This booklet was designed to provide information to assist you in making the right decision when you encounter a situation involving legal or ethical issues in your daily activities.  Obviously, the Hospital’s Code of Conduct (the Code) cannot cover every aspect of your job.  The Hospital has many employees and contractors that are all governed by specific laws, regulations, and policies.  The Code contains the principles that govern our conduct.  Specific compliance policies are included in the Compliance Program and in the written policies and procedures of each department.  When you are confronted with an unusual situation or you have any doubts about the proper course to follow, a variety of resources are available to answer your questions and concerns.

Each contractor and related entity must comply with the Hospital’s Code of Conduct.  The Hospital will develop processes and procedures for each contractor in working with the compliance committee to promote and ensure that all contractors or related entities are in compliance with all applicable laws, rules, and regulations.  Contractual provisions in arrangements with contractors must require ongoing monitoring to be performed by or on behalf of the Hospital.

See Communication of Code of Conduct, Policy No. 001

Over the years, the Hospital, and its affiliates have established numerous policies and procedures to promote compliance with sound legal and ethical principles.  Those policies and procedures are not all included or described in this Code of Conduct.  Nothing contained in this booklet is intended to replace or supersede those established policies and procedures.


The Hospital is committed to providing the highest quality patient care and delivering services that are responsible, appropriate, and cost-effective.  We have a duty to report any actual or perceived quality of care issues to our supervisor or the Compliance Officer, either directly or by calling the compliance hotline.

  • Patients will be provided with the highest quality services without discrimination on the basis of race, gender, color, age, disability, religion, national origin, or ability to pay.
  • Patients will receive considerate and respectful care with recognition of their dignity and right to privacy.
  • The Hospital intends to employ personnel with proper credentials, experience, licensure, and expertise to meet the needs of our patient population, and it shall take reasonable steps to do so.  It is the responsibility, therefore, of the employee to maintain the proper credentials, licensure, and expertise necessary to perform the functions for which he or she was hired.  Management is obligated to verify credentials on a regular basis.
  • Patients have the right to know the identity and role of all the Hospital personnel who provide services to them.  Patients may also request information regarding the qualifications of those personnel providing services to them.
  • Patients have the right to receive information regarding the Hospital’s policies, procedures, and charges.
  • All questions from patients will be answered promptly and courteously or they will be referred to the proper source of information.
  • Patients have the right to participate in decision-making regarding their healthcare, to include refusing treatment to the extent permitted by law, and to be informed of the potential consequences of such action.
  • Patients have the right to voice their complaints about care and services received.  All individuals have the right to complain about uses and disclosures of protected health information (PHI) as defined by the Final Privacy and Security Rules issued by the U.S. Department of Health & Human Services (HHS) under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
  • In addition, the Hospital may be required to notify patients of a breach of the privacy or security of the patient’s PHI in accordance with the most recent Breach Notification Rules.

It is the Hospital’s policy to conduct its business in full compliance with all applicable laws, regulations, and professional standards. As employees and contractors, we have the duty to report any actual or perceived violation of applicable laws, regulations, and professional standards to our supervisor or the Compliance Officer, either directly or by calling the compliance hotline.

  • We provide services that are appropriate and safe and conduct our business affairs in compliance with all applicable laws, regulations, and professional standards.
  • We compensate healthcare professionals and other providers at fair market value and only for documented services provided.
  • We never pursue a business opportunity that is unethical or illegal.
  • We conduct our marketing efforts with truth, accuracy, fairness, and responsibility to patients, the communities we serve, and the public at large.  Marketing materials reflect only those services available as well as their level of licensure and accreditation.  We also comply with applicable laws and regulations dealing with truth in advertising and non-discrimination.
  • We record all financial information in accordance with generally accepted accounting principles and established financial procedures and internal controls.
  • We do not tolerate the making of false or misleading statements to any government agency, healthcare program, or payer source.
  • We understand that our conduct, both at work and away from work, can impact the Hospital.  As a result, we agree to behave accordingly.

The Hospital expects its employees and contractors to refrain from conduct that may violate fraud and abuse laws.  These laws prohibit:  (1) direct or indirect payments in exchange for patient referrals; (2) the submission of false, fraudulent, or misleading claims to any government entity or third party payer; and (3) making false representations to any person or entity in order to gain or retain participation in a program or to obtain payment for any service.


The False Claims Act prohibits a variety of fraudulent acts. The False Claims Act establishes liability when any person or entity improperly receives from, or avoids payment to, the Federal government, with the exception of tax fraud. In summary, the False Claims Act prohibits:

  1. Knowingly presenting, or causing to be presented to the government a false claim for payment.

  2. Knowingly making, using, or causing to be made or used, a false record or statement to get a false claim paid or approved by the government. 

  3. Conspiring to defraud the government by getting a false claim allowed or paid.

  4. Falsely certifying the type or amount of property to be used by the government. 

  5. Certifying receipt of property on a document without completely knowing that the information is true. 

  6. Knowingly buying government property from an unauthorized officer of the government, and...

  7. Knowingly making, using, or causing to be made or used a false record to avoid, or decrease an obligation to pay or transmit property to the government.

In most actions brought pursuant to the False Claims Act, the defendant must have either: (1) had “actual” knowledge of the false nature of the claim; (2) acted in “deliberate ignorance” of the truth or falsity of the claim; or (3) acted in “reckless disregard” of the truth or falsity of the claim.  All employees and contractors have a responsibility to report any actual or perceived violation of the False Claims Act.

The False Claims Act includes a provision, known as a “qui tam” provision, which permits private citizens to file suit on behalf of the federal government to recover damages incurred by the federal government as a result of contractor fraud or other false claims.  If such a suit is successful, a whistleblower is entitled to a significant portion of the proceeds.  Once such a qui tam suit is filed, the federal government conducts an investigation and at the end of the investigation, the Department of Justice must choose one of the following three options: (1) intervene in one or more counts of the pending qui tam action; (2) decline to intervene in one or all counts of the pending qui tam action; or (3) move to dismiss the complaint, either because there is no case, or the case conflicts with significant statutory or policy interests of the United States.  Remedies for the federal government with regard to qui tam claims include recoupment of overpayments, program exclusions, and civil monetary penalties.  Specifically, if the federal government proceeds with the action, the qui tam Plaintiff will receive between fifteen and twenty-five percent of the proceeds.  If the federal government does not proceed with the action and the qui tam Plaintiff does proceed, the qui tam Plaintiff will receive between twenty-five and thirty percent of the proceeds.  Such cases must be brought within six years of the filing of the false claim.

The Fraud Enforcement and Recovery Act of 2009 (FERA) and the Patient Protection and Affordable Care Act of 2010 (PPACA) amendments to the False Claims Act (FCA) have expanded potential FCA liability.  The FCA was made apart of the FERA, which expanded liability to include claims made to all recipients of federal funds (i.e., contractor, grantee, etc.), Formerly, the FCA only applied to claims made to the government.  The term “claims” now means demands made to a “contractor, grantee or other recipient, if the money or property is to be spent or used on the government’s behalf or to advance a government program or interest, as long as the government has provided or will reimburse the recipient for any portion of the money or property requested.”  The Hospital does not have to intend for the Government to pay the claim.  Instead, the use of false records or statements that have a tendency to influence, or be capable of influencing, the payment or receipt of money or property to the fraudulent claim will impose liability. The FERA also amended the reverse false claims provision by removing the requirement that FCA Plaintiffs prove a defendant committed an affirmative act in order for that defendant to be subject to FCA liability for avoiding or decreasing an obligation to pay.  Conscious disregard of claims processing rules or recklessly improper conduct in submitting claims is sufficient for FCA liability to attach under the reverse false claims provision. 

Prior to the PPACA, a whistleblower needed to have direct and independent knowledge of false claims submitted to the government.  Now, a whistleblower need not be the “original source” of the information. As a result, information disclosed in private litigation and during state or local administrative proceedings may potentially be used, as the basis of a whistleblower suit under the FCA, and a person may be a whistleblower merely by having knowledge that materially adds to allegations that have already been publicly disclosed.  In addition, the PPACA expanded the FCA to enhance whistleblower protection from retaliation. Under the new law, employees, agents, and contractors of the Hospital are protected.  Ultimately, the pool of potential Plaintiffs who qualify as an “original source” has increased due to PPACA.

The cost of non-compliance with the False Claims Act can lead to costly penalties.  Civil and administrative penalties range anywhere from $5,500-$11,000 per claim.  A guilty party may also be liable for treble damages of the government’s loss, plus discretionary exclusion from participation in the Medicare program.  If a violation of the law is voluntarily disclosed, damages under the FAC are limited to double damages suffered by the government if it is disclosed to the government within thirty (30) days of learning of the violation and prior to any government investigation involving the claims.

If you believe that you have evidence or knowledge of an actual or perceived violation of the False Claims Act, you should report it immediately to your supervisor, the relevant member of the Compliance Committee, to the Chief Compliance Officer, or call the compliance hotline.

See: False Claims Act Education Policy No. 005, State and Federal False Claims Act Policy No. 005A, Non-Retaliation for Employee Reporting Policy No. 006.


The Georgia Medicaid Unlawful Payment Statute (O.C.G.A. §49-4-146.1) provides that it shall be unlawful:

(1) For any person or provider to obtain, attempt to obtain, or retain for himself, herself, or any other person any medical assistance or other benefits or payments under this statute, or under a managed care program operated, funded, or reimbursed by the Georgia Medicaid program, to which the person or provider is not entitled, or in an amount greater than that to which the person or provider is entitled, when the assistance, benefit, or payment is obtained, attempted to be obtained, or retained, by:

                        (A) Knowingly and willfully making a false statement or false representation.

                        (B) Deliberate concealment of any material fact; or

                        (C) Any fraudulent scheme or device; or

(2) For any person or provider knowingly and willfully to accept medical assistance payments to which he or she is not entitled or in an amount greater than that to which he or she is entitled, or knowingly and willfully to falsify any report or document required under this statute.

Any person violating this statute will be guilty of a felony, which is punishable by a fine of not more than $10,000 and imprisonment of from one to ten years.  In addition, violators will be liable for a civil penalty for committing abuse equal to the greater of three times the amount of any such excess benefit or $1,000 for each prohibited claim.

The Georgia False Medicaid Claims Act (GFMCA) imposes liability on people and corporations who knowingly submit false or fraudulent claims to Georgia's Medicaid program.  The defendant may be ordered to pay up to three times the actual damage to the State, plus a fine ranging from $5,500 to $11,000 for each violation of the GFMCA. The Plaintiff in a successful GFMCA case may recover between 15 and 25 percent of the proceeds from the action if the Georgia Attorney General joins the case.  The Plaintiff may recover between 25 and 30 percent of the amounts recovered if the whistleblower pursues the case on his or her own. The court may reduce a whistleblower's award if he or she was a planner or initiator of the fraud, or if the action is largely based on information disclosed in the media or public hearings. The GFMCA also protects whistleblowers from retaliation by their employers.  Plaintiffs may not file their complaint more than six years after the date on which the violation occurred.

If you believe that you have evidence or knowledge of an actual or perceived violation of the Georgia Medicaid Unlawful Payment Statute or Georgia False Medicaid Claims Act, you should report it immediately to your supervisor, the relevant member of the Compliance Committee, to the Chief Compliance Officer, or call the compliance hotline.


The Anti-Kickback Statute (AKS) prohibits the offer or receipt of anything of value in exchange for a referral of any item or service for which payment may be made under a federal health care program, including Medicare and Medicaid.  The AKS was amended by the PPACA to state that: 1) claims resulting from violations of the AKS also constitute false or fraudulent claims for purposes of the FCA; and 2) a person need not have actual knowledge of the AKS or specific intent to commit a violation of it.  The PPACA has reduced the level of intent required to establish a healthcare fraud offense violation.

If you believe that you have evidence or knowledge of an actual or perceived violation of the Anti-Kickback Statute, you should report it immediately to your supervisor, the relevant member of the Compliance Committee, to the Chief Compliance Officer, or call the compliance hotline.  The amendments to the AKS have created significant civil penalties, as well as criminal sanctions.   With the decreased standard of proof, providers need to be aware of the increased risk of potential criminal and civil prosecution.

Violation of the Anti-Kickback Statute can lead to fines and imprisonment of up to $25,000 and five years in prison.  Civil monetary penalties can reach $50,000 plus three times the amount of the remuneration.  Violators may also be excluded from participation in federal programs.  In addition, the PPACA establishes that every claim for items or services resulting from a violation of the AKS automatically constitutes a “false or fraudulent claim” under the False Claims Act.

See:  Stark and Anti-Kickback Policy No. 025


The Stark Law prohibits physicians who have a financial relationship with an entity from referring patients to that entity for a designated health service for which payment may be made under Medicare or Medicaid.  Under PPACA, the Inspector General of HHS must establish a Medicare Self-Referral Disclosure Protocol (SRDP) that sets forth a process to enable providers and suppliers to self-disclose actual or potential violations under the Stark Law.  The SRDP requires health care providers and suppliers to submit all information necessary for CMS to analyze the actual or potential violation(s).  A disclosing party should make a submission with the intention of resolving its overpayment liability exposure for the identified conduct.

Further changes require physicians who refer patients for in-office ancillary services to, at the time of the referral, inform the patient in writing that he or she may obtain the ordered services from a person other than the ordering physician or the physician’s group. The Physician is then required to provide the patient with a list of providers who perform that service in the area in which the patient resides. 

The Self-Referral Protocol Procedures can be found at:

See:  Stark and Anti-Kickback Policy No. 025

  • We shall maintain complete and accurate patient medical records in accordance with applicable regulations.
  • We shall ensure that all patient information remains strictly confidential, unless the disclosure of patient information is allowable under the Final Privacy Rule, issued by HHS under HIPAA.  Allowable disclosures are those for treatment, payment, or operations (TPO), those for which prior authorization has been given, and as required by law.
  • We shall promote sound environmental and safety practices that will prevent damage to the environment and enhance community resources.
  • We shall be responsible for the proper handling of medical or hazardous waste and radioactive materials.
  • We shall not engage in agreements or practices “in restraint of trade” such as: price fixing; boycotting suppliers or customers; market allocation; pricing intended to run a competitor out of business; disparaging, misrepresenting, or harassing a competitor; stealing trade secrets; bribes or kickbacks.
  • We do not discuss pricing or market information with anyone from another healthcare organization or divide, or attempt to divide, territories or customer lists with competitors.
  • Employees are expected to seek advice from their supervisors if they have any questions about a business decision involving a risk of violation of any antitrust laws.
  • We will preserve the tax-exempt status of the Hospital and its affiliates by acting in a manner that will further the charitable and educational mission of the Hospital and that will enable the Hospital’s resources to be used to benefit the community, rather than the private or personal interests of any individual within the Hospital.
  • We will not engage in compensation arrangements or other transactions in excess of fair market value.  We will accurately report payments to appropriate taxing authorities, and we will file all tax information returns in a manner consistent with applicable laws.
  • We hold our employees’ civil rights in the highest regard, including every employee’s freedom of association, right to vote, and ability to participate in the political process.  The Hospital shall not adopt any policies to restrict these basic rights.
  • We will make reasonable efforts to determine whether an individual is eligible for financial assistance in accordance with the Hospital’s written policy before engaging in extraordinary collection actions.

The Hospital is committed to honesty, accuracy, and integrity in all of its billing, coding, and documentation activities.  We have a duty to report any actual or perceived false claim, misrepresentation, inaccuracy, or problem in billing, coding, or documentation to our supervisor or the Compliance Officer, either directly or by calling the compliance hotline.

  • We only submit claims for services actually rendered for payment or reimbursement.
  • We use billing codes that most accurately describe the services and care provided.  Upcoding or improperly unbundling charges to increase reimbursement is strictly prohibited.
  • We require that our employees involved in billing and coding to be knowledgeable of the applicable laws and regulations.  We take responsibility for proper training and education of our employees so they may properly perform their duties.
  • Submission of any claim for payment or reimbursement that is false, fraudulent, inaccurate, or fictitious is strictly prohibited.
  • All claims submitted for payment must be for services that are supported by medical necessity requirements, and those will be submitted in a timely manner.
  • After we have determined that a refund is due, we shall promptly forward that amount to the party to whom it is owed.
  • We shall take immediate steps to alert appropriate Hospital or health system authorities if inaccuracies are discovered in claims that have been submitted for reimbursement.
  • We shall promptly return and explain any overpayments received from CMS or DCH upon identification of the overpayment to avoid any investigation of a “credible allegation” of fraud, which would result in a suspension of Medicare and Medicaid payments.
  • All policies and procedures related to billing and coding will comply with state and federal rules and regulations.  The Compliance Officer will ensure that policies and procedures related to billing and coding are regularly monitored and audited.  One of the keys to lawful billing and coding is accurate and complete documentation, and employees are obligated to ensure that all documents are true and complete.

See:  Documentation and Reimbursement Policy No. 003, Federal Health Care Program Payor Overpayment Policy No. 019, Billing and Coding Policy No. 028, Physician Billing Practice Policy No. 29.


A “conflict of interest” will be considered to exist in any instance where the actions or decisions of an employee, when acting on behalf of the Hospital, also involves obtaining an improper gain or advantage or results in an adverse effect on the Hospital’s interests.  Conflicts of interest may also arise in other instances.  The Hospital employees will take all reasonable steps to avoid conflicts, or even the appearance of a conflict, between their private interests and the performance of their official responsibilities and duties. We have a duty to report any actual or perceived conflicts of interests to our supervisor or the Compliance Officer, either directly or by calling the compliance hotline. 

  • Situations that may create an actual conflict, or the appearance of a conflict of interest, must be avoided unless approved, in advance, by appropriate management.
  • A conflict of interest exists whenever a trustee, officer, or employee (or a related party such as a business or family member) may receive a financial benefit from any decision or action with which the individual is involved.
  • We will report to our supervisor any potential conflicts of interests concerning ourselves, family members, or business interests in accordance with established policies and procedures.  Family members include parents, grandparents, siblings, children, in-laws, grandchildren, and other persons living in the same household.

See:  Conflicts of Interest Policy No. 007

  • The Hospital has no objection to employees holding other jobs, as long as they can effectively meet the performance standards for their hospital job, or unless prohibited by a personal employment contract.
  • We will not allow the Hospital employees to work at another the Hospital facility through any temporary personnel agency, unless management approves that work in advance.
  • The Hospital conducts its recruiting arrangements within the specific parameters specified by the Stark Law and complies with the Anti-Kickback Statute to provide new physicians with relocation assistance and practice support or to pay fair market value for the services or employment.
  • The Hospital does not negotiate for benefits in exchange of a promissory admission of patients to the Hospital, unless the Physician is to become an employee of the Hospital

See:  Physician Recruiting Policy No. 024

  • It is the policy of the Hospital to conduct its business with vendors (suppliers of goods and providers of services) at the highest level of professionalism.  To this end, the Hospital will take all reasonable steps to avoid conflicts of interest, and the appearances thereof.
  • Conflicts of interest include any circumstances where the actions or decisions of the Hospital involve obtaining an improper gain, advantage, result, or expectation of performance aside from that which the Hospital has contracted for at “arms length”.  Accordingly, there is no obligation or expectation of performance by vendors on behalf of the Hospital beyond that which is contracted for by an authorized representative of the Hospital.
  • The Patient Protection and Affordable Care Act of 2010 (PPACA), requires companies within the medical supply industry to publicly report gifts or payments made to physicians, thereby increasing the importance of our duty to report potential conflicts.
  • We will not solicit any tips, gifts, or personal gratuities from patients, vendors, etc.  Personnel are encouraged not to accept gifts, favors, travel/trips, or hospitality; however, the acceptance of modest gifts or entertainment of nominal value (up to a total of $100 per year from any one source) is allowed.  Employees must report all gifts exceeding the yearly threshold to their direct supervisor or the Compliance Officer to determine whether it may be accepted within two days of receipt of the gift.  A written report regarding the offer is required even if the employee declines to accept the gift.  If any employee/associate has doubts about the appropriateness of a gift, he or she should seek guidance from their supervisor, the Compliance Officer, or call the compliance hotline.
  • The Hospital employees shall not seek to gain any advantage through the improper use of payments, business courtesies, or other inducements.  Offering, giving, soliciting, or receiving any form of bribe or other improper payment is prohibited.  Employees may provide gifts, entertainment, and meals of nominal value to the Hospital’s customers, current and prospective business partners, and other persons when such activities have a legitimate business purpose and are reasonable and consistent with all applicable laws.
  • The Hospital reserves the right to require an employee to return any gifts, regardless of their reported value.

See:  Improper Inducements Policy No. 031


The Hospital is committed to protecting all assets in its care, including the assets of others that are entrusted to us, as well as physical property and proprietary information, against loss, theft, or misuse.  We have a duty to preserve our organization’s assets, property, facilities, equipment, and supplies.  We have a duty to report any actual or perceived loss, theft, or misuse of our organization’s property, or the assets of others to our supervisor, or the Compliance Officer, either directly or by calling the compliance hotline.

  • We will personally be responsible and accountable for the proper expenditure of our organization’s funds and for the proper use of our organization’s property.
  • We will obtain all appropriate approvals prior to commitment or expenditure of any of the organization’s funds.
  • We will follow established internal control procedures in handling and recording the Hospital’s funds, property, and equipment.
  • We will take reasonable steps to safeguard the property of patients, employees, and visitors.
  • We will dispose of surplus or obsolete property in accordance with the Hospital’s policies and procedures.
  • We will not disclose, misuse, or take any confidential or proprietary information or property from our organization.

The Hospital is committed to protecting and supporting all personnel as well as helping them to achieve their fullest potential in a fair and equitable manner.  We have a duty to report any actual or perceived mistreatment, discrimination, safety issue, hostile activity, legal violation, or other non-compliant issue occurring in the workplace to our supervisor or the Compliance Officer, either directly or by calling the compliance hotline.

  • We will give proper respect and consideration to everyone.  Harassment of any type will not be tolerated.
  • We will conform to the standards of our professions and exercise reasonable judgment and objectivity in the performance of our duties.
  • We will ensure that everyone is afforded equal employment and advancement opportunities regardless of race, gender, color, age, disability, religion, or national origin.
  • We will ensure that everyone is afforded equal pay for equal work regardless of race, gender, color, age, disability, religion, or national origin.
  • We will comply with all work and safety rules, regulations, and policies.
  • We will take all reasonable precautions to ensure our safety, as well the safety of our patients, visitors, and other personnel.
  • We are committed to maintaining a smoke free environment at all the Hospital owned facilities. 
  • We do not condone the use of illegal narcotics or the inappropriate use of prescription drugs by the Hospital personnel, patients, or visitors.
  • We encourage open and candid communication, and we respond to issues and concerns in a timely manner.  We have a responsibility to report any significant actual or perceived communication problem to our supervisor or the Compliance Officer, either directly or by the compliance hotline.
  • We are committed to openness, accuracy, and honesty in all marketing plans and communications with:  patients, their families, and legal representatives; staff, physicians, and other healthcare providers; trustees, and the communities we serve.
  • We share ideas and treat opinions with respect and consideration.
  • We practice an “open door policy” which encourages employees to raise legitimate questions or concerns to their immediate supervisor or another member of their facility’s management.
  • We inform employees of their duties and responsibilities and provide timely feedback about their performance.  Although written performance reviews are conducted periodically in accordance with human resources policies, feedback concerning performance is provided on an ongoing basis.
  • We do not discuss patient or other confidential information in areas where unauthorized individuals may overhear (for example, cafeteria, elevator, or waiting rooms).  When these discussions must be held in areas where they may be overheard (semi-private rooms, hallway) we agree to limit the amount of patient information disclosed only to the minimum amount necessary, as prescribed by HIPAA.   In cases when private consultation rooms are available, they should be utilized in order to minimize the amount of PHI disclosed when discussing treatment, care, results, etc., of patients with family members and/or caregivers.
  • All in-house mail should be placed in appropriately marked envelopes in order to protect the sensitivity of information and to provide assurance and efficiency in the delivery process.

See:  Compliance Hotline Policy No. 002, Non-Retaliation for Employee Reporting Policy No. 006, Disclosure Program Policy No. 020


This Code is one part of the Hospital’s Compliance Program.  The Hospital has appointed the Compliance Officer to oversee the day-to-day operations of our Compliance Program. The Hospital’s Compliance Program will include:

  • Written standards of conduct, which are available from the Compliance Officer.
  • Training programs to instruct employees about ethical decision-making.
  • The compliance hotline.
  • Reviewing problem areas identified by the Compliance Officer, Compliance Committee, and callers to the compliance hotline.
  • Consistently enforcing standards through appropriate disciplinary mechanisms in conjunction with managers and Human Resources.
  • Auditing and monitoring mechanisms to ensure ongoing compliance; and
  • Responding to detected violations of standards, laws and regulations and preventing future similar occurrences.

See:  Compliance Department Mission Policy No. 012, Compliance Responsibility Development and Management Policy No. 013, Compliance Policy Development and Implementation Policy No. 014, Corporate Compliance Plan Policy No. 015, Compliance Education and Training Policy No. 016, Board Member Training and Certification Form Policy No. 017, Employee Compliance Surveys Policy No. 018.


Compliance is everyone’s business.  You are expected to become familiar with and adhere to the Hospital’s Code of Conduct, all relevant laws and regulations that affect the performance of your job, and applicable policies and procedures.  Your knowledge or reasonable suspicion of a violation of the Code, law, or regulation should be reported immediately.  Failure to report your suspicions or knowledge of a concern is a violation of the Code.

Failure to abide by this Code of Conduct, or the guidelines for behavior that this Code represents, may lead to disciplinary action, up to and including termination.  For alleged violations of the Code, the Hospital will weigh all relevant facts and circumstances, including, but not limited to:  the extent to which the behavior was contrary to the express language or general intent of the Code, the seriousness of the behavior, the employee’s history with the organization, and other factors that the Hospital deems relevant.

The Hospital intends to employ personnel with proper credentials, experience, licensure and expertise to meet the needs of our patient population, and it shall take reasonable steps to do so.  It is the responsibility, therefore, of the employee to maintain the proper credentials, licensure, and expertise necessary to perform the functions for which he or she was hired.  Management is obligated to verify credentials on a regular basis.

Nothing in this Code is intended to provide, or shall be construed, as providing any additional employment or contract rights to employees, contractors, or other persons.

The Hospital will generally attempt to communicate changes prior to the implementation of such changes.  The Hospital reserves the right to modify, amend, or alter the Code of Conduct without notice to any person or employee.

You should never hesitate to ask a question or raise a legitimate concern.  You should also be open and responsive to questions, complaints, and concerns expressed by patients and the employees you supervise.

If you have any questions about the Code, a law, or any the Hospital policy or practice, you are encouraged to talk to your supervisor, another member of management, or your human resources representative.  If your concern cannot be resolved at that level, or if you prefer, you may report the matter to the Compliance Officer or call the compliance hotline.



To ensure an open line of communication, the Hospital has established a compliance hotline, 1-833-205-7845, The compliance hotline is available to you when you have a compliance question or concern and do not feel comfortable discussing the matter with your supervisor.  Trained personnel answer calls to the compliance hotline, twenty-four hours a day, seven days a week.  Calls are not traced or recorded.  The compliance hotline should be used to report serious concerns about suspected or known instances of fraud or violations of law or policy.

All callers to the compliance hotline are encouraged to remain anonymous.  If callers choose to identify themselves, their confidentiality will be protected to the extent permitted by law.

The Hospital has a policy of non-retaliation.  That is, the Hospital will not take any disciplinary action or allow any other type of retaliation against any employee for reporting in “good faith” a compliance concern.  “Good faith” means that you are telling the truth, as you know it.

Furthermore, the False Claims Act prohibits the discharge or harassment of a whistleblower who makes False Claims Act-protected disclosures or files a qui tam suit. Any whistleblower discharged in violation of these provisions of the False Claims Act may file a wrongful discharge suit.  In a whistleblower’s claim for wrongful discharge, the whistleblower is eligible for double back pay and other damages. As amended by the Fraud Enforcement and Recovery Act of 2009 (FERA), the class of persons who can serve as whistleblowers includes contractors and agents.

Any employee or contractor who believes that he or she has been retaliated against for making a report should contact the Compliance Officer, Compliance Committee, or call the compliance hotline.

The Hospital will also protect its employees from the intentional misuse of the compliance hotline.  Deliberately making a false accusation is a serious violation of this Code and may lead to disciplinary action, up to and including termination of employment.

This means no action of retaliation or reprisal will be taken against anyone for calling the compliance hotline to make a report, complaint, or inquiry.  However, calls to the compliance hotline do not protect callers from appropriate disciplinary action regarding their own performance or conduct.

The Compliance Officer will evaluate and respond to all allegations of wrongdoing, concerns, and/or inquiries made to the compliance hotline in an impartial manner.  The Compliance Officer will respect and protect the rights of all personnel, including anyone who is the subject of a compliance hotline complaint.  To this end, all allegations will be thoroughly investigated and verified before any action is taken.  Furthermore, any disciplinary action or other response resulting from a call will be held confidential.

See:  Compliance Hotline Policy No. 002

For a printable version of the information above, please CLICK HERE.

Irwin County Anonymous Compliance Hotline

The Irwin County Hospital provides a reporting hotline for employees to anonymously report specific incidents.

To view these types of reportable incidents in English, please CLICK HERE.

To view these types of reportable incidents in Spanish, please CLICK HERE.

For additional information, CLICK HERE.