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Vendor Compliance Program

  • Code of Conduct

Code of Conduct

PURPOSE

In line with our Core Values of Integrity, Reverence for Each Person and Stewardship, we conduct our affairs with an emphasis on compliance and ethics. Our mission and core values will guide the behavior of all directors/ trustees, employees, affiliated professionals, contractors, volunteers, students and others affiliated with Mercy Health System (MHS).  This policy sets forth the standards by which all those above will conduct themselves in order to protect and promote organization-wide integrity and to enhance the ability of MHS to achieve its business and strategic objectives in a manner consistent with the Mission and Values of MHS, the Ethical and Religious Directives for Catholic Health Care Services (5th ed.) and applicable laws and regulations.  

 

SCOPE

MHS and all its Subsidiaries

 

DEFINITIONS

The following definitions shall apply to this Policy:

 

Mission:  As a member of Catholic Health East, the mission of Mercy Health System is to be a partner in the healing ministry of the Catholic Church in the spirit of the Sisters of Mercy and Hope Ministries. In fulfilling our mission, we serve the entire community and address the diverse factors that impact the health needs of the whole person. A special concern for persons who are poor and disadvantaged characterizes our mission. We channel our resources to offer accessible, quality service, which is both innovative and compassionate.

Core Values

Reverence for Each Person
We believe that each person is a manifestation of the sacredness of life.

Community
We demonstrate our connectedness to each other through inclusive and compassionate relationships.

Justice
We advocate for a society in which all can realize their full potential and achieve the common good.

Commitment To Those Who Are Poor
We give priority to those whom society ignores.

Stewardship
We care for and strengthen the ministry and all resources entrusted to us.

Courage
We dare to take the risks our faith demands of us.

Integrity
We keep our word and are faithful to who we say we are.

Harassment:

Prohibited discrimination and harassment refers to any physical, written, or spoken conduct toward an individual that might adversely impact an individual's employment opportunities, an individual's work environment or targets, threatens, or places unrealistic demands on an individual due to race, color, religion, creed, national origin, age, sex, sexual orientation, physical or mental disability or any other basis as protected under federal, state or local law.  (Refer to policy #60-20-12, Discrimination and Harassment.)

Sexual Harassment:

Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature constitute sexual harassment when:

A. Submission to the conduct is made either an explicit or implicit condition of employment;

B. Submission to or rejection of the conduct is used as the basis for employment decisions affecting the harassed individual;

C. The harassment substantially interferes with a colleague’s work performance; or

D. The harassment creates an intimidating, hostile or offensive work environment.

Disruptive Behavior

Intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities.  Intimidating and disruptive behaviors are often manifested by health care professionals in positions of power.   Such behaviors include reluctance or refusal to answer questions, return phone calls or pages, condescending language or voice intonation, and impatience with questions.  Overt and passive behaviors undermine team effectiveness and can compromise the safety of patients.  All intimidating and disruptive behaviors are unprofessional and will not be tolerated. 

 

POLICY

This policy sets forth for trustees/directors, employees, affiliated professionals, contractors, volunteers, students and others affiliated with MHS the ethical framework within which MHS operates. Anyone found to be in violation of the Code of Conduct is subject to discipline, up to and including termination.  

 

PROCEDURE

In keeping with the Mission and Values of MHS, all of its trustees/directors, officers, employees, affiliated professionals, contractors, volunteers, students and others affiliated with MHS are expected to comply with the following guidelines. MHS employees and affiliated professionals shall maintain high standards of business and ethical conduct in accordance with applicable federal, state, and local laws and regulations including fraud, waste and abuse. They shall adhere to both the spirit and letter of applicable federal, state and local laws and regulations. Instances of non-compliance shall be promptly reported, and appropriate corrective actions shall be immediately taken.

  • All new employees will sign an Affirmation Statement indicating their adherence to the Code of Conduct.
  • All employees will annually review and agree to abide by the code of conduct.
  • All medical staff members and affiliated professionals will review and agree to abide by the code of conduct as part of the medical staff credentialing and re-credentialing process. 
  • All trustees/directors will annually review and agree to abide by the code of conduct.

1.      Fraud and Abuse

Healthcare providers and suppliers have an obligation, under law, to meet the requirements of the Medicare and Medicaid programs. Fraud and abuse committed against these programs may be prosecuted under various provisions of the United States Code and could result in the imposition of sanctions, fines, and, in some instances, imprisonment. (Refer to False Claims policy #96-119-11.)

Examples of fraud and abuse include: billing for services that were not provided, falsely representing the nature of services provided; altering claims forms to receive a higher payment amount; providing medically unnecessary services; billing for services under the wrong provider name; and duplicate billing.

2.      Antitrust

Antitrust laws are designed to create a level playing field and to promote fair competition. These laws could be violated by discussing MHS business with a competitor, such as how our prices are set, disclosing the terms of our supplier relationships, or agreeing with a competitor to refuse to deal with a particular supplier. Our competitors are other health systems and facilities in markets where we operate.

 

3.      Tax

Most MHS entities are exempt from federal income tax, state sales tax and certain other taxes as prescribed by law. Adherence to the MHS Conflict of Interest Policy (#96-04-11) is essential to the maintenance of this tax-exempt status. Depending upon your position in MHS, you may be required to complete an annual conflict of interest statement.

 

4.      Cost Reports

MHS is required by Federal and state laws and regulations to submit certain reports of our operating costs and statistics. MHS complies with Federal and state laws, regulations, and guidelines relating to all cost reports. These laws, regulations, and guidelines define what costs are allowable and outline the appropriate methodologies to claim reimbursement for the cost of services provided to program beneficiaries. Further guidance on cost reports is available in Cost Report Policy #96-114-11.

 

5.      Political Activities and Contribution

MHS and its representatives comply with all Federal, state, and local laws governing participation in government relations and political activities. Further, MHS funds or resources are not contributed directly to individual political campaigns, political parties, or other organizations which intend to use the funds primarily for political campaign objectives.

Guidance is always available from the Government and Legal Affairs Department as necessary.

 

6.      Discrimination

MHS actively promotes diversity in its workforce at all levels of the organization. MHS is committed to providing an inclusive work environment where everyone is treated with fairness, dignity, and respect.

 

MHS is an equal opportunity employer and no one shall discriminate against any individual with regard to race, color, religion, sex, national origin, age, disability, or sexual orientation status with respect to any offer, or term or condition, of employment. (Refer to Discrimination and Harassment Policy #60-20-12.)

 

7.      Harassment and  Disruptive Behavior

Each MHS employee has the right to work in an environment free of harassment and disruptive or intimidating behavior. MHS does not tolerate harassment by anyone based on the diverse characteristics or cultural backgrounds of those who work with us. Degrading or humiliating jokes, slurs, intimidation, or other harassing conduct is not acceptable in our workplace. MHS does not tolerate disruptive, intimidating or threatening behavior.  Behavior such as verbal outbursts, physical or emotional threats, refusal to perform assigned tasks, lack of cooperation in routine or team activities, condescending language or voice intonation are not acceptable in our workplace. 

 

Sexual harassment is prohibited. This prohibition includes unwelcome sexual advances or requests for sexual favors in conjunction with employment decisions. Moreover, verbal or physical conduct of a sexual nature that interferes with an individual’s work performance or creates an intimidating, hostile, or offensive work environment has no place in MHS. (Refer to Discrimination and Harassment Policy #60-20-12.)

 

MHS fosters a “Culture of Respect” in which all colleagues and physicians recognize the value of each individual’s contribution to the mission and health care ministry.  See section 29 of the code of conduct for reporting violations of the harassment and disruptive behavior guidelines. 

 

8.      Solicitation and Distribution of Literature

Each MHS employee has the right to work in an environment free of solicitation. To solicit is to persuade someone to do something other than perform job duties at Mercy Health System. Some examples of solicitation include efforts to sell merchandise or lottery tickets and to seek donations or support for organizations or causes. An employee may not engage in solicitation or distribute literature during his or her working time. An employee may not be solicited during his or her working time. Solicitation and distribution of literature are forbidden at all times in immediate patient care areas. Individuals who are not MHS employees may not engage in either solicitation or the distribution of literature when they are on MHS property. These rules about solicitation and distribution of literature do not apply to MHS approved fundraising. (Refer to Solicitation Policy #60-11-12 for additional detail.)

 

9.      Health and Safety

All MHS Operating Units shall comply with all applicable government rules and regulations that promote the protection of workplace health and safety. It is the policy of MHS to provide a safe work environment for all employees. In order to provide this safe work environment, each Operating Unit will inform and train all employees about the hazards and risks involved with chemicals with which they may come in contact at work. After providing information concerning such chemicals and their proper use, the Operating Unit will provide any and all protective equipment needed for the safe use of such chemicals. Each affected employee will attend all required training programs and use any protective equipment required for the safe use of chemicals on the job. Employees are prohibited from bringing firearms or explosives of any kind into the workplace.

 

10.  Ineligible Persons

MHS does not contract with, employ, or bill for services rendered by an individual or entity that is excluded or ineligible to participate in a Federal healthcare program; suspended or debarred from a Federal government contract; or has been convicted of a criminal offense related to the provision of healthcare items or services and has not been reinstated in a Federal healthcare program after a period of exclusion, suspension, debarment, or ineligibility. Employees, vendors, and affiliated professionals are required to report to MHS if they become excluded, debarred, or ineligible to participate in a Federal healthcare program; or have been convicted of a criminal offense related to the provision of healthcare items or services.

 

11.  Honest Communication

MHS deals openly and honestly with employees, customers, contractors, government entities and others. Consistent with all applicable laws and regulations that may govern such activities, MHS may use marketing and advertising activities to educate the public, provide information to the community, increase awareness of our services, and to recruit employees. MHS presents only truthful, fully informative, and non-deceptive information in these materials and announcements.

 

12.  Documentation

MHS is responsible for the integrity and accuracy of its documents and records, not only to comply with regulatory and legal requirements, but also to ensure that records are available to support our business practices. No one may alter or falsify information on any record or document. Records must never be destroyed in an effort to deny governmental authorities that which may be relevant to a government investigation.

 

13.  Confidentiality

MHS respects our patients by maintaining their confidentiality. When patients choose a MHS facility, they provide us with sensitive personal information. This can include names, addresses, phone numbers, Social Security numbers, medical diagnoses, family illnesses, prescription histories and other personal information. In accordance with the Federal patient privacy law known as HIPAA (Health Insurance Portability and Accountability Act), this information is protected. The information is accessed and shared with employees and affiliated professionals only when authorized to do so and as needed to do their jobs. Information is released to business partners only in accordance with proper procedures, which may require the authorization of the patient. MHS policies regarding HIPAA provide further detail about disclosing protected health information with or without authorization.

 

14.  Patient Records

MHS employees and affiliated professionals shall make every effort to ensure that entries made into patient records are clear and complete and reflect exactly the item or service that was provided to that patient. Records shall never include guesswork, exaggerations or miscoding. If a record is changed, that change shall be made in the manner in which our internal policies require.

 

Patient Medical Records are the only source of information upon which MHS entities can rely for the proper billing of the services and care provided as ordered by a patient’s physician. Diagnostic or procedural codes and other pertinent medical information included in that patient’s chart must adequately support the “medical necessity” for the service and/or care being billed, regardless of whether billed to Medicare, Medicaid or other third party payors.

 

15.  Proprietary Information

The term “confidential information” refers to proprietary information about MHS’s strategies and operations as well as patient information and third party information. Improper use or disclosure of confidential information could violate legal and ethical obligations. MHS employees and affiliated professionals may use confidential information only to perform their job responsibilities and shall not share such information with others unless the individuals and/or entities have a legitimate need to know the information in order to perform their specific job duties or carry out a contractual business relationship, provided disclosure is not prohibited by law or regulation.

 

Because so much of MHS clinical and business information is generated and stored within our computer systems, it is essential that each colleague protect the computer systems and the information contained in them by not sharing passwords and by reviewing and adhering to our information security policies and guidance.

 

16.  After You Leave MHS

If an employee’s employment or contractor’s contractual relationship with MHS ends for any reason, such individual must still maintain the confidentiality of information viewed, received or used during the employment or contractual business relationship with MHS. This provision does not restrict the right of an employee to disclose, if he or she wishes, information about his or her own compensation, benefits, or terms and conditions of employment. Copies of confidential information in a colleague’s or contractor’s possession shall be left with MHS at the end of the employment or contractual relationship.

 

17.  Conflicts of Interest and Business Courtesies

The conduct of MHS employees and affiliated professionals should be in a manner that is free from unlawful or otherwise inappropriate offers or solicitations of gifts and favors or other improper inducements in exchange for influence or assistance. (Refer to Acceptance of Gifts and Relationships with Vendors Policy #96-111-11 for further guidance on this topic.)

 

a. Business Courtesies/Receiving An Invitation: MHS recognizes that there will be times when a current or potential business associate, including a potential referral source, may extend an invitation to attend a social event in order to further develop a business relationship. A MHS employee may attend social or entertainment events in order to further business relationships under the following conditions:

 

  • Employee business discussions or development of the business relationship will occur and individual events will not exceed a value of $100. If the value of the event exceeds $100, it must be reported on the annual conflict of interest statement under section #4, “Gifts Gratuities and Entertainment” and submitted to the employee’s immediate supervisor. The annual statement is attached to Conflict of Interest Policy # 96-04-11.

 

b. Meals and Entertainment/Extending An Invitation: There may be times when a colleague wishes to extend to a current or potential business associate (other than someone who may be in a position to make a patient referral) an invitation to attend a social event (e.g., reception, meal, sporting event, or theatrical event) to further or develop a business relationship. The purpose of the entertainment must never be to induce any favorable business action. During these events, topics of a business nature must be discussed and the host must be present. The cost associated with such an event must be reasonable and appropriate.

 

c. Sponsoring Business Events: MHS facilities may routinely sponsor events with a legitimate business purpose (e.g., hospital board meetings or retreats). Provided that such events are for business purposes, reasonable and appropriate meals and entertainment may be offered. In addition, transportation and lodging can be paid for. However, all elements of such events, including these courtesy elements, must be consistent with the MHS Policy #96-111-11, “Acceptance of Gifts and Relationships with Vendors”.

 

d. Offering Gifts: It is critical to avoid the appearance of impropriety when giving gifts to individuals who do business or are seeking to do business with MHS. MHS will never use gifts or other incentives to improperly influence relationships or business outcomes.

 

18.  Protection of Assets 

MHS protects its assets and the assets of others entrusted to us, including physical and intellectual property, and protects information against loss, theft or misuse. These assets, supplies and services are used in a manner that avoids waste.

 

19.  Patient Rights

MHS understands and respects the patient’s right to a reasonable response to request and needs for treatment or service, within MHS’s capacity, our stated mission, and applicable laws and regulations.

MHS’s patients, or when appropriate, the patient’s legally designated representative, have the right:

  • to reasonable access to care;
  • to respectful care given by competent personnel;
  • upon request, to be given the name of the attending physician, the names of all other physicians directly participating in the care, and the names and functions of other healthcare persons having direct contact with the patient;
  • to have a family member or representative of his/her choice or own physician notified promptly of his/her admission to the Operating Unit;
  • to every consideration of privacy concerning the patient’s medical care; case discussion, consultation, examination, and treatment are considered confidential and should be conducted discreetly;
  • to have all records pertaining to the medical care treated as confidential except as otherwise provided by law or third-party contractual agreements;
  • to be informed of his or her health status, the right to be involved in care planning and treatment and a right to request accept or refuse treatment;
  • to participate in developing and implementing his or her plan of care;
  • to know what Operating Unit rules and regulations apply to conduct;
  • to expect emergency procedures to be implemented without unnecessary delay;
  • to good quality care and high professional standards that are continually maintained and reviewed;
  • to full information in layperson’s terms, concerning diagnosis, treatment, and prognosis, including information about alternative treatments and possible complications; when it not possible to give such information to the patient, the information shall be given to the patient’s healthcare agent or healthcare representative; except for emergencies, the physician must obtain the necessary informed consent prior to the start of any procedure or treatment;
  • to be advised when a physician is considering the patient as part of a medical care research program or donor program; the patient, or patient’s healthcare agent/healthcare representative, must give informed consent prior to actual participation in such a program; a patient, or patient’s healthcare agent/healthcare representative, may at any time refuse to continue in any such program to which there has been previous informed consent;
  • to refuse any drugs, treatment, procedure offered and a physician shall inform the patient of the medical consequences of the patient’s refusal of any drugs, treatment or procedure;
  • to assistance in obtaining consultation with another physician at the patient’s request and own expense;
  • to medical and nursing services without discrimination based upon age, race, color, religion, sex, sexual orientation, national origin, disability, or source of payment;
  • to expect reasonable accommodations for effective communication, including accommodations for hearing, speech and visual impairments;
  • to have access, when possible, to an interpreter if the patient, or legally designated representative, does not speak English;
  • to be provided with, upon request, within a reasonable time frame, access to all information contained in the patient’s medical records;
  • to expect good management techniques to be implemented within MHS Operating Units, considering effective use of time, and to avoid personal discomfort to a patient; when medically permissible, a patient may be transferred to another facility only after the patient or a patient’s healthcare agent/healthcare representative has received complete information and an explanation concerning the needs for an alternative to such a transfer;  the institution to which the patient is to be transferred must first have accepted the patient for transfer;
  • to examine and receive a detailed explanation of the bill of services;
  • to full information and counseling on the availability of known financial resources for health care;  
  • to expect that MHS Operating Units will provide a mechanism whereby the patient is informed upon discharge of continuing healthcare requirements following discharge and the means for meeting them;  
  • to access an individual or agency who is authorized to act on the patient’s behalf to assert or protect the rights of the patient;  
  • to consult with the Institutional Ethics Committee and to participate in consultation meetings regarding his/her treatment decisions that deal with medical/ethical issues, including issues of conflict resolution, withholding resuscitation, foregoing or withdrawal of life sustaining treatment and participation in investigational studies/clinical trials;
  • to be free from restraints and/or seclusion unless clinically necessary to protect the safety of the patient and/or others;
  • to pastoral counseling and assistance in obtaining other spiritual services at the patient’s request;
  • to express spiritual and cultural practices as long as they do not interfere with treatment;
  • to execute an Advance Directive and to have the Operating Unit staff and practitioners who provide care comply with the patient’s Advance Directive;
  • to be free from all forms of abuse and harassment;
  • to receive care in a safe environment;
  • to exercise the rights of the patient without coercion, discrimination or retaliation;
  • to know the professional status of any person providing care to the patient;
  • to know the reasons for any proposed change in the professional staff responsible for the patient;
  • to personal privacy, security and confidentiality;
  • to be informed of the Operating Unit’s source of reimbursement for services and any limitations that may be placed upon the patient’s care;
  • to have cultural and religious beliefs respected;  
  • to submit, either verbally or in writing, complaints about his or her care, and to have complaints reviewed and, when possible, resolved;
  • to appoint a patient’s healthcare agent/healthcare representative in the event the patient should become incompetent;
  • to be cared for by staff educated about patient's rights and their role in supporting their rights;
  • to request a copy of the MHS Code of Ethics Policy.
  • to receive notice in writing within 10 days of the resolution of the grievance; the Operating Unit will respond within 10 days to complaint registered by a patient and/or significant other; in addition to submitting complaints to the Operating Unit, a patient also has the right to notify the Pennsylvania Department of Health if the patient believes his or her rights have been violated;
  • to be informed about the outcomes of care including unanticipated outcomes;
  • to access protective services;
  • to pain management;
  • to be informed of these rights as soon as possible after admission to a Operating Unit;  and,
  • to sufficient storage space to meet personal needs and to keep/use personal clothing/possessions unless it infringes on others rights or is medically/therapeutically contraindicated or poses a safety hazard;

Patient Visitation Rights –  A hospital must:

  • Inform each patient (support person, where appropriate) of his or her visitation rights, including any clinical restriction or limitation on such rights, when he or she is informed of his or her rights at the time of admission. (Please see hospital policy on visitation)
  • Inform each patient (support person, where appropriate) of the right, subject to his  or her consent to receive the visitors who he or she designates, including but not  limited to, a spouse, a domestic partner, (including a same-sex domestic partner), another family member or a friend and his or her right to withdraw or deny such consent at anytime.
  • Not restrict, limit or otherwise deny visitation on the basis of race, color, national origin, religion, sex, sexual orientation, gender identity, or disability.
  • Ensure all visitors designated by the patient (or support person, where appropriate) enjoy visitation privileges that are full and equal to immediate family members.

 

Rights of Minors and Incompetent Patients

  • To ensure the rights of the neonate, child or adolescent patient, the patient has the right to expect the treatments or individualized needs shall be communicated with the patient’s guardians as necessary.

20.  Patient Care

Patient care services occur throughout MHS. These activities are carried out by a variety of employees and licensed practitioners from various service areas including medical, nursing, pharmacy, dietetics, rehabilitation, and other care disciplines. Patients may only receive care that has been ordered by a physician or qualified practitioner. Given the scope and diversity of services offered, MHS must assure that patient care services are provided through the integration and coordination of and communication among the various disciplines. Quality assessment and performance improvement is the responsibility of everyone associated with MHS.

 

21.  Physicians

Healthcare facilities like those owned and operated by MHS are collaborations between MHS employees and those who have been credentialed and privileged to practice in MHS facilities (affiliated professionals.)  MHS encourages its affiliated professionals to be familiar with this Code of Conduct. There are many portions of this Code of Conduct that pertain to ethical or legal obligations of affiliated professionals. (Refer to Physician Contract Policy #96-05-12.)  Allegations of non-compliance involving a member of the medical staff shall be investigated and actions taken as needed in accordance with the applicable Medical Staff Bylaws as well as the physician contract if applicable.

 

22.  Interactions with Physicians

Federal and state laws and regulations govern the relationship between hospitals and physicians who may refer patients to the facilities. The applicable Federal laws include the Anti-Kickback Law and the Stark Law. It is important that those colleagues who interact with physicians, particularly regarding making payments to physicians for services rendered, providing space or services to physicians, recruiting physicians to the community, and arranging for physicians to serve in leadership positions in facilities, are aware of the requirements of the laws, regulations and policies that address relationships between facilities and physicians. (Refer to Patient Referral Policy #96-110-09.)

 

23.  Extending Business Courtesies to Potential Referral Sources

Any entertainment, gift or token of appreciation involving physicians or other persons in a position to refer patients to MHS healthcare facilities must be made in accordance with internal policies which have been developed consistent with Federal laws, regulations, and rules regarding these practices. Employees must consult MHS policies (including Patient Referral Policy #96-110-09) or the Legal Affairs Department before extending any business courtesy or token of appreciation to a potential referral source.

 

24.  Affiliated Professional Privileges

Affiliated professional membership and privileges in MHS facilities are governed by the applicable affiliated professional bylaws. Individuals associated with MHS may not offer or provide physicians with any benefits, compensation or other inducements with the intent of obtaining, or in exchange for, the referral of patients. MHS shall not enter into any financial relationships with physicians that would violate the prohibitions of the Federal Anti-Fraud and Abuse Statutes, physician self-referral prohibitions, Internal Revenue Service rules/regulations or any other related laws and regulations.

 

25.  Emergency Treatment

MHS hospitals follow the Emergency Medical Treatment and Active Labor Act (“EMTALA”) in providing an emergency medical screening examination and necessary stabilization to all patients, regardless of ability to pay. Provided the hospitals have the capacity and capability, anyone with an emergency medical condition is treated. In an emergency situation or if the patient is in labor, there will not be a delay in the medical screening and necessary stabilizing treatment in order to seek financial and demographic information. The hospitals do not admit, discharge, or transfer patients with emergency medical conditions simply based on their ability or inability to pay or any other discriminatory factor. (Refer to hospital EMTALA Policies.)

 

26.  Electronic Media

All communications systems, including but not limited to computers, electronic mail, Intranet, Internet access, faxes, telephones, pagers and voice mail, are the property of MHS and are to be used for business purposes in accordance with MHS policies.

 

27.  Financial Reporting and Records

MHS has established and maintains a high standard of accuracy and completeness in documenting, maintaining, and reporting financial information. This information serves as a basis for managing our business and is important in meeting our obligations to patients, employees, suppliers, and others. It is also necessary for compliance with tax and financial reporting requirements.

 

28.  Investigations

  1. Government investigators may arrive unannounced at MHS and seek interviews and documentation. Any employee contacted by a government investigator should immediately notify his or her supervisor, Legal Affairs and the Compliance Officer. Further guidance on response to government investigations is provided in Policy #96-103-12 on External Investigations.
  2. Internal investigations may be directed by the Chief Compliance Officer. Your assistance in the conduct of an investigation is essential and failure to do so could result in disciplinary action and in some instances may be a violation of law.

 

29.  Resources for Guidance and Reporting Violations

There are numerous communication tools available to everyone associated with MHS for the reporting of violations of the Code of Conduct, as well as suspected violations of federal, state, and local laws and regulations. You may report concerns directly to your supervisor, your Operating Unit Compliance Officer or the Chief Compliance Officer, Nancy Oetinger at 610-567-6702.

 

You may also use the Compliance Hotline at 877-2COMPLY for anonymous or non-anonymous reporting. All calls to the hotline will be addressed by the Chief Compliance Officer.

 

No supervisor, manager, or other colleague is permitted to engage in retaliation, retribution or harassment directed against any individual who reports a compliance concern. Anyone who is involved in any act of retaliation, retribution or harassment against an individual who has reported suspected misconduct will be subject to disciplinary action.  

 

All trustees/directors, officers, employees, affiliated professionals, contractors, volunteers, students and others affiliated with MHS are informed of and must adhere to this Code of Conduct. Failure to comply with the Code of Conduct and the related policies and procedures will result in disciplinary action. However, this Code of Conduct does not replace sound ethical and professional judgment.

For More Information:
Compliance hotline: 1.877.2COMPLY
E-mail: noetinger@mercyhealth.org