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 Assisted Living, Village Assisted Living Memory Care, Village Hospice, Village Home Health, Village Helpers In-Home Care, Village Nursing, the Resident Wellness Clinic, Village Emergency Medical Service, the Fitness Centers 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:

  1. 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.
  2. 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.
  3.  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.
  4.  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.
  5.  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.
  6.  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.
  7.  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.
  8.  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.

Contact Information

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

(816)347-2109 

 

Complaints

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.

Effective Date

This version’s effective date is November 17, 2017

 

JOHN KNOX VILLAGE CODE OF CONDUCT

 Compliance HELPLINE

Report concerns about the Code of Conduct or compliance with laws or regulations.

  • Calls are accepted 24 hours a day.
  • All calls are confidential.
  • Concerns also can be sent to the corporate compliance officer in the Administrative Center.

 

When calling from outside the Village campus:

816-246-4343 Ext. 7233 (SAFE)

When calling from the Village campus:

Ext. 7233 (S-A-F-E)

 

CONTENTS
________________________________________________________________________________

Principle 1: Resident/Patient Relationships

Quality/Resident and Patient Satisfaction

Resident/Patient Rights

Advance Directives

Discrimination and Harassment of Residents/Patients

Abuse, Neglect or Mistreatment

 

Principle 2: Legal Compliance

Anti-kickback Statute

False Claims

Inducement

Safe Medical Devices Act

Survey and Licensing

Marketing and Advertising

 

Principle 3: Business Ethics

Conflict of Interest

Government Investigations

Media

Tax and Not-for-Profit Issues

 

Principle 4: Privacy and Security Compliance

Confidentiality of Resident/Patient Information

Resident/Patient Privacy

Compliant Use of Computer and Other Electronic Systems

Protection and Use of Information, Property and Assets

 

Principle 5: Associate Conduct with Residents/Patients and Supplies

Gifts

Workshops, Seminars and Training
 

Principle 6: Human Resources Matters —

Workplace Conduct and Employment Issue

Americans with Disabilities Act

Discrimination and Harassment

Health and Safety

Substance Abuse/Drug-free Workplace

Excluded or Sanctioned Providers, Associates, Board

Members, Officers, Volunteers, Contractors and Others

Confidential Personnel Matters

Licenses, Registrations and Certifications

Social Media

Political Activity

 

REPORTING PROCESS AND NON-RETALIATION

Four-step Process

Non-retaliation Policy

 

 

Mission

To enrich the lives of older adults through community living

“Enriching lives and building community”

 

Vision

To be the leader among senior living communities in the greater Kansas City Area

 

To carry out our mission and vision, John Knox Village must maintain the highest reputation for ethics and integrity. The John Knox Village Code of Conduct is your guide to ensure you are making the right decisions for the right reasons. It is the responsibility of everyone associated with John Knox Village, including associates, board members, officers, volunteers, contractors and others to act in accordance with the Code of Conduct and supporting policies.

 

 

Message from the CEO

You are expected to review and adhere to the principles and standards of the John Knox Village Code of Conduct.  It will remind you of the foundational principles of our P.R.I.D.E philosophy – Personal Responsibility in Delivering Excellence. We expect everyone to dedicate themselves to enhancing the physical, mental and spiritual health of the diverse communities we serve. Just as you make decisions that are honest and ethical in your personal life, we expect you to apply compassion and integrity with our residents, patients, their family members, clients and your fellow associates .If, after reviewing the Code of Conduct, you have any questions, please discuss your concerns with your manager, your vice president or your human resources representative. You also can call the 24-hour confidential HELPLINE at  (816)246-4343 Ext. 7233 (from outside the Village) or by simply dialing extension 7233 on the Village campus. This number also can be found on the back of your ID badge. Finally, you can reach the compliance officer at that number or by calling 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 will continue to earn and deserve that trust.

 

Sincerely,

 

Dr. Daniel Rexroth

President and Chief Executive Officer

John Knox Village

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THE CODE OF CONDUCT AND YOU

Compliance is P.R.I.D.E. in ACTION – Do the right things, the right way, the first time, every time.

John Knox Village (JKV) is committed to the goal of serving our residents/patients, associates and the community in compliance with applicable laws, regulations and the ethical standards of the life plan community industry. This commitment means that you are expected to do what is required and what is right.

The Code of Conduct is the backbone of our corporate compliance program. It provides general guidance and does not replace policies and procedures of the Village nor any of its individual departments or business units (i.e. Village Care Center, Village Home Health, Village Hospice, etc.). If there is no specific policy, the principles set forth in the Code of Conduct become the policy.  The Code of Conduct is a “living document” that is updated periodically to respond to changing conditions.

 

JKV reserves the right to modify or terminate any or all

of these standards at any time.

 

You are not expected to have expert knowledge of all

legal and regulatory requirements that may apply to your

job.

You are expected to:

  • Be familiar with the Code of Conduct;
  • Commit to conduct and decisions that are legal and ethical;
  • Ask questions if you are not certain about a particular situation; and
  • Report concerns you may have about potential violations of the Code of Conduct or any misconduct or wrongdoing.

 

There will be no retaliation against anyone for making a good-faith report of inappropriate conduct, including if the report turns out to be wrong. Not reporting known, observed or suspected violations of the Code of Conduct can result in corrective action up to and including separation of employment with JKV. You are expected to cooperate with any investigation and resolution of a compliance issue.

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Retaliatory conduct against anyone who cooperates with an investigation in compliance with the Code of Conduct is absolutely prohibited.

 

Q: What should you do if you have questions or concerns about the conduct of someone at work?

Will you get in trouble for reporting?

A: You have a duty to report a concern. Speak with your manager, your HR representative or contact the compliance officer. You can also use the number on the back of your badge to leave a confidential message on the Compliance HELPLINE. There is no retaliation for good-faith reporting.

CONDUCT PRINCIPLES/STANDARDS and RISKS

 

The following Conduct Principles and Standards provide a summary of the Village’s expectations

regarding specific ethics and compliance risk areas. These are general guidelines that are set out to provide a general overview. There may be specific policies for individual departments or business units that exist for a particular topic.

 

PRINCIPLE 1:

Resident/Patient Relationships

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.

 

Quality/Resident and Patient Satisfaction

John Knox Village has a legacy of excellence and commitment to quality of care and exceeding the expectations of our residents/patients and their families. We provide care and services in a courteous and caring manner, mindful of and sensitive to race, color, national origin, sex, gender, pregnancy status, age, religion, handicap or disability, veteran status, sexual orientation or other status protected by law. JKV is committed to consistently following well designed programs, services and plans of care based on the needs of residents and patients. We strive to provide affordable care that finds its basis in established standards of care and best practices. JKV will continue to strive for excellence in all that we do.

 

The quality of care we provide is directly dependent upon the qualities of the people who are hired to deliver it.

 

Resident/Patient Rights

Residents and patients have a fundamental right to receive services and care that safeguard their personal dignity and respect their unique and diverse values. Every associate is expected to recognize and respect resident and patient-centered values that inform how to meet resident/patient needs and preferences. JKV is committed to preserving everyone’s dignity at all times.

 

Residents/patients have a right to designate a personal representative. Families and personal representatives can raise concerns about ethical and legal/regulatory issues without fear of retaliation or diminished quality of care.

 

Associates are empowered to resolve complaints.

 

Advance Directives

Patients and residents will be informed of their right to make advance directives. JKV strives to comply with policies, laws and regulations regarding advance directives and will follow a resident’s/patient’s wishes set forth in a valid advanced directive.

 

Discrimination and Harassment of Resident/Patients

JKV complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, gender, pregnancy status, age, religion, handicap or disability, veteran status, sexual orientation or other status protected by law. JKV does not exclude people or treat them differently because of any protected status. JKV also provides free aids and services to those whose primary language is not English so that they may communicate effectively.
 

Abuse, Neglect or Mistreatment

Any type of abuse, neglect or mistreatment of residents/patients is not tolerated. All associates shall refrain from committing, and must protect residents from, abuse, neglect or mistreatment. This includes verbal abuse, sexual abuse, physical abuse, mental abuse, involuntary seclusion, neglect and misappropriation of resident/patient property. Associates are mandatory reporters of such conduct.

 

PRINCIPLE 2: Legal Compliance

Standard of Conduct: We are committed to high standards of business and professional ethics and integrity. We will provide resident/patient services and care as well as conduct our business operations while following applicable federal, state and local laws, regulations and JKV policies.

 

Anti-kickback Statute

Federal and state laws prohibit offering, soliciting or accepting a kickback to the organization or person to induce the purchase of services from or refer residents/patients to John Knox Village. JKV associates will not engage in any such behavior or activity. Examples of the types of activity that may violate the Anti kickback

 

Statute and similar Missouri law include the following:

CONDUCT PRINCIPLES/STANDARDS AND RISKS

  • Offering or paying anything of value to induce someone to refer a patient to a JKV health care service/facility, including routine waivers of co-pays or deductibles;
  • Offering or paying anything of value to anyone while marketing health care services;
  • Soliciting or receiving anything of value for the referral of JKV residents/patients;
  • Giving or receiving free goods or discounts, except as permitted by law or policy; and
  • Receiving any payment or item of value outside of the normal compensation arrangement for performance of an associate’s responsibility performed on behalf of JKV.

False Claims

JKV is committed to correct and accurate coding, billing and reimbursement procedures that comply with federal and state regulations. (Refer to the False Claims Act policy on www.myjkv.org.) Billing or submitting a claim for items or services that were not provided as documented, not medically necessary or in any way false, misleading, inaccurate or fictitious is prohibited by law. If any associate becomes aware of claims and/or billing errors, contact your manager, the compliance officer or the Compliance HELPLINE using the number on the back of your name badge.

 

Inducement

Federal and state laws prohibit offering or transferring anything of value to a Medicare or Medicaid beneficiary that the person making the offer knows or should know may or is likely to influence the beneficiary to receive items or services from JKV. Associates will never offer any item or service to a Medicare or Medicaid beneficiary that would influence them in their choice of a health care provider.

 

Safe Medical Devices Act

JKV complies with the FDA’s medical device reporting requirements. Timely reports are made to the FDA and/or the manufacturer where a device-related serious injury or death occurs. Such events are reported to the risk management department. Reporting procedures are followed in accordance with regulations and policy.

 

Survey and Licensing

JKV addresses all authorized federal and state surveyors and accrediting bodies openly, honestly and professionally. Our behavior will never mislead a surveyor or survey team either directly or indirectly.

 

Marketing and Advertising

JKV represents its services, facilities and activities in an accurate and honest manner. Inaccurate or exaggerated statements are not made in promotional materials of any kind.

 

Q:Why can’t we give the therapists gifts or bonuses when we think they are doing a great job with our rehab patients?

A: We have a legal duty to comply with laws that govern relationships between JKV and health care providers, such as therapists and medical directors. We must follow the terms of the contract.

 

 

PRINCIPLE 3: Business Ethics

Standard of Conduct: We are committed to high standards of business and professional ethics and integrity. We will provide resident/patient services and care as well as conduct our business operations while following applicable federal, state and local laws, regulations and JKV policies.

 

Conflict of Interest

JKV (as a system entity of PremierLife) is committed to acting in good faith in all aspects of our work. We will avoid conflicts of interest or the appearance of conflicts of interest of any associate or board member and their work and avoid conduct that is disloyal, competitive or damaging to JKV. Associates, board members, officers, vendors, contractors and others are expected to carry out their job responsibilities independent of personal gain and in the best interest of JKV. In all dealings with and on behalf of JKV, all associates, board members, officers, vendors, contractors and others are held to strict rules of honest and fair dealing at all times. The following is prohibited:

  • No person shall use their position or knowledge gained therefrom in such a way that a conflict might arise between the interests of JKV and the individual;
  • Any act of such persons in their capacity as an associate, board member, officer, vendor, contractor

and other that is not in the best interest of JKV;

  • Use of JKV resources for non-JKV use unless authorized by senior management in accordance with policy; and
  • Engaging in activity that may adversely affect JKV’s tax-exempt status, including certain lobbying and

political activity.

 

Disclose fully and frankly any and all potential conflicts as to JKV that may exist or appear to exist, whether personal or business-related. The following is a partial list of activities and circumstances that must be disclosed:

  • Ownership or financial interest in or employment by any outside concern that does business with JKV or competes with JKV;
  • Intellectual property rights such as a patent, copyright or royalties;
  • Serving as a director, manager or consultant, or performing as an employee of any outside concern that does business with or competes with JKV;
  • Providing any service to a concern or entity that is in competition with any JKV service;
  • Conducting business dealings with any outside concern or entity that does business with or competes with the services of any JKV service offering, renders other services in competition with any JKV service, or is or has the potential to be in an adversarial position with JKV;
  • Represents JKV in any transaction in which the associate or a family member has a personal interest;
  • Any outside employment (moonlighting) for any concern or entity that does business with or competes with any JKV service, or provides other services in competition with any JKV services; and
  • Accepting any gifts, entertainment or other business courtesy from any person or entity with whom JKV

as or may have a business relationship where it could be inferred that such a gift, gratuity or business

entertainment is intended or appears to be intended to influence the associate’s judgment.

 

Any conflict of interest involving an associate, board member, officer, vendor, contractor and other must be disclosed to the manager or to the compliance officer. In such cases and based on review, the associate or board member must complete the Conflict of Interest disclosure form. (Also see the Conflict of Interest policy in the Associate Policy Manual and John Knox Village Corporate Policy 0002-6000-003.)

 

 

If an associate has a question about conflicts of interest, it is his/her responsibility to notify his/her manager and/or the compliance officer. (Also see the Associate Policy Manual, Policy 01-05-6500-411.)

 

Government Investigations

JKV strives to fully comply with the law. The Village seeks to cooperate with authorized officials serving a valid search warrant, subpoena or other legal form of inquiry. JKV must balance its legal rights and ensure its personnel are protected. If you are ever served with a search warrant or subpoena, or receive another inquiry regarding JKV operations from any government agency, or from any

 

Q: I work as a social worker for the Village Care Center. I took a weekend job at another long-term care facility in Kansas City. Do I need to tell anyone?

 

A: Yes, notify your manager. You must complete the Conflict of Interest disclosure form. This allows a review and evaluation of any potential concerns depending on your role at JKV.

 

Q: You or a member of your staff is contacted by a reporter who works for a newspaper, magazine, trade journal or television program and is doing a story involving JKV. What should you do?

A: Refer all media inquiries to MARCOM. They can be reached through dispatch/security. Person claiming to represent a government agency, you must immediately notify the department director, administrator and the corporate compliance officer. If you are contacted at home by a government agency concerning JKV business, you may ask the agency representative to contact you later and immediately contact the corporate compliance officer to review the matter.

 

Upon notice of a warrant, subpoena or investigation an associate must:

  • Notify his/her manager and corporate compliance officer immediately;
  • Never destroy or alter any document or record subject to a search warrant, subpoena or investigation;
  • Never lie or make a false or misleading statement to any authorized official or investigator; and
  • Never try to persuade any other person to provide false, fictitious or misleading information to any authorized official, investigator or auditor.

 

Retaliatory conduct against anyone who reports compliance concerns in good faith or who cooperates with an audit or investigation is prohibited.

 

Media

If contacted by any member of the media with an inquiry, contact JKV media relations personnel in the MARCOM department. You can reach them via dispatch/security as well. Only MARCOM staff is authorized to speak officially on behalf of JKV. Seek assistance in case of any media contact. MARCOM will contact the media about a story or news item about JKV.

 

Compliant Use of Computer and Other Electronic Systems

Based on your job, you will be authorized to access one or more JKV computer systems or communications networks. Passwords or other credentials assigned to access a computer system must never be disclosed to another. Never attempt to access a computer system or device with any other password than your own. If a password is lost or stolen, notify the I.T. systems security officer immediately. Associates are authorized to use the computer system only to fulfill their job responsibility. There will be no casual browsing of resident or patient records allowed. All electronic messaging systems are for JKV business purposes only. All users must follow HIPAA and security policies that can be reviewed on www.myjkv.org.

 

Protection and Use of Information, Property and Assets

John Knox Village property, assets and information will be protected against loss, theft, destruction and

misuse. Non-public business, strategic, financial, personnel or technological information must not be disclosed without management authorization. Many laws protect copyrighted materials, computer software and other media from prohibited uses. Unauthorized duplication or downloading of computer software or files is prohibited. JKV materials, supplies, equipment and other resources are never to be used for personal use except where authorized by management.

 

Tax and Not-For-Profit Issues

JKV has a legal obligation to devote its activities to promote its principle purpose to further the public good rather than the private or personal interests of any one person. JKV must avoid business arrangements that exceed fair market value, not participate in any political campaign for or against any candidate for public office, accurately report all financial operations and comply with all applicable tax law and regulations. Associates are expected to contact the director of finance to address concerns regarding the JKV tax-exempt status or other tax-related concerns.

 

PRINCIPLE 4: Privacy and Security Compliance

Standard of Conduct: We are committed to protecting JKV property and information against loss,

theft, destruction and misuse.

 

Confidentiality of Resident/Patient Information

As part of your job, you may have access the very confidential protected health information of the residents and patients we serve. Residents and patients have important rights regarding their protected health information under HIPAA regulations. JKV complies with those privacy regulations.

The following rights must be complied with at the request of a resident or patient:

  • Right to receive a copy of our Notice of Privacy

Practices,

  • Right to inspect and copy,
  • Right to an Accounting of Disclosure, and
  • Right to amend.

Associates must never disclose resident- or patient specific information unless authorized by the resident/ patient or if the information is part of treatment, payment or health care operations. Any questions regarding what information can be disclosed are to be taken to the privacy officer (816-347-2109) or the system security officer in the I.T. department (816-347-2903.)

 

More information is available on www.myjkv.org.

Q: What does politics have to do with being a tax-exempt organization?

A: The IRS prohibits tax-exempt entities such as JKV from engaging in activities that attempt to influence legislation or any political campaign.

Q: Can I share my password with my co-worker? This would make us more efficient.

A: No. Never share your password, username or other access code with another person. Never use someone else’s username or password to gain access to the computer system or any other electronic device.

 

PRINCIPLE 5: Associate Conduct with Residents/Patients and Suppliers Standard of Conduct:

JKV demonstrates its high standards of health care and other services to residents and patients with every interaction. JKV treats residents and patients and their families with dignity and respect at all times.

 

Gifts (See also: Conflict of Interest)

JKV strives to protect its reputation and to avoid an appearance of improper dealings or conduct. Except in limited ways (see the Tipping and Gifts policy in the Associate Policy Manual, Policy 01-05-6500-432),

associates are prohibited from soliciting or accepting tips or personal gratuities from residents, patients or their families. Occasionally, non-cash gifts are offered in appreciation to an associate. This kind of recognition may be accepted if it is of nominal value. Associates must never directly or indirectly borrow

from or lend money to or engage in any personal financial transaction with a resident/patient or family member for any reason whatsoever. Associates may not act as an agent for or accept power of attorney on behalf of a resident or patient, or be named as an executor of a resident or patient estate (unless the

resident or patient is a relative of the associate). If a resident/patient or family member wishes to make a monetary gift to an associate or department, he/she should be referred to the John Knox Village Foundation. Associates will comply with the Inducement section of the Code of Conduct at all times including interaction and relationships with residents/patients and their families.

 

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Modest non-cash gifts may be accepted. Notify your manager or contact HR or the compliance officer with any questions about acceptable conduct with residents.

 

Workshops, Seminars and Training

JKV pays for authorized expenses related to seminars, workshops and training sessions. Arrangements offered by a vendor to pay for an associate’s training costs and travel must be submitted and approved by management before making a commitment to attend or participate in such activities. Such arrangements must be documented and retained.

 

Q: What if a new vendor seeking JKV business wants to treat your entire staff to a catered barbecue lunch at work in appreciation for considering their services?

A: You must decline. Accepting gifts from vendors is not to be permitted. This conduct can be used as grounds for fines and penalties for violation of anti-kickback and inducement statutes.

 

Q: You know a resident who is in financial distress. The family asks you to set up an online funding page to assist with mounting bills. What should you do?

A: You must decline. Associates must never engage in any kind of financial transaction with a resident/patient or his/her family for any reason whatsoever. Placing any digital content on social media by an associate can result in a serious HIPAA breach as well.

 

PRINCIPLE 6: Human Resources Matters –Workplace Conduct and Employment Issues

Standard of Conduct: JKV is committed to creating a workplace where all 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.

 

Americans with Disabilities Act

JKV will comply with applicable law to ensure qualified applicants and associates with a known disability who are able to perform the essential functions of the job with or without reasonable accommodation and whose employment does not pose a threat to their health and safety or that of others, are provided with equal employment opportunities.

 

Discrimination and Harassment

JKV will strive to provide a work environment for all associates free from harassment and intimidation or hostile interaction. JKV will not tolerate harassing conduct by an associate, volunteer, resident/patient or their family members and all third parties (whether communicated verbally, visually, physically, electronically or otherwise) such as degrading, humiliating jokes; ethnic, racial, religious or sexist slurs; sexually inappropriate communications; or communications based on any protected status (i.e. race, color, sex, national origin, age, disability, religion, genetic information, ancestry, or any other status prohibited by law). If you feel that you or another person may be the subject of discrimination or harassment you should report your concerns to one of the following: your manager, human resources, the compliance officer or the

 

Compliance HELPLINE.

(You can call the number on the back of your badge to leave a confidential message.) Bullying behavior is not acceptable and JKV is committed to the elimination of all forms of bullying. If you encounter any form of hostile or offensive behavior based on race, color, national origin, sex, gender, pregnancy status, age, religion, handicap or disability, veteran status, sexual orientation, gender identity or expression, or other status protected by law, including any form of unwelcome sexual behavior, you should communicate your concerns or objections to the offender and report the matter to one of the following: your manager, Human Resources, the compliance officer or the Compliance HELPLINE. (You can call the number on the back of your badge to leave a confidential message.)

 

Health and Safety

We are committed to maintaining a community that protects the health and safety of our residents, patients and associates. JKV strives to provide an environment that is reasonably free of recognized hazards as well as to minimize the risk of injury and occupational illness. JKV is committed to complying with the numerous federal, state and local safety and environmental laws that apply to its operation.

 

Associates are responsible to comply with all safety policies and procedures. Some examples are:

  • Applicable laws, regulations and accreditation standards (OSHA, insurance companies, EPA, DOT, National Fire Codes, etc.);
  • Lessons learned from monitoring and investigating incidents, accidents and occupational illness;
  • Consulting services regarding health and safety practices; and
  • Input from safety, quality assurance and performance improvement teams and committees.

 

Reporting hazardous work practices or conditions is required. Make such reports timely to your manager, the risk manager, appropriate internal safety contacts or leave a message on the Compliance HELPLINE. (You can call the number on the back of your badge to leave a confidential message.) You are required to complete assigned safety training appropriate for your job or work area. Timely completion of safety and other compliance training is evaluated during your annual performance review.

 

The Village maintains a document retention and destruction policy. (See HIPAA Policies on www.myjkv.org.) All documents related to safety, fire and life safety compliance, environmental conditions or any permits, inspections and authorizations must be maintained in accordance with JKV document retention policies.

 

Substance Abuse/Drug-free Workplace

JKV will follow all laws and policies regarding the manufacture, sale, possession, distribution or use of

controlled substances including alcohol. The unlawful presence of any detectable amount of any drug, including controlled substances on the JKV campus or any satellite facility/property is strictly prohibited.

 

Lawful but impairing drug use:

Any associate in a patient-care or other safety-sensitive position who is using any controlled substance or over-the counter drug legally must advise the associate wellness center or his/her manager while taking such controlled substance or over-the-counter drug if that controlled substance or over-the counter drug might impair safety, judgment, performance or any motor functions or as soon as the associate realizes that the use may be impairing safety, judgment, performance or any motor functions. Failure to timely report such lawful use of a controlled substance or over-the-counter drug may result in corrective action up to and including separation.

 

Please refer to the Associate Policy Manual, Policy 01-05-6500-413 for information related the JKV Drug-

Free Workplace.

 

Excluded or Sanctioned Providers, Associates, Board Members, Officers, Volunteers, Contractors and Others

Federal law prohibits health care providers from employing or doing business with a person or entity that is excluded from providing services in a federal health care program (i.e. Medicare or Medicaid). Prior to starting service to JKV, whether as an associate, board member, officer, volunteer, contractor or other, it will be confirmed and verified that individuals or entities are not excluded or sanctioned from participating in a federal program. Associates are required to report to their manager or to human resources in the event you are excluded or sanctioned. All associates must affirm their exclusion status every year via the annual compliance reporting form.

 

Confidential Personnel Matters

JKV expects all associates to keep information regarding personnel matters such as information in personnel files, salary, benefits, payroll information, disciplinary matters and similar information strictly confidential according to policy and applicable law.

 

Licenses, Registrations and Certifications

To help ensure quality of care and comply with federal, state and local laws, JKV requires associates to provide their current license, registration or certification if it is a requirement related to your job and duties. JKV validates such licenses, registrations and certifications as part of initial employment and periodically thereafter. Independent contractors such as staffing agency individuals are responsible for keeping required credentials current. JKV strives to ensure associates, businesses and independent contractors have and maintain any licenses or credentials required by law.

 

Social Media

The use of social media can foster learning and valuable communication when used with responsible care and good judgment. JKV requires the privacy and confidentiality of residents, patients, families and associates be maintained at all times and under all circumstances. Any social networking conduct in or outside of work that negatively compromises the job performance of JKVassociates or may adversely affect JKV residents/patients, or the business interests of JKV may result in corrective action up to and including separation. In accordance with other sections of the Code of Conduct, HIPAA, social media and networking policies, associates must neverndiscuss residents or patients or any aspect of their care; send or post any pictures of residents/patients; or discuss any confidential, proprietary or business matters using any social media platform. Associates will be held personally responsible for the content they publish on any social media platform and must respect resident and patient privacy and all health care system security laws and regulations.

 

Political Activity

Associates must not conduct themselves in any way that could jeopardize the tax-exempt status of JKV. Likewise, associates must comply with all applicable laws regarding campaign finance and ethics laws. JKV cannot engage in direct or indirect political campaign activities (including publishing and distributing of statements) in support of or in opposition to candidates for public office. Associates are prohibited from using JKV funds in any manner as a contribution to any candidate for political office, political party, candidate’s committee or to any individual in violation of these laws. You may personally participate and contribute to any political organization or campaign, but as an individual and not as an agent of JKV.

JKV advocates and makes public communications and pronouncements concerning legislation or regulations being considered that pertain to health care, social, business or economic issues that affect JKV. All JKV interactions with governmental bodies and public officials are conducted honestly and ethically. We intend to comply with campaign activity laws – federal, state and local.

 

Reporting Process and Non-Retaliation Four-step Process

If you observe or become aware of any activity that you believe may be unethical, illegal or wrong, use the following four-step process to get answers to your questions and report concerns. All associates, credentialed physicians, 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.

  1. Talk to your manager. He/she is most familiar with the laws, regulations and policies that are unique to your work and most problems can be resolved at this level.
  2. If you are not comfortable contacting or discussing your concerns with your manager, if you do not receive an adequate response from him/her, if it is otherwise not possible, or if both you and your manager have additional questions or concerns, talk to your department director or vice president.
  3. If you still have questions, or if you prefer, contact human resources or the compliance officer

(816-347-2109).

  1. If, for any reason, you feel you cannot follow the above steps, call the Compliance HELPLINE. (You can call the number on the back of your badge to leave a confidential message.)
  • When calling from the Village campus: Ext. 7233
  • When calling from outside the Village campus:

816-246-4343 Ext. 7233

The compliance officer will review and address all reports to the HELPLINE. Throughout this process, each concern will be taken seriously and each person involved will be treated with dignity and respect. JKV will conduct a review or investigation and follow up with an appropriate response to the reporting party as quickly as possible. Associates are encouraged to resolve concerns and problems of any kind

through the JVK problem solving process found in the Associate Policy Manual, Policy 01-05-6500-512.

 

Non-retaliation Policy

JKV is committed to protecting associates and others who report compliance concerns and problems 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 False Claims Act or other applicable 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 noncompliance is not insulated from the consequences of such non-compliance.

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Treat everyone with respect and empathy all the time.

 

Contact Us

John Knox Village Compliance

400 N.W. Murray Road

Lee’s Summit, MO 64081

www.jkv.org

Compliance HELPLINE

 

When calling from outside the Village campus: 816-246-4343 Ext. 7233 (SAFE)

When calling from the Village campus: Ext. 7233 (SAFE)

All policies referenced in this document can be found on www.myjkv.org.