’s/client’s rights, each patient/client and his or her representatives are accorded appropriate confidentiality, privacy, security, advocacy and protective services, opportunity for resolution of complaints, and pastoral care or spiritual care. Patients/clients have the right to an environment that preserves dignity and contributes to positive self-image. Patients/clients are treated in a manner that preserves their dignity, autonomy, self-esteem, civil rights, and involvement in their own care. Maxis Health System facilities maintain processes to support patient rights in a collaborative manner which involves the facility leaders and others. These structures are based on policies and procedures, which make up the framework addressing both patient/client care and organizational ethics issues. These structures include informing each patient or, when appropriate, the patient’s representative of the patient’s rights in advance of furnishing or discontinuing care. Patients/clients receive information about the person(s)/client(s) responsible for their care, treatment and services. Patients/clients and, when appropriate, their families are informed about the outcomes of care, treatment and services that have been provided, including unanticipated outcomes. Patients are also involved as clinically appropriate in resolving dilemmas about care decisions. Facilities maintain processes for prompt resolution of patient grievances which include informing patients who to contact regarding grievances and informing patients regarding the grievance resolution.  The hospital addresses the resolution of complaints from patients and their families. Patients have the right to refuse care, treatment, and services in accordance with the law and regulations. Maxis Health System facilities maintain an ongoing, proactive patient safety effort for the identification of risk to patient safety and the prevention, reporting and reduction of healthcare errors. Maxis Health System colleagues receive training about patient/client rights in order to clearly understand their role in supporting them. We strive to provide health education, health promotion, and illness-prevention programs as part of our efforts to improve the quality of life of our patients and our communities.

Patient Information

We collect information about the patient’s/client’s medical condition, history, medication, and family illnesses to provide quality care. We realize the sensitive nature of this information and are committed to maintaining its confidentiality. Consistent with HIPAA, we do not use, disclose or discuss patient-specific information with others unless it is necessary to serve the patient/client or required by law.

Maxis Health System colleagues must never use or disclose confidential information that violates the privacy rights of our patients. In accordance with our appropriate access and privacy policies and procedures, which reflect HIPAA requirements, no Maxis Health System colleague, affiliated physician, or other healthcare partner has a right to any patient/client information other than that necessary to perform his or her job.

Subject only to emergency exceptions, patients/clients can expect their privacy will be protected and patient specific information will be released only to persons authorized by law or by the patient’s written authorization.

Emergency Treatment

We follow the Emergency Medical Treatment and Active Labor Act (“EMTALA”) in providing an emergency medical screening examination and necessary stabilization to all patients, regardless of ability to pay. Provided we have the capacity and capability, anyone 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 the Maxis Health System facility (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.

Physicians

Maxis Health System is committed to providing a work environment for physicians who practice in our facilities that is excellent in all respects.  We know that members of our medical staffs historically have interacted with those who work in our hospital in a respectful and supportive way.  We appreciate this attitude and know that we can expect it to continue.  We encourage members of our Medical Staffs to be familiar with this Code of Conduct.  There are many portions of this Code of Conduct that pertain to ethical or legal obligations of physicians in hospitals, and this document is likely to be a helpful summary of those obligations for our medical staff members.

Interactions with Physicians

Federal and state laws and regulations govern the relationship between hospitals and physicians who may refer patients to the facilities.  The applicable Federal laws include the Anti-Kickback Law and the Stark Law.  It is important that those colleagues who interact with physicians, particularly regarding making payments to physicians for services rendered, providing space or services to physicians, recruiting physicians to the community, and arranging for physicians to serve in leadership positions in facilities, are aware of the requirements of the laws, regulations, and policies that address relationships between facilities and physicians. Any arrangement with a physician must be structured to ensure compliance with legal requirements, our policies and procedures, and with any operational guidance that has been issued.  Most arrangements must be in writing and approved by legal counsel.  Failure to meet all requirements of these laws and regulations can result in violations of the law and may result in consequences.

Keeping in mind that it is essential to be familiar with the laws, regulations, and policies that govern our interactions with physicians, two overarching principles govern our interactions with physicians:

We do not pay for referrals.  We accept patient/client referrals and admissions based solely on the patient’s Medical needs and our ability to render the needed services.  We do not pay or offer to pay anyone — colleagues, physicians, or other persons or entities — for referral of patients.

We do not accept payments for referrals we make.  No Maxis Health System colleague or any other person acting on behalf of the organization is permitted to solicit or receive anything of value, directly or indirectly, in exchange for the referral of patients.  Similarly, when making patient referrals to another healthcare provider, we do not take into account the volume or value of referrals that the provider has made (or may make) to us.

Extending Business Courtesies and Tokens of Appreciation to Potential Referral Sources

Any entertainment, gift or token of appreciation involving physicians or other persons who are in a position to refer patients to our healthcare facilities must be undertaken in accordance with corporate policies, which have been developed consistent with Federal laws, regulations, and rules regarding these practices.  Maxis Health System colleagues must consult the “Relationships with Vendors, Contractors, and Third Parties” corporate compliance policy prior to extending any business courtesy or token of appreciation to a potential referral source.

Business Information and Information Systems

• Electronic media
• Financial reporting and records

Electronic Media and Security Requirements

All communications systems, including but not limited to computers, electronic mail, Intranet, Internet access, telephones, and voice mail, are the property of the organization and are to be used primarily for business purposes in accordance with electronic communications policies and standards.  Limited reasonable personal use of Maxis Health System communications systems is permitted; however, users should assume these communications are not private.  Users of computer and telephonic systems should presume no expectation of privacy in anything they create, store, send, or receive on the computer and telephonic systems, and the Company reserves the right to monitor and/or access communications usage and content consistent with Company policies and procedures.

Colleagues may not use internal communication channels or access to the Internet at work to post, store, transmit, download, or distribute any threatening materials; knowingly, recklessly, or maliciously false materials; ethnic or other personal slurs; obscene materials; or anything constituting or encouraging a criminal offense, giving rise to civil liability, or otherwise violating any laws.  Also, these channels of communication may not be used to send chain letters, personal broadcast messages, or copyrighted documents that are not authorized for reproduction.

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

Colleagues shall comply with Maxis Health System’s security policies governing use of information systems.  Only assigned user shall be used.  Passwords shall never be shared or disclosed.  Colleagues shall never use tools or techniques to break or exploit Maxis Health System information security measures, or those used by other companies or individuals. Maxis Health System information systems shall not be used to access inappropriate or prohibited websites.

Financial Reporting and Records

We have established and maintain a high standard of accuracy and completeness in documenting, maintaining, and reporting financial information.  This information serves as a basis for managing our business and is important in meeting our obligations to patients, colleagues, shareholders, suppliers, and others.  It is also necessary for compliance with tax and financial reporting requirements.

All financial information must reflect actual transactions and conform to generally-accepted accounting principles.  All funds or assets must be properly recorded in the books and records of the Company.  Maxis Health System maintains a system of internal controls to provide reasonable assurances that all transactions are executed in accordance with management’s authorization and are recorded in a proper manner so as to maintain accountability of the organization’s assets.  We diligently seek to comply with all applicable auditing, accounting and financial disclosure laws, including but not limited to the Securities Exchange Act of 1934 and the Sarbanes-Oxley Act of 2002.  Senior financial officers may receive training and guidance through the outside audit firm regarding auditing, accounting and financial disclosure relevant to their job responsibilities.  They are also provided the opportunity to discuss issues of concern with the Board of Directors’ Resource Committee.  Anyone having concerns regarding questionable accounting or auditing matters should report such matters to the Board of Directors’ Resource Committee by calling the Corporate Compliance Hot Line at 1-800-673-0109.

Intellectual Property Rights and Obligations

Any work of authorship, invention, or other creation (“Development”) created by a colleague during the scope of the colleague’s employment with Maxis Health System shall be considered the property of Maxis Health System, including any patent, trademark, copyright, trade secret or other intellectual property right in the Development.  Whether something is developed during the scope of a colleague’s employment depends on a number of factors, including: the nature of the colleague’s work, whether the Development is related to Maxis Health System’s business, whether the colleague was directed to produce the Development as part of the colleague’s work, whether the colleague utilized Maxis Health System intellectual property or resources at least in part to make the Development, and whether the colleague created the Development while being paid by Maxis Health System. If any Development created is copyrightable, then it will be considered a “Work for Hire” under the United States Copyright Act, with Maxis Health System being considered to be the author and owner of such work.

When creating Developments for Maxis Health System, colleagues shall respect the intellectual property rights of others.  Any works or inventions created by colleagues prior to employment by Maxis Health System shall be disclosed to Maxis Health System upon commencement of employment, and management and legal counsel approval shall be obtained prior to any use of these works or inventions at Maxis Health System.

Government Investigations

There are basically two types of externally conducted investigation:  first, an investigation conducted by an outside third party at the request of and on behalf of the Maxis Health System; second, an investigation conducted by an outside third party at the direction of a regulatory agency or other government entity to determine compliance with state and federal laws, statutes, rules, and regulations as they relate to Maxis Health System activities. Maxis Health System policy requires that you provide full cooperation with those individuals conducting a third party investigation.  In most instances, Maxis Health System has agreed to provide regulatory and government agencies access to relevant data and records as a “condition of participation” in a given program. Maxis Health System has certain legal rights that must be protected in any investigative process, and you must follow all related policies and procedures in your response to subpoenas, search warrants, unannounced site visits, requests for interviews, and any other requests to access Maxis Health System property and information.  Prescribed policies and procedures in this area not only protect the rights of Maxis Health System as an organization but also assure that investigators receive the full cooperation necessary to complete their work. Maxis Health System has a responsibility to protect the integrity and confidentiality, as appropriate, of any and all records under its control.

Administration and Application of Code of Conduct

Resources for Guidance and Reporting Violations

There are numerous communication tools available to everyone associated with the Maxis Health System, for the reporting of violations of the Code of Conduct and Compliance, as well as, suspected violations of federal, state, and local laws, regulations, and statutes. The following will list the recommended methods for reporting any concerns you may have:

You may report concerns directly to:

a. Supervisor;

b. Department Director;

c. Any member of the Senior Management Team;

d. Compliance Officer.

Your report of suspected violations may be made anonymously; however, you are encouraged to work with us in developing some method for follow-up should we have questions or need additional information regarding your report.

RHC Corporate Compliance Hotline -- Information and Number

The Corporate Compliance Hotline Number is 1-800-673-009.

Non-Retaliation for Reporting

Reprisals of any nature against individuals reporting suspected violations will not be tolerated. Retaliation or retribution for reporting suspected violations by any individual including but not limited to Directors, governing board members, administrative staff, Medical Staff, Department Leaders, Managers, Supervisors, staff members, and Volunteers is not only against Maxis Health System policy but in some instances may be a violation of the law.

Internal Investigation of Reports

Internal investigations will be authorized and directed by the Maxis Health System Compliance Officer. All internal investigations will be conducted in a prompt and professional manner. Most internal investigations will require audit/review of Maxis Health System records, policies, and other relevant documents, and interviews with those individuals directly involved in the focus of the investigation. All investigations will be guided by a work plan, approved by the Compliance Officer, which identifies the scope and authority of those individuals conducting the investigation. Your assistance in the conduct of an investigation is essential; failure to do so could result in disciplinary action and in some instances may be a violation of the law. Maxis Health System based on the facts and on the advice of legal counsel, will comply with all self-reporting requirements for non-compliance as may be necessary upon completion of all internal investigations.

Discipline

Failure to comply with the Code of Conduct and Compliance and the related policies and procedures of the Maxis Health System will result in disciplinary action. It is Maxis Health System’s responsibility to apply discipline that is sufficient in nature, but not greater than necessary, to ensure that all individuals associated with the system comply with all federal, state, and local laws, regulations, and statutes applicable to its operations. Therefore, in furtherance of the above responsibilities, Maxis Health System will be guided by the following in determining appropriate discipline for non-compliance.

Discipline should:

Reflect the seriousness of the offense;

Promote respect within the System for the Code of Conduct and Compliance;

Provide for just punishment for the offense;

Strive to minimize or eliminate future violations;

Allow for further education and training as may be necessary;

Protect the Maxis Health System from further violations.

The types of discipline that may be applied are as follows:

Counseling/warning;

Reprimand noted in permanent personnel record;

Reassignment of job responsibilities;

Probation;

Demotion;

Temporary suspension;

Termination of employment/privileges;

Any other action as may be deemed appropriate.

In addition, Maxis Health System will, as required by applicable laws and regulations, report violations to the appropriate authorities and pursue any criminal or civil actions that may be required.

Maxis Health System

Carbondale, Pennsylvania 18407

Acknowledgment Process

Certification of Education and Receipt of the Code of Conduct & Compliance

Employee Number: ___________  Entity: ____________________________

1. I have participated in the educational program “Code of Conduct and Compliance” provided by the Maxis Health System.

Date of Attendance_______________________________

2. I have read the Maxis Heath System’s “Code of Conduct and Compliance” dated _____________________, 2006, and I have retained a copy for my guidance.

3. I understand and acknowledge that I am responsible for complying with the Code of Conduct and Compliance and any related policies and procedures, in all activities conducted on behalf of Maxis Health System. I understand I may request any policy and procedure for review for which I am responsible to abide by from my immediate supervisor.

4. I further understand and acknowledge that I am responsible for attending annual (or other regular) training sessions or workshops on issues related to compliance with the Code of Conduct and Compliance.

Name (Please Print): _______________________________________

Signature: ________________________ Date: _________________________