White Horse Village Corporate Compliance & Ethics Program

Introduction

White Horse Village Inc. (WHV), its Board of Directors, and its leadership are committed to operating in a legal and ethical manner in the provision of care and in our professional and business relationships in pursuit of our mission. This program is designed to prevent both accidental and intentional non-compliance with all applicable federal and state laws, including those that prohibit fraud and abuse of healthcare resources.

The purpose of the Compliance & Ethics Program and its policies and procedures is to:

• Establish and maintain a culture that promotes quality and efficient support, services and high standards of ethical and business conduct;
• Establish effective internal controls to ensure compliance with statutes, regulations, and rules;
• Demonstrate to those who we serve, residents, team members, and the community-at-large, WHV’s commitment to responsible conduct;
• Educate and train team members concerning exceptional business practices and the Code of Conduct (Attachment A);
• Establish a mechanism to encourage reporting of potential problems and allow for appropriate internal inquiry and corrective action; and
• Prevent, detect, and resolve conduct that is inconsistent with our policies and regulatory requirements.

The Code of Conduct is a critical component of our Corporate Compliance & Ethics Program and was developed to assure that WHV meets ethical standards and compliances with related laws and regulations. The Code of Conduct provides guidance to all team members and assists the community in carrying out daily activities while meeting our ethical and legal obligations.

The Compliance & Ethics Program applies to all Team Members, including the Board of Directors, physicians, team members, volunteers, and other entities providing services to White Horse Village Inc.

The Compliance Program includes the eight elements recommended by the Office of Inspector General, as outlined in the Compliance Program Guides, and incorporates the Centers for Medicare & Medicaid Services Requirements of Participation for skilled nursing facilities.

• The development and distribution of written standards of conduct, policies, procedures, and protocols that promote a commitment to compliance, including a Code of Conduct.
• The designation of a compliance officer and compliance committee charged with the responsibility for
• The development and implementation of regular, effective education and training programs for all employees
• The creation and maintenance of an effective line of communication between the compliance officer and all employees for anonymous reporting of concerns and protection from retaliation,
• The use of audits and other risk evaluation techniques.
• The completion of sanctions screening to address the non-employment of individuals and non-use of contractors who are disbarred or sanctioned by a federal or state agency.
• The development of policies and procedures with respect to the investigative process for suspected, alleged, or actual compliance concerns.
• An annual assessment of the Compliance & Ethics Program, to include a risk analysis.

Mission Statement 

We intentionally create opportunities for extraordinary living in a vibrant, diverse community through personal growth, connectedness, and relationships.

Vision Statement

To inspire a world of possibilities on life’s journey.

Core Values

Compassion: Demonstrate care and empathy in all our interactions.

Inclusiveness: Create a diverse environment that is welcoming and accepting.

Growth: Explore opportunities for learning and change.

Generosity: Give of oneself to benefit others.

Respect: Value the worth of each person.

Relationships: Develop meaningful connections with one another.

Stewardship: Commit to use our resources wisely.

Program Administration

The following policy statements are a summary of the policies that have been approved and implemented in support of the compliance program.

Under the authority of the Board of Directors (Risk & Compliance Committee), the Corporate Compliance Committee will administer the Compliance Program. The Compliance Committee will be chaired and facilitated by the Compliance Officer (CO), who will be a member of the Compliance Committee.  White Horse Village participates in the Friends Services Alliance Compliance Program (FSA), which provides Compliance program oversight services through a contractual relationship with White Horse Village.

Compliance Committee

The Committee is responsible for assisting the Compliance Officer in the development and implementation and monitoring of the Compliance and Ethics Program.  

The Committee will meet no less than quarterly and will maintain minutes of its meetings, including issues discussed and decisions made.

The Committee will include the Compliance Officer, High Level Official, Privacy Officer, Security Officer and other members as deemed appropriate. The Committee will report to the Chief Executive Officer and the Compliance Officer on all significant issues relating to compliance with applicable laws, regulations, policies and the White Horse Village Code of Conduct.

The Compliance Committee will report to the Chief Executive Officer and the Compliance Officer on any significant issues associated with compliance with applicable law regulations, law policies, and the White Horse Village Code of conduct.

Compliance Officer

White Horse Village will appoint a Compliance Officer. The Compliance Officer will function as an independent and objective individual that reviews and evaluates compliance issues/concerns within White Horse Village Inc.  The Compliance Officer shall have unfettered access to the Board of Directors as needed to assure effective communication associated with compliance issues or concerns.

The Compliance Officer’s primary responsibility is the development, implementation, oversight and effective operation of the Corporate Compliance Program.

Compliance Committee Non-Disclosure

Individuals involved in the Compliance and Ethics Program as members of the Compliance Committee may have access to highly confidential and in some cases privileged information.  Much of this information will pertain to privacy related issues. All such information must be treated in a confidential manner.  

Code of Conduct

The Compliance Officer will develop, maintain and periodically update a written Code of Conduct to provide to Team Members, managers, board members, associated providers, and vendors with guidance on requirements for conduct related to employment or other business association with White Horse Village Inc..

Enforcing the Code of Conduct

White Horse Village Inc. is committed to following uniform enforcement and corrective action practices for individuals who that do not comply with federal and state laws, regulations, guidelines and policies including those specific to each department and discipline, and the White Horse Village Code of Conduct and Team Member Handbook.   

Consistent enforcement and corrective actions will be taken for all substantiated violations of rules, regulations, compliance policies, and the Code of Conduct.  

Non-Retaliation

All Team Members, Contractors and Volunteers have an affirmative duty to report perceived misconduct, or misappropriation including actual or potential violations of law, regulations, policies, procedures, or the Code of Conduct.

An “open-door policy” will be maintained at all levels of management to encourage reporting problems and concerns.

Team Members, Contractors and Volunteers are encouraged to use the chain-of-command or communicate with the Compliance Officer or designee if their problem or concern is not resolved.

Team Members, Contractors and Volunteers may also use the FSA Compliance Line.  Callers to the Compliance Line may remain anonymous. If they choose to identify themselves, their identity will remain confidential to the extent permitted by law.

Any form of retaliation against any Team Member who reports a perceived problem or concern in good faith is strictly prohibited.

Any Team Member who commits or condones any form of retaliation will be subject to corrective action, up to and including termination.

Auditing and Monitoring

It is the responsibility of the Compliance Committee, Compliance Officer, and the management team of White Horse Village to ensure that ongoing auditing and monitoring is properly executed, documented and evidenced. 

Business Courtesies

White Horse Village prohibits Team Members, Directors and Officers from offering, giving, soliciting, or accepting business or professional courtesies, including entertainment and gifts that could be interpreted as attempts to influence decision-making.

Element of Performance

Promotion of, and adherence to, the provisions of the Compliance and Ethics Program, and participation in required compliance training, will be factors in evaluating the performance of all personnel.  Compliance will also be considered in promotion and compensation decisions.

Compliance Training and Education

All Team Members, Officers, Directors and certain Contractors, including new hires, will receive regular Compliance training.  All Team Members will participate in annual compliance training. In addition, new Team Members will be trained no more than 30 days after the start of their employment.

Compliance training is mandatory for all Team Members without exception.  

Compliance Issue Reporting & Resolution

All Team Members are responsible for reporting misconduct, misappropriation of property or finances including actual or potential violations of law, regulation, policies and procedures and the Code of Conduct.

Upon report or notice of suspected non-compliance with any criminal, civil or administrative law, the Compliance Officer will conduct an “Initial Inquiry” into the alleged misconduct.  The purpose of the Initial Inquiry is limited to determining whether there is sufficient information to warrant further investigation. Upon report or notice of suspected non-compliance with any criminal, civil or administrative law, the Compliance Officer will notify White Horse Village Chief Executive Officer, FSA or Board of Directors, and a decision will be made as to next steps. 

Team Members may use any communication channel they deem appropriate to report issues, including the Compliance Hotline. Any compliance issues related to the operation of the Compliance Program should be referred directly to the Compliance Officer. Retaliation or retribution for reporting issues in good faith is prohibited. 

While the Compliance Officer is responsible for resolving compliance-related issues only, Team Members should not be discouraged from using compliance communication channels to report their non-compliance concerns.  The Compliance Officer will direct any non-compliance items reported to the appropriate department/person(s). 

To the extent practicable or allowed by law, White Horse Village must maintain the confidentiality or anonymity of employee team member when requested.

Compliance Records Management

The Compliance Officer is responsible for maintaining records regarding WHV’s Compliance Program, related documents, trainings, investigations into noncompliance, audits, reviews, meeting minutes and other related supporting documents in an organized and systematic way.  The Compliance Officer is also responsible to assure that records are protected from unauthorized disclosure or destruction.

Documentation relating to the Compliance & Ethics Program will be maintained and made available for periodic independent auditing and monitoring by the Compliance Committee and FSA to review the effectiveness of the Compliance Program

False Claims Act

The False Claims Act Policy is designed to help Team members, agents and contractors of White Horse Village and its related entities understand the provisions of federal and state laws regarding the submission of false claims to the federal and/or state governments for reimbursement and to inform such Team Members, agents and contractors of their rights and obligations to report violations of such federal and state laws.

White Horse Village will provide information to Team Members, agents and contractors regarding both the federal and state false claims laws as well as protections available for those who report violations of these laws.  We will also describe White Horse Village’s policies and procedures for detecting and preventing the submission of false claims. It is important that Team Members, agents and contractors understand the provisions of these laws and how we strive to comply with them. 

Anti-Kickback Statute

The Anti-Kickback Statute (AKA) is a criminal statute that makes it illegal for any person to ask for or receive anything of value directly or indirectly in return for referring to another organization or person any patient or business that is covered by a Federal health care program.  The AKS also makes it illegal for any individual to offer or pay anything of value directly or indirectly, to any person to induce that person to refer to the individual any patient or business that is covered by a Federal health care program.

White Horse Village will ensure compliance with the Federal Anti-Kickback Statute (AKS) by prohibiting payments for referrals or inducements for referrals that violate the statute.  We will provide information to our Team Members, agents and contractors regarding the AKS and describes White Horse Village’s policies and procedures for detecting and preventing violations of this law.  It is important that our Team Members, agents and contractors understand the provisions of this law and how we strive to comply with such laws.  

Physician Self-Referral Law (Stark)

The Physician Self-Referral Law, also known as the “Stark Law” was passed by Congress to prevent referral sources, including physicians, from inappropriately profiting from referrals.  Stark prohibits a physician or physician extender from referring a patient needing health services to any entity with which the physician has an ownership interest or compensation arrangement if Medicare pays for the services.  

White Horse Village will comply fully with the federal Physician Self-Referral Law.  We will provide information to our Team Members, agents and contractors regarding Stark that describe White Horse Village’s policies and procedures for detecting and preventing violations of this law.  It is important that our Team Members, agents and contractors understand the provisions of this law and how we strive to comply with such laws.  

Conflict of Interest

All White Horse Village Team Members, including but not limited to employed staff, senior leadership, officers and members of the Board of Directors, have an obligation to conduct business within guidelines that prohibit actual or potential conflicts of interest.  This policy is established to ensure that resident care and business activities are conducted in an objective manner and are not motivated by desire for personal or financial gain.

Team Members are required to disclose any actual or potential conflict of interest and seek guidance on how to handle the situation.  A conflict of interest is any situation in which financial or other personal considerations may compromise or appear to compromise the business activities or resident care of White Horse Village.

Friends Services Alliance Compliance Program (FSA) Record Provision 

Upon termination of a business relationship with Friends Services Alliance (FSA), FSA will ensure that all Protected Health Information obtained by FSA is immediately returned to the organization, or if the organization already has the original of the PHI, destroyed in accordance with the Document Destruction Policy.  FSA will comply with the Health Insurance Portability and Accountability Act (HIPAA) requirements consistent with the executed Business Associates Agreement.

Compliance Hotline

The Compliance Hotline # is 800-211-2713. Team Members, Contractors, visitors, families and residents and others may report problems and concerns either anonymously or in confidence. 

The Compliance Officer is responsible for the oversight of the Compliance Line, including ensuring that all Compliance Line calls are addressed in an appropriate and timely manner in accordance with these and all related policies and procedures. 

Reporting and Returning Medicare Overpayments

White Horse Village will comply with federal laws regarding the timely identification, reporting and repayment of Medicare Part A and/or Part B overpayments.  An overpayment is any funds that a person has received or retained under Medicare Parts A and/or B to which the person, after applicable reconciliation, is not entitled.  An erroneous payment by the Medicare contractor, through no fault of the provider, is still an overpayment.  

Elder Justice Act

All Team Members are notified of their reporting obligations under the Elder Justice Act (EJA) to report a suspicion of crime to state regulatory authorities and local law enforcement.  White Horse Village will post a notice about Team Members’ EJA reporting obligations in the same area where other required Team member notices are posted. The reporting requirements shall be posted in public locations for residents, contractors, visitors or other interested parties.  EJA reporting requirements shall be communicated to appropriate contractors and vendors at least annually.

Team Members are required to report to the state survey agency and local law enforcement any reasonable suspicion of a crime against any individual who is a resident of, or receiving care in the skilled nursing care facility of White Horse Village. If more than one Team member has a reasonable suspicion of a crime, each individual is obligated to file the report.  Coordinated reporting may be completed by the skilled nursing facility administrator or designee.

Resident Gifts

While residents, patients and families often wish to show their appreciation for the care and services rendered by White Horse Village Team Members, White Horse Village must ensure that residents, patients and family members do not feel obliged to give White Horse Village or its Team Members gifts or gratuities in order to assure a resident receives quality care.  Accordingly, it is White Horse Village’s policy that Team Members may not accept gifts or gratuities directly from residents and patients for whom White Horse Village provides care or from the resident’s family or friends.

Rights/Obligations if contacted by Government Agency

Team Members have certain rights and obligations in the event they are contacted by an agent or attorney during the course of an investigation.

While Team Members are free to talk with government investigators, there is not an obligation to do so.  Team Members have a right to decline to be interviewed by a government attorney or investigator.

Absent a formal process, government agents or investigators cannot compel Team Members to be interviewed or make a statement.

Team Members also have a right to choose to speak with a government investigator or agent.  If Team Members choose to be interviewed or make a statement, White Horse Village expects Team Members to respond to questions truthfully.

Regardless of whether Team Members refuse to be interviewed or agree to be interviewed, White Horse Village requests that Team Members inform their supervisor of the date of the contact and the name of the investigator.

Team Members contacted by a government attorney or agent have the right to meet with an attorney.  They also have the right to have an attorney present during an interview. White Horse Village will provide an attorney to meet with any employee who is contacted during the course of an investigation.  The attorney may be able to inform the Team Member of his/her rights in connection with the investigation. However, an attorney provided by White Horse Village is a legal representative of White Horse Village only.  An attorney provided by White Horse Village is not a personal representative of any Team Member.

Sanctions Screening

White Horse Village will not employ or engage in a business relationship with anyone who is currently under sanction or exclusion by any duly authorized enforcement agency, or licensing and disciplining authority.  This includes both Federal and State agencies.

For purposes of this policy “Ineligible Person” shall be designated as any individual or entity who: (i) is currently excluded, suspended, debarred or otherwise ineligible to participate in the Federal healthcare programs; or (ii) has been convicted of a criminal offense related to the provision of health care items or services that has not been reinstated in the Federal healthcare programs after a period of exclusion, suspension, debarment, or ineligibility

Triple Check

White Horse Village is committed to providing accurate and complete information to the government when submitting claims for reimbursement under the Medicare program.  In order to ensure that claims are accurate and complete, it is the policy of White Horse Village to perform a Triple Check review for each Medicare claim prior to submitting the claim to the government.  

Vendor Agreements

White Horse Village is committed to doing business in a manner that subscribes to best legal and ethical practices.  Before entering into a business relationship with an individual or entity, both parties will sign a valid written agreement (indicating the products, terms of sale, price, discounts, terms of payment, etc.) for each contractor, vendor, dealer, distributor, or agent arrangement for ongoing business relationships associated with healthcare related services or products.

White Horse Village will only allow a vendor or supplier access to a residents’ medical record after we have entered into a written agreement with the vendor or supplier and the vendor or supplier requires review the resident’s medical record in order to render the services required pursuant to the contract.

A Business Associate Agreement will be executed as required with vendors and contractors with whom White Horse Village’s relationship meets the criteria set forth by HIPAA.

White Horse Village will provide a copy of the Code of Conduct to all contractors, vendors, dealers, distributors and agents with whom it does business that relates to any federal or state reimbursement funding. 

All vendors and contractor agreements will include language that requires compliance with White Horse Village’s Sanctions Screening policy. 

White Horse Village Code of Conduct

Scope of our Program

Our Compliance & Ethics Program Code of Conduct covers the compliance issues, laws and regulations, and guidelines that are relevant to a provider of senior services including a wide range of healthcare services. This includes but is not limited to Medicare regulatory issues; guidelines from the Office of Inspector General, Internal Revenue Service, and the Office of Civil Rights of the Department of Health and Human Services, Occupational Safety and Health Administration; as well as other federal and state regulatory and business issues. The program fosters a culture of compliance that promotes legal and ethical behavior in the workplace by creating processes that detect and prevent fraud, waste, abuse, and policy violations. The Code of Conduct is supported by our compliance policies and procedures and should be read and understood jointly with those policies and procedures.

We use the term team member to define the various individuals who are associated with White Horse Village Inc.All individuals, including employees, contractors, volunteers, directors, and officers are members of our team in providing care and services to our residents. We use the term Resident to refer to individuals who receive the various types of healthcare and other services that we provide.

Any questions regarding the policies in this Code of Conduct, compliance policies, or related references, should be directed to your immediate supervisor, a member of the Compliance Committee, or the Compliance Officer.

White Horse Village Inc. is a Continuing Care Retirement Community licensed under the laws of the Commonwealth of Pennsylvania to provide the following services:

• Skilled & Long Term Nursing
• Personal Care
• Residential Living 
• Home Care
• Rehabilitation Services
• Alzheimer’s/Dementia Support Services

Compliance Officer

The Compliance Officer works with our President & Chief Executive Officer and has direct reporting responsibility to the Board of Directors. The Compliance Officer is responsible for continued coordination for the development, implementation, training, monitoring, and enforcement activities related to the overall compliance program. The Compliance Officer is assisted by Compliance Managers and Compliance Specialists through FSA Compliance and Risk Management.  

Compliance Program Management

Our Board of Directors, through the President & Chief Executive Officer, carries the overall responsibility for creating a culture that values and emphasizes compliance and integrity.

Dave Kelble has been appointed by the President & Chief Executive Officer and the Board of Directors as the Compliance Officer and is responsible for coordinating the day-to-day compliance activities. These activities include audits, responses to hotline calls, and leading the organization’s Compliance Committee. 

White Horse Village Inc.’s Compliance Committee is comprised of the Compliance Officer, Privacy Officer, Security Officer, President & CEO, and other key staff positions. The Compliance Officer is the chairperson of this committee. The committee meets at least quarterly, and more frequently as needed. 

Introduction

The Code of Conduct is the foundation of the Compliance & Ethics Program. The Code of Conduct is a guide to appropriate workplace behavior; it will help you make the right decisions if you are not sure how to respond to a situation. All team members must comply with both the spirit and the letter of all federal, state, and local laws and regulations that apply to the healthcare and other services that our organization provides, as well as all laws that apply to our business dealings. Violations of these laws and regulations can result in severe penalties for White Horse Village Inc. and the individuals we do work with, including financial penalties, exclusion from participation in government programs, and, in some cases, imprisonment. 

As team members, we share a commitment to legal, ethical, and professional conduct in everything that we do. 

The success of White Horse Village Inc. as a provider of healthcare and other services depends on you, your personal and professional integrity, your responsibility to act in good faith, and your obligation to do the right things for the right reasons. 

The Compliance & Ethics Program provides principles and standards to guide you in meeting your legal, ethical, and professional responsibilities. As a team member, you are responsible for supporting the Compliance & Ethics Program in every aspect of your workplace behavior. Your continued working relationship with White Horse Village Inc. includes understanding and adhering to the Compliance & Ethics Program.

The Code of Conduct discusses the importance of: 

Service Excellence – providing quality, compassionate, respectful, and clinically-appropriate services.

Professional Excellence – maintaining ethical standards of healthcare and business practices. 

Regulatory Excellence – complying with federal and state laws, regulations, and guidelines that govern healthcare, housing services, and other services we provide. 

A Shared Responsibility

Because White Horse Village Inc. is in the business of caring for and providing services for others, it is critical that each of us adheres to appropriate standards of behavior. As individuals and as an organization, we are responsible for many different groups. We must act ethically and responsibly in our relations with: 

Residents and their families;

Colleagues and co-workers;

Volunteers and affiliated colleagues;

Healthcare payers, including the federal and state governments;

Regulators, surveyors, and monitoring agencies;

Physicians, Nurse Practitioners, Physician Assistants;

Vendors and contractors;

Business associates; and

The communities we serve.

Any compromise in our standards could harm our residents, our co-workers, and our organization. Like every organization that provides healthcare, we do business under very strict regulations and close governmental oversight. Fraud, waste, and abuse are serious issues. Sometimes even an innocent mistake can have significant consequences that could result in substantial penalties to White Horse Village Inc.

All team members are required to complete training on the Code of Conduct and the Compliance & Ethics Program as a condition of employment or business relationship. The Code of Conduct sets forth mandatory standards.

Every team member is responsible for ensuring that he or she complies with the Code of Conduct and all policies and procedures. Any team member who violates any of these standards and/or policies and procedures is subject to discipline up to and including termination. 

A Personal Obligation

As we are each responsible for following the Code of Conduct in our daily work, we are also responsible for enforcing it. This means that you have a duty to report any problems you observe or perceive, regardless of your role.

As a team member, you must help ensure that you are doing everything practical to comply with applicable laws. If you observe or suspect a situation that you believe may be unethical, illegal, unprofessional, or wrong, or you have a clinical, ethical, or financial concern, you must report it. You are expected to satisfy this duty by complying with the Three Step Reporting Process. If you fail to report noncompliance with the Code of Conduct, policies and procedures, or applicable federal or state laws, you will be subject to corrective action up to and including termination. We have a zero tolerance for retaliation. No one may retaliate against a member who reports a concern in good faith. 

Reporting Compliance Concerns

The Three Step Reporting Process:

First, talk to your supervisor. He or she is most familiar with the laws, regulations, and policies that relate to your work. 

Second, if you are not able to talk to your supervisor, seek out another member of the leadership team or someone from human resources.

Third, if you still have a concern, contact the Compliance Officer, a member of the organization’s Compliance Committee, or the Compliance Hotline.

Compliance Line

Compliance Line at 800-211-2713 

All calls are confidential, and you may call ANONYMOUSLY if you choose.

The Compliance Line is available 24 hours a day, 7 days a week, for callers to report compliance-related issues. Concerns that are reported to the Compliance Line are taken seriously.

You can make calls to the Compliance Line without fear of reprisal, retaliation, or punishment for your actions. Anyone, including a supervisor, who retaliates against a team member for contacting the Compliance Line or reporting a compliance issue in any other manner, will be subject to corrective action up to and including termination. 

Service Excellence

Our most important job is providing quality care to our residents. This means offering compassionate support to our residents and working toward the best possible outcomes while following all applicable rules and regulations, including the Medicare Conditions of Participation.

Resident Rights

Residents receiving healthcare and other services have clearly defined rights. A document describing these rights is provided to each resident upon admission and is posted in conspicuous locations throughout the White Horse Village Healthcare areas for the residents and your reference. To honor these rights, we must: 

• Make no distinction in the admission, transfer, or discharge of a resident, or in the care we provide on the basis of race, gender, age, religion, national origin, disability, color, marital status, veteran status, medical condition, sexual orientation, or other protected class status, insurance, or financial status;
• Treat all residents in a manner that preserves their dignity, autonomy, self-esteem, and civil rights;
• Protect every resident from physical, emotional, verbal, or sexual abuse or neglect;
• Protect all aspects of resident privacy and confidentiality;
• Respect residents’ personal property and money and protect it from loss, theft, improper use, and damage;
• Respect the right of residents and/or their legal representatives to be informed of and participate in decisions about their care and treatment;
• Respect the right of residents and/or their legal representatives to access their medical records as required by the Health Information Portability and Accountability Act (HIPAA);
• Recognize that residents have the right to consent to or refuse care and the right to be informed of the medical consequences of such refusal;
• Protect residents’ rights to be free from physical and chemical restraints; and
• Respect the residents’ right to self-determination and autonomy.

Abuse and Neglect

Wewill not tolerate any type of resident abuse or neglect – physical, emotional, verbal, financial, or sexual. Residents must be protected from abuse and neglect by team members, family members, legal guardians, friends, or any other person. This standard applies to all residents at all times. 

Federal law defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain or mental anguish. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The failure to follow a resident’s care plan may constitute abuse. 

The Commonwealth of Pennsylvania defines abuse as: 

Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Any team member who abuses or neglects a resident is subject to termination. In addition, legal or criminal action may be taken. Abuse and neglect MUST BE REPORTED IMMEDIATELY to your supervisor or other member of management.  

Elder Justice Act

The Elder Justice Act requires timely reports of any reasonable suspicion of a crime against a resident of a long-term care facility. You must report your reasonable suspicion to the Department of Health at 1-800-490-8505 and local law enforcement at 911 within two (2) hours if the suspected crime involves serious bodily injury or within 24 hours if the suspected crime does not involve serious bodily injury. 

DO NOT call the Compliance Line for allegations of abuse or neglect. 

Resident Confidentiality/HIPAA

All team members must use and disclose medical, financial, or personal information only in a manner consistent with the HIPAA Privacy policies and procedures and state and federal law. You are responsible for keeping resident protected health information (PHI) confidential. PHI is defined as individually identifiable health information that is transmitted or maintained in any form or medium, including electronic health information. 

Any unauthorized exposure of PHI which compromises the security or privacy of information is a potential breach. 

If you become aware of a breach of any protected or sensitive information, it is important that you report it immediately to your supervisor or the Privacy Officer.

If the disclosure results in a breach, White Horse Village Inc. must investigate and comply with all state and federal HIPAA regulations for breach notification. 

Resident Property 

Team members must respect residents’ personal property and protect it from loss, theft, damage, or misuse. Team members who have direct access to resident funds (e.g., resident trust funds) must maintain accurate records and accounts.

Providing Quality Care 

At White Horse Village Inc., our primary commitment is to provide the care, services, and resources necessary to help each resident reach or maintain his or her highest possible level of physical, mental, and psychosocial well-being. White Horse Village Inc. has policies and procedures and provides training and education to help each team member strive to achieve this goal. 

Medical Services 

We are committed to providing comprehensive, medically necessary services for our residents. The Medical Director provides oversight to physicians and other medical providers and services as defined by state and federal regulations. The Medical Director oversees the care and treatment policies and is actively involved in the Quality Assurance Performance Improvement (QAPI) Committee.

Professional Excellence

The professional, responsible, and ethical behavior of every team member reflects on the reputation of our organization and the services we provide. Whether you work directly with residents or in other areas that support resident services, you are expected to maintain our standards of honesty, integrity, and professional excellence, every day. 

Hiring and Employment Practices

White Horse Village Inc. is committed to fair employment practices. When hiring and evaluating, we:

• Comply with federal, state, and local Equal Employment Opportunity laws, hiring the best qualified individuals regardless of sex, race, color, national origin, age, religion, sexual orientation, genetic information, gender identity, gender expression, pregnancy, veteran status, disability, or any other legally protected characteristic All promotions, transfer evaluations, compensation, and corrective actions also follow this policy.
• Conduct employment screenings to protect the integrity of our workforce and welfare of our residents and team members.
• Require all who need licenses or certifications to maintain their credentials in compliance with state and federal laws. Documentation of licenses or certifications must be provided.

Team Member Screening

Team Members are screened in accordance with federal and state. Screening procedures have been implemented and are conducted prior to hire and at a minimum of quarterly thereafter. 

As long as you are employed or affiliated with White Horse Village Inc., you must immediately report to your supervisor: 

• If you are arrested or indicted for a criminal offense;
• If you are convicted of an offense that would preclude employment in a healthcare facility;
• If action has been taken against your license or certification; or
• If you are excluded from participation in a federal or state healthcare program. 

Licensure, Certification, and Exclusion Screening

We are committed to ensuring that only qualified professionals provide care and services to residents. Practitioners and other professionals treating residents must abide by all applicable licensing, credentialing and certification requirements. In addition, every effort is made to validate licenses and certification through the appropriate state or federal agency. 

White Horse Village Inc. is prohibited by federal law from employing, retaining, or contracting with anyone who is excluded from any federal or state funded programs.  Screening of all team members through the Office of Inspector General’s List of Excluded Individuals and Entities, GSA’s System of Award Management, and the Commonwealth of Pennsylvania Medicaid Excluded Provider List database is conducted prior to hire and at a minimum of quarterly thereafter.

Team Member Relations

To maintain an ethical, comfortable work environment, team members must:

• Refrain from any form of sexual harassment or violence in the workplace; 
• Treat all colleagues and co-workers with equal respect, regardless of their sex, race, color, national origin, age, religion, sexual orientation, genetic information, gender identity, gender expression, pregnancy, veteran status, disability or any other legally protected characteristic under federal, state or local law;
• Protect the privacy of other team members by keeping personal information confidential and allowing only authorized individuals access to the information; 
• Not supervise or be supervised by an individual with whom they have a close personal relationship; and 
• Act professionally and use respectful communication at all times.

Workplace Safety

Maintaining a safe workplace is critical to the well-being of our residents, visitors, and co-workers. Every team member should become familiar with safety regulations and emergency plans regarding fire and disaster in his or her work area. 

In addition to organizational policies, we must abide by all environmental laws and regulations. You are expected to follow White Horse Village Inc.’s safety guidelines and to take personal responsibility for helping to maintain a secure work environment. If you notice a safety hazard, you must take action to correct it if you can or to report it to your supervisor immediately.

Drug and Alcohol Abuse

White Horse Village Inc. is committed to maintaining a team dedicated and capable of providing quality resident services. To that end, you are prohibited from consuming any substance that impairs your ability to provide quality services or otherwise perform your duties. 

You may never use, sell, or bring on White Horse Village Inc.’s property alcohol, illegal drugs, and/or narcotics or report to work under the influence of alcohol, illegal drugs, and/or narcotics. For a team member who appears to have work performance problems related to drug or alcohol use, a drug and alcohol screening will be conducted and appropriate action will be taken, if necessary. 

Illegal, improper, or unauthorized use of any controlled substance that is intended for a resident is prohibited. If you become aware of any improper diversion of drugs or medical supplies, you must immediately report the incident to your department supervisor, the Compliance Officer, or use the Compliance Line. Failure to report a known instance of noncompliance with this policy may result in corrective action against the team member, up to and including termination.

Organizational Relations

Professional excellence in organizational relations includes:

• Complying with federal tax law to maintain tax exempt status under section 501(c)(3) of the Internal Revenue Code;
• Maintaining company privacy and keeping proprietary information confidential;
• Avoiding outside activities or interests that conflict with responsibilities to White Horse Village Inc. and reporting such activity or interest prior to and during employment;
• Allowing only designated management staff to report to the public or media; and
• Requiring that White Horse Village Inc. complies with the licensing and certification laws that apply to its business.

Proprietary Information

In the performance of your duties you, may have access to, receive, or may be entrusted with confidential and/or proprietary information that is owned by White Horse Village Inc. and that is not presently available to the public. This type of information should never be shared with anyone outside of White Horse Village Inc. without authorization from the President & Chief Executive Officer.

Examples of proprietary information that should not be shared include:

• Resident and team member data and information;
• Details about clinical programs, procedures, and protocols;
• Policies, procedures, and forms;
• Training materials;
• Current or future charges or fees or other competitive terms and conditions;
• Current or possible negotiations or bids with payers or other clients;
• Compensation and benefits information for team members;
• Financial information; and
• Market information, marketing plans, or strategic plans.

Gifts

You may not give gifts to residents unless you share a legal relationship by blood, adoption, or marriage.  You may not accept tips/gratuities from residents/families, nor can you accept individual gifts from residents/families except as set forth below. 

We recognize that relationships between residents(families) and team members will naturally develop as an outgrowth of the work relationship and, from time to time, residents(families) may wish to express appreciation for services provided.  While individual gifts are not permitted to be accepted, an exception to this would be gifts such as cookies, candy, etc., which are provided by residents (family members) to group of team members will be permitted.   Residents (families) should they choose, can be directed to the White Horse Village Foundation to provide a monetary gift to the Employee Appreciation Fund (EAF), which is a fund that distributes money to team members in non-management positions in a method consistent with specified criteria determined by the White Horse Village Foundation Board of Directors.  The EAF drive is held twice each year and checks are distributed to eligible team members at the same time.

Except in those cases where team members and residents share a legal relationship (by blood, adoption, or marriage), or as otherwise allowed by state law, team members may not do any of the following:   borrow money from residents, lend money to residents,  engage with residents in the purchase or sale of any item (not including the purchase of a vehicle for fair market value), accept any gift from a resident, including by means of will or trust instrument, serve as a resident’s executor, trustee, administrator, or guardian; or provide financial services or act under a power of attorney for a resident.

Business Courtesies

White Horse Village Inc. prohibits any team member from offering, giving, soliciting, or accepting business or professional courtesies including entertainment and gifts that could be interpreted as attempts to influence decision-making. 

We recognize that there will be times when team members may wish to accept from a current or potential business associate an invitation to attend a social event to further develop the business relationship.  These events must not include expenses paid for any travel costs (other than in a vehicle owned privately or by the host company) or overnight lodging.  The cost associated with such an event must be reasonable and appropriate.  As a rule, this will mean the cost will not exceed $125.00 per person. 

Sometimes a business associate will offer training/education that includes travel and/or accommodations at no cost. There also may be circumstances when team members are invited to an event at a business associates’ expense to receive information about new products/services.  Prior to accepting any such invitation, the team member must receive approval from the President & CEO or Compliance Officer. 

Conflict of Interest

A conflict of interest exists any time your loyalty to White Horse Village Inc. is, or even appears to be, compromised by a personal interest. There are many types of conflict of interest and these guidelines cannot anticipate them all, however the following provide some examples:

• Financial involvement with vendors or others that would cause you to put their financial interests ahead of White Horse Village Inc.;
• Team member/Officer participation in public affairs, corporate or community directorships, or public office;
• An immediate family member who works for a vendor or contractor doing business with the organization and who is in a position to influence your decisions affecting the work of the organization;
• Participating in transactions that put your personal interests ahead of White Horse Village Inc. or cause loss or embarrassment to the organization;
• Taking a job outside of White Horse Village Inc. that overlaps with your normal working hours or interferes with your job performance; or 
• Working for White Horse Village Inc. and another vendor that provides goods or services at the same time.

All team members must seek guidance and approval from the President & CEO or Compliance Officer before pursuing any business or personal activity that may constitute a conflict of interest.

Use of Property

We must protect the assets of the organization and ensure their authorized and efficient use. Theft, carelessness, and waste have a direct impact on the organization’s viability. All assets must be used solely for legitimate business purposes.

Everyone must make sure that they: 

• Only use property for the organization’s business, not personal use;
• Exercise good judgment and care when using supplies, equipment, vehicles, and other property; and
• Respect copyright and intellectual property laws; or
• If unable to assess the copyright or intellectual property laws, never copy material and/ or download software.

Computers /Internet/Social Media

Team members are expected to use computers, email, and internet/intranet systems appropriately and according to the established policy and procedure. You are not permitted to use the Internet for improper or unlawful activity or download any games or music without prior approval.

Internet use can be tracked and how you use your time on the Internet may be monitored. You should have no expectation of privacy when you use our computers, email, and internet/intranet system. Our organization has the right to sanction or discipline employees who violate the Code of Conduct in a digital, cyber, or other non-face-to-face environment. You should be familiar with our Social Media policy and abide by it.

Vendor Relationships

We take responsibility for being a good client and dealing with vendors honestly and ethically. We are committed to fair competition among prospective vendors and contractors for our business. Arrangements between White Horse Village Inc. and its vendors must always be approved by management. Certain business arrangements must be detailed in writing and approved by management. Agreements with contractors and vendors who receive resident information, except for care providers, will require a Business Associate Agreement (BAA) with White Horse Village Inc. as defined by HIPAA. Contractors and vendors who provide resident care, reimbursement, or other services to resident beneficiaries of federal and/ or state healthcare programs are subject to the Code of Conduct and must:

• Maintain defined standards for the products and services they provide to us and our residents;
• Comply with all policies and procedures as well as the laws and regulations that apply to their business or profession;
• Maintain all applicable licenses and certifications and provide evidence of sanction screening, current workers compensation, and liability insurance as applicable; and
• Require that their employees comply with the Code of Conduct and the Compliance & Ethics Program and related training as appropriate. 

Marketing and Advertising

We use marketing and advertising activities to educate the public, increase awareness of our services, and recruit new team members. These materials and announcements, whether verbal, printed, or electronic, will present only truthful, informative, non-deceptive information. 

Regulatory Excellence

Because White Horse Village Inc. provides healthcare services, we must follow the many federal, state, and local laws that govern our business. Keeping up with the most current rules and regulations is a big job – and an important one. We are all responsible for learning and staying current with the federal, state, and local laws, rules, and regulations, as well as the policies and procedures that apply to our job responsibilities. 

Billing and Business Practices

We are committed to operating with honesty and integrity. Therefore, all team members must ensure that all statements, submissions, and other communications with residents, prospective residents, the government, suppliers, and other third parties are truthful, accurate, and complete.

We are committed to ethical, honest billing practices and expect you to be vigilant in always maintaining these standards. We will not tolerate any false or inaccurate coding or billing. Any team member who knowingly submits a false claim or provides information that may contribute to submitting a false claim such as falsified clinical documentation, to any payer – public or private – is subject to termination. In addition, legal or criminal action may be taken.

Prohibited practices include, but are not limited to: 

• Billing for services or items that were not provided or costs that were not incurred; 
• Duplicate billing – billing items or services more than once;
• Billing for items or services that were not medically necessary;
• Assigning an inaccurate code or resident status to increase reimbursement;
• Providing false or misleading information about a resident’s condition or eligibility;
• Failing to identify and refund credit balances;
• Submitting bills without supporting documentation;
• Soliciting, offering, receiving, or paying a kickback, bribe, rebate, or any other remuneration in exchange for referrals; and/or
• Untimely entries into medical records.

If you observe or suspect that false claims are being submitted or have knowledge of a prohibited practice, you must immediately report the situation to a supervisor, the Compliance Officer, or call the Compliance Hotline. Failure to report a known prohibited practice will subject you to corrective action up to and including termination.

Referrals and Kickbacks

Team members and related entities often have close associations with local healthcare providers and other referral sources. To demonstrate ethical business practices, we must make sure that all relationships with these professionals are open, honest, and legal.

Resident referrals are accepted based solely on the clinical needs and our ability to provide the services. White Horse Village Inc. never solicits, accepts offers, or gives anything of value in exchange for resident referrals or in exchange for purchasing or ordering any good or service for which payment is made by a federal health care program. Anything of value includes any item or service of value, including cash, goods, supplies, gifts, “freebies,” improper discounts or bribes. 

Accepting kickbacks is against our policies and procedures and against the law. A kickback is anything of value that is received in exchange for a business decision such as a resident referral. To assure adherence to ethical standards in our business relationships, you must:

• Verify all business arrangements with physicians or other healthcare providers or vendors in a written document; and
• Comply with all state and federal regulations when arranging referrals to physician-owned businesses or other healthcare providers.

You cannot request, accept, offer, or give any item or service that is intended to influence – or even appears to influence – the referral, solicitation, or provision of healthcare service paid for by any private or commercial healthcare payer or federal or state healthcare program, including Medicare or other providers. 

Inducements to Prospective Residents

You may not provide anything of value, including goods, services, or money to prospective residents or any beneficiary of a federal or state healthcare program that you know or should know will likely influence that person’s selection of a provider of healthcare services. 

For the purposes of this policy, anything of value includes but is not limited to any waiver of payment, gift, or free service that exceeds a value of $10 per item or $50 annually in total. If you have a question about whether a particular gift or service would be considered “of value,” ask your supervisor or the Compliance Officer.

Copyright Laws

Most print and electronic materials are protected by copyright laws. Team members are expected to respect these laws and not reproduce electronic print or printed material without obtaining permission as required by the writer or publisher. When in doubt, ask your supervisor. 

Financial Practices and Controls 

Ensuring that financial and operating information is current and accurate is an important means of protecting assets. Each one of us must make sure that all information provided to bookkeepers, accountants, reimbursement staff, internal and external auditors, and compliance staff are accurate and complete. This includes ensuring the accuracy of clinical documentation which supports our reimbursement. We must also comply with federal and state regulations when maintaining clinical records, accounting records and financial statements, and cooperate fully with internal and external audits.

Fair Dealing

All team members must deal fairly with residents, suppliers, competitors, and one another. No team member, manager, or director/vice president shall take unfair advantage of anyone through manipulation, concealment, abuse of privileged information, misrepresentation of material facts, or any other unfair dealing practice.

Fair Housing Statement

White Horse Village Inc. pledges to the letter and the spirit of U.S. laws for the achievement of equal housing opportunity under the Fair Housing Act.

Document Creation, Use and Maintenance

Every team member is responsible for the integrity and accuracy of documents, records, and e-mails including, but not limited to, resident medical records, billing records, and financial records. No information in any record or document may ever be falsified or altered.

You must not disclose, internally or externally, either directly or indirectly, confidential information except on a need-to-know basis and in the performance of your duties. Disclosure of confidential information externally must follow organization policies. 

Upon termination of employment, you must promptly return all confidential information, medical and/or business, to White Horse Village Inc. Examples of confidential business information include potential or threatened litigation, litigation strategy, purchases or sales of substantial assets, business plans, marketing strategies, organizational plans, financial management, training materials, fee schedules, department performance metrics, and administrative policies. 

Voluntary Disclosure 

It is our policy to voluntarily report known overpayments and any improper/irregular conduct, including fraudulent conduct, which affects any federal or state healthcare program. Reporting will be completed within the time frames identified under the Patient Protection and Affordable Care Act.

Government Investigations

White Horse Village Inc. is committed to cooperating with requests from any governmental inquiry, audit, or investigation. You are encouraged to cooperate with such requests, conscious of the fact that you have the following rights:

• You have the right to speak or decline to speak; 
• You have the right to speak to an attorney before deciding to be interviewed; and 
• You can insist that an attorney be present if you agree to be interviewed.

In complying with our policy you must not:

• Lie or make false or misleading statements to any government investigator or inspector;
• Destroy or alter any records or documents;
• Attempt to persuade another team member or any person to give false or misleading information to a government investigator or inspector; or
• Be uncooperative with a government investigation.

If you receive a subpoena or other written or oral request for information from the government or a court, contact your supervisor, or the Compliance Officer before responding.

Corrective Action

Corrective action will be given to anyone who does not act in accordance with this Code of Conduct, the Compliance & Ethics Program, supporting policies and procedures, and applicable federal and state laws. Corrective action may be warranted in relation to violators of the Compliance Program and to those who fail to detect violations or who fail to respond appropriately to a violation, whatever their role at White Horse Village Inc. When providing corrective action to a team member, we will utilize standard corrective action processes which may lead to the termination of business relationships and agreements. The Compliance Officer may initiate and recommend corrective action for a team member through the President & CEO and may also monitor appropriate implementation of the corrective action process. We will provide corrective action to anyone who engages in prohibited retaliatory conduct.

Compliance Questions

The laws applicable toour operations are numerous and complicated. When you are not sure whether a particular activity or practice violates the law or the Compliance & Ethics Program, you should not guess the correct answer. Instead, you should immediately seek guidance from your department supervisor or the Compliance Officer. You will not be penalized for asking compliance-related questions. In fact, we are intent on creating a culture in which you should feel comfortable asking questions to ensure you understand the duties that are imposed upon you under this Code of Conduct, the Compliance Program, and other applicable federal and state laws.

Conclusion

The Compliance & Ethics Program is critical to White Horse Village Inc.’s continued success. You are crucial in ensuring the integrity of White Horse Village Inc. The Code of Conduct and the Compliance and Ethics Program set standards for the legal, professional, and ethical conduct of our business. Some key points to remember are:

• White Horse Village Inc. and all our team members are committed to personal and organizational integrity, to acting in good faith, and to being accountable for our actions.
• The Code of Conduct and the Compliance & Ethics Program prepare us to deal with the growing complexity of ethical, professional, and legal requirements of delivering healthcare and other related services.
• The Compliance & Ethics Program is an ongoing initiative designed to foster a supportive work environment, provide standards for clinical and business conduct, and offer education and training opportunities for team members.

The success of the White Horse Village Inc.  Compliance & Ethics Program depends on our commitment to act with integrity, both personally and as an organization. As a team member, your duty is to ensure that White Horse Village Inc. is doing everything practicable to comply with applicable laws. You are expected to satisfy this duty by performing your responsibilities in accordance with professional standards, the regulations guiding our business practices, and our policies and procedures.

Your Compliance Officer
Dave Kelble, Compliance Officer
610-675-2049

Your Privacy Officer
Jeanette Quinones, Sr. Director Healthcare Services
610-558-5043

Your Security Officer

Toll-Free Compliance Line
1-800-211-2713