Our Code of Conduct (the “Code”) reflects our collective commitment and responsibility to provide the best service, practice ethical business behavior, meet rigorous professional standards, comply with laws, regulations and policies that govern our work and to uphold our organization’s reputation. It also provides the mechanisms for asking questions and reporting concerns or suspected violations without fear of retaliation. The Standards described in our Code below, along with our Mission Statement, Purpose and Values serve as guidance in promoting ethical, honest and lawful decisions and actions for us as members of Catalight, its Affiliates and Subsidiaries (the “Family of Companies” or “FoC”). This Code and its related policies may not address every possible situation you may encounter, so it is up to you to use sound judgement and seek help whenever you need it. Talk to your Supervisor, or contact People and Performance, Quality or the Office of Risk Management (ORM) if you have any questions. In the event that more than one policy applies to any situation, all such policies will be applied to the fullest extent possible. If there is a conflict or gap in the individual policy provisions, the provisions of the policy that is most consistent with the Values of the FoC and compliance with the law will be applied. The Code may be modified as the organization continues to grow, and the norms of client care and business practices change. The current Code is available on the FoC Intranet (Confluence).
We will lead a movement to responsibly disrupt and transform home and community-based care by advancing industry standards to ensure effective care paths and optimizing business and technology solutions to deliver scalable person-centered services.
We are bold, community centered, equity informed, and wellbeing driven and we strive to integrate these values into client services, research and business practices. We expect integrity, honesty, transparency and trustworthiness in our work, courage in our decisions and dedication to FoC’s values and beliefs.
The FoC Code of Conduct applies to every individual affiliated with Catalight and all of its Affiliates and Subsidiaries (the “FoC”) including employees, practitioners, volunteers, interns, students, researchers and board members. It also embraces consultants and vendors when they are contracted to do business for the FoC and those who claim an affiliation or association with the FoC. The Code of Conduct applies to all work, operations and activities of the FoC, including clinical service delivery, which might occur both on premises and other locations.
As members of the FoC Community, we are each responsible for upholding these high standards in our work and professional relationships.
Duty to Report
You have an important role in assisting us to comply with laws, regulations and policies. If you have a question, or concern or suspect a violation, it is your individual responsibility to ask about it or report it to the appropriate person. You can also use the FoC Compliance HelpLine. You can ask questions or report concerns without fear of retaliation. Contact your Supervisor OR People and Performance ([email protected]) OR The Office of Risk Management OR the Compliance HelpLine at 1-833-44-PROTECT or [email protected] The FoC takes all reports made to the Compliance HelpLine very seriously. Questions will be answered, all reports will be promptly investigated, and appropriate corrective action will be taken, if warranted by the investigation.
Additional Responsibilities of Managers and Supervisors
Managers and Supervisors have the additional responsibility of shaping a values-based culture within the FoC. You are also responsible for:
- Staying current with regulatory changes, and complying with them;
- Ensuring alignment with FoC Strategy, Objectives, Operational Plans and Approved Frameworks;
- Identifying and reporting opportunities for improving operations through greater efficiency, quality, security and compliance and for promoting meaningful customer impact;
- Ensuring your department obtains necessary licenses, permits, approvals and authorizations before action is taken;
- Assisting your department in determining the appropriate person to notify when they have clinical, quality, compliance, privacy, operational or other questions; and
- Ensuring your staff completes all required training at the start of employment and subsequent mandatory annual and other periodic trainings.
Confidentiality and Anonymity
You can report concerns or suspected violations with your name and contact information. The FoC takes confidentiality very seriously and will maintain, to the full extent of the law, confidentiality of the individual making the report. If an investigation is initiated, information will be shared only on a need-to-know basis. However, you may choose to report anonymously. Please note that in such cases we will not be able to inform you of the results of investigation.
The FoC maintains a Non-retaliation Policy that prohibits any member from retaliating against a community member who has reported a concern or suspected violation in good faith. Retaliation is subject to discipline, up to and including termination from employment and/or suspension of privileges.
We will strive to uphold the below five standards while we fulfill our role at the FoC.
Standard 1 – Quality of Care and Safety
We expect our actions to demonstrate our care for our clients, their families and the community as a whole. The FoC is committed to providing high quality care in a manner that fully complies with all applicable laws, regulations, policies and standards of care. Dignity and Respect We deliver services with dignity and respect for each person, including the client’s family members. We are equitable in our decisions and mindful of their impact on other groups and people. Safety We are committed to providing and maintaining a safe, drug-free and healthy working environment for our clients, practitioners, employees and members of the FoC Community. Access to Quality Care The quality of services provided to our clients is of the utmost importance to us and we will continue to make efforts to enhance them. We will embody respect, caring, fair mindedness and thoughtfulness in our actions towards all those we serve, the community and the FoC. We will ensure that our interactions with clients, providers, vendors and other stakeholders continue to maintain professional boundaries so that quality of care and risk management at the FoC is not compromised. We will respect the right of the individuals we serve to make informed decisions and seek their participation in all aspects of treatment. Similarly, we will also respect their right to refuse services and be informed of the consequences of such action.
Standard 2 – Privacy and Confidentiality
Privacy and confidentiality are vital to us. We will protect the privacy of our clients, employees and other stakeholders’ information, whether written, oral, electronic or image-based, and permit only such disclosures as allowed by applicable law. We expect responsible action on behalf of the organization that is accountable and transparent to our constituents and to one another. We share information, when appropriate, without sacrificing privacy and confidentiality.
Protected Health Information (PHI)
Our clients and families have trusted us with their sensitive information. We will respect the client’s right to privacy and confidentiality. We will safeguard their PHI and request, use, share or disclose only the minimum necessary and on a need-to-know basis. Protected Health Information (PHI) includes any individually identifiable information that relates to past, present or future medical or behavioral conditions, treatment or payment that may identify a patient or client. It can be found in client records or financial and operational systems. There are several federal and state laws governing the privacy and security of PHI including the Health Insurance Portability and Accountability Act (HIPAA) and Security Rules. If you work with PHI, you should familiarize yourself with the laws and attend the training sessions offered by the FoC. Personal Information We possess personal information such as addresses, salaries, benefits and payments of our clients’ families, employees, practitioners, volunteers, interns, students, researchers, board members, donors, consultants and vendors. We should access this information only for the fulfillment of our job requirements. We will protect their privacy and permit disclosures only as mandated by legal obligations. Proprietary Information We do not reveal confidential information related to the FoC’s business strategies, objectives and plans, financial transactions and data, software, intellectual property and research data unless it is for a legitimate business reason and to an authorized person.
We are responsible for ensuring the security of information entrusted to us. We will abide by our security policies and controls to ensure confidentiality. We will access data and facilities using our own log-in credentials, passwords and identification badges.
The FoC respects the rights of its employees and other community members to use blogs and other social media tools as a form of self-expression and communication. However, we will use all forms of social media appropriately and respectfully and ensure that there is no negative impact on our clients and their families, or on our employees, donors, partners and affiliates (even our competitors) or other community members or on the business or reputation of the FoC.
Media and Public Relations Policy
The FoC community members may not speak to or provide written comments to, the media on behalf of the FoC without formal approval and media training. Requests for comment or opinion should be directed to the Communications Department.
Standard 3 – Personal Conduct and Business Ethics
We expect to be treated and to treat others with respect. We respect the opinions of, and the differences among, individuals. We expect fairness to be evident in our actions internally and externally.
Gifts and Gratuities
Community members of the FoC should discourage the acceptance of gifts from clients and business associates. In rare instances, community members may accept gifts which are of nominal value, perishable and are to be shared with office staff, e.g., cakes, brownies, chocolates, flowers, fruits, etc. Gifts of a personal nature are not permitted such as perfume and clothing. Under no circumstances will any member accept cash or cash equivalent as gifts, e.g., gift cards, dining vouchers, tickets to sports, golfing or other entertainments, stocks, bonds, etc.
Gifts and Business Courtesies from Vendors
Community members of the FoC are discouraged from offering gifts to or receiving gifts from vendors even if such gifts are occasional and of nominal value and perishable. In rare instances, gifts such as cakes, chocolates, flowers, etc. which are to be shared with office staff might be accepted. Under no circumstances, might any community member offer or receive a gift when the intent is to generate business or influence an FoC decision.
Conflict of Interest
FoC community members are expected to act at all times in the best interest of the organization, its clients and their families. Employees, volunteers and staff should avoid engaging in outside activities that might compromise or negatively impact their job performance. We will strive to avoid conflict of interest, or perception of such, in all aspects of our work. We will not use our professional positions to assert undue influence or obtain unreasonable services from others. Nor will we aim to gain personally from our role at the FoC. We will maintain all contractual relationships, both, current and potential, in a legal and ethical manner. A conflict of interest occurs if outside activities or personal interests influence, or appear to influence, the ability to make objective decisions on behalf of the FoC. Employees, practitioners, volunteers, interns, students, researchers and board members should disclose any situation where there is an actual conflict, or a potential conflict, to the Compliance and Risk Officer. We will refrain from personal fundraising (other than fund raising on behalf of the FoC) in the workplace.
Discrimination, Diversity and Inclusion
We respect diversity within our workplace and promote inclusion. We practice fair and equal treatment of employees, practitioners, volunteers, interns, students, researchers and board members. Vendors and consultants are expected to abide by our standards. You are expected to report abuse, violence, harassment or intimidation of any kind that you witness or experience in the workplace.
We will be good stewards of the resources entrusted to our care. We will be respectful of the FoC’s property, equipment, supplies and assets and will use them judiciously within the scope of our job responsibilities and to further the mission of the organization.
Duty of Regard
We will ensure that only personnel authorized by policy and agreement bind or commit the FoC (including the witnessing of documents) to obligations which align with the mission and vision of the organization. We will not bring personal property into the workplace that is offensive to others. We will not use FoC electronic mail or other property to convey or communicate inappropriate material. We will strive to ensure that all promotions and marketing of our services are in accordance with the values of our organization guidelines while being respectful and sensitive to the needs of our clients and their families and our other stakeholders.
Standard 4 – Compliance with Laws and Regulations
The FoC are not-for-profit organizations in the business of delivering healthcare services and as such is highly regulated. It behooves each of us to ensure that our professional conduct is in accordance with applicable laws, regulations and policies, especially those relating to the handling of client referrals and placement, billing and payment practices, clinical and payor relationships, vendor contracts, lobbying, environmental health and safety, employment practices, etc. These laws and regulations are complex; hence, the FoC provides regular training and policies. It is your responsibility to ensure that you complete the training required and refer to policies when the need arises. We expect compliance with applicable laws and regulations. We will avoid fraud, waste and abuse.
Fraud, Waste and Abuse Laws
There are several laws and regulations that apply to the provision of healthcare services. Some of them describe “fraud, waste and abuse” in detail such as the False Claims Act, the Anti-kickback statute and the Physician Self-referral Law (also called the Stark Law). The FoC strives to comply with all applicable laws. Employees should not knowingly submit bills/claims that they believe to be inaccurate or improperly coded. Nor should they ignore the knowledge that a claim is false. All bills/claims should be well-supported by internal documentation. Moreover, we should only employ individuals and hire contractors who have not been excluded from participation in federal and state healthcare programs. We are committed to using the funds, time and other resources of the organization in a judicious manner without leading to waste and in accordance with achieving the organization’s mission.
We will endeavor together to provide and maintain a safe, drug-free and healthy working environment for our clients and their families, employees and other community members. We will operate and maintain equipment, facilities and processes in a safe manner.
Cooperation with Government Investigations
We will respectfully cooperate with all government auditors and investigators. You should immediately bring any requests for information, which may include audit requests, search warrants, subpoenas, civil investigative demands, and similar to the attention of your Supervisor or to the Office of Risk Management (ORM).
Tax Exempt Designation
The FoC enjoys the designation of tax-exempt organizations under Section 501 (c) (3) of the Internal Revenue Code operated for charitable purposes. To ensure that the FoC does not lose its tax-exempt designation, community members should ensure they contract to only pay fair market value for goods and services, not engage in activities for the benefit of private interests nor engage in substantial political or legislative, i.e., lobbying activities. In situations where the FoC community members participate in political affairs, it is required that they make clear that they are acting as private citizens and not on behalf of the FoC. If the community member chooses to contribute to a political campaign, it should be as an individual and not as a FoC representative.
Standard 5 – Financial Reporting
We will be responsible and accountable for our actions and decisions. We will conduct business in accordance with accepted business practices.
Accuracy and Completeness
We will make every effort to ensure accuracy, completeness and timeliness in our accounts, financial reports, tax returns, expense reimbursements, time sheets and other documents including those submitted to government agencies and other stakeholders. All entries should reflect the precise nature of the activities and transactions of the business and be free from error.
Audits and Monitoring
We will commit to annual audits by an independent agency to ensure the financial integrity of our records and accurate filings with government agencies. We will monitor and analyze our financial and other information to ensure appropriate use of monies for the achievement of organizational goals.
Last Updated: June 2022