Code of Conduct

Message from the President/CEO

February 2020

Maintaining high ethical standards is everyone’s responsibility and ensures that we truly act in the best interests of the patients, residents and family members who put their trust in us. By conducting ourselves with integrity and honesty and fulfilling all applicable laws, regulations and organizational policies, we maintain that trust and preserve the strong reputation we have worked so hard to build for more than a century.

The Code of Conduct for Charles E. Smith Life Communities (CESLC) is an important resource that helps guide each of us and our organization to fulfill our professional obligations and ensures that we continue to provide a safe and supportive environment. While our code of conduct describes many specific behaviors and actions, it does not cover every situation that you may encounter. That is why we place our trust in you to always use good judgement and to uphold our values, avoiding any action, relationship or situation that is not consistent with our high ethical standards.

Please take the time to become familiar with our code of conduct, which also explains your responsibility to speak up and report, without fear of retaliation, any situation or behavior that you believe is in violation of our code. I also encourage you to consult your supervisor or any member of our CESLC leadership team if you have any questions or need further assistance.

I consider myself very fortunate to be working with so many dedicated people who are passionate about their roles, devoted to our community and each other and committed to always doing the right thing.

Sincerely,

Bruce J. Lederman
President/CEO
Charles E. Smith Life Communities

Our Compliance Program

Compliance Program

A compliance program helps to ensure that we can identify, reduce and mitigate activity that may lead to fraud, waste and abuse. An effective program is based on seven key elements recommended by the federal government:

1. Develop and distribute this code of conduct and other written policies and procedures that promote and illustrate our commitment to compliance, integrity and ethical conduct.
2. Identify a compliance officer and form a compliance committee to develop, operate and monitor our compliance program.
3. Develop and implement regular effective training and education opportunities related to our compliance program requirements.
4. Create and maintain communication opportunities for team members to report concerns without fear of retaliation.
5. Conduct audits and other types of evaluations to monitor compliance, identify risk areas, and correct identified risks.
6. Enforce these compliance standards through well-publicized disciplinary guidelines.
7. Respond to detected offenses and develop corrective action plans.

Our compliance program is a coordinated effort with leaders throughout the organization to create policies and procedures that are repeatable and defendable. The program is led by the director, HIPAA Security, Privacy and Compliance who is guided by a compliance committee comprised of CESLC senior leaders. The committee’s activities are reported to the Board of Governors through the President/CEO.

We provide educational opportunities and promote open communication so that we can identify and remedy risks. This helps us avoid potentially harmful effects on our organization and the residents we serve.

Government Exclusions

We do not knowingly employ anyone who has been excluded from participating in a federal or state program and, as part of our compliance program, we regularly review government exclusion databases for this purpose.. This occurs before joining CESLC and routinely thereafter. We will conduct additional research if a team member is found on a government exclusions database during a routine review.

Compliance Hotline

A successful compliance program is a group effort. We expect and need you to speak up if you believe an action does not emulate our ethical beliefs or legal requirements. Speak to your supervisor, another member of leadership, the HIPAA security, privacy and compliance director or contact the Hotline:  https://secure.reportit.net/creator / 877-778-5463. Our organization’s user name is ceslcrpt and the password is Rockville1. Remember, disciplinary action or any other retaliation for expressing your concerns is strictly prohibited.

Our Responsibility to Promote Ethical Practices

Adhering to Laws and Regulations

CESLC is committed to complying with all relevant federal laws including, but not limited to the Deficit Reduction Act of 2005, the False Claims Act, the Anti-Kickback Statute and the Elder Justice Act. We adhere to the Resident Bill of Rights as prescribed by federal and state law.

Maintaining Ethical Billing and Other Business Practices

We are committed to ethical, honest billing practices and do not tolerate any actions that may lead to fraud, waste or abuse. We submit claims for payment based on the care provided consistent with federal, state and local laws and commercial payer requirements. Copayments, coinsurance and deductibles are only waived consistent with established rules, policies and procedures. Finance and accounting team members ensure that all billing-related communication with residents, prospective residents, family members, government and private payers and other third parties is accurate and complete. We do not bill for items or services that were not rendered, were not medically necessary or did not meet quality standards. All claims for payment must be supported by accurate documentation to substantiate the claim.

Giving or receiving any form of payment, kickback or bribe to induce referrals is prohibited. We do not offer any improper inducements or favors to residents, providers or others to influence or arrange for referrals to any CESLC residence or service. We do not accept anything of value from our current or prospective vendors.

Our Focus on Quality of Care

We expect all residents to receive quality, cost effective care with compassion and integrity. We respect the dignity, comfort and privacy of every resident.

We provide appropriate and timely healthcare by qualified professionals consistent with clinical guidelines to all residents without regard to race, religion, disability, age, sex, sexual orientation, national origin or source of payment. Residents have the right to participate in medical decision-making and to refuse treatment consistent with the law.

The Elder Justice Act

The Elder Justice Act requires that notification be made to the state survey agency and local law enforcement when there is any reasonable suspicion of a crime against any of our residents. If the resident suffers a serious bodily injury, the report must be made within two hours. If there is no serious bodily injury, then the report must be made within 24 hours.

In keeping with the Elder Justice Act, team members must alert a supervisor and not the compliance hotline if they suspect a crime was committed against a resident. This is mandatory. Failing to report a suspected crime against a resident may lead to disciplinary action. We will help the team member make the required government notifications. We cannot and will not retaliate against any team member who makes a report.

CESLC does not tolerate any crime against a resident, including any form of resident abuse or neglect. Any CESLC team member found to have abused or neglected a resident is subject to termination and reported to law enforcement and the state licensing body as appropriate.

Respecting Each Resident’s Privacy and Confidentiality

We respect and protect the privacy of our residents. We safeguard their information and health records according to federal and state requirements, most notably privacy rules implementing the Health Insurance Portability and Accountability Act of 1996. We access and furnish only the minimum amount of health information necessary to provide quality care. All resident information is kept confidential except where disclosure is authorized by the resident or permitted by law.

A resident’s medical record shall be accessed for work-related purposes only. The medical record may not be accessed out of curiosity or because the resident is a friend or family member. Team members should not discuss residents with anyone who does not have a need to know. Make sure any discussions about residents cannot be overheard by anyone who does not have a need to know.

Team members are prohibited from including pictures, voice recordings, videos or otherwise discussing residents on any social media post unless the post is authorized. Examples of social media include, but are not limited to Facebook, Twitter, Snapchat, Instagram, YouTube and LinkedIn. Team members should also be careful when posting anything related to other team members without their permission.

Information Security/Technology

We maintain and monitor all security and data backup systems and storage capabilities to ensure the information is stored and maintained safely in compliance with federal and state requirements as outlined in our policies and procedures. Only authorized individuals are granted access to CESLC computer systems and software programs. Access is granted based on the individual’s job responsibilities.

Following Record Retention Requirements

We are required to retain certain records such as employee records, health, safety and environment records, taxes and other accounting records, contracts and research for specific time periods. We adhere to record retention policies consistent with the law and other applicable guidelines. We are mindful of requests for records during any litigation activity, noting that it may be a crime to destroy these records during litigation or other government investigation.

Our Responsibility to Team Members

Workplace Conduct and Employment Practices

CESLC treats all team members with respect, dignity and courtesy and expects the same of our team members. We are an Equal Opportunity Employer, and prohibit any form of discrimination in employment opportunities or practices based on race, color, religion, ancestry or national origin, sex, age, marital status, sexual orientation, gender identity, disability or genetic information or any other characteristic protected by law. Employment decisions are based on merit, qualifications and abilities.

CESLC does not tolerate discrimination or harassment of any kind. We make reasonable accommodations as appropriate for team members with special needs in compliance with the Americans with Disabilities Act and subsequent amendments.

We support and observe a workplace free of alcohol, drugs, tobacco and smoking. CESLC will respond immediately and appropriately, according to CESLC policies and procedures, if a team member is found to have engaged in substance abuse. We provide support to team members who request assistance with substance abuse as appropriate.

Environmental and Safety Considerations

CESLC maintains policies and procedures to ensure a safe working environment. We comply with established safety and infection control policies and procedures, which are intended to prevent job-related hazards, consistent with ergonomic standards and ensure a safe work environment. Violent or threatening behavior is not tolerated.

Each team member is expected to help maintain a safe and healthy workplace by following CESLC’s safety and health rules and practices and reporting accidents, injuries and unsafe equipment, practices or conditions. CESLC provides professional support to understand how we can all better protect each other and our physical workspace in the event of an act of violence.

We comply with all laws and regulations governing the handling, storage, use and disposal of hazardous materials, other pollutants and infectious waste.

Your Responsibility to CESLC

Avoiding Conflicts of Interest

Conflicts occur when actions or activities result in improper personal gain or advantage to an individual, improperly influence business judgment or the performance of business activities or give rise to divided loyalty. We expect all team members to avoid actions that conflict with the best interests of our organization. We are especially concerned about external activities that may negatively impact: 1) the delivery of resident healthcare; 2) CESLC’s financial health; or 3) CESLC’s overall reputation. All real or perceived conflicts of interest should be reported to an immediate supervisor or other member of CESLC’s leadership for review and action as needed.

Adherence to this code of conduct

We expect everyone to adhere to this code of conduct and the policies and procedures that address specific compliance-related and other ethically-based topics. We expect you to do the right thing and to ask questions if you are unsure. You are never expected to violate the law.

Violations of this code of conduct, CESLC’s compliance requirements or any other applicable law could result in disciplinary action leading to, if serious enough, termination of employment. The decision to take disciplinary action and the extent thereof is made in accordance with our policies and procedures and in collaboration with the VP, Human Resources.

Conclusion

This code of conduct is only a short summary of our overall culture of quality, ethics and integrity. We adhere to regulatory requirements, but we must also be mindful of our obligation to provide quality care to the residents we serve in an environment of integrity.