Corporate Compliance Handbook
Compliance is everyone’s business!!!
REVISED October 2008
Kingsbrook Jewish Medical Center and Rutland Nursing Home (referred to
collectively in this code as “Kingsbrook”), are proud of their
long tradition of ethical and responsible conduct. Kingsbrook is committed
to conducting its business lawfully and ethically. Each Board of Trustees
member, officer, employee, Medical-Dental staff member, Adjunct Staff
member, volunteer, consultant, contractor and vendor of Kingsbrook is
expected to adhere to this high standard whenever he or she acts on behalf
of Kingsbrook, or whether dealing with other Medical-Dental Staff members,
employees, volunteers, patients and their families, visitors, vendors,
regulators, or the general public. Violations of legal or ethical requirements
jeopardize the welfare of Kingsbrook, its employees and patients, and
the community it serves.
Accordingly, the Board of Trustees has reviewed and approved a Corporate
Compliance Program. A key component of the Program is the Code of Conduct
(Code), which is intended as a guide for the conduct of all people affiliated
with Kingsbrook. This Code provides guidance on how to resolve questions
regarding legal and ethical issues, and establishes a mechanism for reporting
possible violations of law or ethical principles within Kingsbrook.
We encourage you to use the chain of command as well as other available
avenues to resolve problems that are suspected to be violations of the
Code. Please feel free to contact any member of the Management Team for
advice or guidance.
The Corporate Compliance Officer is the individual who is responsible for
the day-to-day management and administration of the Compliance Program.
If you have any questions regarding the Compliance Program or need to
report a compliance concern, you may contact the Compliance Officer directly
or call the Hotline (604-5222). All callers to the Hotline are assured anonymity up to the limits of
the law. I give my personal assurance that there will be no retaliation
against anyone for reporting problems, either through the Hotline or through
the chain of command.
Success of the Compliance Program depends on the continuous support of
all people affiliated with Kingsbrook. Kingsbrook is committed to providing
quality cost effective care to a culturally diverse community. We must
work together in upholding the Code to ensure that we continue to be a
vibrant provider of healthcare to our community.
Linda Brady, MD
President and Chief Executive Officer
Kingsbrook Jewish Medical Center, founded in 1925 on Judaic tradition and
rooted in the ethics of healing and devoted service, is dedicated to caring
for all people regardless of religion, race, national origin or the ability
to pay. A not-for-profit multi-specialty teaching hospital, it provides
the most advanced medical treatment and excellence in both acute and long-term
To partner with our culturally diverse communities to provide a continuum
of outstanding health care services to individuals and families through
a caring and trustworthy staff.
We will be distinguished as a premier hospital and trusted partner that
advances the well being of the individuals, families and communities we serve.
The Code of Conduct establishes the general standards, policies and procedures
with which all must comply. Each Board of Trustees member, officer, employee,
Medical-Dental staff member, Adjunct Staff member, volunteer, consultant,
contractor and vendor (each a “Kingsbrook Affiliate”) is required
to read, understand and fully comply with the standards established by
the Code of Conduct. Copies of the full Corporate Compliance Program are
available in the Department of Human Resources, office of the Corporate
Compliance Officer, and on the Medical Center’s website
It is expected that you will ensure that all of the duties you perform
on behalf of Kingsbrook will comply with applicable laws, regulations
and policies. In addition, you are expected to report to your supervisor,
the Compliance Officer, or the Compliance Hotline suspected or known violations
of the Corporate Compliance Program. It is Kingsbrook’s policy that
no adverse action or retribution will be taken against any Kingsbrook
Affiliate for reporting in good faith a suspected violation.
If you have any questions regarding the Corporate Compliance Program or
this Code of Conduct, you should speak with your supervisor, a Department
Head or the Compliance Officer.
Quality of Care
Kingsbrook’s mission is to provide a continuum of outstanding health
care services to a culturally diverse community. It is our vision to be
distinguished as a premier hospital and trusted partner that advances
the well being of individuals, families and communities we serve. All
Kingsbrook Affiliates shall, as appropriate
- Comply with Kingsbrook policies and applicable federal, state and local
laws governing patient/resident care, including but not limited to patient/resident
rights, patient/resident complaints, and the confidentiality of patient/resident
records and information.
- Comply with the Emergency Medical Treatment and Labor Act (EMTALA) in providing
medical screening examinations and emergency medical treatment to all
patients, regardless of the patient’s ability to pay.
- Not discriminate based on a patient’s/resident’s race, age,
sex, religion, national origin, physical or mental disability, sexual
orientation, diagnosis or ability to pay.
- Ensure that all patients/residents admitted to our facilities shall receive
the same quality of care regardless of insurance coverage or payer source.
- Inform their patients, and their representatives, of all information needed
to make decisions regarding the patient’s care, and shall listen
to and follow the choices made by the patients (or their representatives)
with respect to their clinical care, including, the choices expressed
by their advance directives and health care agents.
Any Kingsbrook Affiliate who has knowledge of an event or deficiency must
report it to a supervisor, department head, Risk Management or other member
of the management team because Kingsbrook is mandated to report certain
patient/resident related events and deficiencies to various governmental
and/or regulatory agencies. The issues which must be reported include,
but are not limited to:
- Patient events
- Problems with Federal Drug Administration (FDA)-approved devices
- Elder abuse
- Child abuse
- Domestic violence
Compliance with Laws/Regulations
Kingsbrook strives to comply with all of the rules and regulations governing
its operation. In order to assist Kingsbrook’s compliance, all Kingsbrook
- Are required to obey all federal, state and local laws and government regulations
pertaining to Kingsbrook.
- Are expected to be familiar with the basic legal requirements that are
relevant to his or her duties.
- Are expected to comply with licensure and certification requirements associated
with the performance of their job or duties, in accordance with applicable
federal, state and local laws.
- Shall comply with Kingsbrook’s departmental, administrative and human
resources policies and procedures.
- Shall comply with Kingsbrook policies, applicable federal, state and city
law governing patient care including but not limited to patient/resident
rights, patient/resident complaints, and the confidentiality of patient/
resident records and information.
- Shall refrain from offering or receiving kickbacks or improper inducements
to influence Kingsbrook’s decisions regarding purchases of health
care services or supplies or regarding patient referrals.
- Shall comply with the Health Insurance Portability and Accountability Act
(HIPAA) in protecting against the misuse or disclosure of patients’
§ Shall comply with the Fair and Accurate Credit Transactions Act
of 2003 (FACT Act) and the Medical Center’s Identity Theft Prevention
Program in preventing identity theft of our patients and residents.
- All Kingsbrook Affiliates are expected to report any possible violation
of law or ethical standards in accordance with the procedure set forth
in this Corporate Compliance Program.
Conflicts of Interest
All Kingsbrook Affiliates are expected to be loyal to Kingsbrook, to avoid
using his or her position for personal gain and to comply with the conflict
of interest policy. Generally speaking, a conflict of interest exists
when an obligation or situation resulting from an individual’s personal
activities or financial affairs may adversely influence his or her judgment
in the performance of his or her duty to Kingsbrook.
- It is the policy of Kingsbrook that Kingsbrook will not enter into business
arrangements with companies in which a Trustee or employee, or a close
relative of a Trustee or employee has an ownership interest or financial
- It is the policy of Kingsbrook that a Trustee or employee may not work
for or provide services to a Kingsbrook supplier during the course of
their employment with Kingsbrook. In the event that a Trustee or employee
wishes to work for or provide services to a Kingsbrook supplier, the Trustee
or employee must first disclose the nature of the proposed arrangement
to the CEO and obtain the CEO’s documented approval, in consultation
with the CCO.
It is Kingsbrook’s policy that no Trustee or employee may have an
ownership interest in or a financial relationship with:
- A consultant of Kingsbrook
- A non-publicly traded company that is a supplier of Kingsbrook
- A competitor of Kingsbrook
· A Trustee or employee is never to accept anything of value from
someone doing business with Kingsbrook if the gratuity is offered or appears
to be offered in exchange for any type of advantage or favorable treatment.
No gift or gratuity in any form may be accepted by a Trustee or employee
or any family member of a trustee or employee unless the gift is a commonly
distributed item of modest value. Gifts with an estimated value of over
$100 from one individual or organization during the course of the year
must be reported to the Corporate Compliance Officer.
Billing and Coding Integrity
Kingsbrook and its professional staff provide a wide range of services
to patients. It is crucial that billing statements to patients and third-party
payors accurately reflect the services actually provided, who performed
the services, and the correct charges for those services.
- No employee shall submit a bill or claim for reimbursement for a more complex
service or item than the service or item provided.
- Bills or claims for reimbursement must accurately reflect the rules of
third-party payors regarding bundling of certain services.
- No duplicate or separate bill shall be submitted for outpatient services
provided within the DRG window for inpatient admissions.
- Claims shall only be submitted for services that are medically necessary
and actually rendered. As a part of Kingsbrook’s utilization management
program, Kingsbrook’s professional staff will periodically conduct
reviews to ensure all services rendered are medically necessary.
- No employee shall ever bill Medicare as a primary payor when he or she
is aware that other types of insurance are available.
- Kingsbrook financial staff and Kingsbrook’s external auditors must
guard against submission of inflated or inaccurate cost reports.
- Credit balances may occur when overpayments are made to Kingsbrook. Employees
shall report the existence of a credit balance to their supervisors to
ensure the appropriate reporting process is initiated to enable Kingsbrook
to fulflll its responsibility to report such balances to Medicare and/or
Medicaid, as appropriate.
Safe and competent patient care requires effective communication, collaboration
and collegiality by and among all Kingsbrook Affiliates. Thus, all Kingsbrook
Affiliates are expected to treat others with respect, courtesy, and dignity,
and shall conduct themselves in a professional and cooperative manner,
refraining from disruptive behavior and inappropriate conduct. Examples
of disruptive behavior and inappropriate conduct which are not acceptable
on Kingsbrook premises, include, but are not limited to:
- threatening or abusive language directed at other Kingsbrook Affiliates,
or at patients, family members, or other visitors (e.g., belittling, berating,
and/or non-constructive criticism that intimidates, undermines confidence,
or implies incompetence);
- degrading or demeaning comments regarding other Kingsbrook Affiliates,
patients, family members, or other visitors;
- profanity or similarly offensive language while speaking with or in front
of other Kingsbrook Affiliates, patients, family members, or other visitors;
- inappropriate physical contact with another individual that is threatening
- derogatory comments about the quality of care being provided by Kingsbrook,
another Kingsbrook Affiliate, or any other individual which comments are
made outside of appropriate administrative and/or Medical Staff channels;
- inappropriate medical record entries impugning the quality of care being
provided by Kingsbrook, or any other Kingsbrook Affiliate;
- "sexual harassment," which includes any verbal and/or physical
conduct of a sexual nature that is unwelcome and offensive to those individuals
who are subjected to it or who witness and is affected by it, including,
§ Verbal harassment through innuendoes, epithets, derogatory slurs,
off-color jokes, propositions, graphic commentaries, threats, and/or suggestive
or insulting sounds;
§ Visual or Non-Verbal harassment through derogatory posters, cartoons,
or drawings; suggestive objects or pictures; leering; and/or obscene gestures;
§ Physical harassment through unwanted physical contact, including
touching, interference with an individual's normal work movement,
and/or assault; and
§ Other: making or threatening retaliation as a result of an individual's
negative response to harassing conduct.
Kingsbrook promulgates policies, procedures, rules and regulations to ensure
its safe, compliant and effective operation, and the quality of care it
delivers. Thus refusal to abide by this Code of Conduct; administrative,
departmental and other policies and procedures; and the Medical Staff
Bylaws, Rules and Regulations, which relate to the Kingsbrook Affiliates’
relationship with Kingsbrook (including, but not limited to, those requirements
regarding emergency call issues, response times, medical record keeping,
patient care responsibilities, and unwillingness to work cooperatively
and harmoniously with others) constitutes unacceptable disruptive and
All employment at Kingsbrook is based on individual merit, personal qualifications
and the ability of the applicant to perform the job. Kingsbrook recognizes
that everyone, regardless of job classification, belongs to a knowledgeable
and skilled health care team which contributes to patient care.
- Kingsbrook does not discriminate in any employment decisions on the basis
of race, creed, color, national origin, ancestry, gender, age, disability,
marital status, sexual orientation, alienage or citizenship.
- Kingsbrook provides a work environment that enables everyone to work with
security and dignity, free from unwelcome, insulting, degrading or exploitive
treatment or harassment.
- Kingsbrook encourages and supports a working environment that is free of
illegal drugs or alcohol.
- Kingsbrook hires only qualified individuals with proper expertise, license
and experience. Qualifications are verified before offering employment.
- Kingsbrook shall not employ or contract with an individual or entity that
has been excluded from participation in the Medicare, Medicaid, or any
other federally funded healthcare program.
§ Kingsbrook is required to conduct a reasonable credentialing investigation
using due diligence before granting privileges to professional staff.
This obligation applies to all professions for which a license or certification
§ Federal and state law require Kingsbrook to check all individuals,
regardless of whether their position requires a license, to ensure that
they are not sanctioned, excluded from participation in Medicare or Medicaid,
involved in unlawful drug use, or have criminal backgrounds that are inappropriate
for the position for which they are applying.
Safeguarding Medical Center Assets
It is the responsibility of all Kingsbrook Affiliates to maintain the integrity
of Kingsbrook’s assets, including financial records, equipment,
information and data, and facilities against loss, theft and misuse.
- Employees may never participate in the misstatement of Kingsbrook’s accounts.
- Kingsbrook Affiliates may not remove Kingsbrook property (including, without
limitation, medical equipment, medical records and portions of medical
records) from the premises unless prior approval has been obtained.
- Kingsbrook Affiliates are required to safeguard access to data, systems
and other proprietary assets. It is essential that all Kingsbrook Affiliates
properly utilize and protect passwords, and take other necessary precautions
to guard against access to information.
- Where an employee is responsible for acquiring and disposing of assets,
such employee must be careful to stay within the limits of his or her
Kingsbrook is committed to the provision of a safe, functional and effective
environment in which health, safety, privacy and comfort of patients,
employees and visitors are the first priority.
- Supervisors and managers, with the assistance of the Safety Officer, are
responsible for developing programs to identify, eliminate or minimize
any hazards to health and safety in accordance with applicable law.
- Any practice or condition thought to be unsafe must be reported to the
Safety Officer immediately.
- All hazardous and infectious waste must be stored, handled and disposed
of in accordance with federal, state and local regulations. Any instances
of noncompliance must be reported to the Safety Officer.
- Kingsbrook maintains a smoke-free environment. Patients and residents may
smoke only in designated smoke areas.
Kingsbrook Affiliate Issues and Concerns
The success of the Compliance Program depends on maintaining open and effective
channels of communication. Kingsbrook Affiliates must be willing to identify
and report problems and issues, especially those with regulatory implication.
The management team at Kingsbrook is prepared to address issues as they
are identified. Managers are encouraged to maintain an open door policy
so that employees may refer issues without fear of reprisal.
- If you become aware of an activity that you think may be problematic, or
if you have questions about the Code of Conduct or Compliance Program,
please contact your supervisor immediately. If you are not comfortable
doing that, contact the Compliance Officer.
- For additional guidance regarding Kingsbrook policies and procedures, the
appropriate manuals should be consulted.
- It is the obligation of all Kingsbrook Affiliates to report to the Compliance
Officer conduct he or she reasonably believes to be criminal in nature
or a violation of this Program.
- Retaliation against a Kingsbrook Affiliate for reporting something he or
she sincerely believes may be a violation, or for participating in good
faith in an investigation of misconduct, is prohibited. Acts of retaliation
should be reported immediately and appropriate actions will be taken.
- Compliance with the Code of Conduct will be addressed in the performance
evaluations of all Kingsbrook employees.
- Individuals who violate the Code of Conduct will be subject to disciplinary
action under those Kingsbrook policies and procedures which govern their
relationship with Kingsbrook (including, without limitation, and as applicable,
the Employee Handbook, Kingsbrook’s Bylaws, the Administrative Policy
and Procedure Manual, and/or the Medical Staff Bylaws, Rules and Regulations).
Such discipline may include, without limitation (and as applicable), termination
of any relationship, employment, contractual arrangement or clinical privileges
with Kingsbrook, and/or removal from Kingsbrook premises.