Code of Conduct
2705 Mountain View Drive
La Verne, CA 91750
Phone: (909) 593-4917 Fax: (909) 392-4390
Table of Contents
Scope of our Program-
Our Compliance and Ethics Program Code of Conduct covers the compliance issues, laws and regulations, and guidelines that are relevant to a provider of senior services including Senior Living Communities that provide a wide range of healthcare services. This includes but is not limited to Medicare and Medicaid regulatory issues; guidelines from the Office of Inspector General, Internal Revenue Service, and the Office of Civil Rights of the Department of Health and Human Services, Occupational Safety and Health Administration; as well as other federal and state regulatory and business issues. The program fosters a culture of compliance that promotes legal and ethical behavior in the workplace by creating processes that detect and prevent fraud, waste, abuse, and policy violations. The Code of Conduct is supported by our compliance policies and procedures and should be read and understood jointly with those policies and procedures.
We use the term Associate to define the various individuals who are associated with Brethren Hillcrest Homes (Hillcrest). All individuals, including employees, contractors, volunteers, directors, and officers are members of our team in providing care and services to our residents. We use the term Resident to refer to individuals who receive the various types of healthcare and other services that we provide.
Any questions regarding the policies in this Code of Conduct, compliance policies, or related references, should be directed to your immediate supervisor, the Compliance Official, a member of the Compliance Committee, or the Compliance Officer.
Hillcrest is a Continuing Care Retirement Community licensed under the laws of California to provide the following services:
The Friends Services for the Aging (FSA) Vice President of Compliance, Karla Dreisbach, CHC, CHPC, serves as our Compliance Officer. She has the responsibility to assist the Compliance Official, the CEO, and the Board of Directors in designing and overseeing efforts in establishing, maintaining, and monitoring compliance within our organization.
The Compliance Officer works with our Compliance Official and has direct reporting responsibility to the Board of Directors. The Compliance Officer is responsible for continued coordination with the Compliance Official for the development, implementation, training, monitoring, and enforcement activities related to the overall compliance program. The Compliance Officer is assisted by Peace Church Compliance Program (PCCP) Compliance Managers and Compliance Specialists in providing services to our organization.
Our Board of Directors, through the President and CEO, carries the overall responsibility for creating a culture that values and emphasizes compliance and integrity.
Winnie Dang has been appointed by the Board of Directors as the Compliance Official and is responsible for coordinating the day-to-day compliance activities in conjunction with the Compliance Officer. These activities include audits, responses to hotline calls, and leading the organization’s Compliance Committee.
The Hillcrest Compliance Committee is comprised of members of the management team and other key staff positions. The Compliance Official is the chairperson for this committee. The committee meets at least quarterly, and more frequently as needed.
Hillcrest requires the highest standards of conduct from each Associate in order to maintain its outstanding reputation, strengthen the confidence of residents, associates, and family members, and to preserve the respect of its business partners.
In accordance with our core value of integrity, the Code of Conduct outlines the standards and expectations that you will be required to uphold throughout your employment at Hillcrest. These standards include (but are not limited to) the following:
personal benefits as a result of one’s position at Hillcrest from residents,
resident family members, vendors, etc.
Hillcrest and appropriate government entities.
Resources personnel, Corporate Compliance, or the Corporate Compliance
Hotline at (909) 392-4185.
We have great hopes and high expectations for each of you. We look forward to the contributions each of you will make at Hillcrest as you join in our commitment to serve and enrich the lives of older persons through quality services and facilities. It is my hope and expectation that each of us will do so.
President and Chief Executive Officer
Brethren Hillcrest Homes
Code of Conduct
The Code of Conduct is the foundation of the Compliance and Ethics Program. The Code of Conduct is a guide to appropriate workplace behavior and it is intended to help you make the right decisions if you are not sure how to respond to a situation. All Associates must comply with both the spirit and the letter of all federal, state, and local laws and regulations that apply to the healthcare and other services that our organization provides, as well as all laws that apply to our business dealings. Violations of these laws and regulations can result in severe penalties for us and the individuals we do work with including financial penalties, exclusion from participation in government programs, and, in some cases, imprisonment.
As Associates, we share a commitment to legal, ethical, and professional conduct in everything that we do. We support these commitments in our work each day, whether we care for residents, order supplies, prepare meals, keep records, pay invoices, or make decisions about the future of our organization.
The success of Hillcrest as a provider of healthcare and other services depends on you, your personal and professional integrity, your responsibility to act in good faith, and your obligation to do the right things for the right reasons.
The Compliance and Ethics Program provides principles and standards to guide you in meeting your legal, ethical, and professional responsibilities. As an Associate, you are responsible for supporting the Compliance and Ethics Program in every aspect of your workplace behavior. Your continued working relationship with our organization includes understanding and adhering to the Compliance and Ethics Program.
The Code of Conduct discusses the importance of:
Care Excellence – providing quality, compassionate, respectful, and clinically-appropriate care.
Professional Excellence – maintaining ethical standards of healthcare and business practices.
Regulatory Excellence – complying with federal and state laws, regulations, and guidelines that govern healthcare, housing services, and other services we provide.
Because we are in the business of caring for and providing services for others, it is critical that each of us adheres to appropriate standards of behavior. As individuals and as an organization, we are responsible to many different groups. We must act ethically and responsibly in our relations with:
Any compromise in our standards could harm our residents, our co-workers, and our organization. Like every organization that provides healthcare, we do business under very strict regulations and close governmental oversight. Fraud, waste, and abuse are serious issues. Sometimes even an innocent mistake can have significant consequences that could result in substantial penalties to Hillcrest.
All Associates are required to complete training on the Code of Conduct and the Compliance and Ethics Program as a condition of employment or business relationship. The Code of Conduct sets forth mandatory standards.
There is no justification for departing from the Code of Conduct no matter what the situation may be.
Every Associate is responsible for ensuring that he or she complies with the Code of Conduct and all policies and procedures. Any Associate who violates any of these standards and/or policies and procedures is subject to discipline up to and including termination.
As we are each responsible for following the Code of Conduct in our daily work, we are also responsible for enforcing it. This means that you have a duty to report any problems you observe or perceive, regardless of your role.
As an Associate, you must help ensure that you are doing everything practical to comply with applicable laws. If you observe or suspect a situation that you believe may be unethical, illegal, unprofessional, or wrong, or you have a clinical, ethical, or financial concern, you must report it. You are expected to satisfy this duty by complying with the Three Step Reporting Process. If you fail to report noncompliance with the Code of Conduct, policies and procedures, or applicable federal or state laws, you will be subject to discipline up to and including termination. We have a zero tolerance for retaliation. No one may retaliate against a member who reports a concern in good faith.
The Three Step Reporting Process
First, talk to your supervisor. He or she is most familiar with the laws, regulations, and policies that relate to your work.
Second, if you do not want to talk to your supervisor, seek out another member of the leadership team or someone from human resources.
Third, if you still have a concern, contact the Compliance Official, a member of the organization’s Compliance Committee, or the Compliance Officer.
You may also call the toll free Compliance Line number at any time.
Compliance Line at 800-211-2713
All calls are confidential and you may call ANONYMOUSLY if you choose.
The Compliance Line is available 24 hours a day, 7 days a week, for callers to report compliance-related issues. Concerns that are reported to the Compliance Line are taken seriously.
You can make calls to the Compliance Line without fear of reprisal, retaliation, or punishment for your actions. Anyone, including a supervisor, who retaliates against an Associate for contacting the Compliance Line or reporting a compliance issue in any other manner will be disciplined.
Our most important job is providing quality care to our residents. This means offering compassionate support to our residents and working toward the best possible outcomes while following all applicable rules and regulations including the Medicare Conditions of Participation.
Residents receiving healthcare and other services have clearly defined rights. A document describing these rights is provided to each resident upon admission and is posted in conspicuous locations throughout the organization for the residents’ and your reference. To honor these rights, we must:
We will not tolerate any type of resident abuse or neglect – physical, emotional, verbal, financial, or sexual. Residents must be protected from abuse and neglect by Associates, family members, legal guardians, friends, or any other person. This standard applies to all residents at all times.
Federal law defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain or mental anguish. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The failure to follow a resident’s care plan may constitute abuse.
The State of California defines abuse as having:
Occur[red] when any person who, under circumstances or conditions likely to produce great bodily harm or death, willfully causes or permits any elder or dependent adult, with knowledge that he or she is an elder or a dependent adult, to suffer, or inflicts thereon unjustifiable physical pain or mental suffering, or having the care or custody of any elder or dependent adult, willfully causes or permits the person or health of the elder or dependent adult to be injured, or willfully causes or permits the elder or dependent adult to be placed in a situation in which his or her person or health is endangered.
Any Associate who abuses or neglects a resident is subject to termination. In addition, legal or criminal action may be taken. Abuse and neglect MUST BE REPORTED IMMEDIATELY to your supervisor or other member of management.
The Elder Justice Act requires timely reports of any reasonable suspicion of a crime against a resident of a long term care facility. You must report your reasonable suspicion to the California Department of Public Health Services and the Department of Social Services and local law enforcement within two (2) hours if the suspected crime involves serious bodily injury or within 24 hours if the suspected crime does not involve serious bodily injury.
DO NOT call the Compliance Line for allegations of abuse or neglect.
Report abuse or neglect immediately to your supervisor!
All Associates must use and disclose medical, financial, or personal information only in a manner consistent with the HIPAA Privacy policies and procedures and state and federal law. You are responsible for keeping resident protected health information (PHI) confidential. PHI is defined as individually identifiable health information that is transmitted or maintained in any form or medium, including electronic health information.
Any unauthorized exposure of PHI which compromises the security or privacy of information is a potential breach.
If you become aware of a breach of any protected or sensitive information it is important that you report it immediately to your supervisor or the Privacy Officer.
If the disclosure results in a breach, Hillcrest must investigate and comply with all state and federal HIPAA regulations for breach notification.
Associates must respect residents’ personal property and protect it from loss, theft, damage, or misuse. Associates who have direct access to resident funds (e.g., resident trust funds) must maintain accurate records and accounts.
As a CCRC, our primary commitment is to provide the care, services, and resources necessary to help each resident reach or maintain his or her highest possible level of physical, mental, and psychosocial well-being. Hillcrest has policies and procedures and provides training and education to help each Associate strive to achieve this goal.
Our care standards include:
We are committed to providing comprehensive, medically necessary services for our residents. The Medical Director provides oversight to physicians and other medical providers and services as defined by state and federal regulations. The Medical Director oversees the care and treatment policies and is actively involved in the Quality Assurance Performance Improvement (QAPI) Committee.
The professional, responsible, and ethical behavior of every Associate reflects on the reputation of our organization and the services we provide. Whether you work directly with residents or in other areas that support resident services, you are expected to maintain our standards of honesty, integrity, and professional excellence, every day.
Hiring and Employment Practices
Hillcrest is committed to fair employment practices. When hiring and evaluating, we:
Associates are screened in accordance with federal and state law to ensure the safety of our residents. Screening procedures have been implemented and are conducted prior to hire and at a minimum of quarterly thereafter.
Hillcrest is prohibited by federal law from employing, retaining, or contracting with anyone who is excluded from any federal or state funded programs. Screening of all Associates through the Office of Inspector General’s List of Excluded Individuals and Entities, GSA’s System of Award Management, and the California Medi-Cal Suspended and Illegible Provider List database is conducted prior to hire and at a minimum of quarterly thereafter.
As long as you are employed or affiliated with Hillcrest, you must immediately report to your supervisor:
We are committed to ensuring that only qualified professionals provide care and services to residents. Practitioners and other professionals treating residents must abide by all applicable licensing, credentialing and certification requirements. In addition, every effort is made to validate licenses and certification through the appropriate state or federal agency.
To maintain an ethical, comfortable work environment, staff must:
Maintaining a safe workplace is critical to the well-being of our residents, visitors, and co-workers. That is why policies and procedures have been developed describing the organization’s safety requirements. Every Associate should become familiar with safety regulations and emergency plans regarding fire and disaster in his or her work area.
In addition to organizational policies, we must abide by all environmental laws and regulations. You are expected to follow organizational safety guidelines and to take personal responsibility for helping to maintain a secure work environment. If you notice a safety hazard, you must take action to correct it if you can or to report it to your supervisor immediately.
We are committed to maintaining a team dedicated and capable of providing quality resident services. To that end, you are prohibited from consuming any substance that impairs your ability to provide quality services or otherwise perform your duties.
You may never use, sell, or bring on our property alcohol, illegal drugs, and/or narcotics or report to work under the influence of alcohol, illegal drugs, and/or narcotics. For an Associate who appears to have work performance problems related to drug or alcohol use, a drug and alcohol screening will be conducted and appropriate action will be taken, if necessary.
Illegal, improper, or unauthorized use of any controlled substance that is intended for a resident is prohibited. If you become aware of any improper diversion of drugs or medical supplies, you must immediately report the incident to your department supervisor, the Compliance Official, the Compliance Officer, or the Compliance Hotline. Failure to report a known instance of noncompliance with this policy may result in disciplinary action against the Associate, up to and including termination.
Professional excellence in organizational relations includes:
In the performance of your duties you, may have access to, receive, or may be entrusted with confidential and/or proprietary information that is owned by Hillcrest and that is not presently available to the public. This type of information should never be shared with anyone outside the organization without authorization from a member of the leadership team.
Examples of proprietary information that should not be shared include:
You may not accept any tips or gratuities from residents and you may not receive individual gifts from residents. You may not give gifts to residents.
Associates may accept gifts from “gift funds” established from resident funds so long as the gifts provided to employees are of equal value and the contributions by residents to the “gift fund” are voluntary and anonymous such that there is no way for an employee who benefits from the fund to determine whether a resident contributed to the fund.
You may not borrow money from nor lend money to residents; nor may you engage with residents in the purchase or sale of any item. No Associate may accept any gift from a resident under a will or trust instrument except in those cases where they are related by blood or marriage.
Associates may not serve as a resident’s executor, trustee, administrator, or guardian or provide financial services or act under a power of attorney for a resident except in those cases where they are related by blood or marriage unless otherwise allowed by state law.
Hillcrest prohibits any Associate from offering, giving, soliciting, or accepting business or professional courtesies including entertainment and gifts that could be interpreted as attempts to influence decision making. Under no circumstances will an Associate solicit or accept business courtesies, entertainment, or gifts that depart from the Business Gifts and Entertainment policy.
A conflict of interest exists any time your loyalty to the organization is, or even appears to be, compromised by a personal interest. There are many types of conflict of interest and these guidelines cannot anticipate them all, however the following provide some examples:
All Associates must seek guidance and approval from our CEO or Compliance Official before pursuing any business or personal activity that may constitute a conflict of interest.
We must protect the assets of the organization and ensure their authorized and efficient use. Theft, carelessness, and waste have a direct impact on the organization’s viability. All assets must be used solely for legitimate business purposes.
Everyone must make sure that they:
Associates are expected to use computers, email, and internet/intranet systems appropriately and according to the established policy and procedure. You are not permitted to use the Internet for improper or unlawful activity or download any games or music without prior approval.
Internet use can be tracked and how you use your time on the Internet may be monitored. You should have no expectation of privacy when you use our computers, email, and internet/intranet system. Hillcrest has the right to sanction or discipline employees who violate the Code of Conduct in a digital, cyber, or other non-face-to-face environment. You should be familiar with our Social Media policy and abide by it.
We take responsibility for being a good client and dealing with vendors honestly and ethically. We are committed to fair competition among prospective vendors and contractors for our business. Arrangements between Hillcrest and its vendors must always be approved by management. Certain business arrangements must be detailed in writing, and approved by management. Agreements with contractors and vendors who receive resident information, with the exception of care providers, will require a Business Associate Agreement (BAA) with the organization as defined by HIPAA. Contractors and vendors who provide resident care, reimbursement, or other services to resident beneficiaries of federal and/ or state healthcare programs are subject to the Code of Conduct and must:
We use marketing and advertising activities to educate the public, increase awareness of our services, and recruit new Associates. These materials and announcements, whether verbal, printed, or electronic, will present only truthful, informative, non-deceptive information.
Because we are in healthcare, we must follow the many federal, state, and local laws that govern our business. Keeping up with the most current rules and regulations is a big job – and an important one. We are all responsible for learning and staying current with the federal, state, and local laws, rules, and regulations, as well as the policies and procedures that apply to our job responsibilities.
Billing and Business Practices
We are committed to operating with honesty and integrity. Therefore, all Associates must ensure that all statements, submissions, and other communications with residents, prospective residents, the government, suppliers, and other third parties are truthful, accurate, and complete.
We are committed to ethical, honest billing practices and expect you to be vigilant in maintaining these standards at all times. We will not tolerate any false or inaccurate coding or billing. Any Associate who knowingly submits a false claim, or provides information that may contribute to submitting a false claim such as falsified clinical documentation, to any payer – public or private – is subject to termination. In addition, legal or criminal action may be taken.
Prohibited practices include, but are not limited to:
Associates and related entities often have close associations with local healthcare providers and other referral sources. To demonstrate ethical business practices, we must make sure that all relationships with these professionals are open, honest, and legal.
Resident referrals are accepted based solely on the clinical needs and our ability to provide the services. Hillcrest never solicits, accepts offers, or gives anything of value in exchange for resident referrals or in exchange for purchasing or ordering any good or service for which payment is made by a federal health care program. Anything of value includes any item or service of value including cash, goods, supplies, gifts, “freebies,” improper discounts or bribes.
Accepting kickbacks is against our policies and procedures and is also against the law. A kickback is anything of value that is received in exchange for a business decision such as a resident referral. To assure adherence to ethical standards in our business relationships, you must:
You cannot request, accept, offer, or give any item or service that is intended to influence – or even appears to influence – the referral, solicitation, or provision of healthcare service paid for by any private or commercial healthcare payer or federal or state healthcare program, including Medicare and Medicaid, or other providers.
You may not provide anything of value including goods, services, or money to prospective residents or any beneficiary of a federal or state healthcare program that you know or should know will likely influence that person’s selection of a provider of healthcare services.
For the purposes of this policy, anything of value includes but is not limited to any waiver of payment, gift, or free service that exceeds a value of $10 per item or $50 annually in total. If you have a question about whether a particular gift or service would be considered “of value,” ask your supervisor or the Compliance Official.
Most print and electronic materials are protected by copyright laws. Associates are expected to respect these laws and not reproduce electronic print or printed material without obtaining permission as required by the writer or publisher. When in doubt, ask your supervisor.
Ensuring that financial and operating information is current and accurate is an important means of protecting assets. Each one of us must make sure that all information provided to bookkeepers, accountants, reimbursement staff, internal and external auditors, and compliance staff are accurate and complete. This includes ensuring the accuracy of clinical documentation which supports our reimbursement. We must also comply with federal and state regulations when maintaining clinical records, accounting records and financial statements, and cooperate fully with internal and external audits.
All Associates must deal fairly with residents, suppliers, competitors, and each other. No Associate, manager, or director shall take unfair advantage of anyone through manipulation, concealment, abuse of privileged information, misrepresentation of material facts, or any other unfair dealing practice.
Every Associate is responsible for the integrity and accuracy of documents, records, and e-mails including, but not limited to, resident medical records, billing records, and financial records. No information in any record or document may ever be falsified or altered.
You must not disclose, internally or externally, either directly or indirectly, confidential information except on a need to know basis and in the performance of your duties. Disclosure of confidential information externally must follow organization policies.
Upon termination of employment, you must promptly return all confidential information, medical and/or business, to the organization. Examples of confidential business information include potential or threatened litigation, litigation strategy, purchases or sales of substantial assets, business plans, marketing strategies, organizational plans, financial management, training materials, fee schedules, department performance metrics, and administrative policies.
It is our policy to voluntarily report known overpayments and any improper/irregular conduct, including fraudulent conduct, which affects any federal or state healthcare program. Reporting will be completed within the time frames identified under the Patient Protection and Affordable Care Act.
Hillcrest is committed to cooperating with requests from any governmental inquiry, audit, or investigation. You are encouraged to cooperate with such requests, conscious of the fact that you have the following rights:
In complying with our policy you must not:
If you receive a subpoena or other written or oral request for information from the government or a court, contact your supervisor, the Compliance Official, or the Compliance Officer before responding.
Disciplinary action will be taken against anyone who fails to act in accordance with this Code of Conduct, the Compliance and Ethics Program, supporting policies and procedures, and applicable federal and state laws. Disciplinary action may be warranted in relation to violators of the Compliance and Ethics Program and to those who fail to detect violations or who fail to respond appropriately to a violation, whatever their role in the organization. When taking disciplinary action against an Associate, we will utilize standard disciplinary processes which may lead to the termination of business relationships and agreements. The Compliance Officer may initiate and recommend corrective or disciplinary action against an Associate through the Compliance Official and President and CEO and may also monitor appropriate implementation of the disciplinary process. Hillcrest will discipline anyone who engages in prohibited retaliatory conduct.
The laws applicable to our operations are numerous and complicated. When you are not sure whether a particular activity or practice violates the law or the Compliance and Ethics Program, you should not guess the correct answer. Instead, you should immediately seek guidance from your department supervisor or the Compliance Official. You will not be penalized for asking compliance-related questions. In fact, we are intent on creating a culture in which you should feel comfortable asking questions to ensure you understand the duties that are imposed upon you under this Code of Conduct, the Compliance and Ethics Program, and other applicable federal and state laws.
The Compliance and Ethics Program is critical to Hillcrest’s continued success. You are crucial in ensuring the integrity of Hillcrest. The Code of Conduct and the Compliance and Ethics Program set standards for the legal, professional, and ethical conduct of our business. Some key points to remember are:
Your Compliance Official The success of Hillcrest’s Compliance and Ethics Program depends on our commitment to act with integrity, both personally and as an organization. As an Associate, your duty is to ensure that the organization is doing everything practicable to comply with applicable laws. You are expected to satisfy this duty by performing your responsibilities in accordance with professional standards, the regulations guiding our business practices, and our policies and procedures.
Your Compliance Officer
Karla Dreisbach, CHC, CHPC
Peace Church Compliance Program
Friends Services for the Aging (FSA), along with the Brethren, Mennonite, and Quaker organizations involved in providing services to the elderly, have established a collaborative Compliance and Ethics Program known as the Peace Church Compliance Program (PCCP).
670 Sentry Parkway
Blue Bell, PA, 19422-2325