Code of Ethics and Business Conduct

Letter from the Hospital Director

The mission of East Mississippi State Hospital (EMSH) is to provide behavioral health, chemical dependency and nursing home services in a caring and compassionate environment. EMSH values integrity and honesty, and we treat all Individuals Receiving Services(IRS), employees, physicians and visitors with dignity and respect.

To ensure we conduct our business according to the highest standards, we established a Code of Ethics and Business Conduct to guide our decision-making regarding IRS care, employee relations and business practices. These principles apply to all employees, physicians, agents and vendors so it is important to familiarize yourself with the legal and ethical standards outlined on this site.

If you have any questions regarding our Code of Ethics and Business Conduct or have concerns that any part of our Code is not being met, please contact your supervisor, the EMSH Compliance Officer or the Human Resource Office. Your involvement and vigilance are important. We continuously monitor our compliance with the Code of Ethics and Business Conduct and provide training as needed to achieve these goals.

We are dedicated to providing the highest quality care and commit to keeping the IRS at the center of all our decision-making.

Thank you for your adherence to these values and standards. Our IRS and colleagues deserve no less.

Charles Carlisle
Hospital Director
August, 2013

Purpose of the Code of Ethics and Business Conduct

Our Code of Ethics and Business Conduct (Code) assists us in carrying out our daily activities within appropriate ethical and legal standards. These obligations apply to our relationships with IRS, our medical staff, third-party payers, and all covered individuals of the organization. The Code is intended to be comprehensive and easily understood. In some instances, the Code deals fully with the subject matter. In many cases, however, the subject matter is more complex and requires additional guidance for those individuals directly involved. More specific guidance is provided in the EMSH Policy and Procedure Manuals. If there is no specific policy, our Code becomes the policy. If a policy and our Code conflict, the Code takes precedence.

The Code communicates to all covered individuals the expectation and requirement of ethical conduct and compliance with all applicable laws, as well as the policies of EMSH. All covered employees are responsible to ensure that their behaviors and activities are consistent with the Code. Ethical conduct and compliance is a personal responsibility and every covered individual is held accountable for his/her conduct. Each individual has an affirmative duty to report compliance issues and failure to do so could may result in disciplinary action, including termination of employment.

Our Code of Ethics and Business Conduct provides guidance to all EMSH "covered individuals." Covered individuals include all employees, medical staff, trainees, agents, contractors and vendors of EMSH.

Our Code builds upon the Mission, Vision and Values of EMSH and applies to all entities that are part of EMSH. These entities include:

• Adult Psychiatric Services
• Adult Chemical Dependency Unit
• Adolescent Psychiatric and Chemical Dependency
• Nursing Home Services
• Community Residential Services
• Adult Day Treatment Services

Leadership Responsibilities

While all covered individuals are obligated to follow our Code, EMSH expects our leaders to set the example and be a model. Our leaders must ensure that those on their team have sufficient information to comply with laws and EMSH policy as well as the resources to resolve ethical dilemmas. Our leaders must help to create a culture within EMSH that promotes high standards of ethics and compliance. This culture must encourage everyone in the organization to raise concerns when they arise. EMSH must never sacrifice ethical and compliant behavior in the pursuit of business objectives.

Supervisor and Management Responsibilities

Managers and supervisors are expected to set an ethical "tone" and to be role models for ethical behavior in their departments. These leaders should create a departmental culture that promotes the highest standards of ethics and compliance, and encourages everyone in the department to voice concerns when they arise. Leaders are responsible for ensuring that all individuals under their supervision receive a copy of the Code of Ethics and Business Conduct, receive training on the Code and understand the Code's application to the individual's day-to-day responsibilities. If there are questions regarding the Code, leaders should facilitate communication with the Compliance Office for clarification or training. Finally, leaders are required to ensure and verify that all individuals reporting to them attend appropriate compliance training.

Acting with Integrity

It is the policy of EMSH to provide and maintain a culture characterized by integrity, responsible behavior and a commitment to the highest legal and ethical standards. All EMSH covered individuals share responsibility for ensuring that EMSH conducts its activities in a compliant manner. This includes ensuring the integrity of all claims, reporting of inappropriate conduct and protecting the rights of any individual who reports concerns. EMSH complies with federal and state False Claims Acts, Whistleblower Rights and Protection, and the Compliance Program structure as required by the Deficit Reduction Act of 2005.

Compliance Program Structure

EMSH is committed to effectively communicating our standards, policies and procedures to all covered individuals by providing education and training to develop compliance awareness and commitment. It is the responsibility of each manager to ensure the individuals reporting to him/her receive all required training. The EMSH Internal Governing Board has adopted a Compliance Program and has appointed a Compliance Officer. The Compliance Officer chairs the EMSH Compliance Committee. Each covered individual remains responsible and accountable for his/her own compliance with applicable laws and EMSH policies.

All EMSH entities should ensure:

• All covered individuals are educated about the EMSH Code of Ethics and Business Conduct, applicable laws and EMSH policies
• There is reasonable auditing, monitoring and oversight of compliance with these laws and policies
• Mechanisms exist to investigate, discipline and correct noncompliance
• Responsibility is not inappropriately delegated to individuals who have previously violated the law or EMSH policies
• Covered individuals are encouraged to report noncompliance without fear of retribution

Code of Ethics and Business Conduct Guidelines

EMSH expects all covered individuals to conduct themselves in accordance with all legal requirements and institutional policies that apply to their position. Covered individuals should each understand EMSH policies, procedures and associated laws, as well as EMSH policies applicable to their individual responsibilities. You should ask questions when you do not understand, are confused, or feel that EMSH practices are inconsistent with these laws and policies.

When faced with a tough ethical decision, EMSH expects individuals to consider the following:

• Does the action comply with EMSH policy?
• Does the action comply with applicable laws?
• How would the action look to covered individuals, our IRS and our community if it were published on the front page of the newspaper?
• Are we being fair and honest?

Most importantly:

• When we know the action is wrong, do not do it!
• When you are not sure, you should ask your supervisor, or call the Compliance Office, or the Human Resources Office.

Reporting Wrongdoing

Ethical behavior is the responsibility of every covered individual. Each individual has a personal obligation to report any activity that appears inconsistent with applicable laws or EMSH policies. EMSH encourages communication, dialogue and reporting of incidents of potential wrongdoing or suspected violations. If a covered individual has reasonable cause to believe that such an incident has occurred, he/she is expected to report these concerns to his/her supervisor or manager. Alternatively, he/she may report these concerns anonymously to the Compliance Office. It is important that individuals act in good faith in making any report. EMSH will not retaliate against any person that reports an incident in good faith.

Compliance with Applicable Laws

EMSH is committed to complying with all applicable laws, standards of care and accreditation standards which govern our organization. This requires an extensive team effort on every individual's part. EMSH is also committed to complying with our obligations to those who pay for the services we provide. These include all federal and state health care programs (including Medicare and Medicaid), commercial payers, grant-funded programs and our IRS themselves. It is incumbent on each of us to ensure the integrity of all claims submitted for payment of the services and supplies of the care that we render.

IRS Care

All IRS are entitled to equal access to care, to be treated with caring and respect, and to the protection of their privacy and the confidentiality of their medical and financial records.

EMSH is committed to:

• Achieving IRS-focused excellence through the highest standards of quality care, IRS safety and IRS satisfaction
• Equal access to care
• Providing care consistent with EMSH policies, professional standards and regulatory requirements, including but not limited to Joint Commission standards of care and the Centers for Medicare and Medicaid Services Conditions of Participation
• Treating IRS with warmth, respect and dignity, and providing care that is both necessary and appropriate
• Informing IRS of their rights and responsibilities, and notice of privacy practices
• Clinical decision-making focused upon IRS needs, ensuring that IRS admission, discharge and transfer policies are based on the IRS's clinical needs and not the source of payment
• Inclusion of IRS in decisions regarding their care, and alternatives and risks associated with this care
• Assuring that all staff has the necessary credentials to perform their specific duties
• Accurate, timely and complete documentation supporting clinical services provided, and correctly billed
• Privacy and confidentiality of medical record information, with access to IRS care information limited to those involved with the treatment of the IRS, quality oversight or administration of IRS accounts

Cultural Differences

EMSH recognizes that individual caregiver's personal cultural values, ethics and religious beliefs may, on occasion, be in conflict with the care or treatment to be provided to individual IRS. Individual employees may make a request to the Human Resource Office based on their personal cultural values, ethics, or religious beliefs to recuse themselves from the specific care required, provided that alternative arrangements can be made and that negative outcomes for the care and treatment of the IRS are not incurred.

Licenses and Credentials

Covered individuals must obtain and maintain required licenses or other credentials needed for their area of service. The granting of licenses, credentials or other privileges must be based upon accurate and complete information by the applicant. The suspension or revocation of these credentials or licenses must be immediately communicated, as appropriate, to the covered individual's supervisor or manager, Clinical Director, and the Human Resource Office. EMSH does not allow any individual or practitioner, allied health care professional or clinician to work within any entity without current licensure and/or required credentials.

Occurrence Reporting

All employees and licensed independent practitioners are required to notify their supervisor, immediately or as soon as possible after IRS care priorities are met, of any events in which they are involved or become aware of which have or might endanger a IRS's safety or well-being. Covered individuals who report adverse events may do so without fear of reprisal in relationship to their employment or medical staff status as a result of reporting. If it is determined that an individual may be in violation of these principles, if there is evidence of criminal intent and/or if there is a pattern of behavior that could threaten IRS safety and/or is indicative of ongoing substandard job performance, further action may occur under pertinent policies and procedures.

Joint Commission and Other Accreditation or Oversight Agencies

EMSH believes strongly in the Joint Commission and other applicable accreditation processes, and is committed to adhering to the accreditation standards and to the highest quality IRS care. EMSH deals with all survey or accreditation bodies in a direct, open and honest manner. No action should ever be taken in relationships with survey or accrediting bodies that would mislead the members of the survey or accrediting teams, either directly or indirectly.

Privacy and Security of IRS Health Information

To provide quality care, EMSH collects sensitive information about every IRS's medical condition, history, medication and family illness. Because of the nature of this information, EMSH is committed to maintaining its confidentiality and security. Under the Health Insurance Portability and Accountability Act, commonly referred to as HIPAA, we are required by law to maintain the privacy of IRS health information and to provide a notice of information practices to our IRS, which outlines our legal duties and IRS rights related to their health information maintained by our organization.

EMSH does not use, disclose or discuss IRS-specific information with others except as necessary for treatment, payment, or as authorized by law. In accordance with our policies and procedures, EMSH covered individuals may only access information necessary to perform their jobs, and this information is released only to persons authorized by law or by the IRS's written authorization. EMSH has determined standards for electronic protected health information to safeguard the confidentiality, integrity and availability of this information while it is stored and during electronic transmission.

Workplace Conduct

EMSH strives to provide a working environment based on respect, fairness, honesty and integrity, and has developed workplace policies and practices to support this goal. Safety and quality of IRS care are fostered by a collaborative environment of courtesy and mutual respect. Intimidating and disruptive behaviors are unprofessional and are not tolerated. Behaviors that are considered intimidating and disruptive can be verbal or physical. They include verbal outbursts and foul language; sexual harassment in any form; physical roughness; threats; refusing to perform assigned tasks; quietly exhibiting uncooperative attitudes during routine activities; reluctance or refusal to answer questions, return telephone calls or pages; condescending language or voice intonation; and impatience with questions. Covered individuals should conduct themselves in a responsible manner that protects the interests of EMSH. Failures to promote, support, and foster a professional demeanor and attitude or displaying disruptive behavior may result in disciplinary action, including termination of employment.

Diversity and Equal Employment Opportunity

EMSH is committed to enhancing diversity in the workplace and a positive work environment. EMSH is an equal opportunity employer and complies with all applicable federal and state laws in this area. Employee hiring, personnel actions, and social and recreational programs sponsored by EMSH are designed and administered without discrimination with respect to race, color, religion, gender, age, sexual orientation, national origin, veteran status, disability or any other category protected by law. EMSH workforce members strive to celebrate our diversity, and to build on each other's' differences and expertise.

Discrimination and Harassment

The policies of EMSH prohibit discrimination or harassment. Retaliation against any person seeking to report concerns in good faith regarding our compliance with applicable laws or EMSH policies is not tolerated. Employees should bring concerns to their supervisor or the Human Resources Office. The supervisor, in consultation with the Human Resources Office will promptly follow up to address the particular behavior and to ensure that all parties understand that EMSH policies prohibit discrimination or harassment, and that retaliation against any individual for reporting concerns is not tolerated.

Workplace Violence

EMSH prohibits workplace violence, including behavior that is threatening, overly aggressive, confrontational or violent (e.g., verbal threats, stalking, terrorism, hate crimes or similar conduct).

Individuals with Disabilities

EMSH is committed to providing access for individuals with disabilities in compliance with the law. Covered individuals should not discriminate against individuals with disabilities in any manner that violates the law, including discrimination in an offer, term or condition of employment at EMSH.

Alcohol-free and Drug-free Workplace

EMSH is committed to an alcohol-free and drug-free workplace. Prescription medications and devices, including controlled substances, must be handled only by legally authorized people. While on duty, employees or contractors may not be under the influence of alcohol or any other substance, whether or not legally obtained, that may interfere with their ability to perform their job. The EMSH Employee Assistance Program is available at no cost to employees with alcohol, drug or other personal problems that may affect work performance.

Health and Safety

EMSH is committed to providing a safe and healthy workplace. Employees must understand and comply with EMSH policies and applicable laws relating to health and safety that apply to their areas of responsibility. These policies and laws include, but are not limited to, occupational safety and environmental laws, and laws applicable to the proper storage and disposal of medical waste and other hazardous materials.

Fraud and Abuse and Self-referral Laws

Covered individuals must understand and comply with applicable fraud and abuse laws and EMSH policies relating to their areas of responsibility. Covered individuals must be vigilant in ensuring the complete and accurate documentation of IRS care services and submission of associated claims. They must not offer to pay, solicit or accept money, gifts or services in return for the referral of IRS, or to induce the purchase of items or services. Covered individuals must avoid any conduct that could violate federal or state laws concerning fraud and abuse, false claims, anti-kickback and self-referrals (Stark), or even appear to violate these laws.

Prohibited activities include but are not limited to the following:

• Billing for supplies or services not delivered
• Misrepresenting services actually provided
• Duplicate billing for services rendered
• Seeking to increase reimbursement by "upcoding," which results in billing for medical procedures/tests or services meriting higher reimbursement than those actually furnished, in order to increase reimbursement
• Seeking to collect amounts exceeding the copayment and deductible from a Medicare or Medicaid beneficiary, or any beneficiary who has assigned his/her rights to health benefits to EMSH
• Falsely certifying that services were medically necessary (certifying a nonexistent medical condition)
• Entering into contracts, leases or other business transactions at other than fair-market value (for example, paying in excess of fair-market value in return for other goods or services such as referrals, other contractual arrangements or personal items)
• Entering into contracts, leases or other business transactions or relationships with referral sources such as physicians, without meeting strict regulatory requirements; the Administrative Services Division should pre-approve any contractual relationships with referral sources
• Offering money, gifts or other items of value to a IRS or prospective IRS to influence the receipt of services from EMSH
• Permitting a provider or supplier who is excluded from federal health care programs to provide goods or services through EMSH to federal health care program beneficiaries

Contracting

EMSH business must be conducted in compliance with applicable laws and EMSH policies. Any financial, governance or family relationships which covered individuals have with existing or prospective vendors or personnel should be disclosed promptly prior to the commencement of any bidding or contracting process. EMSH complies with all State of Mississippi purchasing laws and regulations.

Vendor Discounts/Rebates

Commissions, rebates, discounts and allowances are customary and acceptable business practice, if they are consistent with EMSH policy and State of Mississippi purchasing laws and do not constitute illegal payments.

They should be:

• Reasonable in value
• Competitively justified
• Properly documented
• Appropriately accounted for
• Made to or by the EMSH entity to which the original agreement or invoice was made or issued

Accuracy of Financial Reporting and Billing

All EMSH records, documents and reports must be accurate, complete and in compliance with applicable laws and EMSH policies. Among other reports required to be filed, EMSH business involves reimbursement under government programs that require the submission of certain reports of our costs of operations. EMSH complies with federal and state laws relating to all cost reports. The law defines what costs are allowable and outlines the appropriate methodologies to claim reimbursement for the cost of services provided to program beneficiaries.

All bills for EMSH services must be supported by actual services and supplies provided and by required documentation. As part of our documentation efforts, EMSH maintains current and accurate medical records. Any subcontractors engaged to perform billing or coding services must have the necessary skills, quality assurance processes, systems and appropriate procedures to ensure that all billings for government and commercial insurance programs are accurate and complete.

Avoiding Conflicts of Interest

Covered individuals owe loyalty to EMSH and may not use their positions to profit personally or to assist others in profiting at the expense of the organization. Covered individuals must comply with all State of Mississippi laws regarding conflict of interest. Conflicts of interest can take many forms.

The following examples of activities by a covered individual or family member may constitute a conflict of interest:

• Ownership in or employment by any outside concern which does business with EMSH
• Representation of EMSH by a covered individual in any transaction in which he/she or a family member has a substantial personal interest
• Competition with EMSH by a covered individual, directly or indirectly, in the purchase, sale or ownership of property or property rights or interests, or business investment opportunities
• Disclosure of confidential, special or inside information of or about EMSH, particularly for personal profit or benefit of a covered individual or family member

Covered individuals should discuss potential conflicts of interest with the Human Resource Office and should contact the Compliance Officer with questions or issues. Any covered individual involved with purchasing or contractual arrangements with external parties should ensure potential conflicts are discussed with and disclosed to the Human Resource Office and, as necessary, with the Compliance Officer prior to the commencement of such processes.

Gifts from IRS

All covered individuals are prohibited from soliciting money, personal gratuities or gifts, and from accepting personal gratuities and gifts of value from IRS and their families. Money may never be accepted by a workforce member from a IRS or IRS family. IRS and family members should not be expected or encouraged to provide gifts or gratuities in return for IRS care.

Safeguarding and Use of Resources

Covered individuals must ensure EMSH resources are used to support the mission of EMSH and that these resources are protected against loss, theft or misuse. These resources include, but are not limited to, employee time, supplies, equipment, databases, records, proprietary business information, strategic plans, business plans and financial data. Limited, occasional, incidental personal use of resources such as telephone or e-mail may be permitted, subject to EMSH and the Department of Mental Health policies and procedures. Decisions related to support or sponsorship of outside organizations or activities must be approved by the Hospital Director.

Political Activities and Contributions

EMSH resources are not to be used for political purposes promoting or benefiting any candidate for office or any political party. Resources include financial (e.g., gifts, payments), human, and property or space for use in campaigning. Furthermore, as a tax exempt organization, EMSH is prohibited from engaging in any activity that is intended to support or oppose any candidate for public office. Covered individuals may participate in the political process on their own time and at their own expense.

Marketing Activities

Marketing materials should always accurately represent EMSH Care at any of our entities, and address the care, treatment and services that we provide either directly or by contractual arrangement.

Reporting of Violations

Covered individuals have an individual responsibility to come forward with any information regarding violation of this Code, EMSH policies or applicable laws. Covered individuals are expected to cooperate fully in the investigation of any alleged violation of which they have knowledge.

Reports may be made either in person, by telephone or in writing to any of the following:

• Your supervisor or division director
• Chief Compliance Officer
• Human Resource Office

Protection from Retaliation

There will be no retaliation for good faith reporting of actual or possible violations of the Code. Any covered individual who deliberately makes a false accusation with the purpose of harming or retaliating against another covered individual will be subject to disciplinary action. EMSH will protect the identity of anyone reporting a violation to the extent permitted by law, unless doing so prevents EMSH from fully and effectively investigating an alleged violation.

Discipline for Violations

EMSH will take appropriate disciplinary action, including termination of employment when appropriate, against any covered individual who violates any applicable legal requirements or EMSH policies.