BUSINESS CONDUCT & CODE OF ETHICS

BUSINESS CONDUCT & CODE OF ETHICS

TABLE OF CONTENTS 1. Scpe 2. Purpse 3. Cde f Ethics 4. Hw t Reprt A Cncern (Decisin Tree) 5. Nn-Retaliatin/Nn-Intimidatin 6. Standards fr Business Cnduct-Guiding Principles 6.1. Ethical Business Practices 6.2. Healthcare Fraud, Waste and Abuse 6.3. Cnflicts f Interest 6.4. Gifts, Meals, Entertainment 6.5. Fair Treatment f Individuals 6.6. Fair Taxatin f Individuals 6.7. Quality f Care and Services 6.8. Billing Practices 6.9. Accuracy f Recrds 6.10. Cnfidentiality f Infrmatin 6.11. Infrmatin Technlgy Security 6.12. Marketing 6.13. Imprper Use f Funds 6.14. Excess Benefit Transactins and Intermediate Sanctins 6.15. Plitical Activities and Cntributins 6.16. Health, Safety and Envirnmental Cncerns 6.17. Prtecting Assets 6.18. Gvernment Audits and Reviews 7. Crrective Actin/Discipline 8. Yur Respnsibilities 2

MISSION WE ARE PASSIONATE HEALERS DEDICATED TO HONORING THE SACRED IN OUR BROTHERS AND SISTERS 1. SCOPE: This Cde f Cnduct applies t St. Jseph s Hspital Health Center, St. Jseph s Hspital Health Center Fundatin, Inc., St. Jseph s Cllege f Nursing at St. Jseph s Hspital Health Center, St. Jseph s Health Center Prperties, Inc., St. Jseph s Physician Health P.C., St. Jseph s Medical P.C, Franciscan Assciates, Inc., and any cntrlled subsidiaries f any f thse entities ( St. Jseph s ). 2. PURPOSE: St. Jseph s has adpted the fllwing Cde f Cnduct t prvide standards by which the medical staff, resident physicians, students, clinical affiliates, emplyees, vlunteers, affiliates ( Wrkfrce ), Bard f Trustees and Officers will cnduct themselves in rder t assure that the rganizatin perates in a manner that is cnsistent with laws and regulatins, and t fulfill its Missin. Nte: fr the purpse f this dcument, the term affiliate is defined as an entity that prvides services n behalf f St. Jseph s whse activities have an effect n the claim submissin prcess. 3. CODE OF ETHICS: The Cde f Ethics is based upn the missin f the Sisters f St. Francis f Neumann Cmmunities. The purpse f the Cde f Ethics is t prvide clear behaviral guidelines that determine apprpriate actin in cnducting business and persnal activities at all levels f ur Health Care System. Our Cre Values f Integrity and Reverence fr all are integral t hw we seek t achieve ur missin and visin, as well as ur expectatins f thers. OBJECTIVE: T ensure the integratin f the missin, nrms, visin, and values f St. Jseph s in all ur business practices. T especially cnsider ur ethical behavir in the areas f marketing, admissin, transfer, discharge, billing practices and ur relatinships with ther health care prviders, educatinal institutins, and payrs. INTEGRITY OF SERVICE: T be truthful and accurate in public advertising and infrmatin disseminatin. T emphasize nly thse prgrams deemed necessary fr the cmmunity served. T develp and prvide services t patients in a cmpetent manner. T act with tact and discretin in rder t avid creating uneasiness, fear r anxiety n the part f any patient. T bill patients and /r payrs nly fr services actually prvided and t assist in the understanding f thse csts. T avid the intentinal prvisin f services that are ineffective. T assure that services are nt cmprmised fr financial reasns. T assure that qualified medical persnnel diagnse and treat illness and injury. T prmte that emplyees cnduct their private and prfessinal life in a manner cnsistent with the mral standards represented by St. Jseph's Hspital Health Center. T encurage emplyees t respect cmmunity mral standards. T assure that emplyees nt accept persnal gifts r mney frm patients fr services rendered. T abide by the Hspital s Cnflict f Interest Statement. In the event f questinable practice, refer the matter t the Crprate Cmpliance Cmmittee r t the Chief Cmpliance Officer. T educate staff, patients, and significant thers f the services available thrugh the Ethics Cmmittee. T prvide cnsultatin n patient related ethical issues. REVERENCE FOR ALL: T admit patients and prvide a standard level f care withut regard fr race, clr, creed, natinal rigin, sex, sexual rientatin, age, disability, r ability t pay. T treat everyne in a manner sensitive t the diversity f ethnicity, culture, and lifestyle. T guard carefully the privacy and cnfidentiality f all we serve. T assure that nly the hspital administratr r his/her designated representative may release infrmatin fr publicatin. T seek t reslve cnflict, at whatever levels, fairly and bjectively with respect fr all invlved parties. 4. HOW TO REPORT A CONCERN (DECISION TREE): Each persn is required t reprt a cmpliance cncern and failure t d s culd result in crrective actin/discipline including terminatin. St. Jseph s encurages Wrkfrce members, Bard Members and Officers, t use the fllwing mechanisms t find the answers they need. 3

When yu have a cncern, remember that it is always better t raise a questin befre taking an actin that may be imprper. It is plicy t ensure that n member f the Wrkfrce, Bard Member r Officer is penalized fr raising an issue f cncern. Any member f the Wrkfrce, Bard Member r Officer, may call the Cmpliance Office directly at any time t ask questins r reprt cncerns regarding ethical r legal cnduct. St. Jseph s recmmends that cncerns be directed t the fllwing individuals in the rder they are presented: WORKFORCE: 1. Yur immediate supervisr 2. The Directr r Manager f yur Service Area 3. The Vice President f yur service area 4. Chief Cmpliance Officer: 315-448-5756 5. St. Jseph s Physicians Cmpliance Officer: 315-744-1876 6. Franciscan Cmpanies Cmpliance Officer: 315-458 -3600 x411 7. General Cunsel: 315-448-5880 8. St. Jseph s Cmpliance Annymus Htline: 315-448-6484 9. St. Jseph s Physicians Annymus Htline: 315-744-1465 10. Franciscan Cmpanies Annymus Htline: 315-458-3600 x444 MEDICAL STAFF: 1. Reprt their cncern t the Department Chairman; r 2. The Vice President fr Medical Affairs: 315-448-5880 3. The Medical Staff Directr fr Crprate Cmpliance (Vice President fr the Medical Staff) 4. Chief Cmpliance Officer: 315-448-5756 5. St. Jseph s Cmpliance Annymus Htline: 315-448-6484 BOARD MEMBER OR OFFICER (Cncerns shuld be reprted t ne f the fllwing): 1. Bard Chairpersn 2. President/CEO 3. General Cunsel: 315-448-5880 4. Chief Cmpliance Officer: 315-448-5756 5. St. Jseph s Cmpliance Annymus Htline: 315-448-6484 Fllw-up actins: Yur Cmpliance Officer will initiate an investigatin f apprpriate matters brught t his/her attentin that cannt be therwise reslved at the service area level. The Cmpliance Office will track and manage the issue until it is reslved and will keep Administratrs apprised f the findings. Whenever the identity f the persn filing the reprt is knwn, the utcme f the investigatin will be reprted t the individual. 5. NON-RETALIATION/NON-INTIMIDATION: It is the respnsibility f members f St. Jseph s t create and maintain a wrk envirnment in which individuals are treated with respect and where diversity is valued. Harassment, intimidatin, disruptive behavir r abuse f any kind is prhibited in the wrkplace. NO WORKFORCE MEMBER, BOARD MEMBER OR OFFICER WHO IN GOOD FAITH REPORTS A SUSPECTED COMPLIANCE CONCERN WILL BE SUBJECT TO INTIMIDATION OR RETALIATION. 6. STANDARDS OF BUSINESS CONDUCT GUIDING PRINCIPLES: 6.1 Ethical Business Practices Cnduct business with hnesty, fairness and integrity. These qualities are demnstrated thrugh truthfulness, the absence f deceptin r fraud, and respect fr the laws applicable t ur business. Act with Integrity regardless f facility r lcatin. 6.2 Healthcare Fraud Waste and Abuse St. Jseph s is cmmitted t preventing and detecting healthcare fraud, waste, and abuse. Fraud is when a dishnest prvider (i.e. hspital, physician, diagnstic center, hme care, DME Cmpany) r cnsumer (i.e. patient) submits n purpse r causes smene else t submit, false r misleading infrmatin that is used in deciding hw much healthcare benefits may be paid. There are several things yu can d t reduce the risk f healthcare fraud, waste and abuse. A. Make sure yu understand the rules that relate t the services and gds being prvided and billed. Infrmatin cntained in any claim must be accurate and as cmplete as pssible. B. If yu becme aware f a ptential cmpliance issue yu shuld immediately ntify yur supervisr, the Chief Cmpliance Officer/Cmpliance Officer, r call the Cmpliance Htline. 4

C. Act swiftly s the matter can be reviewed and the prper actin taken. 6.3 Cnflicts f Interest - Avid cnflicts and the appearance f cnflicts f interest. A cnflict f interest ccurs when an individual s private interest interferes in any way r even appears t interfere with the interests f St. Jseph s. A cnflict f interest can arise when any member f the Wrkfrce, Bard Member r Officer, takes an actin r has interests that may make it difficult t perfrm his r her duties bjectively and effectively. Cmpeting respnsibilities, bligatins, and interests are a cnflict f interest. It is never apprpriate fr an individual s actins r decisins made in the curse f his/her business activities t be determined r influenced by cnsideratins f persnal financial gain. All persns are expected t cmpete fairly and in cmpliance with all anti-trust laws. Behavir prhibited under the anti-trust laws include, agreements t fix prices, bid rigging, cllusin (secret cperatin between peple in rder t d smething illegal r dishnest), price sharing with cmpetitrs, byctts, certain exclusive dealing and price discriminatin agreements, unfair trade practices including bribery, misuse f trade secrets, dishnesty, intimidatin and ther unfair practices. If yu think yu may have a Cnflict f Interest, yu are expected t disclse it and btain assistance frm yur Immediate Supervisr r the Chief Cmpliance Officer/Cmpliance Officer t determine if a cnflict exists and hw it shuld be reslved. If a cnflict f interest is cnfirmed t exist, the persn with the cnflict f interest will nt be allwed t make any decisins n the related transactin r arrangement. If a cnflict f interest is nt disclsed, and the failure t disclse is discvered, apprpriate crrective actin r discipline will be taken. 6.4 Gifts, Meals, Entertainment (This sectin applies t emplyees, vlunteers, resident physicians, students, bard members and fficers. Medical staff will fllw the plicy that exists within their private practice) The slicitatin f persnal gifts, lans, business curtesies r services frm any patient, visitr, vendr, cntractr, r anyne that may want t d business with St. Jseph s is nt allwed. Gifts f cash r cash equivalents are never allwed. If a cash r cash equivalent gift r lan is received, it must be returned and the Cmpliance Office ntified. A nn-cash gift f de minimus value (s small in value that it des nt matter) extended as a business curtesy, such as sales prmtin items, fruit baskets r candy is permissible. Unslicited gifts f nminal value (nt t exceed $50.00 in any ne calendar year frm any ne individual r rganizatin) may be permissible. Any nn-cash gifts that exceed r has the ptential t exceed $50.00 per calendar year must be disclsed t the individual s Manager, Directr r Vice President r the Cmpliance Officer s that it may be reviewed. All decisins made must be dcumented in writing t the emplyee making the request. Reasnable business curtesies such as meals, attendance at sprting events, glf turnaments, lcal entertainment, business meetings, cnferences extended by vendrs r ther persns which d business with St. Jseph s r may want t d business with St. Jseph s is allwed as lng as the individual is representing and acting in the best interest f St. Jseph s, and reprts n such activity n a quarterly basis t the individual s Directr, Vice President f service area r the Chief Cmpliance Officer. Leadership is prhibited frm taking these curtesies int accunt when awarding r renewing cntracts r purchasing items r services. 6.5 Fair Treatment f Individuals The greatest strength f St. Jseph s, lies in the effrts and talents f ur Wrkfrce wh create ur success and reputatin. We treat each ther with respect, dignity, fairness and curtesy. It is the respnsibility f leadership t create and maintain a wrk envirnment in which individuals are treated with respect. Discriminatin is prhibited in any wrk-related decisin and equal emplyment pprtunities are prvided t prspective and current emplyees, based slely n merit, qualificatins and abilities. St. Jseph s des nt discriminate in emplyment pprtunities r practices n the basis f race, clr, religin, sex, natinal rigin, ancestry, age, physical r mental disability, sexual rientatin, veteran status r any ther status prtected by law. St. Jseph s supprts and bserves a wrkplace and campus free f alchl, drugs and smking. 5

St. Jseph s seeks a Wrkfrce, vendrs, and business partners wh have nt been sanctined by any regulatry agency and are able t perfrm their designated respnsibilities. 6.6 Fair Taxatin f Individuals All cmpensated Wrkfrce members and independent cntractrs will be prperly taxed fr emplyment r services rendered in cmpliance with state and federal tax laws. 6.7 Quality f Care and Service 6.8 Billing Practices St. Jseph s is cmmitted t the greatest pssible penness and frankness in medical errr reprting subject t specific limited qualificatins set ut belw, n blame will be assigned t individuals fllwing their reprting f medical errrs including thse instances where they themselves may have nt fllwed (breached) plicies and prcedures. The nly exceptin t this general plicy f n blame relates t the fllwing serius failures f staff members t act respnsibly, thereby creating r wrsening risk expsures t patient safety. A. Premeditated r intentinal acts f vilence against peple r damage t equipment/prperty, B. Actins r decisins invlving a reckless (cnscius) disregard f a visible, significant risk tward the safety f ur patients r ur fellw emplyees, C. Practicing under the influence f alchl r drugs. Individuals wh act irrespnsibly in ne f these ways remain expsed t disciplinary actin. Outside these specific and rarely invked exceptins, Wrkfrce members wh make hnest mistakes r misjudgments will nt incur blame; prvided that they reprt such events in a timely and prper fashin. St. Jseph s must ensure that cding and billing are perfrmed accurately and cmpletely, in accrdance with natinally recgnized standards and rules. Failure t d s can result in penalties and fines being impsed n individuals and entities, like St. Jseph s, as indicated in the NYS False Claims Act and/r the Federal False Claims Act. St. Jseph s nly bills fr services that are actually rendered. Prper medical dcumentatin must be prvided t substantiate all services rendered. Billing will be submitted nly fr services and care prvided and dcumented, and rendered in accrdance with medical necessity guidelines. (If it s nt dcumented, it wasn t dne and can t be billed) St. Jseph s ensures that all payments and ther transactins are prperly authrized by management and prperly dcumented in the system s bks and recrds. Payrs must be ntified f payment errrs and refunds are t be prmptly and accurately prcessed. 6.9 Accuracy f Recrds Prepare and maintain all patient and cmpany recrds, bth written and electrnic, accurately and retains such recrds fr perids described by law and by St. Jseph s plicy. Ensure that all patients and business recrds fr which yu are respnsible are accurate and cmplete. N ne may erase, falsify r impermissibly alter infrmatin n any St. Jseph s recrd r dcument. Financial transactins shuld be recrded in accrdance with generally accepted accunting principles and St. Jseph s plicies and prcedures. 6.10 Cnfidentiality f Infrmatin Prtect cnfidential and prpriety infrmatin Observe cpyrights, trademarks and/r licenses and safeguard the intellectual prperty f St. Jseph's and thse with whm we d business Infrmatin related t the peratins, activities, business affairs and finances f St. Jseph s is cnfidential and shuld nt be disclsed t anyne utside f the St. Jseph s including friends, family, relatives, business r scial acquaintances, custmers, suppliers r thers. D nt disclse this infrmatin t ther members f the Wrkfrce except n a need t knw basis with the understanding that the individual receiving the infrmatin needs t treat it as cnfidential. All patient infrmatin is regarded as cnfidential, regardless f the medium (written, verbal, electrnic) and available t authrized persns. Fr example, an authrized persn culd be a treating r cnsulting physician, an emplyee that may be prviding patient care, an emplyee that is carrying ut a healthcare peratins prcess, r t a third party in rder t facilitate reimbursement. N member f ur Wrkfrce has a right t access any patient infrmatin than what is needed t d his r her jb. As a result, in general, we d nt use, disclse r discuss patient specific infrmatin with thers unless it is necessary t treat the 6

patient, we have the patient s explicit cnsent (this is called an authrizatin), r it is required by law. Never disclse cnfidential patient infrmatin t any unauthrized persn. When using scial media and scial netwrking sites d nt publish any infrmatin abut a patient either specifically r in general. This includes but is nt limited t any infrmatin that may be cnsidered a distinguishing characteristic and/r case uniqueness. The nly exceptin in the case f scial netwrking pstings is Public Relatins and Marketing. 6.11 Infrmatin Technlgy Security Abide by all infrmatin security plicies. D nt access, attempt t access r allw unauthrized individuals t access systems r physical areas withut prper authrizatin. D nt share yur unique user name and passwrd. Reprt any actual r suspected unauthrized access r attempted unauthrized access. 6.12 Marketing Represent St. Jseph s accurately and truthfully and avid any false, misleading r deceptive infrmatin that wuld create unreasnable expectatins. Our Cathlic heritage hlds us t be mindful f the trust the cmmunity places in us t prvide advertising that prmtes ur rganizatins withut disparaging r demeaning ur cmpetitrs. 6.13 Imprper Use f Funds St. Jseph s funds may nt be used fr imprper r illegal activities. Any payment that may be viewed as a bribe, kickback r inducement is prhibited. A bribe r kickback is any payment r cnsideratin f value ffered with the intent t influence a decisin n grunds nt directly related t its business merits. Payments r cnsideratins f value given t physicians r ther parties t influence referrals t St. Jseph s are inducements and are prhibited. 6.14 Excess Benefit Transactins and Intermediate Sanctins (nnprfit entities nly) The Internal Revenue Cde defines an excess benefit transactin as a transactin in which the ecnmic benefit prvided by a tax exempt rganizatin directly r indirectly t a disqualified persn exceeds the cnsideratin (benefit) the tax exempt rganizatin receives fr prviding the benefit. Disqualified Persns are fficers, directrs, and ther individuals with substantial influence ver the rganizatin. These rules apply t St. Jseph s nnprfit entities and must be adhered t strictly. Any cmpensatin r business transactin cvered by these rules shuld be reasnable. Objective infrmatin will be btained and analyzed t determine if a transactin r cmpensatin may be cnsidered fair and reasnable. 6.15 Plitical Activities and Cntributins (nnprfit entities nly) All Sectin 501 (c) (3) rganizatins and are abslutely prhibited frm directly r indirectly participating in, r intervening in any plitical campaign. Vilatin f this prhibitin may result in denial r revcatin f taxexempt status and the impsitin f excise taxes. The IRS defines plitical campaign interventin as including any and all activities that favr r ppse ne r mre candidates fr public ffice. Prhibited Activities: Neither St. Jseph s r any individual acting n behalf f St. Jseph s may engage in the fllwing plitical activities: A. Dnating r cntributing t any plitical campaign fr any federal, state, r lcal ffice; B. Any campaigning by a St. Jseph s Wrkfrce member, fficers, directrs, r agents n St. Jseph s prperty r during wrking time; C. Any endrsement f candidates thrugh St. Jseph s; D. Any fund raising fr r against candidates thrugh St. Jseph s; E. And any ther activity that encurages peple t vte fr r against a specific candidate thrugh St. Jseph s. F. Unintentinal actins are equally prhibited, e.g., the mere fact that an imprper expenditure ccurred, regardless f intent, is a vilatin. Candidates fr public ffice may be allwed t appear r speak at an rganizatin s events in a nncandidate capacity. If the individual is publically recgnized by St. Jseph s, St. Jseph s must ensure that the individual is chsen t speak slely fr reasns ther than candidacy fr public ffice. If there are any questins the Cmpliance Office shuld be cnsulted befre planning any such event. 6.16 Health, Safety and Envirnmental Cncerns 7

6.17 Prtecting Assets Cmply with all applicable health, safety and envirnmental laws and regulatins within the wrkplace; thereby prviding a safe physical envirnment that is reasnably free f hazards and staff activities are managed t maintain the envirnment in a safe secure atmsphere fr patients, emplyees, visitrs and the general public. Prperty is made available t the Wrkfrce, Bard Members and Officers, and shall nly be used fr business purpses. This applies t physical asset such as ffice equipment, cmputers, sftware and supplies r medical supplies, as well as ther types f prperty, such as cmpany recrds, patient infrmatin and custmer lists. 6.18 Gvernment and Investigatins Cperate with legitimate gvernment investigatins. If any persn wh identifies him r herself as a gvernment investigatr appraches a Wrkfrce member, Bard Member r Officer, they may rely n any f the fllwing t verify identity: If the request is made in persn, presentatin f an agency identificatin badge, ther fficial credentials, r ther prf f gvernment status; If the request is in writing, the request is written n apprpriate gvernment letterhead; If the request is by telephne, the Wrkfrce member must btain the requesting persn s phne number and cnfirm their affiliatin. Gvernment investigatrs r persns presenting themselves as gvernment investigatrs, may cntact individuals utside f the wrkplace, during nn-wrking hurs, r at hme. It is the legal right f individual s t cntact legal cunsel befre respnding t questins by an investigatr. Individuals must never: Destry r alter any system dcument/recrd fr the purpse f when respnding t a request. Lie r make false r misleading statements t any gvernment investigatr. Attempt t persuade any ther persn, Wrkfrce member, Bard Member r Officer, t prvide false r misleading infrmatin t a gvernment investigatr r t fail t cperate with a gvernment investigatin. 7. CORRECTIVE ACTION/DISCIPLINE: St. Jseph s may impse sanctins n any member f the Wrkfrce, Bard Member r Officer, wh intentinally r unintentinally vilates established plicies r prcedures. This means that every cnfirmed act f nn-cmpliance may result in crrective actin r discipline. Sanctins, which are penalties impsed, can result in nt nly disciplinary actin placed in persnnel files, but the remval f privileges, discharge f emplyment, cntract penalties, and in sme cases civil and/r criminal prsecutin. 8. YOUR RESPONSIBILITIES: Attend required training, and read and understand the St. Jseph s Business Cnduct & Cnduct f Ethics. Fllw the St. Jseph s Business Cde f Cnduct and abide by all plicies and prcedures, guidelines, and Federal and State laws and regulatins. Be alert t any situatin that culd vilate the St. Jseph s Business Cnduct & Cde f Ethics, plicies and prcedures, guidelines and/r federal and state laws and regulatin. Prmptly reprt any issues, cncerns, vilatins r suspected vilatins t yur supervisr, ther management staff, Cmpliance Officer r thrugh the cmpliance ht lines. DO THE RIGHT THING EVERY TIME 8

RELATED DOCUMENTS 1. Emplyee Handbk 2. Internal Auditing and Mnitring 3. Crprate Cmpliance Htline Calls 4. Crprate Cmpliance Inquiries & Investigatins 5. Ntificatins 6. Risk Mitigatin 7. Medical Staff By-Laws 8. Medical Staff Rules and regulatins 9. Annual In-service 10. Identity Theft Detectin and Preventin 11. Cnfidentiality and Patient Privacy 12. Electrnic PHI Integrity 13. Wrkstatin Usage & Security 14. Infrmatin Security Plan 15. Nn-Intimidatin/Nn-Retaliatin, Whistleblwer Prtectin Plicy 16. Investigatins (What t d if an investigatr cmes t yur service area.) 17. Outside Services by Leadership Original: August 2000 Revised: May 2001 Reviewed: June 2002 Revised: Nvember 2003 Revised: June 2006 Revised: July 2007 Revised: December 2008 Revised: May 2009 (editrial) Revised: September 2010 Revised: Nvember 2011 (editrial) Revised: April 2012 (editrial) Revised: July 2014 9