CODE OF CONDUCT 2009 Presentedto TheSuburbanHospitalHealthcareSystem BoardofTrustees Approved2-2-00 Revised/Approved3-26-03 Revised/Approved2-2006 Revised/Approved4-24-2009
TABLE OF CONTENTS INTRODUCTION... 1 VISION,MISSIONANDVALUES... 2 ISSUESANDCONCERNS... 3 QUALITYOFCAREANDPATIENTRIGHTS... 4 HUMANRESOURCES... 6 ENVIRONMENTALCONSIDERATIONS... 8 COMPLIANCEWITHLAWS,REGULATIONSAND ACCREDITATIONSTANDARDS... 9 CONFLICTSOFINTEREST... 11 SAFEGUARDINGRESOURCESAND/ORASSETS... 12 CODINGANDBILLINGINTERGRITY... 14 AUDITANDCOMPLIANCECOMMITTEECHARTER... 16 ii
INTRODUCTION TheSuburbanHospitalHealthcareSystemiscommittedtoensuringthatallemployeesshare intheresponsibilityforkeepingthesysteminfullcompliancewithalllawsandregulations governing ethical business practices. This document explains the expected behavior and conductofallemployees,volunteers,membersoftheboardoftrusteesandmembersofthe Hospital smedicalstaffinourworkplace. ThisisyourcopyoftheSystem'sCodeofConduct.It hasbeendesignedtobeaclearand conciseguide.pleasefamiliarizeyourselfwithittoensureunderstanding. ThisCodeofConductaddresses: VisionandMission Values QualityofCare HumanResources EnvironmentalConsiderations CompliancewithLawsandRegulationsConflictsofInterest SafeguardingtheSystem'sResources/Assets CodingandBillingIntegrity This Code of Conduct is a broad guideline which is reinforced in greater detail by the variouspolicyandproceduremanualsutilizedthroughoutthesystem.itistheresponsibility ofeveryemployee,volunteer,memberoftheboardoftrusteesandmedicalstaffmember toactinamannerconsistentwiththiscode,thevaluesandprinciplesitexpresses,andits supportingpolicies. TheSystem'sCodeofConductisa"livingdocument"thatwillbeupdatedperiodically.If youhavesuggestions,recommendationsorideasforimprovingthecode,pleasecontactthe ComplianceOfficerat301-896-3956.
SUBURBAN HOSPITAL HEALTHCARE SYSTEM VISION, MISSION AND VALUES VISION SuburbanHospitalHealthcareSystemwillsetthestandardforexcellenceinhealthcarein thewashingtonmetropolitanregion.throughouraffiliations,weaspiretoprovideworldclasspatientcare,technology,andclinicalresearch. MISSION We are a not-for-profit healthcare provider guided by the needs of our patients and community. We distinguish ourselves through service and clinical excellence, affiliations with the National Institutes of Health and Johns Hopkins Medicine, and state-of-the-art technologyandfacilities.wearecommittedtocontinuousimprovementandappropriateuse ofresources.wecreateanenvironmentthatencouragesthesuccessandfulfillmentofour physicians,staff,andvolunteers. VALUES Compassion: Wetreatourpatientsaswewouldwanttobetreated Excellence: We provide patient care with clinical competence, service excellence and safety. Integrity: Wetrusteachothertodotherightthing. Teamwork: Weworkasateaminanenvironmentthatsupportsdiversity. Accountability: Weareaccountableforhowweuseourresources 2
ISSUES AND CONCERNS An important factor in the success of the Compliance Program will be maintaining open channels of communication. Employees, volunteers, Trustees and Medical Staff members mustbewillingtobringforwardproblemsandissues,especiallythosethathaveregulatory implications. In fact, we have an affirmative duty to do so. Managers are expected to maintain an open door policy and be receptive to all concerns brought to them by any employee.every manager alsohastheresponsibilityforensuringthathisorheremployees areawareofandunderstandthecomplianceprogramandreceivethesystem'scompliance CodeofConducttraining. Itisexpectedthatallwhoareemployees,medicalstaffmembers,trusteesorvolunteerswill conduct themselves in a professional and cooperative manner and shall not engage in disruptivebehavior.however,whenworkrelatedproblemsofthesystem'semployeesarise should,wheneverpossible,shouldberesolvedbytheirimmediatesupervisorormanager.in the event the problems cannot be resolved by the employee's immediate supervisor or manager(orintheeventtheimmediatesupervisorormanageristheperceivedsourceofthe problem and the employee does not feel comfortable approaching that individual), the employee should proceed to the next level of management. Any employee legitimately raisingquestionsorrelatingproblemswillnotberetaliatedagainstbyanysystemmanager, employeeorofficial.ifyouareunsatisfiedwiththeresponseorhaveadditionalconcerns, youshouldcontinuethroughthechainofcommand.youmayalsocontactotherresources within the organization including Human Resources, Risk Management and/or the ComplianceOfficer. You need not identify yourself when calling the Hotline. Your anonymity will be maintained. If you choose to identify yourself, your identity will be preserved within the limits of the law. The Compliance Officer will investigate all allegations and concerns raisedthroughthehotline. Dial 1-800-301-3082 to reach the Suburban Hospital Healthcare System Compliance Hotline. 3
QUALITY OF CARE AND PATIENT RIGHTS Providingqualityofcare,whilerespectingtherightsofpatients,isthecentralfocusofthe System.Wearecommittedtoprovidingservicesthatmeetandexceedpatientexpectations whilefocusingoncontinuousimprovementofquality. Weshalltreatallpatients,visitors,employees,medicalstaffandvolunteerswithrespect, dignityandcourtesy. We shall respect the rights and autonomy of all those we serve throughout the organization. Weshallprovidehigh-qualitycareandserviceinaresponsiveandresponsiblemanner. Weshallnotdiscriminatebasedonapatient'srace,age,religion,nationalorigin,gender, sexualorientation,disability,diagnosis,sourceofpaymentorabilitytopay. Weshallprovidecompassionatecareandappropriatetreatmentandservicestopatients that are considerate and respectful of their personal dignity and privacy and their cultural,psychological,andspiritualvaluesandbeliefs. Webelievethepatientcomesfirstanditisourdutytoprotectthepatient'shealth,safety, security,well-beingandcomfort. Weshallconsistentlyprovidequalitycareandmaintainuniformstandardsofcarebased upontheneedsofpatientsinallsettingsofthisorganization. We shall ensure that all patients are evaluated by a qualified healthcare practitioner responsible for determining medical necessity of treatment before a treatment plan involvingourprogramsandservicesisdetermined. We shall make all our care decisions strictly upon medical necessity. Only a qualified healthcarepractitionerwillmakethedeterminationastotreatmentplans. We believe that all patients have the right to be involved in all aspects of their care, participate in the development and implementation of their plan of care, and have sufficient information to provideinformed consent for surgery and other significant or invasivetreatmentsorprocedures. Webelievethatallpatientshavetherighttobefreefromrestraintsandseclusionofany kind that is not medically necessary or is used as a means of coercion, discipline, convenience,orretaliationbystaff. 4
Webelievethatpatientshavetherighttofilecomplaintsandexpectpromptreferralto appropriatehospitaladministrativepersonnelforresolution. We believe that patients have the right for formulate advance directives and to have hospitalstaffandpractitionerscomplywiththosedirectives. We believe that patients have the right, where possible, to an interpreter or other reasonableaccommodation,ifthepatientcannot speak, write,orunderstand spokenor writtenenglish,orthereareotherbarrierstocommunicationduetodisability. Webelievethatpatientshavetherighttoexpectunrestrictedaccesstocommunication (visitors,mail,telephone,etc.)withanypersonorpersonsoftheirchoice,including,but notlimitedto,physicians,attorneysandclergymen,atanyreasonablehour. We shall continuously monitor deficiencies or variance from standard practice. Any identifieddeficiencyorvariancewillbereportedpromptlyandthroughtheappropriate channels.improvementinitiativeswillbeconductedasnecessary. We shall provide an appropriate medical screening examination to any individual who requestsexaminationortreatment,regardlessofabilitytopay,andsuchfurthermedical examination or treatment as required to stabilize any emergency medical condition, or provide a medically appropriate transfer, and will not delay a medical screening examination,oranyfurtherexaminationandtreatmentrequired,inordertoinquireabout theindividual'smethodofpayment,abilitytopay,orinsurancestatus. Wearecommittedtoprotectingtheprivacyofourpatients.Anyuseordisclosureofany patient information that is not in compliance with Federal and State law, and the Hospital spoliciesandprocedures,isstrictlyforbidden. WeshallensurethatindividualsemployedbytheSystemareappropriatelytrainedand qualifiedforthepositiontheyhold. We shall ensure high-quality healthcare through the provision of educational training andteachingexperiencesfor allemployees. 5
HUMAN RESOURCES The System recognizes that all employees, regardless.of job classification, belong to a knowledgeableandskilledhealthteamwhichcontributestopatientcare.wewanttocreate acaringandpositiveenvironmentinwhichallemployeesaretreatedfairlyandhaveample opportunitiesforprofessionaldevelopment. We shall expect all individuals within our facilities to be treated courteously, respectfully,andwithdignity. Weshallrespecttherightsofallemployeesthroughouttheorganization. Weshallconductourselvesinaprofessionalandcooperativemanner. Weshallbehonestintheperformanceofourduties. Weshalloperateinanenvironmentthatisfreeofalcoholandsubstanceabuse. We shall maintain a working environment that is free of harassment, fighting, or violenceofanytype. We shall support equal employment opportunity with hiring, advancement and compensationbasedonmeritandwithoutregardtorace,color,religion,gender,sexual orientation, national origin, age, marital status or disability. We will comply with all lawsrelatedtonon-discriminationinallofourpersonnelactions,includinghiring,staff reductions, transfers, terminations, training, evaluations, recruiting, compensation, benefits,correctiveaction,discipline,andpromotions. We will not take any adverse action against an employee for filing a complaint of discriminationorharassment. We shall continually develop our skills and knowledge in order to better serve our patientcommunity. We shall provide reasonable training to employees to assure they carry out duties in a professionalmanner. Weshallperformdutiesinaccordancewithapplicableprofessionalstandardsandlegal requirements. We shall exercise judgment and objectivity in the performance of our duties. Any differences in opinion in professional judgment should be referred to appropriate managementlevelsforresolutioninaccordancewithstandardprocedures. 6
We shall provide a comprehensive review of employee performance at least annually includinganagreeduponplanfordevelopmentandestablishmentofannualgoals. Weshallcompensateouremployeesfairlyinthecontextofthevalueoftheposition,the externalmarketandtheemployees'overallperformance. We require candor and honesty from all employees in the performance of their responsibilities and in communication with our attorneys, auditors, administrators, supervisors,andfellowemployees. All communication systems, electronic mail, Internet access, and voice mail, are the property of Suburban Hospital Healthcare System and are to be used for business purposes. Prescriptiondrugs,controlledsubstances,andothermedicalsuppliesaretobehandled properly and only by authorized individuals, and any diversion of drugs from the organizationmustbereportedtoasupervisorand/orthecomplianceofficer. Employeesshallnotacceptgifts,favors,services,entertainment,orotherthingshaving more than a nominal value from vendors, contractors, and other third parties to the extentthatdecisionmakingoractionsareinfluenced,orhavetheappearanceofbeing influenced. Employees are prohibited from soliciting or accepting tips, personal gratuities, or gifts frompatients,exceptthatemployeesmayacceptunsolicitedgiftsofanominalornonmonetaryvaluefrompatients. 7
ENVIRONMENTAL CONSIDERATIONS The System is committed to creating and maintaining a safe, compassionate treatment environmentforouremployees,patientsandtheirfamilies. We will comply with all environmental laws and regulations as they relate to our organization s operations, and will operate each of our facilities with the necessary permits,approvals,andcontrols. We will strive to protect employees, patients and the environment from exposure to hazardousandinfectiouswaste. We recognize that all hazardous and infectious waste should be stored, handled and disposedofinfullcompliancewithallfederalandstateregulations. We recognize that unsafe storage of a potentially toxic or hazardous material, the improperreleaseofanysuchmaterialsintotheenvironmentortheunsafetransportation or disposal of any such materials must be immediately reported to the appropriate officialsatthesystem. We shall maintain a drug-free, smoke-free environment. Smoking is permitted only outsideinspecificallydesignatedareas. Weshallmodelandassistinthepromotionofcourteousbehaviorasitrelatestovisitor andemployeeconduct. We shall report to our supervisor any practice or condition that may violate any rule, regulationorstandard,safetyorotherwise. WeshallbefamiliarwithalloftheSystem'ssafetyandhealthproceduresandputthem intodailypractice. We will report in a timely manner all unusual events or accidents, by both verbal and writtenreport,involvingapatient,anemployee,avendororavisitor. We will be alert to equipment and report any hazards or malfunctions to Clinical Engineering. We recognize that possession of a deadly weapon while on duty or on the System's premisesisstrictlyforbidden. Wewillutilizeallrequiredsafetyequipment,followallsafetyproceduresandattendall safetytrainingsessionsasdictatedbythesystem. EmployeesmustwearpictureIDsatalltimes 8
COMPLIANCE WITH LAWS, REGULATIONS AND ACCREDITATION STANDARDS The System strives to comply fully with all of the laws, rules, regulations and applicable accreditationstandardsgoverningthehealthcareindustry. Wearecommittedtocompliancewithallfederal,stateandlocallawsandregulations, including all licensure and Certificate of Need laws and regulations, as well as the Medicarehospitalconditionsofparticipation. Weshallbeguidedbystandardsoflegalandethicalconduct. Weshallmaintaincorporatestandardsthatreflecthonesty,integrityandaccountability inourbusinesspractices. Wehaveanaffirmativedutytodisclosecurrent,accurateandcompletecostandpricing datawheresuchdataarerequiredunderfederalorstatelaworregulation. Weshallensurethatanyfiledcostreportsaccuratelyreflectappropriatecostsincurred forfurnishinghealthcareservicestothebestofourknowledge. Weshallnotengageinanyillegalorunethicalbusinesspractices.Contractual/financial arrangementswithphysicians,vendors,thirdpartypayors,managedcareorganizations orotherreferralsourceswillbestructuredtoensurecompliancewithapplicablefederal andstatelawsandregulations,fulfillthemissionstatementofthesystem,andbeinthe bestinterestsofthesystemandthepatientsweserve. Weshallensurethatalldrugsorothercontrolledsubstancesusedinthetreatmentof patients shall be maintained, dispensed and transported in conformance with all applicablelawsandregulations. We shall not make or offer to make payment or provide anything of value to another person if the intent is with the understanding or intention that such payment is to be used to influence referrals or for any unlawful or improper purpose. Weshallavoidallunethicaland/orillegalconduct. We shall not knowingly take any action that is in violation of any statute, rule or regulation. Wewillcomplywithapplicableantitrustandsimilarlawsthatregulatecompetition. 9
Suburban Hospital Healthcare System and its employees will avoid compensation arrangements in excess of fair market value, will accurately report payments to appropriate taxing authorities, and will file all tax information returns in a manner consistentwithapplicablelaws. Suburban Hospital Healthcare System expects each of its employees to refrain from engaging in activity that may jeopardize the tax exempt status of the organization. SuburbanHospitalHealthcareSystemfundsorresourcesmaynotbeusedtocontribute to political campaigns or for gifts or payments to any political party or any political organization. Any business arrangement with a physician must be structured to ensure compliance withlegalrequirements.sucharrangementsmustbeinwritingand,whereappropriate, reviewed by the Hospital s legal counsel. In order to ethically and legally meet all standards regarding referrals and admissions, we will adhere strictly to the following rules: We do not pay for referrals. We make and accept patient referrals and admissionsbasedsolelyonthepatient sclinicalneedsandourabilitytorender theneededservices. Wedonotacceptpaymentsforreferralsthatwe make. NoSuburban Hospital Healthcare System employee or any other person acting on behalf of the organization is permitted to solicit or receive anything of value, directly or indirectly,inexchangeforthereferralofpatients. SuburbanHospitalHealthcareSystemexpectsitsemployeestorefrainfromconductthat violatesfederalandstateanti-kickback statutes, aswell asthe Stark physicianselfreferrallawandregulations. Allemployeesmustbeknowledgeableabout,andensurecompliancewith,alllawsand regulationsapplicabletotheperformanceoftheirjob,andperformanceevaluationswill takethesefactorsintoaccount. It is the responsibility of each employee to immediately report any violations or suspectedviolationstoasupervisor,administrator,and/orthecomplianceofficer. All employees will deal with accrediting and regulatory bodies in a direct, open and honestmanner.noactionshouldeverbetakeninrelationshipswithanaccreditingor regulatorybodythatwouldpurposelymisleadasurveyteam. 10
CONFLICTS OF INTEREST Trustees, officers, Medical Staff officers and committee members, and employees owe a duty of loyalty to Suburban Hospital Healthcare System. Persons holding such positions maynotusetheirpositionstoprofitpersonallyortoassistothersinprofitinginanywayat the expense of the organization. Employees are expected to conduct the business of the System to the best of their ability and for the benefit of the System and its patients. Employeesmustbecarefulnottocreateanyconflictsofinterest(actualorperceived).Such circumstancesshouldbepromptlyreportedtothecomplianceofficer. WeshallensurethatcharitablecontributionsfromvendorsdirectlybenefittheSystemor thesuburbanhospitalfoundationandarechanneledthroughtheappropriateexecutive. We will manage our contractor and supplier relationships in a fair and reasonable manner,consistentwithallapplicablelawsandgoodbusinesspractices.ourselection ofcontractors,suppliers,andvendorswillbemadeonthebasisofobjectivecriteria,and notonpersonalrelationshipsandfriendships. Weshalladheretotherulesandguidelinesregardingemploymentofrelatives. We shall ensure that proprietary information of the System, including intellectual property;patientrecords,financialconflictinformation,etc.isusedinthebestinterests ofthesystemandthepatientsitserves. Weshallavoidsituationsorcircumstanceswhichinterferewithourabilitytodoourjob properlyandinaccordancewithestablishedrules,regulations,lawsandregulations. We shall disclose to those we serve the relationships that exist among the various entitiesandprovidersinthecorporation. We shall represent ourselves fairly and accurately to the public and we shall provide serviceswithinourcapabilities. 11
SAFEGUARDING RESOURCES AND/OR ASSETS The System expects that resources will be used wisely and in the best interests of the organization.inaddition,wewillmakeeveryeffortpossibletoensurethatthepropertyof ourpatientsissafeguarded. Weshallsupportthecomprehensivesafetymanagementprogram. We shall protect the System's assets and assets of others entrusted to the System including,withoutlimitation,physicalpropertyandproprietaryinformationagainstloss, theft,destruction,misappropriation,andmisuse. We shall take every reasonable precaution to safeguard all confidential information, including, but not limited to, patientrecords, financial records, marketing information, businessplansandpersonalinformationofpatients,employeesandallthoseweserve. Weshallnotallowproprietaryinformationtobemadeavailabletothepublicoranyof ourcompetitors. We shall take every reasonable precaution to limit patient record access to only authorizedindividualswithavalidreasonforaccess. We shall not discuss any patient in an external or internal environment where such informationcouldbeoverheardbyunauthorizedpersonnelorthosewhodonotneedto know. Weshallonlyusecomputersystems,networksandsoftwareasauthorized,andtakeall reasonablestepstoprotectsuchsystemsandtheinformationtheycontain.allsoftware installation must conform to the licensing requirements of the software vendor, and software may be modified only as permitted by the applicable license agreement. PersonalsoftwareshallneverbeinstalledonanyHospitalcomputer. Employeesshallneverborrow,bootleg,orcopyHospitallicensedsoftwareforpersonal use. We shall operate a cost-effective records management policy that ensures appropriate creation,distribution,retention,storage,retrieval,anddestructionofdocuments.each employeeisresponsiblefortheintegrityandaccuracyofourorganization sdocuments andrecords,andnoonemayalterorfalsifyinformationonanyrecordordocument. Medical and business documents and records are retained in accordance with the law andourrecordretentionpolicy. 12
WeshallensurethattheassetsoftheSystemshallbeusedproperlyandinamannerthat supportsthebestinterestsoftheorganizationanditspatients. We shall exercise reasonable care for our own protection and for that of our personal propertywhileonthesystem'spremisesandwhileawayonofficialbusiness. We shall be responsible and accountable for the proper expenditure of the System's fundsandfortheuseofthesystem'spropertyentrustedtous. PersonsnotemployedbytheSystemmaynotsolicitordistributeliteratureonSystem property at any time, for any purpose. Employees of the System may not solicit or distributeliteratureduringworkingtimeforanypurpose,normayemployeessolicitor distributeliteratureatanytime,foranypurpose,inpatientcareareasorotherareasthat wouldcausedisruptionofhealthcareoperationsordisturbanceofpatients. 13
CODING AND BILLING INTEGRITY TheSystemiscommittedtothepropositionthatallpaymentsandothertransactionsmustbe properlydocumentedandauthorizedbymanagement.weexpectthatemployeesandthose professionals working at our facilities will adhere to rules and regulations regarding documentation. All transactions must be accurately and completely supported in the System'sbooksandrecords. Weshallmaintainhonestandaccuraterecordsofallouractivities. Weshallensurethatbillingpracticescomplywithallfederalandstatelawsregulations, guidelinesandpolicies. We shall not knowingly submit a claim or bill for services that were not rendered or were not rendered as described on the claim form or statement, nor shall we misrepresentserviceswhichwererendered,oralteramedicalrecord. We will not submit a claim requesting payment or bill a third party for medically unnecessary services, or seek reimbursement fora service that is not warranted by the patient scurrentmedicalconditionasdocumentedinthemedicalrecordandphysician s orders. Weshallnotknowinglysubmitclaimsforpaymentthathavenotbeenproperlycoded, documentedorbilledaccordingtoallapplicablelawsandregulations. We shall ensure that diagnoses are properly coded and that they are supported by the appropriatemedicaldocumentation. We will not submit bills in a piecemeal or fragmented fashion to maximize the reimbursementforvarioustestsorproceduresthatarerequiredtobebilledtogetherand thereforeatareducedcost( unbundling ),norbillseparatelyforeachcomponentofa group of procedures that are commonly used together for which Medicare and/or Medicaidprovidesaspecialreimbursementrate. Weshallmakeeveryreasonableefforttoidentifyandlocatetheowneroffundsreceived thatarenotduethesystemandpromptlyrefundthem. WewillnotfailtorefundoverpaymentsmadebyaFederalhealthcareprogramorother payor. Weshallpromptlyinformthepayerandcorrectthebillifinaccuraciesarediscoveredin billsthathavebeensubmitted. 14
WeshallsubmitclaimsonlyforservicesorderedandrenderedbyqualifiedHealthCare Professionals. Weshallnotsubmitaclaimcontaininginformationknowntobefalseornotsupportable bythemedicalrecord. We shall assure that all payments and other transactions are properly authorized by managementandproperlydocumentedinthesystem'sbooksandrecords. Wewillnotsubmitmorethanoneclaimforthesameserviceor submitabilltomore thanoneprimarypayoratthesametime( duplicatebilling ). Wewillnotsubmitfalsecostreports. Wewillnotmakefalsestatementstogovernmentalagenciesaboutourcompliancewith anystateorfederalrules. We believe that patients have the right to request and receive an itemized bill and to receiveinformationandcounselingontheavailabilityofknownfinancialresourcesfor healthcare. Weshallofferassistancetopatientsseekingtounderstandthechargesfortheircare. WewillcomplywithFederalandStatelawsrelatingtoallcostreports. 15
SUBURBAN HOSPITAL HEALTHCARE SYSTEM AUDIT AND COMPLIANCE COMMITTEE CHARTER JULY2002 Authority PursuanttotheSuburbanHospitalHealthcareSystembylaws,theAuditandCompliance CommitteeisresponsibleforallauditandcomplianceactivityofSuburbanHospital HealthcareSystem,includingtheentitiesthatmakeupthehealthcaredeliverysystem, exceptforthoseauditsrelatedtoqualityofcareinclinicalareas.thecommittee'sauthority appliestoindependentauditorsandcorporatecompliance.theauditandcompliance CommitteeisastandingcommitteeoftheBoardofTrusteesthatwillmeetnolessthanfour (4)timesperyear. Composition TheAuditandComplianceCommitteeshallconsistofnotlessthanfive(5)members,of whomnotmorethanone(1)shallbeamemberofthefinancecommitteeoftheboardof Trustees,andnotmorethanone(1)shallbeamemberoftheFinanceCommitteeofthe SuburbanHospitalFoundationBoardofTrustees,andnotlessthanthree(3)shallbe memberswithastrongfinance,accountingorbusinessbackgroundwithasound understandingoftheresponsibilitiesofdirectorsandmanagement.thecommitteechair shallhavethenecessaryqualitiestoassumealeadershiprolewithinthegroupandbea SuburbanHospitalHealthcareSystemBoardofTrusteesMember.MembershipontheAudit andcompliancecommitteeshallbeopentoassociatemembersoftheboardoftrustees andsystemmembersoftheboardoftrustees.themajorityofthememberswhoserveon theauditandcompliancecommitteeshallnotsimultaneouslyserveonthefinance Committee. Responsibility IndependentAuditors TheresponsibilityoftheAuditandComplianceCommitteeintheareaoffinancialreporting istoprovideassurancethatfinancialdisclosuresmadebymanagementreasonablyportray SuburbanHospitalHealthcareSystem'sfinancialcondition,resultsfromoperationsand long-termcommitments.specifically,theauditandcompliancecommitteeshould: Establishcriteriafortheselectionandevaluationoftheindependentauditfirm conductingtheyear-endfinancialaudit. Recommendtheappointmentof,negotiatethefeesfor,andbetheauthorizedsignatory oftheengagementletterfortheindependentauditors. Reviewtheindependentauditor'sproposedscopeandapproach,includingany subsequentchanges. Reviewwithmanagementandtheindependentauditors,theannualfinancialstatements, andanydisputes(resolvedorunresolved)betweenmanagementandtheindependent auditorsthataroseinconnectionwiththepreparationandauditofthefinancial statements. 16
Reviewexplanationsofsignificantvariancesinfinancialstatementsbetweenyears. ReviewthemanagementletterthatsuggestsareasofimprovementinSuburbanHospital HealthcareSystem'saccountingandfinancialreportingpractices,internalaccounting controlsandmanagement'sbusinesspractices. Reviewandapprovetheselectionofindependentauditfirmsfornon-auditservices, suchasconsultingservices,asnecessary. CorporateCompliance TheresponsibilityoftheAuditandComplianceCommitteeintheareaofcorporate complianceistoprovideassurancethatthesystemisinreasonablecompliancewith pertinentlawsandregulationsandisconductingitsaffairsethically.theresponsibilityalso includesoversightofthecorporatecomplianceprogram.thepurposeofthecorporate ComplianceProgramistoensurecompliancewithallapplicablelawsandregulationsby promotingethicalbehavioramongemployees,providingappropriateeducationandcreating amechanismforassessment,monitoringandimprovingandtrackingcomplianceactivities. Specifically,theAuditandComplianceCommitteeshould: ReviewandapprovetheSuburbanHospitalHealthcareSystemCorporateCompliance ProgramandanysignificantchangestotheProgram. Reviewcorporatepoliciesrelatingtocompliancewithlawsandregulations,codeof conduct,ethicsandtheinvestigationofmisconductandfraud. ReviewtheCorporateComplianceOfficer'sactivitiesincludingtheanalysisof regulatoryrequirementsandriskareas,theassessmentofcompliancewiththose requirements,thedevelopmentofinternalsystemsandcontrolstopromoteandensure compliance,andthedevelopmentofasystemtosolicit,evaluateandrespondto complaintsandproblems. ReviewtheresultsofreviewsconductedbytheCorporateComplianceOfficerand relatedrecommendationsandimprovements. Reviewcurrent/pendinglitigationorregulatoryproceedingsinwhichthesystemisa party. EnsurethatSuburbanHospitalHealthcareSystemmanagementprovidesadequate considerationtoandimplementstherecommendationsmadebythecorporate ComplianceOfficer. EnsurethattheCorporateComplianceOfficerisabletoperformherfunction independentlyfromanyinappropriateinternalorexternalinfluence. Confer,fromtimetotime,privatelyandseparatelywiththeCorporateCompliance Officerasappropriate. 17