Compliance / HIPAA
JOHN KNOX VILLAGE
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT THE JOHN KNOX VILLAGE CORPORATE COMPLIANCE OFFICER AT 816-347-2109.
This Notice of Privacy Practices (or “Notice”) describes how we will use and disclose protected health information (“PHI”) and data that we receive or create related to your healthcare. We understand that your PHI is personal to you, and we are committed to protecting the information about you. John Knox Village is an organization with a variety of services available to our residents and other clients. There are many departments that could access PHI for the performance of those services. These departments include, but are not limited to, Village Home Health, Valley View Residential Care, Valley View Memory Care, Village Assisted Living, Village Hospice, Village Helpers, Village Nursing, Village Emergency Medical Service, the Fitness Center and the Village Care Center. All of John Knox Village’s departments follow the terms of this Notice.
We are required by federal law and applicable state law, regulations, and other authorities to protect the privacy of your PHI and to provide you with this Notice. We are required to protect the confidentiality of your PHI and will disclose your PHI to a person other than you or your personal representative only when permitted under federal or state law. This protection extends to any PHI that is oral, written, or electronic, such as health information transmitted by facsimile, modem, or other electronic device. This Notice describes how we may use and disclose your health information. In some circumstances, as described in this Notice, the law permits us to use and disclose your PHI without your express permission. In all other circumstances, we will obtain your written authorization before we use or disclose your PHI. This Notice also describes your rights and the obligations we have regarding the use and disclosure of PHI. Under federal and applicable state law, we are required to follow the terms of the Notice currently in effect. YOU ARE NOT REQUIRED TO AUTHORIZE ADDITIONAL USES AND DISCLOSURES OF YOUR PHI.
Uses and Disclosures
How We May Use And Disclose Your PHI Without Your Permission
The following categories describe the different ways we may use and disclose (or release) your PHI without your permission.
- Treatment. We may use PHI while providing, coordinating, or managing your healthcare, including emergency treatment situations. For example: Information obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his/her expectations for the members of your healthcare team (in the form of orders). Members of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment. We will also provide your physician or subsequent healthcare provider with copies of various reports that should assist him/her in treating you once you are discharged or move to another level of care at John Knox Village or discharged to a hospital or another healthcare facility.In addition, we may disclose your PHI from time-to-time to another physician or healthcare provider (e.g. a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your healthcare diagnosis or treatment.
- Payment. We may use and disclose medical information to obtain or provide compensation or reimbursement for providing your healthcare. For example: Your PHI will be used, as needed, to obtain payment for your healthcare services. This may include certain activities that your health payor may undertake before it approves or pays for healthcare services, such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity and undertaking utilization review activities (e.g. obtaining approval for a stay may require that your relevant PHI be disclosed to obtain approval for that stay).
- Health Care Operations. Members of staff and/or quality improvement team may use information in your health record to assist the care and outcomes in your case and others like it. We may use and disclose your health information to deal with certain administrative aspects of your healthcare, to provide services and to manage our business more efficiently. For example: We may use or disclose, as needed, your PHI in order to support the business activities of John Knox Village. These activities include, but are not limited to, quality improvement activities, associate review activities, training of healthcare students, licensing, and conducting or arranging for other business activities. We may combine medical and other health information about many residents or patients to evaluate the need for new services or treatment. Members involved with quality improvement may use information in your health/medical record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and services we provide. We may remove information that identifies you from combined sets of information to protect your privacy.
How We May Use And Disclose Your PHI In Other Special Circumstances
We are permitted under federal and applicable state law and are likely to use or disclose your PHI without your permission only when certain circumstances may, arise as described below.
- Business Associates. There are some services provided in our organization to you through other companies termed as “business associates.” Federal law requires us to enter into business associate agreements with these other companies to safeguard your PHI. Examples include temporary staffing agencies, physician services, laboratory services, therapy services, consultants and information technology vendors. When these services are contracted, we may disclose your health information to our business associate so that it can perform the job we have requested and then bill for services rendered.
- Fundraising. We may use certain information and may contact you for the purposes of raising funds. If you do not want us to use your information for fundraising purposes, you may notify us using the information listed at the end of this Notice.
- Individuals Involved In Your Care or Payment for Your Care. Unless you notify us that you object, we may disclose to a family member, other relative, a close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care. If you are unable to agree to such a disclosure, we may disclose such information, as necessary, if we determine that it is in your best interest based on professional judgment. We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, of your location and general condition.
- Public Health. We may disclose your PHI to federal, state, or local authorities, or other public entities charged with preventing or controlling disease, injury, or disability for public health activities. These activities may include the following: disclosures to notify individuals of exposure to a disease or risk for contracting or spreading a disease or condition.
- Facility Directories. Unless you notify us that you object and wish to “opt-out,” we may use and disclose in our facility directory your name, location in the facility, general condition (e.g. good, fair), and religious affiliation. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name. If you elect to “opt-out” of the directory, we will not acknowledge your presence at John Knox Village.
- Future Communications. We may communicate with you via newsletters, mailings, or other means regarding treatment options, health-related information, disease management programs, wellness programs, or other community-based initiatives or activities in which our facility is participating.
- Required By Law. We may use or disclose your PHI to the extent that law requires the use or disclosure. The use and disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, when required by law, of any such uses or disclosures. We will disclose health information to the following entities, including but not limited to:
- The U.S Food and Drug Administration
- Public health or legal authorities charged with preventing or controlling disease, injury or disability
- Correctional institutions (if you are in custody of the correctional institution or a law enforcement officer
- Worker’s compensation agents
- Organ and tissue donation organizations
- Military command authorities
- Health oversight agencies
- Funeral directors, coroners, medical examiners
- National security and intelligence agencies
- Protective services for the president of the United States and others
- Organ Donation. Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs for the purpose of tissue donation and transplant.
- Research. If you are participating in a research protocol, please notify John Knox Village. Your medical information will not be released for a research project unless you consent in writing or, in the case of pre-study evaluation, an authorized Institutional Review Board has issued a waiver of authorization for review of records at the John Knox Village.
- Military, National Security, or Incarceration/Law Enforcement Custody. If you are involved with the military, national security or intelligence activities, or you are in the custody of law enforcement officials or an inmate in a correctional institution, we are permitted to release your health information to the proper authorities so they may carry out their duties under the law. We are permitted to release medical information about you to authorized federal officials so that they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
- Workers’ Compensation. We are permitted to disclose your health information to the appropriate persons in order to comply with the laws related to worker’s compensation or other similar programs.
We May Use Or Disclose Your PHI For Other Purposes Only With Your Authorization
We will obtain your valid written authorization before using or disclosing your PHI for purposes other than those described above (or as otherwise permitted or required by law) including before using or disclosing your PHI for marketing purposes or in exchange for remuneration and before using and disclosing your psychotherapy notes under certain circumstances. You may revoke this authorization at any time by submitting a written notice to our Compliance Officer at the address listed below. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your authorization. Understandably, we are unable to rescind any disclosure we have already made with your authorization.
- YOUR HEALTH INFORMATION RIGHTS
Although your health record is the physical property of John Knox Village, you have the right to:
- Inspect and Copy health information that may be used to make decisions about your care. You have the right to access and copy your PHI contained in the “designated record set,” which includes medical and billing records. We will respond to your request in writing within 30 days (with a possible 30-day extension). You also have the right to request an electronic copy of your PHI. If your PHI is not readily producible in such an electronic form or format, we will provide your PHI in a readable electronic form and format as agreed to by you and John Knox Village. A fee may be charged for the expense of fulfilling your request. We may deny your request to inspect and copy, in certain very limited circumstances, such as if we have reasonably determined that providing access to PHI would endanger your life or safety or cause substantial harm to you or another person. If you are denied access to medical information, you may request that the denial be reviewed in some situations. Another licensed professional chosen by John Knox Village will review your request and the denial. The person conducting the review will not be the same person that denied your request. We will comply with the outcome of the review. To inspect or copy your PHI, submit a written request to our Compliance Officer.
- Request an amendment. If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for John Knox Village. To request an amendment, submit a written request to our Compliance Officer. Request must identify: (i) which information you seek to amend, (ii) what corrections you would like to make, and (iii) why the information needs to be amended. We will respond to your request in writing within 60 days (with a possible 30-day extension). In our response, we will either: (i) agree to make the amendment, or (ii) inform you of our denial, explain our reason, and outline appeal procedures, if applicable.
- An accounting of disclosures. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice. Not all health information is subject to this request. For example, it excludes disclosures we may have made for a facility directory, to family members or friends involved in your care, disclosures authorized by you or for notification purposes. To obtain an accounting, submit a written request to our Compliance Officer. Requests must specify the time period, not to exceed six years, for which you would like to receive the accounting. We will respond in writing within 60 days of receipt of your request (with a possible 30-day extension). We will notify you in advance of the cost involved, and you may choose to withdraw or modify your request at that time.
- Request restrictions or limitations on the health/medical information we use or disclose about you for treatment, payment, or healthcare operations. You also have the right to request a limit on the information we disclose about you to someone who is involved in your care or the payment for your care such as a family member or friend by submitting a written request to our Compliance Officer. For example, you could ask that we not use or disclose information about a surgery that you had. You must identify in this request: (i) what particular information you would like to limit, (ii) whether you want to limit use, disclosure, or both, and (iii) to whom you want the limits to apply. All requests will be carefully considered, but we are not required to agree to those restrictions, except in certain circumstances. We will provide you with a written response to your request within 30 days. If we do agree to restrict use or disclosure of your PHI, we will not apply these restrictions in the event of an emergency. We also have the right to terminate the restriction if: (i) you agree orally or in writing, or (ii) we inform you of the termination, which becomes effective only with respect to your PHI created or received after we inform you of the termination. All requests for restrictions must include your full name, date of birth, and address.
- Request confidential communications. You have the right to request that we communicate with you about your healthcare matters in a certain way or at a certain location. For example, you may ask that we contact you by mail at home or at work. John Knox Village will strive to grant requests for confidential communications at alternative locations and/or via alternative means only if the request is made in writing and the written request includes a mailing address where you will receive bills for services rendered and related correspondence regarding payment for services. Please realize that we reserve the right to contact you by other means and at other locations if you fail to respond to any communication from us that requires a response. We will notify you in accordance with your original request prior to attempting to contact you by other means or at another location.
- A paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still required to a paper copy of this notice. You may obtain a copy of this notice at our website at www.jkv.org. To exercise any of your rights, please obtain the required forms from the Corporate Compliance Officer and submit your request in writing.
- Restriction on disclosure of PHI when paying out of pocket. You have the right to request a restriction on the disclosure of your PHI (for payment or healthcare operations) to your health plan when you have paid for the service or item in question completely out of pocket in full by submitting a written request to our Corporate Compliance Officer. We are required to agree to this restriction. We will provide you with a written response to your request within 30 days. All requests for PHI must include your full name, date of birth, and address.
- Breach Notification. You have the right to be notified when a breach of your unsecured PHI has occurred. We will provide you with such notification as soon as information regarding the breach is available.
Our contact person for all questions, requests, or for further information related to the privacy of your health information is:
Corporate Compliance Officer
400 N.W. Murray Road
Lee’s Summit, MO 64081
If you believe your privacy rights have been violated, you can file a complaint with the Corporate Compliance Officer of John Knox Village (400 N.W. Murray Rd., Lee’s Summit, Missouri 64081) and/or with the Secretary, Department of Health and Human Services (200 Independence Avenue SW, Washington, D.C. 20201).
Changes to This Notice
We reserve the right to change our practices and Notice, and to make the new provisions effective for all PHI we maintain. Any revision to our privacy practices will be described in a revised Notice that will be distributed and posted prominently at various locations in our organization (including our web site).
A copy of the current Notice in effect is always available upon request. Requests are to be made to the Corporate Compliance Officer at (816) 347-2109.
This version’s effective date is November 17, 2017
JOHN KNOX VILLAGE CODE OF CONDUCT
A Letter from the CEO
As a team member of John Knox Village, you have the great privilege of providing quality care to our residents and other customers, either directly or through the support you provide to others. Village associates are committed to enriching lives and building community by taking personal responsibility in delivering excellence. With that privilege there is an important responsibility. –You are expected to adhere to the highest level of legal and ethical standards. The Village expects this from you and so do the residents and patients we serve.
The regulators call this practice corporate compliance. A corporate compliance plan begins with a code of conduct. We rely on every associate to meet these standards through hard work and commitment to their job. We are a results-oriented company and every associate is expected to achieve their work objectives. The results we achieve must always be attained through execution of our strategic mission and decisions made with the highest level of integrity and P.R.I.D.E.
The John Knox Village Code of Conduct is your guide to ensure you are making the right decisions for the right reasons. It also ensures we comply with all applicable laws and regulations. Further, it serves as the conscience of our company, providing guidance and expectations to correctly handle situations that arise. Finally, it supports you in your job responsibilities in a manner that complies with our policies and Village expectations.
As you review the Code of Conduct, much of it will seem like common sense. It will also remind you of the principles of our P.R.I.D.E. philosophy — Personal Responsibility In Delivering Excellence. Just as you make decisions that are honest and ethical in your personal life, we expect you to apply honesty, compassion and integrity with our patients, residents, family members, customers and fellow associates.
Please review the Code of Conduct and adhere to its guidance. If after reviewing the Code you have questions about anything you have read or perhaps something you didn’t see covered, please discuss your concerns with your manager, vice president or human resources administrator. You can also contact the 24-hour confidential HELPLINE at 816-246-4343 Ext. 7233 from outside the Village, or Ext. 7233 inside the Village. Concerns also can be reported confidentially via interoffice or regular mail sent to the corporate compliance officer (the CCO), Risk Management in the Administrative Center. You can reach the compliance officer at 816-347-2109.
The most important job each of us has is to ensure that our residents and their families maintain a high level of trust in the service and care we provide. By consistently following our Code of Conduct and striving to provide the highest quality of care, we can continue to earn and deserve their trust.
Mission, Vision, Values and P.R.I.D.E.
To enrich the lives of older adults through community living, “Enriching lives, building community.”
To be the leader among senior living communities in the Greater Kansas City area.
- We value older adults and their importance to our society.
- We foster an environment that nourishes supportive, trusting and caring relationships with our residents, their families and our associates.
- We promote a community that encourages meaningful involvement and personal fulfillment.
- We emphasize an open community that welcomes and celebrates diversity in its aspects.
- We value business practices that promote careful stewardship of resources – human, physical and financial.
- We encourage active involvement in the local communities in which we operate.
John Knox Village is committed to creating and sustaining a workplace where:
- We bring a Positive Attitude to work every day.
- We treat everyone with Compassion.
- We are a Team Player.
- We work and live a life of Integrity.
- We show Respect to everyone.
- We are Empowered to carry out our job duties.
- We are Accountable for our decisions and actions.
- We constantly strive to achieve Excellence in all we do.
- We are Knowledgeable and seek to improve our skills to be of maximum service to those we serve.
Introduction to the Code of Conduct
John Knox Village (JKV) is committed to the goal of serving our residents/patients, associates and the community in an ethical, professional and responsible manner. Further, JKV is committed to providing quality care and services in an ethical and professional manner and in compliance with all applicable laws, regulations and guidelines, as well as our own policies and procedures. We are particularly sensitive to those requirements applicable to Federal and state health care programs and the submission of accurate claims.
The Code of Conduct (Code) provides guidelines for everyone, regardless of position, to conduct business ethically and in a law abiding manner. The Code, as well as all statutes, guidelines and JKV policies, must be observed by everyone: associates, volunteers, staffing agencies, members of the board of directors, affiliated school personnel and anyone else engaged in our work environment providing care or services, performing billing or coding functions, or acting on behalf of JKV. No one, regardless of position, will be allowed to compromise adherence to the Code, statutes, regulations, business standards, policies or procedures. Failure to comply with the Code, statutes, regulations, guidance, policies and procedures can result in serious damage to our standing in the community, regulatory action against individual JKV associates, and disciplinary action up to and including immediate separation, and possible exposure to civil and criminal penalties.
If there are any questions about the Code or about any policies or practices of JKV, you should raise the questions with your manager, our human resources staff, or the corporate compliance officer. Our managers have a special obligation to be available and responsive to associates when questions arise about adherence to the Code. If you are not satisfied with the response received from the management staff concerning applications of the Code, you are encouraged to continue raising concerns to the highest level of management.
Further, the Code adopted by JKV is intended to ensure that we meet our compliance goals in a highly regulated business environment. The Code is designed to provide general guidance, and does not replace the policies and procedures of JKV. If there is no specific policy, the standard set forth in the Code becomes the policy. If a policy and a standard conflict, the standard becomes the policy. The Code is a “living document,” which will be updated periodically to respond to changing conditions. Thus, JKV reserves the right to modify or terminate any or all of these provisions at any time.
Responsibilities under the Code
Who must comply with the JKV Code of Conduct?
The JKV Code of Conduct (Code) is the foundation of our compliance program and applies to everyone, regardless of position, to conduct business ethically and in a law abiding manner. The Code, as well as all statutes, guidelines and JKV policies, must be observed by everyone: associates, volunteers, staffing agencies, members of the board of directors, affiliated school personnel, consultants, contractors and anyone else engaged in our work environment providing care or services, performing billing or coding functions, or acting on behalf of JKV
What are the responsibilities of each associate with regard to the Code?
- Understand how the compliance program applies to your job and seek assistance and clarification from your manager, the corporate compliance officer, or other JKV resources when you have questions about the application of the standards and other JKV policies to your work.
- Report any conduct that you think may be in violation of the Code.
- Listen and respond to questions, suggestions, complaints or concerns expressed by residents/ patients, family members, visitors, other customers or co-workers.
- Complete the annual compliance report and all required compliance training. Ensure all confirmations of confidentiality and compliance forms are completed.
What are the responsibilities of John Knox Village leadership?
Build and maintain a culture of compliance:
- Personally lead compliance efforts through regular meetings and proactive steps that include compliance reports and regular monitoring of compliance matters. Contact your department compliance coordinator or the CCO for assistance.
- Know, understand, and follow the statutes, rules and regulations that govern your area(s) of responsibility.
- Encourage associates to raise conduct and ethical questions and concerns.
- Use appropriate actions and judgments in promoting and complying with JKV’s Code and other policies as considerations when evaluating and rewarding associates.
- Ensure you and all subordinates complete all required compliance training.
- Work with the board of directors, the CEO and the CCO to ensure a culture promoting compliance is engrained at JKV.
- Orient all new associates to the compliance plan and the Code of Conduct.
- Ensure all managers and affected staff complete compliance program training annually.
- Ensure all associates complete the annual compliance form on time.
Prevent compliance problems:
- Identify compliance risks and propose appropriate policies and procedures addressing such risks.
- Provide education and counseling to assist associates to understand the Code, JKV policies and procedures, as well as applicable law.
Detect compliance problems:
- Implement and maintain appropriate controls to monitor compliance and mechanisms that foster the effective reporting of potential compliance issues.
- Promote an environment that permits associates to raise concerns without fear of retaliation.
Respond to compliance problems:
- Pursue prompt corrective action to address weaknesses in compliance measures.
- Apply appropriate disciplinary action when necessary.
- Consult with the corporate compliance officer so that compliance issues are promptly and effectively addressed.
What are the responsibilities of the John Knox Village Board of Directors?
- Set the mission and adopt resolutions for the JKV Compliance Program and exercise oversight through the CEO and CCO.
- Make decisions that are in the best interest of JKV and not affected by conflicts of interest.
- Receive appropriate reports from the CEO and CCO concerning the status of the JKV Compliance Program and ensure the provision of the resources required to maintain its vitality and JKV’s response to identified compliance deficiencies.
- Seek and act upon advice received from management, including JKV’s president/chief executive officer, chief financial officer, corporate counsel, corporate compliance officer, and compliance and quality assurance committees.
- Maintain the confidentiality of all compliance-related information provided, subject to the requirements of applicable law.
- Complete required compliance training.
Quality of Care
STANDARD OF CONDUCT: We strive to provide outstanding quality care and services. Our first responsibility is to our residents/patients, associates and the communities we serve.
- We will provide care and services that are based on current standards of practice.
- We will monitor the clinical quality of our services and strive to improve the quality of the services provided.
- We have a duty at every level of the organization to maintain our integrity and the quality of our job performance.
- We have a duty and responsibility to address any deficiency or error by reporting it to a manager who can assess the problem, take appropriate action and follow the problem to resolution.
- We will encourage each associate to continually evaluate existing methods of service delivery in order to discover more effective ways of serving our residents/patients through teamwork.
- We will respect the human dignity of each resident/patient and family member by responding to all questions, concerns and needs in a timely and sensitive manner.
- We will effectively communicate to residents in a clear, professional, informed and understandable manner.
- We will treat all of our customers, associates, volunteers, staffing agencies, members of the board of directors, affiliated school personnel and anyone else engaged in our work environment providing care or services, performing billing or coding functions, or acting on behalf of JKV with courtesy, dignity, respect and professionalism.
- We will periodically assess and evaluate the goals and objectives established for care and related services provided to assure delivery of services according to current standards of practice, and strive to use the most current knowledge in the field.
- We will ensure that admissions, transfers and discharges are medically appropriate and in accordance with all legal requirements.
- We will employ only fully licensed and properly credentialed providers with proper expertise and experience to care for our residents/patients.
- We will not discriminate against any resident/patient for any reason including race, color, sex, national origin, age, disability, religion or any other classification protected by law.
Compliance with Laws and Regulations
STANDARD OF CONDUCT: We are committed to high standards of business and professional ethics and integrity. We will provide resident/patient care and conduct business while following applicable federal, state and local laws, regulations and JKV policies.
- We will promptly report to management, the corporate compliance officer or compliance HELPLINE when any possible violation of law, regulation or JKV policy has occurred.
- We will act upon any reported compliance issues or concerns in a fair and truthful manner. Any retaliation or other retribution against an associate who in good faith reports a suspected violation will not be tolerated.
- We will not offer, provide, solicit or receive kickbacks, bribes, rebates or anything else of value in order to influence the referrals of residents/patients or services payable by a government health care program.
- We will accept resident/patient referrals and admissions based on the resident/patient’s clinical needs and our capacity to render the needed services.
- We will ensure all compensation and other agreements, including but not limited to financial arrangements, with individuals or organizations that may be possible referral sources are in writing and approved by appropriate management and legal counsel prior to execution (consistent with the Anti-Kickback statute and Stark laws).
- We will exercise due care including implementing controls striving to prevent, detect and correct violations of applicable federal and state laws and internal policies and procedures, to ensure all billings to government and to private insurance payers are complete and accurate.
- We will not engage in anti-competitive conduct in violation of antitrust laws.
- We will bill payers and patients according to all applicable laws, regulations and policies.
- We will ensure information regarding JKV, both oral and written, provided to customers and others is clear, correct, non-deceptive and HIPAA-compliant.
- We will maintain complete and accurate medical records and will maintain such records in accordance with federal and state privacy and security laws, regulations and policies.
- We will ensure confidential patient information is accessible only by authorized personnel involved in the resident/patient’s care, payers and others authorized to review patient information.
- We will not hire or contract with individuals who have been sanctioned by the Office of Inspector General of the U.S. Department of Health and Human Services (OIG) or barred from Federal and/or state procurement programs.
- We will ensure associates who are providers of resident/patient medical services are properly licensed and trained prior to administering care.
- We will ensure all drugs or other controlled substances used in treatment are maintained, dispensed and transported in compliance with applicable laws and regulations.
STANDARD OF CONDUCT: We are committed to creating a workplace where associates are treated with respect and fairness while being empowered to get the job done at or above expectations. JKV strives to attract and retain associates who share a personal commitment to our mission, vision and values.
- We recognize our associates are our most valuable assets.
- We will expect all associates to be hospitality-driven in their daily behaviors and performance.
- We will expect all associates to treat all residents/patients, guests, vendors, volunteers and fellow associates with P.R.I.D.E. (Personal Responsibility in Delivering Excellence).
- We will strive to provide a work environment for all associates free from harassment and intimidation or hostile interaction. We will not tolerate harassing conduct (whether communicated verbally, visually, physically, electronically, or otherwise) such as degrading, humiliating jokes; ethnic, racial, religious or sexist slurs; sexually inappropriate communications based on any protected status (e.g. race, color, sex, national origin, age, disability, religion, genetic information, ancestry, or any other status protected by law).
- We will review and evaluate each associate’s performance periodically in an objective manner consistently and uniformly to the position held.
- We will continually strive to build confidence and professionalism in every associate.
- We will work to maintain open lines of communication so that the views of each associate may be considered and their opinions given proper respect.
- We will maintain the confidentiality of personal associate information in accordance with the associate Code of Conduct policy 6500-401 (4).
- We will hold all associates accountable to the Code of Conduct and personnel policies and procedures equally to all associates regardless of position in the workplace.
- We will provide reasonable training opportunities to assist associates to build and maintain professional skills.
- We will provide equal employment opportunities and ensure our associates are hired, trained, promoted and compensated, and if necessary disciplined or separated, on the basis of qualifications, personal competence, performance, conduct and potential for advancement without discrimination on the basis of race, color, sex, national origin, age, religion, age, disability, genetic information, ancestry, or other as well as any other status protected by law.
- We will encourage associates to continually evaluate existing methods of delivering services in order to discover more effective ways of allocating resources for care and services.
- We will make promotion decisions based on qualifications, associate performance and conduct, skills and abilities.
- All associates in a position requiring licensure/certification will be properly licensed/certified by Federal, state, local and professional agencies.
- We will not engage in political activities during work time, or in resident/patient care areas or in working areas.
Billing and Coding
STANDARD OF CONDUCT: We are committed to fair and accurate billing that is in accordance with all Federal and state laws, regulations, related administrative remedies and similar state statutes and JKV policies and procedures.
- We will bill only for services or items that are medically necessary, actually provided and documented in the resident/patient’s medical records.
- We will not knowingly submit for payment or reimbursement a claim we know to be false, fraudulent or fictitious.
- We will ensure all claims for services are accurate and correctly identify the services rendered.
- We will assign diagnostic, procedural and billing codes that accurately reflect the services that were provided. Upcoding, unbundling or any other means of artificially enhancing reimbursement is unlawful and strictly prohibited.
- We will periodically perform reviews of coding practices and policies, including software edits, to ensure they are consistent with applicable Federal, state and private payer health care program requirements. Results of such reviews will be documented.
- We will determine the cause and scope of identified problems based on our internal reviews and implement corrective action plans. We will ensure the corrective action is taken by following up on problems with appropriate monitors.
- We will regularly review our records for credit balances and promptly refund any overpayments.
- We will not routinely waive insurance co-payments or deductibles.
- We will ensure claims for services submitted to Medicare or other federally funded health care programs are accurate and correctly identify the services ordered and performed.
- We will comply with laws and regulations related to government cost reports. All questions or issues related to cost reports will be promptly reported to the chief financial officer.
- We will maintain records in a secure location for the period of time required by law. The premature destruction or alteration of any document in response to, or in anticipation of, a request for those documents by any government agency or court is strictly prohibited.
- We will conduct general collection/credit procedures according to the Fair Debt Collection Practices Act to the extent it applies to JKV.
- We will respond to questions and complaints related to a resident/patient’s bill in a direct and honest manner.
Federal and State False Claims Act
STANDARD OF CONDUCT: We are committed to maintaining fair and accurate billing procedures in accordance with the Federal False Claims Act and State False Claims Act.
Federal False Claims Act
- We will implement policies for all associates (including management), and any contractor or agent of JKV, pertaining to the Federal False Claims Act (FCA), including the administrative remedies for false claims and statements, any state laws pertaining to civil or criminal penalties for false claims and statements, and whistleblower protections under such laws.
- We will not knowingly present or cause to be submitted a false or fraudulent claim to the government. “Knowingly” is a broad term meaning:
- Actually knowing that a claim is false;
- Deliberately ignoring whether the claim is true or false; or
- Recklessly disregarding whether the claim is true or false.
- We will not knowingly make or use a false record or statement to obtain payment by the government of a false claim.
- We will not engage in a conspiracy to defraud the government by the improper submission of a false claim for payment.
- We will not knowingly make, use or cause to be made or used false records or statements to conceal, avoid or decrease an obligation to pay or transmit money or property to the government.
- We understand that effective in August, 2016 damages and penalties for violating the False Claims Act include:
- Civil penalties of not less than $10,781.40 and not more than $21,652.80 per claim, plus
- Three times the amount of damages which the government sustains because of the violation.
- We understand that Qui Tam Provisions (whistleblower rights) of the FCA allow a person to bring an action under the FCA on behalf of the federal government and share in any recovered amount by the government.
- We will train affected associates on these false claims policies, as well as for preventing, detecting and reporting fraud, waste and abuse.
- We will not engage in retaliatory conduct against associates exercising their rights under the FCA.
State False Claims Act
- We understand that the Healthcare Fraud and Abuse Act (“Missouri Medicaid Fraud Act”) is not as broad as the Federal False Claims Act.
- We will not knowingly present any false claim for payment of goods and services that may be paid for by Medicaid.
- We will not knowingly present any false statement for use in determining payment, the rate of payment of goods and services that may be paid for by Medicaid.
- We will not knowingly present any claim for services that were medically unnecessary.
- We understand that damage and penalties for violating the State False Claims Act include:
- The attorney general can bring criminal or civil actions under the act; and,
- Violations of the Missouri Medicaid Fraud Act, which constitutes a felony, are punishable by fines, imprisonment or both.
- We understand Missouri’s Medicaid Fraud Act does not have a “whistleblower provision” similar to the one in the Federal False Claims Act.
- We understand that under the Missouri Medicaid Fraud Act, if the attorney general initiates a criminal or civil action, the individual who is the original source of information may receive ten percent (10%) of any recovery.
Associate Conduct with Residents
STANDARD OF CONDUCT: We are committed to high standards of healthcare and services provided to residents/patients of JKV. JKV treats residents/patients and their families with dignity and respect at all times.
- We will report any reasonable suspicion of a crime against one of our residents/patients to the proper authorities.
- We will not tolerate abuse, neglect or mistreatment of any resident/patient or family member/significant other.
- We will not tolerate any conduct that creates a perception of undue influence, pressure or intimidation to obtain an unfair economic advantage over a resident/patient and/or their property.
- We will encourage residents/patients and families, when appropriate, to express appreciation to Village associates with thank you notes or a contribution to the JKV Foundation or to funds designated for use by the associate’s department.
- We will accept tips only as authorized by associate policy (01-05-6500-432, Tipping and Gifts).
- We accept gifts offered by residents/patients or family only as authorized in the tipping and gifts policy (above).
- We do not directly or indirectly borrow from or lend money to, or engage in, any personal financial transaction with our residents/patients or their families.
- We may perform work for a Village resident outside of regular work duties or work hours. We disclose such work or agreement with the manager and complete the required Resident Work Agreement Form. (See: MyJKV/My Company/Forms, or contact the director of compliance for assistance.)
- We also rely on the Conflict of Interest standards and policies for guidance regarding conduct with residents, and others.
- We will comply with all Resident Rights regulations set forth under federal and state law.
Protection and Use of Information, Property and Assets
STANDARD OF CONDUCT: We are committed to protecting JKV’s property and information against loss, theft, destruction and misuse.
- We will honor the privacy of residents/patients and not reveal or discuss patient-related information except with health care personnel involved in their care, payers and others authorized by law to review resident/patient information.
- We will release resident/patient records in accordance with JKV’s policies and applicable federal and state laws and regulations.
- We will maintain the confidentiality of quality assurance, health care and other services information in accordance with laws and regulations.
- We will maintain all medical and business records in accordance with laws and our record retention policies. We will not alter or falsify information on, or improperly alter any record or document.
- We will correctly use and care for all property and equipment entrusted to us.
- We will protect confidential JKV information and not use or reveal such information except in the proper performance of duties and in accordance with the law.
- We will maintain, inventory and keep all supplies secure.
- We will dispose of surplus or obsolete property and equipment according to established procedures.
- We will not permit making unauthorized copies of computer software or using personal software on JKV’s computer equipment.
- We will not knowingly communicate or transfer any information or documents to any unauthorized persons.
- We will not use JKV owned vehicles, equipment, materials or other JKV owned property for personal gain, convenience or financial benefit.
- We will not use computers, email, facsimile machines and other technology to communicate information to unauthorized people. Further, the use of technology to send, receive or store offensive, discriminatory or harassing messages is prohibited.
- We will use computers, the email system, the Internet, MyJKV and other technology primarily for work-related purposes. We understand all information sent, received or stored in the email system is the property of JKV, and we should have no individual expectation of privacy regarding such information in JKV’s systems, nor on personal devices in accordance with the law and JKV policies.
- We will safeguard the use and disclosure of protected health information, including information related to treatment, medical history, current health status, payment for treatment and other information contained in resident/patient records, in accordance with HIPAA and HITECH privacy and security regulations, state law and JKV policies and procedures.
Conflicts of Interest
STANDARD OF CONDUCT: We are committed to acting in good faith in all aspects of our work. We will avoid conflicts of interest or the appearance of conflicts between private interests of any associate and his or her work duties and avoid conduct which is disloyal, competitive or damaging to JKV. We devote our best efforts towards the interests of John Knox Village.
- All board members will comply with federal and state laws, rules and regulations governing the ethical conduct of board members, including the disclosure of conflicts of interest.
- We require all senior management, associates, contract labor and anyone acting on behalf of JKV to routinely disclose any ownership interest and/or other relationships that are or may appear to be in conflict with their responsibilities to JKV.
- We will avoid instances where the actions or activities of an individual acting on behalf of or with JKV involve obtaining an improper personal gain or advantage by such individual or a member of his or her family or a potentially adverse effect on JKV interests.
- We will avoid conflicts of interest that may exist whenever an associate or a related party (e.g. family member, friend or business associate) receives a benefit from any decision or action taken by the associate.
- We will maintain unbiased relationships with actual and potential vendors and contractors.
- We will exercise good faith and fair dealing in all transactions that involve our responsibilities to JKV and follow all associate policies regarding tips and gifts.
- We will not misuse our position with JKV for personal gain or participate in outside activities that could be perceived as a conflict with Village responsibilities.
- We will not accept outside employment that conflicts with our position with JKV.
- We will report actual or perceived conflicts to a manager.
- We will not hire a family member to be supervised by or to supervise another family member or where a conflict of interest may occur between the family member’s duties.
- We will not borrow money from residents, their families or vendors, other than recognized loan institutions.
- We will not own, directly or indirectly, a financial interest in a business entity that does or seeks to do business with, or is in competition with JKV.
- We use good judgment and exercise caution to avoid the appearance of impropriety.
- We will not offer or accept any payment, benefit or offer by a person or organization doing business or seeking to do business with John Knox Village if the appearance may appear to influence decision making or actions.
- We may occasionally accept a vendor’s invitations for a meal, refreshment or attend a local entertainment event at the vendor’s expense. Associates are expected to use good judgment and avoid such invitations on a frequent basis to avoid the appearance of impropriety.
Health and Safety
STANDARD OF CONDUCT: We are committed to maintaining a community that protects the health and safety of our residents/patients and associates.
- We will comply with all applicable environmental, health and safety requirements whether established by management, federal, state or local laws or our licensing or accrediting organizations.
- We will take all reasonable precautions and follow all safety rules and regulations striving to maintain a safe environment for our residents/patients, associates, physicians and visitors.
- We will strive to provide an environment that is free from violence.
- We will follow all laws regarding possession and use of weapons on Village property and minimize their presence, in accordance with such laws.
- We will follow all laws and regulations regarding the disposal of medical waste and hazardous material. We will promptly report all spills or accidents involving medical waste or hazardous materials to a supervisor and take action right away to help prevent harm.
- We will promptly report to a manager or supervisor any accidents or near misses involving an associate, resident/patient, volunteer or visitor.
- We will provide training in healthy and safe work practices to reduce hazards to the health and safety of associates and others.
- Managers are responsible for inspecting the work area under their control for health and safety risks, eliminating or reporting risks to management, being familiar with health and safety procedures and training their associates in health and safety precautions.
- We will follow all laws and policies regarding the manufacture, sale, possession, distribution or use of controlled substances and/or alcohol. Illegal manufacture, sale, possession, distribution or uses of controlled substances are strictly prohibited at JKV. Reporting to or remaining at work, while under the influence of alcohol will not be tolerated. Similarly, having any controlled substance illegally present in one’s body at any time while working on behalf of JKV, or on JKV premises, will not be tolerated.
- We will safely store, secure and count all resident/patient drugs and pharmaceuticals. Missing or diverted drugs will be promptly reported to your manager.
Reporting Process and Non-Retaliation
If you have a question or concern about an activity being unethical, illegal or wrong, use the following four-step reporting process to answer questions and report concerns. All associates, credentialed physicians, contractors, volunteers and agents of JKV have an affirmative duty to report any violations. Throughout this process your identity will be kept confidential as much as possible.
- Talk to your supervisor/manager. He or she is most familiar with the laws, regulations and policies that relate to your work and most problems can best be resolved at this level.
- If you are not comfortable contacting your supervisor/manager, if you do not receive an adequate response from them, if it is otherwise not possible, or if both you and your supervisor/manager have what you believe to be questions or concerns, talk to another member of the management team.
- If you still have questions, contact human resources or our corporate compliance officer at 816-347-2109.
- If for any reason you feel you cannot follow the above steps, call JKV’s confidential compliance HELPLINE at 816-246-4343, Ext. 7233 externally or at Ext. 7233 (SAFE) internally. The JKV compliance officer will review and address all reports to the compliance HELPLINE or the corporate compliance department.
Throughout this process, each problem will be taken seriously and each person involved will be treated with dignity and respect. JKV will conduct a review or investigation and give the associate a response as quickly as possible.
We recognize there are times when questions or problems cannot be addressed through the normal communication and reporting process. When this happens, you should use the JKV compliance HELPLINE. The HELPLINE is available 24 hours at 816-246-4343, Ext. 7233 externally or at Ext. 7233 (SAFE) internally.
You will remain anonymous, unless you choose to identify yourself. If you do give your name, your identity will be protected to the extent allowed by law. No disciplinary action or retaliation will be taken against you for calling the HELPLINE in good faith.
All calls made to the HELPLINE will be reviewed by JKV’s compliance officer and will be responded to fairly. All calls will be investigated before any action is taken. The rights of all associates, including anyone who is the subject of a HELPLINE call, will be respected and protected. Actions taken will not be made public.
JKV is committed to protecting associates and others who report problems and concerns in good faith from retaliation and retribution. No disciplinary action or retaliation will be taken against you when you report a perceived issue, problem, concern or violation to management, human resources, corporate compliance or the compliance HELPLINE “in good faith” or act as a whistleblower pursuant to the Federal False Claims Act or other law. The “good faith” requirement means an associate actually believes or perceives to be true the information reported. Of course, an associate who reports his or her own non-compliance is not insulated from the consequences of such non-compliance. If in doubt, it is always best to ask about the propriety of your own acts before they are taken. We value and respect the dignity of the individual and strive to ensure that all individuals are treated accordingly.
When in Doubt
Warning Signs and a Quick Quiz
There may be times when you are unsure whether an activity or a situation is unethical or illegal. If you are not sure, pursue it until you are confident it is either resolved or that the right person at JKV knows the facts and has taken action. A delay on your part could be serious to you, for others and for JKV.
There are words and phrases that raise “red flags” about potential problems and should send a warning signal to you. The following are examples of such words and phrases:
- “Well, maybe just this once.”
- “Everyone does it.”
- “No one will ever know.”
- “Shred that document – no problem.”
- “No one will get hurt.”
If you hear comments like these or you begin to say things like this, then the following “quick quiz” could be helpful as a guide for what needs to be done next:
- “Does this break a law, regulation, policy or our Code of Conduct?”
- “How will I feel about myself afterwards?”
- “What would my family, friends, our physicians or residents think?”
- “How would this look if it were in the newspaper tomorrow?”
- “Am I being fair and honest?”
If you are not comfortable with any of your answers to the above questions or if you are still not sure whether an activity is wrong, contact your manager, another trusted manager of JKV or the compliance officer at 816-347-2109. The four-step communication and reporting process outlined in the previous section should be a helpful guide.