CODE OF ETHICS


TABLE OF CONTENTS
Message from our President and CEO

Mission/Vision/and Motto

Introduction to the Code of Ethics

Reportable Behaviors

Laws and Regulations

Fraud and Abuse and DRA

Conflict of Interest

Compliance Hotline


Message from our President and CEO
To the Family of Hoboken University Medical Center

Just as the patients who come to us expect and deserve the highest quality care we can provide, everyone who deals with any of us in any way expects that we will act in accordance with the highest ethical standards.

An organization such as ours can write and disseminate strong words declaring our commitment to those standards, but it is thousands of individual actions every day that show the world we mean what we say. The effect of our behavior far outweighs the power of our words.

I urge each member of our Family to read this information more then once, to discuss it with your co-workers, to remember it all times, and to behave in accordance
with our high standards. If each of us does this, we will always know what to expect of each other and we will live up to what people expect of us.

This packet includes information about how to “blow the whistle” if you become aware of unethical behavior and it explains the protections afforded to you if you do so.
But that’s only a small piece of this message. The importance of this booklet is to reinforce the commitment we all have to Caring for patients and their families; being Accountable to our community and Respecting one another, while assuring Excellence in all that we do.

Living that commitment brings individual and organizational pride to all of us.


Sincerely,


Spiros Hatiras
Chief Executive Officer

Mission/Vision/and Motto

Care for the patients and families

Accountability to our community

Respect for one another

Excellence in all we do

INTRODUCTION TO THE CODE OF ETHICS
The Code of Ethics sets forth our commitment at Hoboken University Medical Center to comply with applicable laws, regulations, and standards. Should certain situations occur it may not be clear to employees what to do or how to act. The Code of Ethics establishes guidelines and covers a variety of situations that could occur.

Employees are expected to recognize reportable behaviors and report questionable behaviors in good faith. Employees may report questionable behaviors to his/her supervisor/manager/director, Human Resources, the Corporate Responsibility Officer, or the Compliance Hot-Line. No adverse action or retribution will be taken against any employee reporting a suspected violation.



REPORTABLE BEHAVIORS
Discrimination/Harassment
• Discrimination or harassment of patients or employees, including but not limited to
race, color, creed, religion, national origin, sex, marital status, disability, sexual
orientation, or age.

Violation of Patient/Employee Confidentiality
• Discussing a patient care matter in public areas such as hallways, elevators, patient lounges, or the cafeteria.
• Discussing matters with others who do not have a need to know.
• Improperly revealing information from personnel files, such as salary, benefits, or personal data.

Conflicts of Interest
• Being involved in a business owned or operated by oneself/or one’s immediate family that does business with our organization or a competing organization.
• Accepting gifts, cash, entertainment or favors from any vendor or potential vendor. Gifts of nominal value, less than Fifty Dollars ($50.00), are the exception.

Stealing or misuse of assets
• Unauthorized use of the organization’s equipment, supplies, materials, or services.
• Inappropriate use of the organization’s computers or internet services.
• Inappropriate use of the organization’s phone system.
• Taking office supplies home for personal use.

Environment, Health, & Safety Issues
• Improper disposal of waste.
• Violations of OSHA regulations.
• Improper storage or use of equipment or supplies.
• Performing work duties under the influence of drugs or alcohol.
• Smoking in non-designated smoking areas.

Improper Lobbying/Political Activity
Employees can contribute or participate in political events as private citizens; however, Hoboken University Medical Center is a tax-exempt organization. Therefore, employees may not
• Contribute to a political campaign or organization on behalf of Hoboken University Medical Center.
• Use the organization’s assets for their own personal political purposes.

Improper Use of Proprietary Information
• Stealing confidential or proprietary information belonging to another person or entity.
• Improper copying or documents, books, computer programs in violation of copyright laws.
• Improper use of customer lists, price lists, or contracts.


COMPLIANCE WITH LAWS/REGULATIONS
All employees are expected to follow all applicable federal, state and local laws, regulations and standards and to represent Hoboken University Medical Center accurately and honestly. All employees must be aware of and follow all organizational and departmental policies relating to their areas of responsibility.

No one, regardless of their position, has the authority to ask or knowingly allow any employee to violate a law, regulation, standard, or organizational policy. Those that become aware of such situations are expected to report the violation. Failure to do so violates our Code of Ethics.

• All patient care must be appropriately charted and documented. Employees involved in billing and coding must take all reasonable steps to ensure their work is accurate, timely and supported by the medical record.

• Federal Anti-Kickback Laws states that anyone who knowingly and willfully receives or pays anything of value to influence the referral of federal health care program business can be charged with a felony.

• Anti-Trust Laws prohibit anti-competitive behavior and unfair business practices. Those behaviors that are prohibited include price fixing, bid rigging or collusion, including sharing price information with competitors, unfair trade practices, including bribery, and agreements with competitors not to compete within each other’s geographic areas.

• Stark Laws prohibit physicians from referring patients to a facility or organization in which the physician or immediate family member has a financial interest or compensation arrangement. This prohibition always applies unless certain exceptions stated in the law are met. In the event a referral is prohibited, Hoboken University Medical Center will not submit a bill or claim for reimbursement.

• The Emergency Medical Treatment and Labor Act (EMTALA) prevents hospital emergency departments from rejecting patients, refusing to treat them, delaying a screening or exam while inquiring about insurance coverage or transferring them because of their insurance coverage or lack of coverage.

• As a not-for-profit, tax-exempt organization, Hoboken University Medical Center has an obligation to comply with laws specifically for tax-exempt organizations, and to ensure that our resources are used for community benefit rather than the private interests of any individual. We will not make payment arrangements or provide other benefits that exceed the fair market value of the services provided, will not pay more than the fair market value for purchases and will not charge less than the fair market value for services sold.

• Hoboken University Medical Center will not employ or contract with any individuals or organizations that are excluded or ineligible to participate in federally-funded health care programs.

• It is the responsibility of every employee to understand and ensure full compliance regarding federal standards for the security and privacy of health data established under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Any items containing Protected Health Information (PHI) must not be put into trash cans or bins. All PHI must be placed into Shred-It containers.

• All hazardous and infectious waste shall be stored, handled and disposed of in compliance with federal and state regulations.

• Hoboken University Medical Center maintains a drug free, smoke free environment. Any employee found smoking in non-designated areas or performing their work duties under the influence of drugs or alcohol will be subject to disciplinary actions.


FRAUD AND ABUSE
Employees may not engage in any activities that violate fraud and abuse laws. Examples of fraud include;
• Misappropriation of funds, securities, supplies, or other assets.
• Impropriety in the handling or reporting of money or financial transactions.
• Disclosing confidential and proprietary information to outside parties.
• Accepting or seeking anything of value from contractors, vendors, or persons providing services/materials to the organization.
• Submitting false or misleading claims to any government or third party payer.

DEFICIT REDUCTION ACT (DRA)
In order to comply with the DRA requirements, Hoboken University Medical Center has established written policies applicable to all of our employees, contractors, and agents that provide detailed information with respect to the role of certain laws in preventing and detecting fraud, waste and abuse in Federal Health Care Programs. The Deficit Reduction Act/False Claims Act and the Fraud policy outline information contained in the Federal False Claims Act (FCA), the federal penalties under the FCA and administrative remedies for false claims and statements under the Program Fraud Civil Remedies Act (PFCRA), whistleblower protections, and any State laws pertaining to civil or criminal penalties for false claims and statements.

The specific acts prohibited by the FCA include;
• Knowingly presenting or causing to be presented a false or fraudulent claim to an officer or employee of the United States Government.
• Knowingly making or using (or causing the making or use) of a false record or statement to get a false or fraudulent claim paid.
• Conspiring to defraud the Government by getting a false or fraudulent claim paid.
• Knowingly making or using (or causing to be made or used) a false record or statement to conceal, avoid or decrease an obligation to the Government.

Penalties under the FCA can be subject to monetary penalties ranging from $5,500 and $11,000 for each false claim submitted in violation of the FCA. In addition, persons can be liable to the Government for three times the amount of damages that the Government sustains. Under PFCRA, the United States can obtain an assessment in lieu of damages of twice the amount of the false claim and a penalty of up to $5,000 for each false claim submitted.

Whistleblower Protections under the DRA
The FCA permits both the United States and private citizens (whistleblowers) to bring action for violation of its liability provisions. When a private citizen or whistleblower brings such an action, it is brought in the name of the United States and the lawsuit is filed under seal or in secret. Whistleblowers are given protections against any retaliation in the workplace for filing an action.

Beside Federal and State agencies, you may report internally any suspicions of fraud and abuse to any member of management, the Corporate Responsibility Officer, or the Corporate Responsibility Hotline.


CONFLICTS OF INTEREST
Employees of Hoboken University Medical Center must not use their positions to profit personally or assist in profiting at the expense of the organization. Employees are required to inform the Corporate Responsibility Officer of any conflict of interest that they may have. Board Members, physicians, senior staff members, directors, managers and supervisors are required to fill out an annual conflict of interest statement. Should any conflicts be detected they will be recorded and presented to the Board for determination as to whether there is indeed a true conflict of interest. If a conflict of interest is determined, the employee will not be entitled to participate in actions such as votes or discussions with any issues surrounding that which could affect the organization.

Examples of Conflicts of Interest;
• Having an ownership, investment interest, or compensation arrangement with any entity that Hoboken University Medical Center has an arrangement or transaction or is negotiating an arrangement or transaction.

• Serving as a board member or consultant to any outside business that works with or competes with the services offered by Hoboken University Medical Center.

• Working for a competitor or supplier of Hoboken University Medical Center without the prior approval of their department director.

• Accepting gifts, entertainment, or favors from any supplier or potential supplier to Hoboken University Medical Center if one could see that this action can possibly influence the employee in performing his or her job duties. Gifts of nominal value, $50.00 or less are exceptions to this standard.

CORPORATE COMPLIANCE HOTLINE
If you believe in good faith, meaning that you believe that you are truly reporting a violation of the Code of Ethics or any of the laws, regulations or organizational policies, are telling the truth as you know it, and not acting out of spite, it is encouraged that you report this misconduct.

There are a number of ways that you can go about reporting misconduct in the workplace. You may go directly to your supervisor, manager, director, or Human Resources Representative. You may also report either directly or anonymously to the Corporate Compliance Officer.

The Compliance Hotline is another method that can be used for reporting misconduct. If you call the Hotline you may or may not talk directly to the Compliance Officer. The Hotline telephone does not have any identifiable features. For anonymous reporting you must dial the complete telephone number. You must leave a code name or word and the time and date of your call. This information will be used for follow up purposes. Based upon your recorded complaint, a written report will be generated and a full investigation will begin. You may call back the hotline at a designated time for follow up purposes.

The Hotline number is 201-418-2110.