The foundation upon which our Company is built is our commitment to provide compassionate, high-quality care and service to our patients and their families. Our reputation for providing this high standard of care and doing so in an ethical manner is what distinguishes Compassus from our competitors. To this end, it is critical that we each act with absolute integrity when conducting business on behalf of the Company.
Compassus and all of our Colleagues follow a Code of Ethical Conduct with respect to all those with whom we interact, including patients and their families, regulatory agencies, Colleagues, payors, and business partners. This Code is the cornerstone of the Compassus Corporate Integrity and Compliance Program, and it can be found in our Colleague Guide and on the Comfort Zone>Colleagues>HR Policies, Procedures, and Practices>Policies>Code of Ethical Conduct.
Our Code of Ethical Conduct is based upon our shared core values of Compassion, Integrity, and Excellence, which guide our actions. Adherence to our Code is critical in achieving success through our Six Pillars of Success:
- Regulatory Compliance
- Colleagues and Culture
- Service Excellence
- Financial Performance
Adherence to our Code is particularly critical as explained in our first Pillar – Regulatory Compliance. The healthcare industry is highly regulated; almost every healthcare activity, from ordering drugs to billing for services rendered, is covered by rules and regulations. The Code of Ethical Conduct provides guidance to ensure that our work is done with integrity and in accordance with applicable laws, rules, and regulations.
If you have questions about any part of our Code, or if you encounter any situation that you believe may violate its provisions, you should immediately contact your Supervisor or another Leader. If you are not completely satisfied with the response of your Supervisor or other Leader, you must promptly report your concerns to the Compliance Officer via email to firstname.lastname@example.org or report a concern anonymously at the compliance line at 1-866-569-7193.
Please become thoroughly familiar with this Code of Ethical Conduct, as it is now your own. Your adherence to its spirit, as well as its specific provisions, is critical to our success. Please join me in committing to our Code of Ethical Conduct.
James A. Deal
Chief Executive Officer
A fundamental principle on which we operate is compliance with all laws, rules and regulations to which we are subject. Company Policies and Procedures have been developed to guide our colleagues to operate within these laws, rules and regulations. Colleagues are expected to understand and adhere to company policies and procedures. If you are ever unsure if any action is appropriate, ask your supervisor. If your supervisor doesn’t know the answer to your question or if you are not comfortable with the answer you receive, ask another member of management or call the Compliance Officer. Remember that it is always better to ask a question before taking any action that may be improper.
Our hospices are frequently subject to internal and external surveys, audits and investigations. This includes state and federal regulatory surveys and investigations, probe edits, internal surveys conducted by Company staff or third party consultants, compliance investigations, and Joint Commission accreditation surveys. Colleagues are expected to cooperate fully and provide truthful and accurate information when responding to those conducting surveys, audits, inquiries or investigations.
We will strive to maintain a positive and professional work environment for all colleagues. All colleagues should be treated with fairness, respect, courtesy and consideration. We will maintain a safe, positive working environment free from harassment. We will not tolerate any form of harassment, sexual, physical or otherwise, including degrading or humiliating jokes, slurs, or intimidation. We strongly support equal employment and advancement opportunities for all individuals without regard to race, color, religion, sex, national origin, age or disability.
We promote an “open door” policy and encourage direct and honest communication among colleagues and management. We strive to maintain a professional environment where colleagues may develop their skills and their careers based upon ability, effort and job performance.
We understand that colleagues may not want to report compliance or other concerns if they feel they may be subjected to retaliation or harassment. No supervisor, manager or other colleague is permitted to engage in retaliation or any form of harassment against a colleague who reports a concern. Any manager, supervisor or other colleague who engages in retaliation or harassment is subject to discipline, up to and including termination. Open and candid reporting of errors and other issues is encouraged so that such issues may be addressed and corrected at the earliest possible time.
A “conflict of interest” occurs when a colleague’s private interests interfere (or appear to interfere) with the interests of the Company as a whole or one of its locations. A potential conflict may arise from business relationships, financial investments, part time jobs or other activities that could influence or appear to influence your judgment or duties on behalf of the Company. Avoid making any business decision that involves yourself, friends or family without first making appropriate disclosure and seeking appropriate approval though your Executive Director or corporate department head.
Patients and their families are our first priority. We treat all patients, their family members and their caregivers with compassion, dignity and respect. We recognize that our patients have a right to be involved in decisions affecting their Plan of Care. We include family members* and caregivers, as appropriate, and seek to understand their needs and the patient’s needs as it affects the care provided. We strive to treat our patients and their families in the same manner that we would desire to be treated.
*Family members in this context include family and friends as determined by the patient.
All colleagues, prior to starting work, are subject to background checks as required by federal and state laws and Company policy. We will not employ or otherwise engage any individual whom we know to have failed the background check requirements or to have been excluded from participating in any federal healthcare program. To ensure compliance, we will check the status of all potential new colleagues prior to their first day of work.
Colleagues are expected to maintain all required professional licenses, certifications or other accreditations and to comply with the ethical standards of their respective professional organizations. Also, colleagues are expected to perform only those professional duties that are within their authority to perform.
Colleagues can expect the Company to provide mandatory training for all jobs. All colleagues are required to attend training at various times each year, including compliance training.
Supervisors must ensure that only properly screened, qualified and trained colleagues are assigned to care for our patients.
For each patient admitted to hospice, a Plan of Care, tailored to meet the specific needs of the patient and family, is established by the Interdisciplinary Team (IDT) and attending physician. The Plan of Care is reviewed on a regular basis and revised as necessary to provide palliation of the patient’s symptoms and management of the terminal illness. Services are provided in accordance with the Plan of Care and are documented accurately and in a timely manner and made a part of the permanent patient record.
We strive to maintain a culture of service excellence and have developed the Compassus Service Commitment, an eight point service commitment to our patients and their family members and to our referral sources. All colleagues are expected to make fulfilling the Compassus Service Commitment their top priority.
Compassus Service Commitment
Patient care and quality service are our highest priorities.
Compassus will always be the leader in quality hospice care in each community we serve.
We will initiate contact with patients/families within 2 hours of receiving a referral. Patients referred to us with required documentation will be admitted on that same day or within 24 hours, when family and/or guardians are available.
We will provide compassionate, timely, and effective pain and symptom management to patients and offer support to their families, 24 hours a day.
We recognize the special relationship between physicians and their patients and we offer to provide those physicians regular patient status reports on any schedule they request.
Telephone calls to our staff will always be answered promptly and politely.
Trained staff will respond to urgent calls made to our after-hours call service within 15 minutes, 24 hours per day.
We will address patient, family, or physician questions, issues or concerns within 24 hours of the appropriate staff being notified about the issue.
We will care for our patients and their families with the same compassion, dignity and respect we give our own families.
We regularly survey our patients, families, facilities and physicians to ensure we are meeting our service commitment to the people, professionals and communities we serve.
In the course of serving our patients and their families, we collect sensitive information about our patients’ medical conditions, treatments, family history, and/or medications. Much of this information is personal in nature and must be considered highly sensitive. We must maintain the confidentiality of this information at all times.
All of our colleagues shall comply with the Health Insurance Portability and Accountability Act (HIPAA) in accessing, using, processing, or disclosing protected health information. (HIPAA is a law which protects the confidentiality of an individual’s healthcare information). Each colleague should be familiar with our Notice of Privacy Practices because, as a colleague, you are required to comply with the terms of this document. We will not share protected information except when authorized under HIPAA for treatment, payment, or healthcare operations; or as required by law. If you have questions you should ask your supervisor or Executive Director or call the Compliance Officer.
We will not conduct discussions of patient issues in public areas or with non-authorized individuals. We will take all reasonable measures to protect medical record information in all forms whether paper or electronic.
Growth of a hospice program is an affirmation that the program is achieving success in Pillars 1 through 4 and an indication that the hospice is meeting the needs of the community it serves.
Only patients meeting established eligibility criteria (Local Coverage Determinations – LCDs) shall be admitted and recertified for hospice care. Patients on service are certified by their attending physician and our Medical Director to be terminally ill with a prognosis of six months or less, if the disease follows its normal progression. It is not unusual for patients to live beyond six months and continue enrollment in hospice. Continued enrollment in hospice is determined by the IDT and requires appropriate documentation by the IDT members and recertification by the attending physician or the hospice Medical Director.
All patients that meet established admission criteria shall be admitted without regard to age, race, color, sex, national origin, disability or religion.
Gifts and entertainment should never be offered or accepted in exchange for or as a reward for referrals. Personal/individual gifts should not be given to referral sources. Any type of seasonal gift provided to physicians or facilities should be something to be shared by the staff. Cash and cash equivalents (gift cards) should never be given or received. Marketing lunches/dinners, as a general guideline, should be reasonable, and of nominal value, and approved by your Executive Director beforehand. All gifts and entertainment should be thoroughly documented on expense reports or check requests with specifics of who attended, what, when and where.
All financial arrangements with physicians, nursing homes or other referral sources must be necessary for legitimate business purposes, set forth in writing at fair market value, and signed by all parties involved. We will not pay for referrals, nor will we accept payment for referrals made to other entities. We will not consider the volume or value of referrals in establishing compensation under our agreements with physicians, nursing homes or other referral sources. All financial arrangements involving physicians, nursing homes or other referral sources must comply with Company policies and be documented in company approved contracts.
Successful financial performance is the direct outcome of achieving success in the first five Pillars and managing our programs in a fiscally responsible manner. We strive to be good stewards of our limited financial resources and of the Medicare Hospice benefit.
All claims to government and commercial payors must accurately reflect the dates of service and level of care to our patients and must comply with all pertinent billing rules and regulations.
We will not tolerate false, fictitious or fraudulent claims.
Any billing errors identified through audit processes or other means shall be promptly corrected. Any overpayment received from Medicare, Medicaid or any other payor source must be promptly returned.
Colleagues are expected to maintain complete and accurate business and medical records for which they are responsible. This includes but is not limited to: time sheets, financial reports, accounting records, expense reports, check requests, billing records, patient records, colleague records, and any other business or medical record documents. Records should never be destroyed or altered to cover up an error or omission or for the purpose of receiving any payment to which the Company or the colleague is not entitled. Colleagues should never sign someone else’s name to a hospice document.
- Always follow the “Golden Rule” – treat your colleagues, patients, families and others you interact with in a manner you would desire to be treated.
- Never knowingly falsify information in a medical record.
- Never sign another individual’s name to a medical record document.
- Never take action that would result in billing for services that were not provided.
- Never pay money nor give anything of value to any person in order to encourage referrals.
- Never accept money or anything of value in return for referring business to another provider.
- Never personally accept money or anything of value from a patient or family member. All gifts from patients and family are presumed to be property of the Foundation affiliated with your program. Executive Directors must approve any exceptions.
- Never share the protected health information of any individual without proper authorization.
- Never participate in business relationships that pose a conflict of interest with your hospice responsibilities.
- If you are unsure if as to whether your actions violate the Code of Ethical Conduct, ask before you act.
- You have a responsibility to act in a manner consistent with this Code of Ethical Conduct.
- You have a responsibility to learn and understand the requirements of your specific job and to strive to learn and understand laws and regulations that affect your specific job.
- You have a responsibility to report any activity you encounter that is inconsistent with the guidelines presented in this Code. You should report any concern to your supervisor, program Executive Director, the Compliance officer or if you prefer you can report a concern anonymously to the ComplianceLine at 866-569-7193.