Standards of Conduct
A Personal Commitment to Ethics, Integrity and Job Performance
1. Everything I do and every decision I make will be guided by principles of honesty, integrity, and high ethical standards. I will…
… learn my job and do it to the best of my ability. I will not underestimate the importance of my role in the success of Asbury Heights and our mission. Every member of Asbury Heights contributes to or supports our ability to provide quality resident care.
… let management know of issues that may interfere with my ability to fulfill my professional responsibilities. Asbury Heights supports a culture of accountability and fairness. Staff is encouraged to communicate concerns to management in order to assist in identifying system issues or barriers to performing professional responsibilities.
… fulfill my personal responsibilities to report quality measures. I will promptly and efficiently fulfill my responsibilities regarding compliance with, but not limited to, the standards and surveys of the Pennsylvania Department of Health and other regulatory or professional groups as appropriate.
…maintain honesty. I will not misrepresent, falsify, or alter data. I will act with honesty and in good faith in all aspects of my job. In doing so, I will not make false or misleading statements. I will never take unfair advantage of anyone by manipulating or concealing information that is essential for conducting business within Asbury Heights.
…consider the consequences before acting. When someone asks me to do something that appears to violate the Standards, I will have the courage to ask for advice before acting, even if the request comes from the person who supervises my work. For advice, I may speak in confidence with the Corporate Compliance Officer (CCO) or call the Asbury Heights confidential Compliance Hotline.
…admit mistakes and correct them. Everyone makes mistakes - but a mistake that is covered up is a serious matter. If I discover that I have made a mistake, I will report it to the person who supervises my work as soon as possible and take steps to rectify it.
RT ONE Principles of Conduct
Quality of Care & Commitment to Our Residents
2. I will demonstrate my personal commitment to ensuring that Asbury Heights provides high-quality, compassionate, skilled care in a safe and healing environment, even if I do not work directly with residents. I will…
… report any incident of resident care that does not appear to meet standards of quality or that puts a resident in danger.
… assist residents in communicating compliance-related issues and unresolved quality issues. If a resident approaches me with a compliance issue or a quality-of-care issue that remains unresolved although it has been reported to other resources, I will assist the resident in communicating it to the CCO or the Compliance Hotline.
… come to the aid of residents who appear to be in need of assistance
... report resident care issues. I will report any incident of resident care that does not appear to meet Asbury Heights’ standards of quality. If I see that any aspect of resident care is being provided in a manner that puts a resident in danger or appears to violate our standards, I will report it to my supervisor, to the Corporate Compliance Officer, or to the Compliance Hotline. I may also report any concerns regarding safety or quality of care to Pennsylvania Department of Health, Department of Public Welfare, or other regulatory agency. Asbury Heights will take no disciplinary action if I report a concern with reasonable belief and in good faith.
… courteously assist residents and visitors. If I am in contact with residents and visitors in person, on the phone, or by any other means of communication, I will remember that in the eyes of the person I am communicating with, I am the appointed representative of Asbury Heights.
… protect the confidentiality of residents and visitors. If I learn the identity of a resident or visitor through my job or through casual observation, I will respect the privacy of the identified individual. I will not share this information with anyone, including colleagues, family, or friends.
3. If I work directly with residents, I will…
… ensure I am appropriately qualified and have current credentials, the expertise, and the knowledge to provide the care I am responsible for.
… provide residents with care that is necessary, appropriate to the situation, safe, and in compliance with professionally recognized standards of care.
… maintain complete and accurate records of resident information that fulfill the requirements of Asbury Heights policies, professional standards, and all applicable laws and regulations.
… adhere to infection prevention and control practices.
… look for ways to improve service. I will strive to continuously discover new performance improvement opportunities and participate in performance improvement projects to achieve positive outcomes.
…make sure every resident receives the Asbury Heights Notice of Privacy Practices and information describing patients’ rights.
… involve residents in decisions regarding the care they will receive, to the extent possible.
4. If I have responsibility for overseeing the care provided to residents, I will…
… be familiar with and understand the quality initiatives and goals of Asbury Heights and encourage continuous quality improvement among staff.
… utilize the measurement tools, benchmarks and methods promoted at Asbury Heights to measure quality.
…support and implement our Resident Care and Nursing Standards.
…ensure that resident choice is included in clinical decision making.
… be knowledgeable of and ensure that Asbury Heights policies and procedures as well as regulatory requirements are followed by staff.
…implement plans of correction where needed and monitor continued compliance.
Conduct with Residents and Colleagues
5. I will apply Asbury Heights’ values in my relationships with residents and their families, visitors, and my colleagues. I will…
… strive to create the best possible experience for our residents, their families, and visitors.
… take the initiative to find safe, creative, and effective solutions to resident-related concerns.
… work cooperatively with my colleagues. I will demonstrate respect for my colleagues by communicating positively with them and about them.
… comply with policies on maintaining an alcohol-, drug-, and smoke-free workplace.
… follow the specific guidelines outlined in the Employee Handbook.
… not engage in any inappropriate behavior involving confrontation or conflict, verbal, physical or sexual abuse, or any other form of harassment or provocation.
… expect that all staff, volunteers, students and other associates of Asbury Heights support and promote an environment free from disruptive behavior and poor interpersonal work relationships.
… treat each person respectfully, as a unique individual. I will not discriminate against or harass anyone on the basis of race, color, religion, sex, sexual orientation, gender and/or gender identity, expression, marital or parental status, national origin, ethnicity, citizenship status, veteran or military status, age, or disability.
… maintain personal responsibility for a positive workplace environment by:
- taking necessary actions to remedy inappropriate/disruptive behaviors of individuals which may include acknowledging the behavior with the individual or a superior
- adhering to maintenance of a non-retaliatory environment
Federal, State, and Local Laws, Regulations, and Policies
6. I will obey the letter and spirit of the laws, regulations, and policies that apply to me. I will…
… familiarize myself with the laws and regulations that relate to my position. I will uphold both the written words and the meaning behind those words. I will take responsibility to maintain any licenses and/or credentials required for my position.
… familiarize myself with and avoid the actions that constitute professional misconduct if I am a licensed professional governed by a Pennsylvania board.
… review the Asbury Heights’ Corporate Compliance Information relative to the compliance program policies and procedures, available to me either electronically and/or in my department’s Policies and Procedures Manual.
… learn and obey the regulations, policies and procedures that relate to my own position, as well as the Compliance Program policies and procedures relative to all individuals and parties that represent Asbury Heights.
… ask questions. If I have questions about law, regulations, and policies, or my responsibilities for them, I will ask the person who supervises my work or the Corporate Compliance Officer.
… inform the organization if I become excluded from participating in federal and state
programs. Asbury Heights receives money from the federal and state government through participation with Medicare and Medicaid. Because we receive these funds, we cannot employ or contract with anyone excluded from participating in a program funded by the federal or state government. If I learn that I have become excluded, I will contact the Corporate Compliance Officer or Human Resources.
7. If I have management or supervisory responsibility, I will…
… make a sincere effort to keep up with regulatory changes that affect my areas of responsibility by reviewing professional journals, websites, listserves, and other relative publications available to me.
… familiarize myself and my staff with all internal compliance program policies, procedures and Standards of Conduct as they become available. I will ensure that all such information posted in the Corporate Compliance folder on the Asbury Heights’ share drive, are easily accessible to all staff through other means as well, such as the departmental Policy and Procedure Manual.
… seek out both internal and external professional development opportunities, as they become available.
… act as a role model for my staff, demonstrating my understanding of and compliance with all applicable laws and regulations.
… make ensure that departmental policies and standards are complete and up-to-date.
… make sure my department obtains all necessary licenses, permits, and approvals required for operation.
Conflicts of Interest
8. I will avoid situations in which my personal interests influence (or appear to influence) my ability to act in the best interest of Asbury Heights. I will act with the highest degree of integrity and loyalty to Asbury Heights. I will…
…avoid situations that may create a conflict of interest. If I believe that I have a conflict of interest, I will disclose it.
…consult with management for guidance on handling any potential situation that may create a conflict of interest.
…act in a manner that does not conflict with the best interests of Asbury Heights. I will never use my position or any confidential information for my own personal gain.
…fill out a Conflict of Interest Disclosure Statement on an annual basis if I am identified as being in a fiduciary or other certain position of power.
…not make any contributions to any political party or candidate using the funds, property, services or name of Asbury Heights.
…not accept or solicit monetary or other substantial personal gifts, gratuities, trips, entertainment or favors from any resident, healthcare provider, customer, or from a vendor or company doing or seeking to do business with Asbury Heights unless it meets one of the exceptions specified in the Asbury Heights’ policy on “Gifts and Gratuities.”
Anti-Kickback and Physician Self-Referral
9. I will not solicit, receive, offer, or pay anything of value in exchange for referring patients/residents, products, or services for which payment may be made under a federal healthcare program. I will…
… adhere to organizational guidelines on accepting referrals. If I am in a position to accept resident referrals and admissions, I will do so based solely on the resident’s medical needs and our ability to render the services needed. I will never offer anything of value, directly or indirectly, to anyone — colleagues, physicians, or anyone else—in exchange for referral of residents or patients.
… adhere to guidelines on making referrals. If I am in a position to make referrals, I will not solicit or receive anything of value, directly or indirectly, in exchange for referring residents or patients.
… not engage in “swapping” business. If I am in a position to make referrals to another health care provider, I will not take into account the volume or value of referrals that the provider has made, or may make, to myself or the organization.
… learn the rules that apply to the Stark Law (i.e., Physician Self-Referral Law) if I am a physician.
… not refer patients for “designated health services” to a facility that I have an ownership interest in, or compensation arrangement with, if services are being paid for by Medicare or Medicaid, unless a specific exception applies.
Privacy and Security
10. I will safeguard confidential information about residents, family members, research subjects, employees, students, and the organization itself. I will…
… prevent the disclosure of confidential information to anyone who does not have a permissible and legitimate need to know.
… access confidential information only to perform my responsibilities within the organization and for no other purpose.
… refrain from sharing competitive information concerning Asbury Heights with representatives from any other health care providers and/or organizations. Among the matters I will not discuss without approval from the appropriate regulatory and internal authorities include:
- Business arrangements such as our financial and contractual arrangements with suppliers and managed care companies.
- Information about our strategic plans, planned investments, or any potential acquisitions.
- Our marketing efforts or future plans.
- Employee salaries, pay scales, professional reimbursement or other remunerations.
11. Because of the nature of health care, I may, or will acquire or learn of personal information from residents and their family members. It is imperative that I only request, access and/or disclose the information that is absolutely necessary for legally acceptable and legitimate intentions, including treatment, payment and/or business operations. I will…
... protect any personally identifiable information after I receive it. I will be knowledgeable of and follow the laws regarding protect health information, as set forth in the Health Insurance Portability and Accountability Act (HIPAA).
… not e-mail unencrypted information that contains PHI to e-mail addresses external to Asbury Heights (i.e. ---@asburyheights.org)
… not transport, text or e-mail PHI on unencrypted mobile and portable devices. If I must use such devices to discuss a particular resident, I will take appropriate precautions not to use any individually identifiable information. I will use only ambiguous and obscured identifiers such as first name only or first name and last initial only.
… comply with Asbury Heights guidelines for reporting breaches of Protected Health Information (PHI). If I discover or learn of unsecured PHI that was improperly accessed, used, or disclosed, or if I find or receive PHI that I am not authorized to have, I wil report the incident to the Corporate Compliance Officer within 24 hours of the event.
… follow the HIPAA requirements and internal policies for secure transfer and disposal of equipment that contains PHI including but not limited to computers, mobile devices, fax machines, and copiers, by contacting Asbury Heights IT department. Any equipment containing Protected Health Information must be appropriately cleaned of such information prior to transfer, return or disposal.
… properly dispose of paper that contains PHI by shredding it with cross cut shredders or placement in designated locked containers to be shredded by Asbury Heights contracted shredding specialists.
…protect and safeguard my personal password for computer access.
… provide physical safeguards to PHI as appropriate, such as logging off my computer and/or locking my doors and drawers when I am away from my desk or office.
…take precautions not to discuss resident PHI in a public location and/or manner in which I may be overheard by the general public.
…take precautions not to access electronic PHI in view of unauthorized individuals.
…not use personal e-mail accounts to transmit PHI.
Accurate and Truthful Documentation, Coding, Billing, and Financial Reporting
12. If I am responsible for any type of documentation, financial reporting, coding and/or billing for products or services, I will perform my duties accurately, truthfully, and in accordance with regulated time limit requirements. I will…
… create and maintain thorough, accurate records. I will promptly document information as required by my job, according to ethical, professional and legal standards and departmental policies.
… fairly and accurately represent the financial condition of the organization or area I am responsible for.
… ensure that the financial transactions I report reflect actual transactions and conform to generally accepted accounting principles (GAAP).
…accurately record all funds, assets, liabilities, revenues, and expenses.
… produce cost reports that are true, correct, and complete, and prepared in accordance with regulatory requirements.
… never sign a document that I know to be inaccurate.
… take responsibility for ensuring the accuracy of claims as applicable to my responsibilities for documentation, coding and/or billing.
…take required measures to ensure claims are submitted only for medically necessary services as warranted by an authorized medical professional.
… comply with the Federal False Claims Act in accordance with policy. I will not knowingly or willfully make, or cause to be made any false, fraudulent or misleading statement or representation of material fact in any claim application, or report under any health care program or health benefit plan.
… only assign and report billing codes that are clearly and consistently supported by documentation in the resident’s medical record.
… report any improprieties I may suspect to the Corporate Compliance Officer or Compliance Hotline.
… report suspected and/or known incidents of fraud, waste, and abuse such as fraudulent or fictitious claims, with the knowledge that I will be fully protected from retaliation of any kind, for reporting such suspicions.
… promptly report and return any identified overpayments received due to an inaccurate or improper claims submission.
13. I will protect Asbury Heights’ assets to the extent possible, from loss, damage, theft, misuse, and waste. Such occurrences and assets include but are not limited to…
… equipment and supplies intended for my own personal use. These supplies and equipment include items such as vehicles, machinery, tools, computers, printers, furniture, telephones, and medical devices, as well as office, medical, cleaning, and food supplies.
… time. I report my time and attendance accurately and use my time to work productively during the hours I am paid to do so.
… departmental funds. If I am in a supervisory or management position, I will maintain careful internal controls and accurate records of departmental funds, including cash and cash equivalents. I will exercise careful oversight of financial reports, expense accounts, and timesheets.
… records. I will comply with the organization’s record retention and destruction policy and schedules that apply to my job responsibilities.
Pharmaceuticals, Prescription Drugs, and Controlled Substances
14. If I have responsibility for, or access to, prescription drugs, controlled substances, over-the-counter drugs, or any street-valued medical supplies (for example, needles), I will maintain the highest possible professional and ethical standards with regards to them. I will…
… adhere to all laws, regulations, internal policies, and the nationally recognized Professional Standards of the American Nurses Association, in relation to my contact with these drugs and supplies.
… understand and acknowledge that drugs can only be provided or taken with a valid prescription written by an authorized professional that is officially state licensed to write prescriptions.
… keep all drugs and supplies secure. I will take appropriate precautions to keep drugs secured at all times and ensure they are not available to anyone who does not have a valid prescription or the proper authority for access. I will follow policies, procedures, and standards in the management and handling of outdated, deteriorated, or unusable drugs.
… report problems that I am aware of or suspect to my supervisor, Human Resources, the Corporate Compliance Officer or the Compliance Hotline, regarding lapsed security or the improper distribution or acquisition of drugs and supplies.
Health, Safety and Environment
15. I am committed to my responsibilities that affect the health and well-being of all residents, visitors, employees and other associates, and in providing a safe environment for all. I will…
… comply with all laws, regulations, and internal policies regarding the shipping, handling, use, storage, transportation, and disposal of all hazardous materials, including radioactive materials and medical, human or chemical wastes.
… comply with all rules and regulations that apply to my own actions and conduct. I will use my best efforts to ensure that my actions and job duties are carried out in a safe manner.
… know and follow the safety procedures that apply to my job.
… report suspected violations. If I suspect a violation of an environmental or occupational safety or health law, I will report it immediately to my supervisor, the Corporate Compliance Officer or the Compliance Hotline.
16. I understand that participation in any political activities is not permitted in connection with Asbury Heights’ name or through the use of any Asbury Heights’ resources or assets. I will…
… not use company funds or assets for contributions of any kind to any political party, political action committee, political candidate, or political office of any national, state or local government.
… clearly label any political communications or activities that I choose to participate in as a private citizen, as my own, and not as correspondence coming from or in any way connected with Asbury Heights.
… refrain from providing or offering any benefit in an attempt to influence government officials. If I am responsible for conducting transactions or handling contracts with governmental agencies, I will ensure that they are handled honestly and ethically.
… report inappropriate requests or demands from any governmental representatives, for any type of benefit or advantage, to a senior official at Asbury Heights or to the Corporate Compliance Officer.
Government Investigations, Accreditations, and Surveys
17. I will cooperate fully with requests from governmental agencies and accrediting associations concerning Asbury Heights’ operations. I will…
… report any requests I receive from a government investigator to my department managers, a senior administrator, or the Corporate Compliance Officer.
… cooperate with representatives from governmental agencies in an open and honest manner.
… never destroy or alter records requested for a government investigation, survey or audit, nor will I commit perjury or make misleading statements about documents.
… never pressure anyone or suggest that anyone hide information from, or provide false information to government investigators, surveyors and auditors.
18. I understand that enforcement is an integral component of the Compliance Program at Asbury Heights and federal, state and local government authorities . I am aware …
… that if I violate the Standards or regulatory requirements, I will be subject to disciplinary action up to and including termination which will depend upon the nature and severity of the violation.
…that if I fail to comply with applicable laws and regulations, I will be subject to administrative, civil, and/or criminal liability, as well as exclusion from federal health care programs in addition to termination from Asbury Heights.
19. If I am aware of or suspect a violation, I am obligated to report it in order to minimize or possibly prevent any adverse consequences. I will…
… report my concern even if I’m not certain whether it is a violation of the Standards or not. I may report my concerns anonymously if I choose to do so.
… report my concerns to any of the following resources:
- Corporate Compliance Officer/Compliance Hotline
- Human Resources
- Senior Executive Officers
- Administrator Department Manager/Director/Supervisor
… provide only information that I believe to be true but understand that I do not have to be absolutely sure that I’m right to make a report.
… not report any information that I know to be false for any reason whatsoever.
…be thorough and present any evidence I have to support my allegations.
… provide the opportunity for Asbury Heights to investigate reported concerns and violations and, if possible, correct them before they can cause serious legal matters or negative publicity.
… be subject to possible disciplinary action if I am aware of a violation and don’t report it, as this is a violation in itself.
20. I understand that I am protected from retaliation if I report violations or suspected violations in good faith. I am aware…
…there will be no retaliation against me if I raise concerns or questions about misconduct or report violations of the Standards. Examples of retaliation include termination of employment, unjustified negative performance reviews, harassment, or exclusion from meetings or social activities.
…if I report a violation and believe I am experiencing retaliation, I will report the situation to the Compliance Officer or Director of Human Resources. Retaliation against anyone who has raised a concern or reported a violation of the Standards will be subject to disciplinary action, including possible termination.