Organizational Integrity

As a value driven, not for profit organization we operate according to a set of values that are at the heart of all that we do. Our Organizational Integrity program ensures that we meet our responsibilities to those we serve, to each other, and to our payers. Training for OI is mandatory upon hire and annually.

Standards of Conduct

The Standards of Conduct apply to everyone associated with the Manor.We must adhere to the Standards of Conduct and all relevant laws that affect the performance of our jobs. If we become aware of or have reasonable suspicion of a violation of the law, regulation or Standard of Conduct, we must report our knowledge immediately. If we fail to report a violation we may be subject to disciplinary action. Associates who fail to immediately disclose any proposed or actual disbarment, exclusion or other event that makes them ineligible to participate in Federal Health Care Programs will be subject to immediate termination.

The Standards of Conduct are a set of principles that guide use to do the right thing. They do not replace current policies or government regulations. They are an additional tool that will help us stay on the path to fairness and integrity.

Standard One – Quality of Care: We are committed to providing high quality care. We treat everyone with dignity and respect.

Standard Two – Compliance with Laws & Regulations: Each of us has a responsibility to understand the legal and regulatory requirements that directly affects our job.

Standard Three – Billing & Coding: The facility is committed to properly billing for the services that we provide. We do not falsify documentation so that we can be reimbursed for services at a higher rate.

Standard Four – Conflicts of Interest: A conflict of interest exists whenever a person’s outside interests influence or appear to influence his or her ability to make objective decisions in the course of this or her duties for the Manor.

Standard Five – Human Resources: Each of us shares a responsibility for treating our fellow associates fairly and for maintaining a workplace that is free from harassment and abuse.

Standard Six – Environment of Care: It is everyone’s responsibility to maintain a safe environment. This includes resident safety, emergency preparedness, hazardous materials and fire safety.

Standard Seven – Safeguarding Resources & Assets: We use our money carefully & ethically. We ensure that it is used to support our mission and for legitimate business purposes only.

Standard Eight – Communication: We encourage communication and practice an open door policy where you are free to raise issues without fear of retaliation.

Purpose of the Organizational Integrity Program

To ensure that St. Joseph Manor’s associates, contractors and agents understand (i) the Manor processes for preventing false claims, fraud, waste and abuse, (ii) the Federal False Claims Act, (iii) similar state laws, (iv) administrative remedies for false claims and statements, and (v) applicable whistleblower protections.

Procedure:

The Manor’s processes for Detecting and Preventing False Claims, Fraud, Waste and Abuse includes: Education of Associates, Contractors and Agents Regarding the State and Federal False Claims Acts.

The Manor is committed to submitting claims for payment that are compliant with all laws and regulations. The Manor is committed to proper and timely documentation of all items and services prior to billing to ensure that all such items and services are actually ordered or performed and that appropriate documentation supports all claims. In furtherance of this commitment, the Manor participates in Covenant Health Systems, Inc.’s Organizational Integrity Program and detailed policies to deter, detect, and prevent, fraud, waste and abuse.

As more fully described in the Standards of Conduct, Policies and Procedures Manual and related policies and procedures, the Organizational Integrity Program consists of compliance policies, training, audits, anonymous reporting mechanisms, and an investigative process to minimize the risks of fraud, waste and abuse, such as the filing of false claims.

The Manor’s Organizational Integrity Coordinator or Covenant’s Organizational Integrity Officer can provide you with a more thorough discussion of the Standards of Conduct or the Policies and Procedures Manual and any applicable laws designed to protect federal and state health care programs from fraud, waste and abuse.

As reflected in the Manor’s Standards of Conduct, and more particularly in the Manor’s Policy on Problem Reporting & Non-Retaliation, at any time any Manor associate, contractor or agent becomes aware of any actual or threatened violation of any Manor policy, including any policy contained in the Manor’s Standards of Conduct or Policies and Procedures Manual, or of any applicable law (including but not limited to the federal and state false claims and statements laws), regulation or standard of conduct, such Manor contractor or agent must report the situation to one of the designated individuals. As described in the Policy on Problem Reporting & Non-Retaliation, associates, contractors and agents are encouraged to discuss the matter first with their supervisor or a member of Administration. If the issue or concern is not addressed at this level, the associate may seek advice and assistance from the Human Resources Department or representative, or the Organizational Integrity Coordinator. Or, the associate may call the Covenant Health Systems Organizational Integrity Officer or the toll-free Integrity Helpline at 1-877-631-0013.

The Manor will not take any adverse action against any associate, contractor or agent who reports, in good faith, any violation, actual or threatened, regardless of whether the situation giving rise to the report is ultimately determined not to have any factual basis. If any Manor associate, contractor or agent knows of any actual or threatened violation of any applicable law, regulation or standard, they must report it as required by this policy and the Policy on Problem Reporting & Non-Retaliation. Any associate, contractor or agent that knows of such actual or threatened violation and fails to report the situation, such associate, contractor or agent, or contractor or agent may be subject to disciplinary action, including termination of employment or status as a contractor or agent, as applicable.

Consistent with the spirit of the Organizational Integrity Program, and the mission of the Manor, it is the policy of the Manor that no associate, contractor or agent of the Facility may file or cause to be filed a false or fraudulent claim for payment, or make a false statement in connection with the filing of a claim, to any health care payor. Federal and Massachusetts laws strictly forbid any health care provider from submitting false or fraudulent claims to health care payors including Medicare, Medicaid, and other Federal or State health care programs. The Federal False Claims Act can be found at 31 U.S.C. §§3729 to 3733 and the Massachusetts False Claims Law at G.L. c.12, §§5A to 5O. There are also a variety of laws that punish the making of false statements to the state and federal health care programs. It is the policy of the Manor that no associate, contractor or agent violate any of these laws or be aware of another person violating these laws without making a report of such alleged violation to the individual’s immediate supervisor or to the Manor’s Organizational Integrity Coordinator. The following is a summary of Federal and Massachusetts false claims laws.

The Federal False Claims Act

The Federal False Claims Act (the “FCA”) helps the Federal government combat fraud and recovers losses resulting from fraud in Federal programs, purchases, or contracts. A person or entity may violate the FCA by knowingly: (1) submitting (or causing to be submitted) a false claim for payment, (2) making or using a false record or statement to obtain payment for a false claim, (3) conspiring to make a false claim or get one paid, or (4) making or using a false record to avoid payments owed to the U.S. Government (the “Government”). “Knowingly” means that a person: (1) has actual knowledge of the information; (2) acts in deliberate ignorance of the truth or falsity of the information; or he truth or falsity of the information, and no proof of specific intent to defraud is required.

The FCA imposes penalties of $5,500 to $11,000 per claim plus three times the amount of damages to the Government for FCA violations. Lawsuits must be filed by the later of either: (1) three years after the violation was discovered by the federal official responsible for investigating violations (but no more than ten years after the violation was committed), or (2) six years after the violation was committed.

Whistleblower Protections and Private or Qui Tam Actions under the Federal False Claims Act

An individual has the right to file a civil suit for him or herself and for the Government to challenge a FCA violation. The suit must be filed in the name of the Government. Such an individual is called a qui tam plaintiff or “realtor.” Successful realtors may receive between 15 and 30 percent of the total amount recovered (plus reasonable costs and attorney fees) depending on the involvement of the realtor and whether the Government prosecuted the case. Individuals cannot file a lawsuit based on public information, unless he or she is the original source of the information.

The FCA contains important protections for whistleblowers that apply to the Facility employees. Associates who in good faith report fraud and consequently suffer discrimination are entitled to all relief necessary to be made whole, including two times their back pay plus interest, reinstatement at the seniority level they would have had except for the discrimination, and compensation for any costs or damages they have incurred.

Federal Administrative Remedies for False Claims and Statements.

Federal law also provides administrative remedies against any person who makes, or causes someone else to make, a false claim or a false statement in the amount of $5,000 for each false claim or statement. A “false claim” (for purposes of the administrative remedies) is defined as a claim that the person knows or has reason to know (i) is false or fraudulent, (ii) includes or is supported by any written statement which asserts a material fact which is false, (iii) includes or is supported by any written statement that omits a material fact, is false as a result of such omission, and is a statement in which the person making such statement has a duty to include such material fact, or (iv) is for payment for the provision of property or services which the person has not provided as claimed. A “false statement” is defined as a statement that the person knows or has reason to know asserts a material fact that is false or omits a material fact that makes the statement false. The administrative remedies for false claims and statements are found at 31 U.S.C. 3801-3812.

Whistleblower Protections and Private or Qui Tam Actions under the Massachusetts False Claims Law.

The Massachusetts False Claims Law prohibits employers from preventing associates from helping to prevent the submission of false claims. Under the Law, no employer may have any policy preventing an associate from disclosing information to the government or from acting to further a false claims action. No employer may require that any associate agree to limit the employee’s rights to bring an action or provide information to a government or law enforcement agency pursuant to the Law.

No employer may discharge, demote, suspend, threaten, harass, deny promotion to, or in any other manner discriminate against an associate in the terms or conditions of employment because of lawful acts done by the associate on behalf of the associate or others in disclosing information to a government or law enforcement agency or in furthering a false claims action.

An employer who violates this rule may be liable for damages and may also be required to reinstate the employee and offer two times the amount of back pay, interest on the back pay, and compensation for any special damage sustained plus litigation costs and reasonable attorneys’ fees.

Whistleblower Protections and Private or Qui Tam Actions under the Massachusetts False Claims Law, Continued.

Like the Federal False Claims Act, the Massachusetts False Claims Law provides that individuals may serve as qui tam relators and bring an action on behalf of the Commonwealth against a person or entity that has violated the False Claims Law. If successful, the relator may be entitled to an award of between 15 and 30 percent of the proceeds recovered and collected in the action or in settlement depending upon the extent to which the relator substantially contributed to the prosecution of the action and whether the Attorney General intervened in the case to which the relator substantially contributed to the prosecution of the action and whether the Attorney General intervened in the case.

These are summaries of very complex laws. Many of these laws have been further interpreted by state and Federal courts over the years. Thus, the application of any of these laws to any given situation will vary. Also, there are a variety of other state and Federal laws that prohibit (with civil and criminal consequences) the filing of false claims and the making of false statements.

The Facility’s Organizational Integrity Coordinator or the Covenant Organizational Integrity Officer can provide you with more thorough discussions of any of these laws, or their application to any situation you may encounter. These laws all serve the important function of protecting the Federal and state health care programs from fraud, waste, and abuse and allow those funds to go to protect the beneficiaries of these programs. These beneficiaries are the patients of the Facility, and the Facility requires all associates, contractors and agents to comply with these laws, as part of our mission of providing services to our patients.

All contractors, subcontractors, agents, or other persons which or who, on behalf of the Facility, furnishes, or otherwise authorizes the furnishing of Medicaid health care items or services, performs billing or coding functions, or is involved in monitoring of health care provided by the Facility are expected to adopt this policy.