Code of Conduct
Effective Date: May 1, 2019
Seminole Hospital District strives to provide quality healthcare services consistent with the needs of the community while maintaining the financial integrity of the organization.
Seminole Hospital District will set the standard for exceptional healthcare in our region.
- Quality of Care
- Growth and Fiscal Responsibility
- Positive Attitude
MESSAGE FROM THE CEO
Our Code of Conduct (“COC”) is a vital part of achieving our mission and vision, and provides guidance to ensure that our work is performed in an ethical and legal manner. Seminole Hospital District has worked together as a healthcare team to create the core values we believe are at the heart of our existence and are critical to our ability to provide exceptional healthcare to our community and surrounding area.
The COC is the cornerstone of our Compliance Program and is based on appropriate ethical and legal standards that will be updated periodically to reflect changes in law. Our Compliance Program outlines what we do as an organization to comply with legal and ethical requirements. As part of that Compliance Program, we:
- Establish standards with written policies, procedures, and the COC.
- Educate and train our workforce, volunteers, and providers on compliance matters.
- Provide a process for reporting potential violations of laws, policies, or the COC.
- Conduct auditing and monitoring to prevent and identify potential improprieties.
- Conduct investigations and respond to reported compliance issues.
- Perform routine exclusion verifications to ensure we are not conducting business with ineligible parties that cannot participate in federal or state healthcare programs.
- Maintain an effective Compliance Committee and organizational structure.
- Appoint a Compliance Officer with an independent reporting relationship to the Board of Directors.
INTEGRITY WITH PATIENT CARE
We have the gift to recognize and empathize with each individual’s needs and go the extra mile to meet those needs. We will provide support and encouragement in addressing each individual’s needs and will be considerate and understanding to promote a nurturing and healing environment. Our empathy will be demonstrated through kind thoughts, words and actions.
Patients and families are given a statement of patient rights and responsibilities upon admission, including information about the right to make decisions regarding medical care. We involve patients and families in decisions regarding care to the extent that this is practical and possible. We inform patients about therapeutic alternatives and the risks associated with the care they are seeking.
We provide coordinated discharge planning to all patients as an integral part of the treatment plan in order to support the level of medical, psychological, occupational, rehabilitative, and social services needed post-discharge. Patients, families, and caregivers are participants in the care and discharge processes and their preferences and choices are given priority whenever possible. We address the wishes of patients related to advance directives and end- of-life decisions.
Patients and their families trust us with highly personal and sensitive information regarding their medical conditions. We collect information about a patient’s medical condition, history, medication, and family illnesses in order to provide quality care. We are committed to complying with state and federal privacy laws, and to assisting patients with exercising their patient privacy rights.
Federal and state laws govern the privacy of our patients and their health information in verbal, written, and electronic form. The laws apply to the organization, as well as to you as an individual, even after you no longer work here. Patient privacy laws include serious consequences for failing to protect patient privacy, including potential fines, imprisonment, loss of your professional license, and patients’ right to sue both the organization and you personally. Additionally, violating our privacy policies can lead to disciplinary actions, up to and including termination. Our Compliance Officer monitors electronic patient records to determine who is accessing the record and whether the access is consistent with job functions.
We believe in treating others with kindness, dignity, and courtesy regardless of age, race, ethnicity, socio-economic status, sexual orientation, perceived disability, or gender, respecting cultural and religious personal differences. We will speak clearly and concisely to our patients and their families, avoiding the use of complex medical or clinical terminology when possible.
QUALITY OF CARE
We believe in providing healthcare services that exceed the expectations and changing needs of our community. We are committed to putting our patients first, to avoid injuries and provide clinical services based on scientific knowledge, best practice and cost-effectiveness. We provide care that does not vary in quality due to gender, ethnicity, geographic location, socio-economic status, sexual orientation, or perceived disability. We treat all patients and their families with dignity, respect, and courtesy.
BILLING AND FINANCE
Financial assistance is available to patients in the form of charity care based on the patient’s individual financial situation. This assistance supports our statutory responsibility to provide all necessary hospital and medical care for the district’s needy inhabitants. Eligibility criteria may be found in our Charity Care Policy.
DOCUMENTATION, CODING, AND BILLING
Seminole Hospital District will provide medically necessary services that are documented, coded, and billed accurately based on current payor and/or government standards, within the scope of applicable federal, state, and professional guidelines, and applicable staff bylaws.
We believe in advancing and extending the services we provide by responsibly using our assets to protect the future of Seminole Hospital District. We maintain a high standard of accuracy and completeness in the documentation and reporting of all financial records. Our financial information conforms to generally accepted accounting principles (GAAP) or other applicable rules and regulations.
State and federal laws require us to submit reports of our operating costs and statistics, known as cost reports. These laws define what costs are allowable and outline the appropriate methodologies to claim reimbursement for the cost of services provided to government program beneficiaries. We are committed to the preparation, submission and settlement of accurate, timely, and complete cost reports.
Any funds identified and reconciled that we have received (within 6 years) and retained in excess of the amount due or payable will be promptly refunded to the appropriate federal healthcare program and/or in accordance with commercial payors’ policies. A credit balance may exist in a patient account after payment by both the patient and a federal or state healthcare program. We endeavor to accurately track, report, and refund credit balances.
Seminole Hospital District is dedicated to responsible stewardship, and its resources must be used for business purposes and not for personal gain. All accounts, financial reports, tax returns, expense reimbursements, timesheets, and other documents, including those submitted to government agencies, must be accurate, clear, and complete.
ACCURACY OF RECORDS/DOCUMENT RETENTION AND DESTRUCTION
It is our duty to create and maintain accurate and complete records, as well as only destroy organizational records, in compliance with federal and state laws and applicable policies. Seminole Hospital District policies provide guidance on the proper creation, amendment, maintenance, retention, and destruction of our records and documents. Contact the Compliance Officer for additional guidance.
The federal Anti-Kickback Law prohibits individuals and organizations from knowingly or willfully offering or paying, directly or indirectly, any form of remuneration in return for, or to induce, the referral of any patient or business that is covered by Medicare, Medicaid, or any other federal or state healthcare financing program. Remuneration includes kickbacks, bribes, or rebates.
If one purpose or reason for a financial transaction or arrangement with an individual or organization is to induce that individual or organization to refer patients or business to Seminole Hospital District or to recommend the services of either organization, then such transaction or arrangement may constitute a violation of the anti-kickback laws.
All agreements involving patient referral sources, including physicians, hospitals, ambulance services, managed care organizations, and other healthcare organizations and service providers, must be reviewed and approved by our legal counsel prior to execution. Our Contracts Administration Policy provides additional guidance.
We do not engage in activities or negotiate agreements that improperly restrain or obstruct competition or illegally share proprietary information with competitors. The illegal obtainment or use of proprietary information from competitors is strictly prohibited.
Anti-trust violations may subject our organization to severe civil and criminal monetary fines, civil liability for treble damages, and injunctions that could impair our ability to compete effectively. Anti-trust violations may also subject us individually to imprisonment, personal liability, and substantial monetary fines.
We are required not only to comply with the law but also to avoid activities which, though not illegal, may pose unnecessary risks of litigation, government investigation, or injury to our reputation. The limitations on information exchanges with competitors are designed to aid compliance with anti-trust laws and protect our competitive, financial, ethical, and reputational interests. Except with legal advice, we do not communicate with a competitor, either directly or indirectly, about the cost of goods, supplies, equipment, salaries, wages, employment contracts, severance agreements, and other proprietary information.
We are creators and custodians of various types of confidential, proprietary, and private information. Seminole Hospital District workforce and third parties must follow our policies regarding access, use protection, disclosure, retention, and disposal of public, private and confidential information.
CONFLICTS OF INTEREST
Seminole Hospital District workforce have an obligation to be objective and impartial in making decisions on behalf of Seminole Hospital District. External professional activities, private financial interests, or the receipt of a benefit from third parties can cause an actual or perceived conflict between Seminole Hospital District’s interests and an individual’s private interest. Seminole Hospital District workforce will accept payments, remuneration, benefits, awards, and prizes from external entities only in accordance with established Seminole Hospital District policies and standards. Relationships with third parties, such as ownership interests, monetary payments, financial relationships, consulting, board membership, or professional services, with a potential or actual conflict of interest, must be disclosed in writing to our Compliance Officer at the time any such relationship is entered into.
Seminole Hospital District does not hire employees, accept volunteers, contract with, or bill for services rendered by, individuals or organizations excluded from participating in federal or state healthcare programs. This includes exclusion from those programs administered by the DHHS Office of Inspector General List of Excluded Individuals Entities (LEIE), the System for Award Management (SAM), and the State Medicaid exclusion list. We conduct initial excluded parties checks on potential employees, medical staff, vendors, and volunteers, as well as periodic excluded parties checks after the commencement of the relationship to ensure continued eligibility to participate in federal and state healthcare programs. You have a duty to immediately report any change in your eligibility status to the Compliance Officer.
FALSE CLAIMS ACT AND DEFICIT REDUCTION ACT
The state and federal False Claims Act (FCA) and the federal Deficit Reduction Act (DRA) protect government programs such as Medicare, Medicaid, and Tricare from fraud and abuse. It is illegal to submit claims for payment to government programs that we know, or should know, are false or fraudulent. No specific intent to defraud the government is required for a claim to qualify as a false claim. The FCA defines “knowing” to include not only actual knowledge, but also instances of deliberate ignorance or reckless disregard of the truth or falsity of a claim. Filing false claims may result in damages of up to three times the amount of the government program’s loss, fines, imprisonment, entering into a Corporate Integrity Agreement, and exclusion from participation in federal and state health care programs. If you know of a potential false claim, contact our Compliance Officer immediately, or call the Compliance Hotline to notify the Compliance Officer.
We maintain high ethical standards regarding the offering and acceptance of gifts. Offering or accepting personal gifts may influence our decisions, or the decisions of others, and may constitute a conflict of interest. The appropriateness of offering or accepting gifts depends on the specific circumstances of the gift and who is offering and receiving it. For any questions, refer to our Physician Non-Monetary Compensation Policy and to the gifts policy applicable to employees.
All employees must contact the Chief Executive Officer before responding to any media inquiries or initiating contact with the media. Additionally, communications with media involving patient information must comply with federal and state privacy laws in order to fulfill our legal and ethical duty to protect patient privacy.
POLITICAL SUBDIVISION OF THE STATE OF TEXAS
We are a special hospital district created by the Texas legislature under the authority of the Texas Constitution, and as such are a political subdivision of the state of Texas. We have full responsibility under the statutes of the state of Texas for providing hospital care for our district’s indigent residents and are required to provide all necessary hospital and medical care for the district’s needy inhabitants. We are not organized or operated for the benefit of private interests. No organizational earnings may financially benefit any private individual.
POLICIES, LAWS, AND REGULATIONS
Seminole Hospital District is committed to sustaining a culture of trust, ethics, and compliance. We want individuals to be comfortable raising concerns when there is a good faith belief that actions of individuals and/or the organization are not consistent with laws, regulations, policies, or standards. Seminole Hospital District’s leadership is committed to maintaining the community trust by ensuring appropriate actions to resolve non-compliance. Employees, providers, students, vendors, and volunteers will report suspected compliance violations through standard management channels beginning with one’s immediate supervisor, management, the Compliance Hotline, or the Compliance Officer.
POLITICAL CONTRIBUTIONS AND ACTIVITIES
As a political subdivision of the state of Texas, Seminole Hospital District is restricted in the amount of political lobbying activities we may conduct. We are not permitted to influence legislation that is not directly related to our mission. In addition, we may not endorse or intervene on behalf of any candidate for public office and may not solicit funds or endorsements in support of political issues or causes.
As individuals, we may exercise our civil liberties by participating, advocating, or supporting the political candidates and causes of our choice outside of the workplace. Seminole Hospital District’s assets, name, or logo may not be used on any written political material. Political campaign clothing, buttons, or symbols representing a political candidate or cause, excluding health initiatives or those defined as “protected activities” by the National Labor Relations Board, are prohibited on the property of the Seminole Hospital District.
We expect our workforce to report potential violations of compliance law, policy, or our Code of Conduct to the Compliance Officer. Failure to report such violations to the Compliance Officer may result in disciplinary action, up to and including termination. All reports will be evaluated promptly, completely and fairly. You can report compliance concerns in one of the following ways:
- Email your concern to Complianceofficer@seminolehospitaldistrict.com.
- Call the Compliance Hotline provided by Lighthouse Services to include making anonymous reports.
English speaking USA and Canada: 833-950-0009
Spanish speaking USA and Mexico: 800-216-1288
Spanish speaking Mexico: 01-800-681-5340
Reporting a compliance concern in good faith will not jeopardize one’s employment. Retaliation against any individual for reporting a compliance concern in good faith is not tolerated. Confirmed violations of this COC will result in appropriate consequences for the violators, up to and including termination of employment or other relationships with Seminole Hospital District.
We conduct all of our business practices with physicians in conformity with the federal Physician Self-Referral or “Stark” Law. The Stark Law prohibits referrals for certain Medicare items and services furnished by an organization with which the referring physician, or his or her immediate family member, has a financial relationship, unless a specific legal exception applies. We are required to immediately report all known or suspected violations of any of these policies to the Compliance Officer.
Seminole Hospital District may directly engage physicians and community providers to provide certain services, such as on-call coverage, moonlighting, training, consulting, or administrative services, and pay these physicians directly for such services. In such arrangements, there is a direct compensation relationship between the hospital and the physician, and we must consult with our legal counsel to execute a personal services agreement (PSA) with the physician.
We must also strictly follow our organization’s Physician Non-monetary Compensation Policy when offering non-monetary compensation or incidental benefits to physicians or their immediate family members.
We believe in performing our jobs to the highest standards, always demonstrating exceptional character and following the Code of Conduct. We will demonstrate an ethical work environment by being accountable, responsible, dependable, completing jobs assigned, and being flexible with change. We will wear our name badges visibly, greet patients and their families with an uplifting spirit, and be attentive to their needs. We will listen, acknowledge, and respond respectfully to the concerns of our patients and their families, and verify understanding by asking questions and encouraging their feedback.
Seminole Hospital District employees are a network of skilled individuals working together to achieve the common goal of providing exceptional healthcare that benefits the people we serve and our organization. We will offer a safe, positive, and family-oriented environment by executing our core values. We will continue to update our skills, education, and training while responsibly managing the assets of Seminole Hospital District.
As an organization, we are committed to maintaining an environment that is free of unlawful harassment or intimidation. Harassment includes any behavior or conduct that is based on a protected characteristic and that unreasonably interferes with an individual’s work performance or creates an intimidating, hostile or offensive work environment.
Some examples of harassment are: disparaging or abusive words or phrases; persisting in the use of any name or term which you know may be offensive to that individual; or sabotaging someone’s work.
Harassment also includes sexual harassment. The determination of what constitutes sexual harassment may vary with the particular circumstance. In general, unwelcome sexual advances, requests for sexual favors, or other verbal, visual, or physical conduct of a sexual nature may constitute sexual harassment when: submission to such behavior is made a term or condition of employment; submission to or rejection of such behavior is used as a basis for making employment decisions; or such conduct unreasonably interferes with someone’s work performance or creates an intimidating, hostile, or offensive work environment.
WORKPLACE HEALTH AND SAFETY
In our continuing commitment to an environment of healing and good health, smoking is not permitted anywhere inside the hospital buildings or outside on campus. The use of illegal drugs and abuse of controlled substances in the workplace is strictly prohibited. As a condition of employment, any involvement in the unlawful use, sale, manufacture, distribution, or possession of controlled substances, and/or unauthorized use of alcohol in the workplace or working under the influence of such substances is prohibited. Please contact your supervisor or Human Resources if you seek treatment and/or rehabilitation.
We promote personal safety and follow safe workplace practices, including participating in applicable education sessions, using appropriate personal safety equipment, and reporting incidents, injuries, and unsafe situations. We will protect the environment, including carefully handling hazardous waste, harmful agents, materials or conditions, and recycle material whenever possible.