Good Shepherd Home Code of Conduct

©2018.RolfGoffmanMartinLangLLP.AllRightsReserved.

GoodShepherdHomeCodeofConduct

ComplianceandEthicsProgram

©2018.RolfGoffmanMartinLangLLP -iiof29- ComplianceandEthicsProgramManual

T A B L E O F C O N T E N T S

OURCOMPLIANCECULTURE..................................................................................................................................................................................3CODEOFCONDUCT.....................................................................................................................................................................................................5REPORTING&RESPONSE........................................................................................................................................................................................6COMPLIANCEPOLICIES.............................................................................................................................................................................................9ETHICALBUSINESSPRACTICE......................................................................................................................................................................10BILLING....................................................................................................................................................................................................................12COSTREPORTING................................................................................................................................................................................................14EMPLOYEESCREENING....................................................................................................................................................................................15GIFTS&KICKBACKS...........................................................................................................................................................................................16RESIDENTRIGHTS..............................................................................................................................................................................................18QUALITYOFCARE...............................................................................................................................................................................................19RECORDS&DOCUMENTATION....................................................................................................................................................................20GOVERNMENTRELATIONS............................................................................................................................................................................21PHYSICIANAGREEMENTS...............................................................................................................................................................................22HOSPICE...................................................................................................................................................................................................................23CONFIDENTIALITY.............................................................................................................................................................................................24TRANSPARENCY&RESIDENTCHOICE.....................................................................................................................................................25

EDUCATION.................................................................................................................................................................................................................26MONITORING..............................................................................................................................................................................................................27ENFORCEMENT&DISCIPLINE............................................................................................................................................................................28COMPLIANCEOVERSIGHT....................................................................................................................................................................................29

©2018.RolfGoffmanMartinLangLLP -3of29- ComplianceandEthicsProgramManual

OURCOMPLIANCECULTURECommitmenttoComplianceGoodShepherdHomeiscommittedtooperatingitsbusinessinanhonest,ethical,andlegalmanner.TherearemanylawsandregulationsgoverningGoodShepherdHome’soperations,andGoodShepherdHomestrivestocomplywithallofthem.GoodShepherdHomealsoendeavorstobeagoodcorporatecitizenandtoactethicallyinitsdealingswithvendors,referralsources,competitors,andothers.

GoodShepherdHomestrivestofosteracultureofcompliancewithinitsorganization,suchthatallemployees,agents,andcontractorswill“live”compliancewhencarryingouttheirresponsibilitiesonbehalfofGoodShepherdHome.GoodShepherdHomerecognizesthatcomplianceisacooperativeeffort,andthatitcannotmeetitshighstandardswithoutthesupportandassistanceofitsemployees,agents,andcontractors.1GoodShepherdHomeexpectsitsemployeestocontributetoitscomplianceculturebyrecognizinganddoing“therightthing.”

ThisComplianceandEthicsProgramManual(CEPM)formalizesGoodShepherdHome’scommitmenttocompliancebyestablishingGoodShepherdHome’sstandardsofconduct,aswellaspoliciesandproceduresregardingcompliancewithapplicablelaws.ThisCEPMisintendedtoapply,whereapplicable,toallrelationshipsbetweenGoodShepherdHome and other health care providers, vendors, and suppliers. This CEPM also reaffirms Good Shepherd Home’scommitment to the delivery of quality health care consistentwith applicable State and Federal health and safetystandards.OversightGood Shepherd Home has appointed a Compliance Officer2 and has a compliance committee3 charged with theresponsibility of developing, operating andmonitoring its compliance and ethics program (CEP). The ComplianceOfficer and his/her committee report directly to Good Shepherd Home’s governing body on compliancematters.QuestionsregardingtheapplicationofthisCEPMmaybedirectedtotheComplianceOfficer.EmployeeEducationEmployeeswillreceiveannualeducationregardingcomplianceandshouldbefamiliarwiththelawsgoverningtheirjobresponsibilitiesandthematterssetforthinthisCEPM.ReportingofViolationsAnimportantgoalofGoodShepherdHomeinfosteringitscompliancecultureisthatallemployeesfeelcomfortablereporting to Good Shepherd Home any inappropriate activity. In fact, all employees have an obligation to reportviolations, suspected violations, questionable conduct, or questionable practices in accordancewith the reportingmechanismsestablishedinthisCEPM.Retaliationagainstanyemployeeforreportingisstrictlyprohibited.

BecauseGoodShepherdHomebelievesthatcomplianceisacooperativeeffort,GoodShepherdHomehasadoptedachainofcommandapproachwithrespecttocompliancereportingandresponse.Thatis,allemployeesareexpectedtoreportsuspectedviolationstotheirimmediatesupervisor.Assumingthattheissueiswithinthesupervisor’sareaofexpertise,thesupervisorwilldeterminetheappropriateresponse.Ifasupervisorneedsassistance,thesupervisorcanreportthepotentialviolation“upthechain”tohissupervisorforadditionalinput.Furtherreportsupthechainmaybenecessaryintheeventofsignificantcomplianceissues.

1Indeed,weusetheterm“employees”throughthisCEPMforeaseofreference,butobligations,training,discipline,andotherpoliciesinthisCEPMalsoapplytoouremployees,agents,contractors,andvolunteers,asapplicable.2NotethatonlythoseorganizationswithfiveormoreSNFsarerequiredtohaveadesignated“ComplianceOfficer”pursuant to the Requirements of Participation. However, we believe that it is appropriate for even smallerorganizationstodesignateanindividualasa“ComplianceOfficer”sothattheindividualresponsibleforoversightoftheprogramisclear.TheOfficeofInspectorGeneral(“OIG”)ComplianceProgramGuidanceforNursingFacilitiesalsoidentifieshavingadesignatedComplianceOfficerasoneofitssevenelementsofaneffectivecomplianceprogram.3Similarly,whiletheRequirementsofParticipationforSNFsdonotspecificallyrequireacompliancecommittee,theOIGComplianceProgramGuidance forNursingFacilitiesalso identifies thecompliancecommittee (alongwith theComplianceOfficer)asoneofthesevenelementsofaneffectivecomplianceprogram.


GoodShepherdHomerecognizesthatsituationsmayarisewhereanemployeedoesnotfeelcomfortablereportingtohissupervisor,oranemployeemaybeconcernedthathissupervisorwillnotaddresstheissue.BecauseGoodShepherdHomedoesnotwish for these concerns to deter employees from reporting legitimate compliance concerns, GoodShepherdHomehasalsodevelopedmechanismsforemployeestoreportissuesanonymouslyand/ordirectlytotheComplianceOfficer.ToreportanonymouslyGoodShepherdhasput2mechanismsinplace.

1.) Call:1-844-664-14252.) Webportal:goodshepherdhome.ethicspoint.com

ContinuousImprovementWeappreciateyourcontributionstoGoodShepherdHome’scomplianceculture.Ifyouhaveanythoughtsabouthowwe can improve our CEP, please share them. Good Shepherd Home alwayswelcomes your comments, questions,concerns,andsuggestions.


1.0CODEOFCONDUCT

Wewillnotlie,cheat,steal,harmothers,ortoleratethosewhodo.OGoodShepherdHomerequiresthateverypersonandeverycompanyworkingwithGoodShepherdHomeconducttheirbusiness ethically and in compliance with the law. Good Shepherd Home considers its standards to apply toindependentcontractors,volunteersandvendorsinadditiontoitsemployees,andGoodShepherdHomewilljudgewhethertocontinueitsrelationshipsbasedoncompliancewiththesestandards.GoodShepherdHomebelievesthatifthoseindividualsandcompaniesworkingwithGoodShepherdHomeabidebysomegeneralprinciples,theywillbeabletomeetGoodShepherdHome’sstandardsforcompliance:

Follow Our Policies. Good Shepherd Home is required to abide by a large number of laws andregulationsbecauseofthenatureoftheservicesthatweprovide.Theselawswillbemanifestedthroughourpoliciesandthetrainingandin-servicesinwhichyouwillbeexpectedtoparticipate.GoodShepherdHomecanfaceseriousconsequencesforfailuretoabidebythelaw.Therefore,GoodShepherdHomeexpectsthatallpolicieswillbefollowed.DotheRightThing.Whiletherightthingisnotalwaystheeasything,youmostlikelyknowwhatitiswithouthavingtobetold.GoodShepherdHomeexpectsthatitsemployeeswillworkhardanddiligentlyonbehalfofGoodShepherdHomeandperformtothebestoftheirabilities.GoodShepherdHomealsoexpectsitsemployeestobehonest,trustworthy,andrespectful.FollowtheGoldenRule.Treatothersasyouwouldwantthemtotreatyou.Treatotherswithrespectanddignity.Neverharmanotherpersonorallowthemtobeharmedwhiletheyareinyourcare.

WeexpecteverypersonandcompanyworkingwithGoodShepherdHome to reportanyviolationsofourcodeofconducttousimmediately.Themostimportantthingistoreport–themethodofreportingislessimportant.Wehaveadoptednumerouswaysforpeopletobringconcernstoourattention: ifyouareanemployee: tellyoursupervisor; ifyouareacontractor:informyourprimarycontactatGoodShepherdHome;oruseoneofournumerousofficialreportingmechanismstodirectlynotifytheComplianceOfficer.

OThiscodeofconductisavariationoftheWestPointCadetHonorCode.


2.0

REPORTING&RESPONSE2.1 ReportingSuspectedViolationsandInquiriesGoodShepherdHomebelievesthataCEPfunctionsbestwhenallemployeesassistinpromotingcompliancewithintheirownareaofexpertise.Totakeadvantageofthedifferentcompetenciesandknowledgewithinitsorganization,GoodShepherdHomehasadoptedachainofcommandapproach tocompliancereportingand inquiriesregardingpotentialcomplianceissues.Allemployeesarerequiredtoreportviolations,suspectedviolations,questionableconduct,orquestionablepracticesofwhichtheybecomeawaretotheirimmediatesupervisors(ordirectlytotheComplianceOfficer,ifpreferred).Iftheemployee’s immediate supervisor does not have the necessary knowledge to respond to a report or inquiry, thesupervisormay,inturn,movetheissueanotherrungupthechainbyreportingtohissupervisor.Reportsandinquiriesaretobemovedfurtherupthechainofcommand,andallthewaytotheComplianceOfficer,asnecessary,untiltheindividualwiththeappropriateexpertise isreachedandcanrespondtothereport inaccordancewithSection2.3.Furtherreportsupthechainmayalsobenecessaryintheeventofsignificantcomplianceissues.GoodShepherdHomebelievesthatthemajorityofcomplianceissuesmaybeappropriatelyhandledthroughthechainof command approach, as supervisors can report issues up the chain to the Compliance Officer as appropriate.However,intheeventanemployeedoesnotwishtoreporttohisorhersupervisor(e.g.,thesupervisorisimplicatedin the potential wrongdoing, the employee is concerned that the supervisor will not respond to a report), GoodShepherdHomehasestablishedalternateproceduresforreporting.First,theemployeemaychooseto“skip”alevelandmakethereporttothenextsupervisorinthechainofcommand.Alternately,theemployeemayreportdirectlytotheComplianceOfficer,inwritingat725ColumbusAve,Fostoria,Ohio44830,byfilingareportthroughGoodShepherdHome’s toll-free fraud and abusehotline1-844-664-1425,orby reporting throughGoodShepherdHome’s securecompliancewebsitegoodshepherdhome.ethicspoint.com.GoodShepherdHomeiscommittedtofosteringacomplianceculturewhereallemployeesfeelcomfortableandareproactiveinreportingpotentialviolationsdirectlytotheirsupervisors.GoodShepherdHomestrictlyprohibitsanyretaliationor discrimination against employees for reportingpotential compliance violations, and itmaybemoredifficult for Good Shepherd Home to investigate and resolve reports if it is unable to communicate with thecomplainant.However,becauseGoodShepherdHomedoesnotwishforinappropriateactivitytogounreportedforanyreason,employeesarealwaysfreetoreportpotentialviolationstotheComplianceOfficeranonymously.Please note that there may be additional reporting obligations for certain compliance violations under the lawsgoverningtheoperationofnursingfacilities.Employeesarealsorequiredtocomplywiththesereportingobligations,whichareaddressedinotherpoliciesandproceduresofGoodShepherdHome.Forexample,employeesmustreportresidentabusetotheAdministratorinaccordancewithGoodShepherdHome’sabusepoliciesandprocedures.2.2 ReportingGuidelinesThefollowingguidelinesshallapplytoallreportsmadepursuanttothisCEPM:A. NoRetaliation.GoodShepherdHomeprohibitsanyretaliatoryactionagainstanemployeeformakinganyverbal

orwrittencompliancecommunicationingoodfaithtohisorhersupervisor,thecompliancehotline,ananonymousdropbox,theComplianceOfficer,ortoanygovernmentagency.

B. Discipline.Therewillbedisciplineorotherconsequencesforfailuretoreporttimelyandthoroughly.Promptand

completedisclosuremaybeconsideredamitigatingfactorindetermininganemployee'sdisciplineorsanctioniftheyarethewrongdoer.Thedisciplineorsanctionshallnotbeincreasedbecauseanemployeereportedhisorherownviolationormisconduct.


C. InterferencewithReporting.Noemployeeshallattempt topreventanyperson frommakingacompliancereport.Ifanemployeedoestrytopreventapersonfrommakingareport,thenthatemployeeshallbesubjecttodisciplinaryaction,whichmayincludetermination.

2.3 SupervisorResponseWhenareportofasuspectedviolationof thepolicies inthisCEPMisbroughttotheattentionofasupervisor, thesupervisorwillassesstheissueandconductareasonableinvestigationtodeterminewhetheraviolationhasoccurredandwhetherasignificantcomplianceissuehasbeenraised.SupervisorswillexercisediscretionregardingwhetherasuspectedviolationissosignificanttoreporttotheComplianceOfficer,butwillgenerallyerronthesideofreporting.Generally,systemicissues,issuesthatinvolvequestionsofethicalbusinesspractices,provisionofcarebyanunlicensedorexcludedindividual,and/orlegalorbillingviolationsshouldbereportedtotheComplianceOfficer.Ifasignificantcomplianceissuehasbeenraised,thesupervisorwillreporttheissuedirectlytotheComplianceOfficerforinvestigationandresponse.Ifthesupervisordeterminesthataviolationhasoccurred,butdoesnotrequiretheassistanceoftheComplianceOfficer,thesupervisormaydeterminetheappropriateresponse,suchasrecommendingdisciplinaryaction,providingemployeetraining,orcorrectingabillingerror.Ifasupervisorneedsdirectionorhasaquestionregardinghowtorespondtoareportofsuspectactivity,thesupervisormaytakehisorherinquirytothenextsupervisorinthechainofcommand.2.4 ComplianceOfficerResponseWhenareportofasuspectedviolationofthepoliciesinthisCEPMisbroughttotheattentionoftheComplianceOfficer,thefollowingstepsshallbefollowed:A. InitialAssessment.TheComplianceOfficerwilldeterminewhetherthereportraisescomplianceissues.Often,

reportsthataremadetotheComplianceOfficerthroughreportingmechanismsinvolveHumanResourcesissues,andnotcomplianceissues.TheComplianceOfficercanredirectHumanResourcescomplaintstotheappropriateindividual.

B. Investigation&Report.Ifacomplianceissueisraised,theComplianceOfficerwillinvestigatethesuspectedviolationorquestionableconduct,and/orshalldelegatetheinvestigationoranalysisofsuspectedviolationsorquestionableconducttoanyindividual(s)heorshedeemsappropriate.Areportregardingsuchinquiryshallbeprepared.Thereport, ataminimum,shall address:1) theallegation thathasbeenmade;2) thespecific stepsand/or methods used in investigating the matter (such as people interviewed, records reviewed, analysesperformed,etc.);3)thespecificfindingsand/orresultsoftheinvestigation;and4)aproposedplanofaction(suchasdisciplinaryaction,policyorprocedurechanges,in-servicetrainingregardingexistingpolicyand/orprocedure,orothersuggestedactions)topreventfuturenon-compliance.

Iftheissueraisedisnotacomplianceissuebutrequiresadditionalattention,theComplianceOfficerwillrefertheissuetotheappropriatepersonforfollow-up.

C. Post-InvestigationAssessment&Referral toComplianceCommittee. If, after the investigation, theComplianceOfficerbelievesthatasignificantcomplianceissuehasbeenraised,thenthereportwillbeforwardedtotheComplianceCommitteeforreview,andadeterminationofhowitbelievestheallegationshouldbeaddressed.TheComplianceCommittee’sproposeddispositionofaviolationmayinclude,butisnotlimitedto,contactingLegalCounsel,revisingtheCEPM,conductingeducationalinservicesforstaff,institutingdisciplinaryaction,reportingtheviolationtotheappropriateauthorities,repaymentoffunds,and/ormakingamonetaryrestitutiontoaffectedthirdparties.

D. Response.BasedontheresultsoftheinvestigationbytheComplianceOfficer,andtakingintoconsiderationanyothersuggestionsbytheComplianceCommittee,theAdministrator,ComplianceOfficer,orotherappropriatelydesignatedpartywilltakeappropriatecorrectiveand/ordisciplinaryaction,orwillrecommendsuchactiontotheBoardofDirectors,ifnecessary.Theresponseshouldalsotakeintoconsiderationhowtopreventfurthersimilar


violations,includinganynecessarymodificationtoGoodShepherdHome’sCEPtopreventanddetectcriminal,civilandadministrativeviolationsundertheSocialSecurityAct.

E. Storageof&AccesstoComplianceFiles.TheComplianceOfficershallplaceallfilesregardingcompliancemattersinasecurelocation.AccesstofileswillbeprovidedonlytotheComplianceOfficer,LegalCounsel,CEO,andauthorizedmembersoftheBoardofDirectors.


3.0

COMPLIANCEPOLICIESAspartofitscommitmenttocompliancewiththelaw,GoodShepherdHomehasestablishedpoliciesandprocedureswhichspelloutthestepsthatemployeesmusttaketomaintaincomplianceinseveralareasofriskfornursingfacilities.3.1 EthicalBusinessPractice

3.2 Billing

3.3 CostReporting

3.4 EmployeeScreening

3.5 Gifts&Kickbacks

3.6 Residents’Rights

3.7 QualityofCare

3.8 Recordkeeping&Documentation

3.9 GovernmentRelations

3.10 PhysicianAgreements

3.11 HospiceReferrals3.12 Confidentiality3.13 Transparency&ResidentChoice


3.1

ETHICALBUSINESSPRACTICEPOLICYEmployeesareexpectedtoconductthemselvessoastoavoidactualimproprietyand/ortheappearanceofimproprietyinmakingbusinessdecisions.EmployeesmaynotusetheirpositionsatGoodShepherdHometoprofitpersonallyortoassistothersinprofitinginanywayattheexpenseofGoodShepherdHome,oritsresidents.EmployeesshalldisclosetotheirsupervisorandtotheComplianceOfficeranyfinancialinterest,ownershipinterest,oranyotherrelationshipthey(oramemberoftheirimmediatefamily)havewithGoodShepherdHome’sresidents,vendors,orcompetitors.PROCEDUREA. ServicesforCompetitorsorVendors.Noemployeeshallperformworkorrenderservicesforanycompetitor

ofGoodShepherdHomeorforanyorganizationwithwhichGoodShepherdHomedoesbusiness,orwhichseekstodobusinesswithGoodShepherdHome,withouttheapprovalofhis/hersupervisor.Noemployeeshallbeadirector,officer,orconsultantofanoutsideorganization,norpermithis/hernametobeusedinanyfashionthatwouldtendtoindicateabusinessconnectionwithsuchorganizationwithoutthepriorapprovaloftheemployee’ssupervisor.

B. StealingInformation.GoodShepherdHomeemployeesshallnotstealinformationbelongingtoanotherpersonorentity,includingfromGoodShepherdHome,oruseanypublication,document,computerprogram,informationor product in violation of a third party’s interest in such product. All Good Shepherd Home’s employees areresponsibleforensuringthattheydonotimproperlycopyfortheirownusedocumentsorcomputerprogramsinviolation of applicable copyright laws or licensing agreements. Employees shall not use confidential businessinformation obtained from competitors, including customer lists, price lists, contracts or other information inviolationofacovenantnottocompete,prioremploymentagreements,orinanyothermannerlikelytoprovideanunfaircompetitiveadvantagetoGoodShepherdHome.

C. UseofInsiderInformation.Employeesmaynotuse“insider”informationforanybusinessactivityconductedbyoronbehalfofGoodShepherdHome.Allbusinessrelationswithcontractorsmustbeconductedatarm’slengthbothinfactandinappearance,andincompliancewithGoodShepherdHome’spoliciesandprocedures.Employeesmustdisclosepersonalrelationshipsandbusinessactivitieswithcontractorpersonnelthatmaybeconstruedbyanimpartialobserverasinfluencingtheemployees’performanceorduties.Employeeshavearesponsibilitytoobtainclarificationfrommanagementonquestionableissuesthatmayarise.

D. FinancialReporting.Allfinancialreports,costreports,accountingrecords,researchreports,expenseaccounts,timesheetsandotherdocumentsmustaccuratelyandclearlyrepresenttherelevantfactsorthetruenatureofatransaction.Improperorfraudulentaccounting,documentationorfinancialreportingiscontrarytothepolicyofGoodShepherdHomeandmaybeinviolationofapplicablelaws.

E. Travel&Entertainment.ItisGoodShepherdHome’spolicythatanemployeeshouldnotsufferafinanciallossorafinancialgainasaresultofbusinesstravelandentertainment.EmployeesareexpectedtoexercisereasonablejudgmentintheuseofGoodShepherdHome’sassetsandtospendGoodShepherdHome’sassetsascarefullyastheywouldspendtheirown.EmployeesmustalsocomplywithGoodShepherdHomepoliciesrelatingtotravelandentertainmentexpense,includingthosegoverningthetreatmentofspousesorsignificantothers.

F. PersonalUseofCorporateAssets.AllemployeesareexpectedtorefrainfromconvertingassetsoftheGoodShepherdHometopersonaluse.AllpropertyandbusinessoftheGoodShepherdHomeshallbeconductedinamannerdesigned to furtherGoodShepherdHome’s interest rather than thepersonal interestofan individualemployee.EmployeesareprohibitedfromtheunauthorizeduseortakingofGoodShepherdHome’sequipment,supplies,materialsorservices.


G. ConflictsofInterest.EmployeesshallavoidsituationsthatmaycreateaconflictofinterestwiththeirprimaryresponsibilitiestoGoodShepherdHome.Whilenotallinclusive,thefollowingshouldactasaguidetothetypesofactivitiesbyanemployee,oranimmediatefamilymemberofanemployee,whichmightcauseaconflictofinterest:

1. OwnershipinoremploymentbyanyoutsideorganizationwhichdoesbusinesswithGoodShepherdHome.(Thisdoesnotapplytostockorotherinvestmentsheldinapubliclyheldcorporation,providedthevalueofthestockorotherinvestmentsdoesnotexceed5%ofthecorporation’sstock.)

2. Conduct of anybusinessnot onbehalf ofGood ShepherdHome,with any vendor, supplier, contractor, oragency,oranyoftheirofficersoremployees.

3. RepresentationofGoodShepherdHomebyanemployeeinanytransactioninwhichheorsheoranimmediatefamilymemberhasasubstantialpersonalinterest.

4. Disclosureoruseofconfidential,specialorinsideinformationoforaboutGoodShepherdHome,particularlyforpersonalprofitoradvantageoftheemployeeoranimmediatefamilymember.

5. Competition with Good Shepherd Home by an employee, directly or indirectly, in the purchase, sale orownershipofpropertyorpropertyrightsorinterests,orbusinessinvestmentopportunities.


3.2

BILLINGPOLICY GoodShepherdHomeiscommittedtoprompt,complete,andaccuratebillingofallservicesprovidedtoresidentsforpaymentbyresidents,governmentagencies,orotherthirdpartypayors.Billingshallbemadeonlyforservicesactuallyprovided,directlyorundercontract,pursuanttoalltermsandconditionsspecifiedbythegovernmentorthirdpartypayorandconsistentwithindustrypractice. GoodShepherdHomeanditsemployeesshallnotmakeorsubmitanyfalseormisleadingentriesonanybillsorclaimforms,andnoemployeeshallengageinanyarrangement,orparticipateinsuchanarrangementatthedirectionofanotheremployee(includinganyofficerofGoodShepherdHomeorasupervisor),thatresultsinsuchprohibitedacts.AnyfalsestatementonanybillorclaimformshallsubjecttheemployeetodisciplinaryactionbyGoodShepherdHome,includingpossibleterminationofemployment.PROCEDUREA. Reporting False Billing Practices. If an employee has any reason to believe that anyone (including the

employeehimself orherself) is engaging in falsebillingpractices, that employee shall immediately report thepractice.Failuretoactwhenanemployeehasknowledgethatsomeoneisengagedinfalsebillingpracticesshallbeconsideredabreachofthatemployee'sresponsibilitiesandshallsubjecttheemployeetodisciplinaryactionbyGoodShepherdHome,includingpossibleterminationofemployment.

B. ProperReportingofResidentCase-Mix.GoodShepherdHomewilltrainstaffontheproperwaytocomplete

MDSassessmentsandwillperiodicallyconductauditsoftheseassessmentsforvalidityandaccuracy.C. MedicareandMedicaidBillings.GoodShepherdHomewillperiodicallyauditservicesbilledtomakesure

theyarebothmedicallynecessaryandproperlydocumentedtomeetthefederalandstatebillingrequirements.D. ProhibitedBillingPractices.GoodShepherdHomeshallnotsubmitfalse,fraudulent,ormisleadingclaimsto

anygovernmentalentityorthirdpartypayor.Falseclaimsandbillingfraudmaytakeavarietyofdifferentforms,including,butnotlimitedto,falsestatementssupportingclaimsforpayment,misrepresentationofmaterialfacts,concealmentofmaterialfacts,theftofbenefitsofpaymentsfromthepartyentitledtoreceivethem,orretaininganoverpayment,asdefinedbylaw.GoodShepherdHomeandemployeesshallspecificallyrefrainfromengaginginthefollowingbillingpractices:

1. Makingclaimsforitemsorservicesnotrenderedornotprovidedasclaimed,suchasbillingforthreehoursof

therapywhenonlyafewminuteswereprovided.2. SubmittingclaimstoMedicarePartAforresidentswhoarenoteligibleforPartAcoverage;inotherwords,

whodonotrequireservicesthataresocomplexthattheycanonlybeeffectivelyandefficientlyprovidedby,orunderthesupervisionof,professionalortechnicalpersonnel.

3. Submittingclaimstoanypayor,includingMedicareforservicesorsuppliesthatarenotmedicallynecessary

orthatwerenotorderedbytheresident’sphysicianorotherauthorizedcaregiver.4. Submittingclaimsforitemsorservicesthatarenotprovidedasclaimed,suchasbillingMedicareforexpensive

prostheticdeviceswhenonlynon-coveredadultdiaperswereprovided.5. Submittingclaimstoanypayor,includingMedicareandMedicaid,forindividualitemsorserviceswhensuch

itemsorserviceseitherareincludedinthehealthfacility’sperdiemrateforaresidentorareofthetypethatmaybebilledonlyasaunitandnotunbundled.


6. BillingresidentsforservicesorsuppliesthatareincludedintheperdiempaymentfromMedicare,Medicaid,amanagedcareplan,orotherpayer.

7. Doublebillings(billingforthesameitemorservicemorethanonce).8. Providinginaccurateormisleadinginformationforuseindeterminingtheresourceutilizationgroups,(RUG)

assignedtotheresident,includingbutnotlimitedtomisrepresentingaresident’smedicalconditionontheminimumdataset(MDS).

9. Paying or receiving anything of financial benefit in exchange forMedicare orMedicaid referrals, such as

receivingnon-coveredmedicalproductsatnochargeinexchangefororderingMedicare-reimbursedproducts.10. Altering documentation or forging a physician signature on documents used to verify that serviceswere

orderedand/orprovided,includingmedicalrecordsandnursingnotes.

11. FailingtoreportandreturnanyfundsreceivedfromanypayorsourcetowhichGoodShepherdHomeisnotentitled,afterapplicablereconciliation,inaccordancewithlaw.


3.3COSTREPORTING

POLICYGoodShepherdHomeisrequiredtosubmitvariouscostreportstotheFederalandStategovernmentinconnectionwith itsoperations inorder to receivepayment. It is thepolicyofGoodShepherdHome that such reportswillbepreparedasaccuratelyaspossibleandinconformitywithapplicablelawandregulations.PROCEDUREA. AccuracyofCostReports.GoodShepherdHomewillprepareallcostreportsusingaccuratereportingmethods

andappropriateaccountingpractices.GoodShepherdHomewillnotengageinanyofthefollowinginappropriatepracticeswithrespecttocostreporting:(i)claimingsalaryexpensesforemployeeswhodonotexist,(ii)inflatingthenumberofresidentsserved,or(iii)includingnon-reimbursablecosts.

B. Documentation.GoodShepherdHomewill implementmeasures toensureallof the following: (i)adequatedocumentationexiststosupportinformationprovidedincostreports,(ii)non-allowablecostsareappropriatelyidentifiedandremoved,and(iii)relatedpartytransactionsaretreatedconsistentwithprogramrequirements.

C. Identification of Errors. If errors are discovered, billing personnel shall contact an immediate supervisorpromptly foradviceconcerninghowtocorrect theerror(s)andnotify theappropriatepayor.TheComplianceOfficerwillbenotifiedofanyerrorsinasubmittedcostreporttodeterminewhetheranoverpaymenthasoccurred.


3.4EMPLOYEESCREENING

POLICYItisthepolicyofGoodShepherdHometoundertakebackgroundchecksofallemployees,whererequiredbylaw,andtoretainonfileapplicablerecordsofcurrentemployeesregardingsuchinvestigations.ItisthepolicyofGoodShepherdHometoundertakeexclusionandlicensurechecks,whereapplicable,ofallemployees.PROCEDUREA. NurseAssistantRegistries.GoodShepherdHomewillcheckwithallStatenurseassistantregistriespriorto

usinganyindividualasanurseassistant,dietaryaide,businessofficemanager,receptionist,etc.

B. Licensure & Certification Status. Good Shepherd Home will check with all applicable licensing andcertificationauthoritiestoensurethatemployeesholdtherequisitelicenseand/orcertificationstatustoperformtheirjobfunctions.

C. Reference Checks. To the extent the information is available, Good Shepherd Home will also check theapplicant’sreferencesfromprioremployers.

D. ExclusionCheck.GoodShepherdHomewillcheckallemployees(aswellasvendors/contractors)forexclusionfromtheMedicareand/orMedicaidprogramsusingtheOfficeofInspectorGeneral'sCumulativeSanctionsReportandtheOhioMedicaidProviderExclusionandSuspensionListand/orcomputersearchabledatabaseforpotentialemployeeswhoseactivitieswouldberecordedthere.

E. Criminal Background Check. Good Shepherd Home will perform criminal background checks for allemployeesinaccordancewithapplicablelawtoconfirmthattheyhavenotbeenconvictedofanoffensethatwouldprecludethemfromprovidingdirectcaretoanolderadult.

F. ApplicantCertification.Applicantsforemploymentwillberequiredtocertifyontheiremploymentapplication

thattheyhavenotbeenconvictedofanoffensethatwouldprecludeemploymentinanursingfacilityandthattheyarenotexcludedfromparticipationinthefederalhealthcareprograms.

G. TemporaryEmploymentAgencies.TemporaryemploymentagencieswillberequiredbycontracttoensurethattemporarystaffassignedtoGoodShepherdHomefacilitieshaveundergonealloftheabovelistedemployeescreeningchecksandarenotprecludedfromemploymentwiththefacility.

H. OngoingDutyofEmployeestoReport.ItistheongoingandcontinuousobligationofallemployeesofGoodShepherdHometoalerttheHumanResourcesdepartmentofanylapseorlossof licensureandofanyoffense,charge,indictment,finding,plea,settlementorconvictionthatwoulddisqualifythemfromcontinuedemploymentintheircurrentcapacitywithGoodShepherdHomeunderStateorFederallaw.


3.5GIFTS&KICKBACKS

POLICYEmployeesshallnotacceptgifts,favors,services,entertainmentorotherthingsofvaluetotheextentthatdecision-makingoractionsaffectingGoodShepherdHomemightbeinfluenced.Similarly,theofferorgivingofmoney,servicesorotherthingsofvaluewiththeexpectationofinfluencingthejudgmentordecisionmakingprocessofanypurchaser,supplier,governmentofficialorotherpersonbyGoodShepherdHomeisabsolutelyprohibited.Anysuchconductmustbeimmediatelyreported.PROCEDUREInorder toavoid theappearanceof impropriety,and toavoid thepotentialofprovidingorreceivingan improperkickback,GoodShepherdHomeshallnotengageinanyofthefollowingactivities:A. GiftsfromResidents.Employeesareprohibitedfromsolicitingtips,personalgratuitiesorgiftsfromresidents

andfromacceptingmonetarytipsorgratuities.Employeesmayacceptgratuitiesandgiftsofanominalvaluefromresidentsonlywith theapprovalof theSocialServices. Ifa residentoranother individualwishes topresentamonetarygift,he/sheshouldbereferredtotheappropriateadministrationoffice.

B. GiftsfromVendors.Employeesmayretaingiftsfromvendorswhichhaveanominalvalue.Ifanemployeehasanyconcernwhetheragiftshouldbeaccepted,theemployeeshouldconsultwithhis/herAdministrator.Totheextentpossible,thesegiftsshouldbesharedwiththeemployees’co-workers.Employeesshallnotacceptexcessivegifts,meals,expensiveentertainmentorotheroffersofgoodsorserviceswhichhavemorethananominalvaluenormaytheysolicitgiftsfromvendors,suppliers,contractorsorotherpersons.Forexample,anemployeewhowas given a promotional coffee mug may accept this gift from a vendor, however, the employee would beprohibitedfromacceptingatelevisionsetfromthatvendor.

C. BeneficiariesofGovernmentReimbursementPrograms.GoodShepherdHomeanditsemployeesshallnotofferorprovideanygift,hospitality,orentertainmentofmore thanNominalValue toanybeneficiaryofagovernmentreimbursementprogram.Examplesofpermissible items includenominalmarketing itemssuchaspens,T-shirts,waterbottles,etc.

D. WaiversofCoinsurance/Deductible.GoodShepherdHomeanditsemployeesshallnotofferwaiversofcoinsuranceordeductible amounts aspart of anyadvertisementor solicitation.GoodShepherdHomeand itsemployeesshallnotroutinelywaivecoinsuranceordeductibleamounts,andshallonlywaivesuchamountsafterdeterminingingoodfaiththattheresidentisinfinancialneed,oraftermakingreasonableeffortstocollectthecost-sharingamountsfromtheresident.

E. Arrangements with Health Plans. Good Shepherd Home and its employees shall not participate in anyarrangementwithahealthcareplanthateffectivelyrequiresGoodShepherdHomeanditsemployeestoforgocertainMedicare cost-sharing amounts. Good Shepherd Home and its employees shall not participate in anyarrangementwithahealthcareplanthatrequiresGoodShepherdHomeanditsemployeestowaivechargesforcopaymentsanddeductibleswhenMedicareistheprimarypayorandtheapplicableMedicarereimbursementishigherthantheplanfeescheduleamount.

F. GovernmentEmployees.GoodShepherdHomeanditsemployeesshallnotofferanygiftsorentertainmenttoanyfederal,stateorlocalelectedofficialorgovernmentemployee.

G. Swapping.GoodShepherdHomeanditsemployeeswillnotacceptdiscountsonitemsandservicespaidforbyGoodShepherdHomeinreturnforthereferralsofotherbusiness,sometimescalled“swapping”.

H. AccesstoHealthInformation.GoodShepherdHomeanditsemployeeswillnotsolicitorreceiveitemsofvalueinexchangeforprovidingasupplierormedicalprovideraccesstoresidents’medicalrecordsorotherinformationneededtobillMedicareorMedicaid.


I. Third Party Guarantees & Supplementation. Good Shepherd Home will not condition admission orcontinuedstayonathirdpartyguaranteeofpayment,norwillitrequireanypersontosupplementtheirMedicareorMedicaidpayment.

J. PartDPlans.GoodShepherdHomeanditsemployeeswillnotacceptanypaymentsfromanyplanorpharmacytoinfluenceabeneficiarytoselectaparticularPartDplan.GoodShepherdHomeoritscontractedpharmacywillinformresidentsaboutallof thePartDplansavailable to themand,wherepossible, try toassist/educate theresidentsregardingwhetherandtowhatextentthoseplanscovertheresident’smedications.


3.6RESIDENTRIGHTS

POLICYIt is the policy of Good ShepherdHome that residentswill be cared for in amanner and in an environment thatpromotesmaintenanceorenhancementofeachresident'squalityoflife.GoodShepherdHomehasnumerouspoliciesandproceduresdesignedtoprotectaresident’squalityoflifeandiscommittedtoassuringthattheresident’srightsarticulatedunderfederallawareprotected.PROCEDUREA. Transfer&Discharge.GoodShepherdHomewillmaintainidenticalpoliciesandpracticesforallindividuals

regardingtransferanddischarge,regardlessofpaymentsource,andtocomplywithallapplicablelawwithrespecttoadmissionsdecisions,aswellastheprovisionofservicesunderthestateMedicaidplan.

B. PersonalPrivacy.GoodShepherdHomewilltakemeasurestoensurethateachresidenthastherighttopersonalprivacy.Forpurposesof thispolicy, the term"personalprivacy" includesaccommodations,medical treatment,writtenandtelephonecommunications,personalcare,visits,andmeetingsoffamilyandresidentgroups,butdoesnotincludetherighttoaprivateroom.

C. ClinicalRecords.GoodShepherdHomerecognizesthattheresidenthastherighttoconfidentialtreatmentofhisorherpersonalandclinicalrecords,andmayapproveorrefusethereleaseofhisorherpersonalandclinicalrecordstoanyindividualoutsideGoodShepherdHome,exceptwhentheresidentistransferredtoanotherhealthcareinstitution,ortherecordreleaseisauthorizedorrequiredbylaw.

D. MedicalCare&Treatment.GoodShepherdHomerecognizesthattheresidenthastherighttochoosehisorherownpersonalphysician(inaccordancewiththefacility’sappropriatecredentialingpolicies)andhastherighttoprivacyduringmedicalexaminationortreatment,andinthecareofpersonalorbodilyneeds.Theresidentalsohastherighttobefullyinformedofhisorherhealthstatusandtoparticipateintreatmentdecisions,includingtherighttorefusetreatment,unlessadjudgedincompetentorincapacitated.

E. Communication.GoodShepherdHomerecognizesthattheresidenthastherightuponreasonablerequesttoprivateandunrestrictedcommunicationswithhisorherfamily,socialworker,andanyotherperson,unlessnotmedicallyadvisableasdocumentedinhisorhermedicalrecordbytheattendingphysician.Theresidentalsohastherighttoprivateandunrestrictedcommunicationswitharesident’sphysician,attorneyorwithpublicofficials.Theresident’srightofprivateandunrestrictedcommunicationshallincludetherightto:1)receive,send,andmailsealed,unopenedcorrespondence;2)reasonableaccesstoatelephoneforprivatecommunication;and3)privatevisitsinaccordancewithGoodShepherdHome’spolicies.

F. FinancialAffairs.GoodShepherdHomerecognizesthattheresidenthastherighttomanagehisorherfinancialaffairsorpermitthefacilitytoholdandmanagehisorherfunds.PersonalfundsmaynotbeusedtopayforitemsorservicespaidforbyMedicaidorMedicare.

G. Abuse,Neglect&MisappropriationofResidentFunds.GoodShepherdHomerecognizesthattheresidenthastherighttobefreeofabuse,neglectandmisappropriationofhisorherfunds.Allallegationsofabuse,neglectofmisappropriationwillbereportedtothestateagencyandlawenforcement(inthecaseofacrime)inaccordancewithstateandfederallaw.


3.7QUALITYOFCARE

POLICYItisthepolicyofGoodShepherdHomethatitstrivetoprovidethecareandservicesnecessarytoattainormaintainnursingfacilityresidents’highestpracticablephysical,mentalandpsychosocialwell-beingandto,ataminimum,meetallMedicarerequirementsofparticipation.PROCEDUREA. Staffing.GoodShepherdHomeiscommittedtomeetingbothstateandfederalstaffingrequirements,andassuring

thatthereisarelationshipbetweenthelevelofstaffingandtheacuityoftheresidentsbeingserved.GoodShepherdHomewillalsomakeeffortstoreduceemployeeturnover.

B. ComprehensiveCarePlans.EachresidentofGoodShepherdHomewillhaveacomprehensivecareplanthatisdesignedandimplementedbyvariousmembersoftheinterdisciplinaryteamincluding,butnotlimitedto,theresident’s physician nurses, dietician, social service, activities, and therapists where applicable. Theseinterdisciplinary teammeetings will be documented and the content and participants in themeetingwill berecorded.

C. Medication Management. Good Shepherd Home will manage the medications of its residents, includingpsychotropics,andiscommittedtothegradualreductionoftheiruse,wheremedicallypossible,andtomonitoringresidents foradversesideeffects.GoodShepherdHomehascontractedwithaconsultingpharmacistwhowillassistinthemanagementofeachresident’smedicationsandwillperformregulardrugregimenreviews.

D. ResidentSafety.GoodShepherdHomebelievesthatitistheresponsibilityofeveryonewhocomesincontactwithourresidentstopreservetheirsafetyandwellbeing.Withthatinmind,GoodShepherdHomehasapolicythat its residentswill be freeof abuseandneglect, and that theirpossessionswill notbemisappropriatedbyanyone. Anyonewho is aware of or suspects that a resident is being abused or neglected, or that his or herpossessionshavebeenmisappropriatedwillimmediatelyreportthisknowledgeorsuspicioninaccordancewithGoodShepherdHome’sabusepolicy.Good ShepherdHome also recognizes that its residents have thepotential to suffer abuse fromnot only staffmembers, but also from other residents and/or visitors. Therefore, Good Shepherd Home not only conductsbackgroundandexclusionchecksofitsstaffmembersandprovidesemployeeswithregularinservicetrainingonabuse,neglectpreventionandreporting,butGoodShepherdHomeenforcesitspolicywithrespecttoallthatabuseormistreatGoodShepherdHomeresidents.

E. RestorativeandPersonalCare.GoodShepherdHomehaspoliciesandproceduresaddressingthepreventionandtreatmentofpressureulcers,thedeliveryofrangeofmotionexercisesandrestorativecare,fallsmanagementandprevention,incontinencemanagementandthedeliveryofpersonalcareandgrooming.GoodShepherdHomestrivestomeetallstateandfederallicensingrulesandregulationsgoverningthehealthcareservicesprovidedtoourresidents,andtomonitorthequalityofthoseservicesthroughourqualityassuranceprograms.


3.8RECORDS&DOCUMENTATION

POLICYAccurateandcompleterecordkeepinganddocumentationiscriticaltovirtuallyeveryaspectofGoodShepherdHome’soperations.ItisthepolicyofGoodShepherdHomethatalldocumentationshallbetimely,accurate,andconsistentwithapplicable professional, legal, and facility guidelines and standards. This includes all aspects of the facility'sdocumentation, including resident assessments and care plans, clinical records, and all billing and paymentdocumentation.Falsificationofrecordsisstrictlyprohibited,includingbackdatingofrecords.Appropriatelateentriesdulynotedandunderapplicableprofessionalandlegalstandardsmaybemade.PROCEDUREA. LegallyRequiredDocumentation.GoodShepherdHomewillkeepallbillingandclaimsdocumentation,cost

reports, MDS assessments, care plans and survey plans of correction in accordance with state and federalrequirements.

B. ComplianceandEthicsProgram(CEP)Documentation.GoodShepherdHomewillkeeprecordsofitsCEPoperations,suchasthecompliancelog,educationalactivities,correspondinginvestigationsandreports,inordertodemonstratetheeffectivenessofitsCEP.

C. Storage.Alldocumentswillbestoredinasafeandsecureplaceandinamannerastobeeasilyretrievable.

D. Destruction.Destructionpolicieswillconformtoapplicablestateandfederallaws.Employeesshallnotdestroyor alter Good Shepherd Home information or documents in anticipation of, or in response to, a request fordocuments by any applicable government agency or from any court, or from any party in conjunctionwith alawsuit.


3.9GOVERNMENTRELATIONS

POLICY

GoodShepherdHomehasmanycontactsanddealingswithgovernmentalbodiesandofficials.Allsuchcontactsandtransactionsshallbeconductedinanhonestmanner.ItisthepolicyofGoodShepherdHometoensurethatitsdealingswithfederal,stateand localgovernmentalofficials,agencies,representatives,andcontractors fullycomplywithallapplicablelawsandregulations.Itistheorganization’sdesiretoatalltimesbeincompliancewiththelaw,preserveandprotectitsreputation,andtoavoideventheappearanceofimpropriety.Anyattempttoinfluencethedecision-makingprocessofgovernmentalbodiesorofficialsbyanimproperofferofanybenefitisabsolutelyprohibited.Anyrequestsordemandsbyanygovernmentalrepresentativeforanyimproperbenefitshouldbeimmediatelyreported.PROCEDURE

A. LicensureandCertification.GoodShepherdHomeoperatesanursingfacilitythatislicensedbytheStateinwhichitoperatesandcertifiedtoparticipateintheMedicareandMedicaidprograms.EmployeesareexpectedtobefamiliarwiththelawsgoverningtheoperationofanursingfacilitythataffecttheirspecificjobresponsibilitiesandtocomplywithlicensureandcertificationlawsapplicabletoGoodShepherdHome.Employeesshallreportanyconcernsthattheyhavewithregardtoappropriatenessor legalityofanyactionstakenbyGoodShepherdHome.

B. Lobbying&PoliticalActivities.Noindividualmaymakeanyagreementtocontributeanymoney,property,or services at Good Shepherd Home’s expense to any political candidate, party, organization, committee orindividualinviolationofanyapplicablelaw.Officersandemployeesmaypersonallyparticipateinandcontributetopoliticalorganizationsorcampaigns,buttheymustdosoasindividuals,andtheymustusetheirownfunds.

C. Governmental Investigations. Good Shepherd Home shall not unlawfully obstruct or interfere withgovernmentenforcementinvestigations,andshallcooperatetothefullestextentpossiblewithintheconfinesofapplicablelawwiththerelevantgovernmentagency/official/agentonsuchoccasions.

D. Prohibitions.GoodShepherdHomeexpectsitsemployeestorefrainfromengaginginanyactivitiesthathave

eventheappearanceofimpropriety.

1. GiftsorEntertainment.Employeesarestrictlyprohibitedfromofferinggiftsorentertainmenttoanyfederal,state,orlocalgovernmentorelectedofficialoremployee,surveyor,lawenforcementofficer,auditorworkingundercontractwithagovernmentagency,peerreviewagency,oranyotherregulatoryentityoragencythatinteractswithGoodShepherdHome.Anyemployeewhobecomesawareofsuchactivityshall immediatelyreporttheviolation.

2. DemandsforImproperBenefits.Anyrequestsordemandsbyanyfederal,state,orlocalgovernmentorelected official or employee, surveyor, law enforcement officer, auditor working under contract with agovernmentagency,peerreviewagency,oranyotherregulatoryentityoragencythatinteractswithGoodShepherdHomeforanyimproperbenefitshouldbeimmediatelyreported.

3. FalseRepresentations. Good ShepherdHome shall notmake false representations to any governmentalentityorofficialinordertogainorretainparticipationinaprogramortoobtainpaymentforanyservice.


3.10PHYSICIANAGREEMENTS

POLICYFederalandStateanti-kickbackandphysicianself-referrallawsprohibittheofferorpaymentofanycompensationtoanypartyforthereferralofresidentsorhealthcarebusiness.PROCEDUREA. Contracting.Inordertocomplywithapplicablelawsgoverningthereferralofresidentsorhealthcarebusiness,

GoodShepherdHomeshalldothefollowing:1. Gifts.ComplywiththepoliciesgoverninggiftssetforthinthisCEPM;

2. SubmissionofClaims.Notsubmitnorcausetobesubmittedabillorclaimforreimbursementforservicesprovidedpursuanttoaprohibitedreferral;and

3. ReferralsofDesignatedHealthServices.Notacceptorsolicitareferralfromaphysiciantoanentityinwhich the physician (or an immediate family member) has a financial relationship (broadly defined toencompass any ownership interest, investment interest, or compensation arrangement) for a designatedhealthserviceasdeemedin42U.S.C.§1395nn(h)(6),exceptaspermittedbylaw.

“Designated health services” include: a) Clinical laboratory services; b) Physical therapy services; c)Occupational therapy services; d) Radiology services, including magnetic resonance imaging (MRI),computerized axial tomography (CAT) scans, and ultrasound services; e) Radiation therapy services andsupplies; f)Durablemedical equipment and supplies; g)Parenteral andenteralnutrients, equipment, andsupplies;h)Prosthetics,orthotics,andprostheticdevicesandsupplies;i)Homehealthservices;j)Outpatientprescriptiondrugs;andk)Inpatientandoutpatienthospitalservices.

B. AdditionalRequirements.Inaddition,physicianagreementsshall:

1. Beinwriting;

2. BeapprovedbyLegalCounselpriortoexecution;

3. BenegotiatedonlybytheComplianceOfficer,LegalCounsel,theAdministratorortheirdesignees;

4. Besignedbyallparties;

5. Whentakenasawhole,bereasonableintheirentirety;

6. Specify the termsunderwhichcompensationandanyotherbenefitsareprovided, andcompensationandbenefitsshallbeconsistentwiththefairmarketvalueoftheservicesprovided;

7. Specifyallobligationsoftheparties;

8. NottakeintoconsiderationthevalueorvolumeofreferralsprovidedtoGoodShepherdHome;and

9. Beforatermofatleastoneyear.

C. Certificationof Credentials. Good ShepherdHome also shall require certification that anyphysicianwithwhomanagreement isexecuted,and/orwhoservesasanattendingphysicianinthefacility,hascurrentvalidlicensesasrequiredbylaw,hasnotbeenexcludedfromparticipationintheMedicareandMedicaidprograms,andhasadmittingprivilegesatatransferhospital.


3.11HOSPICE

POLICYGoodShepherdHomeiscommittedtomakingavailableappropriatehospiceservicestoresidentswhoelecthospicecoverage.PROCEDUREFor residents who are eligible for hospice benefits under Medicare or Medicaid, Good Shepherd Home and itsemployeesshall:A. ServiceAgreement.Provideservicespursuanttoawrittenagreementwithahospiceprogramthatmeetsthe

conditionsofparticipationforhospicesuponevidencethattheresidentqualifiesforandhasproperlyelectedthehospicebenefit.

B. PlanofCare.Developandimplement,inconjunctionwiththehospiceprogram,acoordinatedplanofcare.

C. Billing.BilltheMedicareand/orMedicaidprogramsonlyforthetreatmentofconditionsunrelatedtotheterminalillness,aspermittedbylaw.

D. Payments fromHospice.Forresidentseligible forMedicarehospicebenefitsandMedicaidcoverageof theresident's roomandboard, Good ShepherdHome shall not accept payment by a hospice for roomandboardprovided to ahospice resident in excessof theamount thatGoodShepherdHomewouldhave received if theresident had not been enrolled in hospice. Any additional payment from the hospice for items and servicespurchasedfromthefacilitymustrepresentthefairmarketvalueofsuchadditional itemsandservicesactuallyprovidedtotheresidentthatarenotincludedintheMedicaiddailyrate.

E. Provision of Services. Provide only those services Good ShepherdHome is allowed to provide to hospiceresidentsunderapplicablelaw.

F. Referrals.NotengageinanyarrangementinwhichGoodShepherdHomeoffers,accepts,provides,orreceivesfreeservicestoorfromahospiceinexchangeforapromiseoragreementtorefernursingfacilityresidentstothehospice,orviceversa.


3.12CONFIDENTIALITY

POLICYGood Shepherd Home and its employees are in possession of and have access to a broad variety of confidential,sensitiveandproprietaryinformation.Theinappropriatereleaseofthisinformationcouldbeinjurioustoindividuals,GoodShepherdHome’sbusinesspartnersandGoodShepherdHome.EveryGoodShepherdHomeemployeehasanobligationtoactivelyprotectandsafeguardconfidential,sensitiveandproprietaryinformationinamannerdesignedtopreventtheunauthorizeddisclosureofinformation.PROCEDUREA. ResidentInformation.AllGoodShepherdHomeemployeeshaveanobligationtomaintaintheconfidentiality

of resident information in accordancewith all applicable laws and regulations. Employees shall refrain fromrevealinganypersonalorconfidentialinformationconcerningresidents,unlesssupportedbylegitimatebusinessorresidentcarepurposes.Ingeneral,employeesshallnotdiscloseconfidentialmedicalorpersonalinformationpertainingtoGoodShepherdHome’sresidentswithouttheexpresswrittenconsentoftheresidentorappropriatelegalrepresentative,andinaccordancewithapplicablelawandGoodShepherdHome’spoliciesandprocedures.Ifquestionsariseregardinganobligationtomaintaintheconfidentialityofinformationortheappropriatenessofreleasinginformation,employeesshouldseekguidancefromtheirsupervisor.

B. GoodShepherdHomeInformation.InformationpertainingtoGoodShepherdHome’scompetitivepositionor business strategies, payment and reimbursement information, information relating to negotiations withemployeesorthirdparties,qualityassurancematerials,tradesecrets,andprotocolsanddocumentationdevelopedinordertooperateGoodShepherdHomeshouldbeprotectedandsharedonlywithemployeeshavinganeedtoknowsuchinformationinordertoperformtheirjobresponsibilities.

C. PersonnelInformation.Salary,benefitandotherpersonalinformationrelatingtoemployeesshallbetreatedas confidential. Personnel files, payroll information, disciplinary matters and similar information shall bemaintained inamannerdesignedtoensureconfidentiality inaccordancewithapplicable laws.Employeeswillexerciseduecaretopreventthereleaseorsharingofinformationbeyondthosepersonsoroutsideentitiesthatmayneedsuchinformationtofulfilltheirjobfunctionordutiesunderthelaw.


3.13TRANSPARENCY&RESIDENTCHOICE

POLICYAttimes,residentshaveachoicefromwhichhealthcareproviderstheywishtoreceiveservices.Inaddition,GoodShepherdHomebelievesthatresidentsshouldunderstandtherelationshipsamongtheirvarioushealthcareproviderssothattheycanmakeinformedchoicesindeterminingfromwhomtheywishtoreceiveservices.Therefore,itisthepolicyofGoodShepherdHometoprovidefulltransparencyandaccuratedisclosuretoallresidentsregardingcommonownershiporaffiliations ithaswithotherproviders,so thatresidentscanmakean informedchoiceregarding theentitiesfromwhichtheyreceiveservices.PROCEDUREA. FullTransparency.GoodShepherdHomewillnotifyresidentsofanycommonownershipof,oraffiliationswith,

otherhealthcareprovidersfromwhichtheresidentmayreceiveservicesuponadmissionandwheneverareferralis made. Good Shepherd Home will attempt to answer any questions by residents or their representativesregardingGoodShepherdHome’saffiliationshonestlyandfully.

B. RespectofResidentChoice.GoodShepherdHomewillinformresidentsandtheirresponsiblepartiesoftheir

freedom to choose among credentialed providers, when appropriate, and will respect the resident’s andresponsibleparty’spreferenceswhentheyareexpressed.GoodShepherdHomewillnotrequireanyresidenttoselectaprovideraffiliatedwithGoodShepherdHomeforservices,threatenanyresidentwhodoesnotwishtoselectsuchaprovider,orotherwiseintimidateorretaliateagainstanyresidentforhisselection.


4.0EDUCATION

4.1 ContinuedProfessionalCompetence

Employees are expected to participate in educational “in services” offered byGood ShepherdHome and byvariousprofessionalgroupsandassociations,whereappropriate,andtobefamiliarwiththelawsgoverningtheoperationofanursingfacilitythataffecttheirspecificjobresponsibilities.

4.2 EducationalElements

Therearethreebasiceducationalelementstothecomplianceeducationplan:(1)newemployeeeducation;(2)continuingeducation;and(3)correctiveeducation.

A. Newemployeeeducation.AllnewemployeesofGoodShepherdHomewillberequiredasaconditionof

theiremploymenttoattendatrainingsession,whichshallincludeanintroductiontoGoodShepherdHome’scultureof compliance, anoverviewof theCodeof Conduct and the compliancepolicies andproceduresapplicabletoeachemployee'sjobresponsibilities;proceduresforreportingcomplianceviolations,includingavailable reporting mechanisms; and the disciplinary system. Employees will be informed that strictcompliancewiththesepoliciesandproceduresisalsoaconditionoftheiremployment(orengagementwithourorganization,ifapplicable).

B. ContinuingEducation.Allemployeeswillberequiredtoattendperiodicin-servicetrainingsessionson

fraud and abuse andGoodShepherdHome’sCEP. In addition,GoodShepherdHome shall post a noticedetailingitscommitmenttoethicalstandardsandcompliancewithallapplicablelawsandregulationsintheconductofitsbusinessateachofitsfacilities.

C. Corrective Education. Directed corrective educationwill be instituted on a case-by-case basiswhen

issuesareraisedthroughaudits,reportsofviolations,orothermonitoringactivities.TheComplianceOfficershall be responsible for recommending corrective education, and the Compliance Committee shall beresponsiblefordeterminingtheformandcontentofthateducation.

D. Volunteer/VendorEducation.VolunteersandvendorswillreceiveanintroductiontoGoodShepherd

Home’sCEPandmayberequiredtoparticipateintrainingregardingGoodShepherdHome’sCEPasitrelatestotheirvolunteerand/orjobresponsibilities.

4.3 DocumentationofEducationalEfforts

AllcomplianceeducationatGoodShepherdHomeshallbedocumented.TheComplianceOfficerisresponsibleforestablishingappropriatesystemsofdocumentation,andforreportingonthestatusofeducationaleffortstotheBoardofDirectors.


5.0MONITORING

5.1 ComplianceOfficerResponsibility

TheComplianceOfficer,orhisorherdesignee,shallberesponsibleforconductingperiodicreviewsofvariousareas, such as beneficiary billing, admissions procedures, code assignment, employee screening, vendorcontracting,andqualityofcareandlife(includingcompliancewithapplicableStateandFederalhealthandsafetystandards),toensurethatapplicablelawsandregulationsarebeingfollowed,andthataccurateinformationisbeingconveyedorsubmitted.Infulfillingthisresponsibility,theComplianceOfficer:

A. Mayusetheservicesofemployeesandqualifiedlegaloraccountingconsultants,asnecessary;

B. Mayuse interviews,questionnaires,onsitevisits,unannouncedmocksurveys,anddocumentreviews,as

wellassamplingtechniquesinconductingthereview;and

C. Shallincludeacopyofwhateverfindingsaremadeinrelevantcompliancefiles.5.2 ComplaintAudits

Upon receiptof a credibleallegationor complaint alleging improperor inaccuratebillingpracticesbyGoodShepherdHome,anauditofbillingpracticesmaybeundertaken inaccordancewithGoodShepherdHome’sinternal auditing policies and protocols, if deemed necessary by the Compliance Officer or the ComplianceCommittee.

5.3 AnnualReview

GoodShepherdHomewillreviewtheCEPannuallyandrevisetheCEPasneededtoreflectchangesinapplicablelawsorregulationsandtoreflectchangeswithinGoodShepherdHometoimproveitsperformanceindeterring,reducing,anddetectingviolationsundertheActandinpromotingqualityofcare.


6.0ENFORCEMENT&DISCIPLINE

A. Performance Evaluation. Adherence to the elements of this CEPM will be a factor in evaluating the

performanceofallemployees,contractorsandvolunteers.

B. Consistent Enforcement. The standards established in this CEPM shall be consistently enforced throughdisciplinaryproceedingsandsanctions.Theseshallinclude,butarenotlimitedto,informalreprimands,formalreprimands,demotion,suspension,andtermination.Indeterminingtheappropriatedisciplineforanyviolationofthe CEP, Good Shepherd Home shall treat all employees equally, without taking into account a particularemployee'stitle,position,orfunctionwithinGoodShepherdHome.

C. DisciplineforComplianceViolations.Anyemployeewhoengagesinaviolationofstandardsestablishedin

theCEPM,oranyotherlawsorregulations,shallbesubjecttodisciplinaryaction,uptoandincludingterminationinaccordancewithGoodShepherdHome’sdisciplinarypolicy located in itsEmployeeManual.GoodShepherdHome shall accord no weight to a claim that any improper conduct was undertaken for the benefit of GoodShepherdHome.AnysuchconductisnotforthebenefitofGoodShepherdHomeandisexpresslyprohibited.

Whenappropriate,disciplineshallbeenforcedagainstemployeesforfailingtodetectorreportwrongdoing.Thismeansthatemployeesmustunderstandthattheyhaveanaffirmativedutytoreportwrongdoing.

D. MisconductbyAgents&Contractors.GoodShepherdHomewill investigatereportsofmisconductby itsagents,contractors,andvolunteers. Ifmisconduct is found,thenappropriateactionswillbetaken, including, ifnecessary,terminationoftheindependentcontractoragreementand/orremovalfromavolunteerposition.


7.0COMPLIANCEOVERSIGHT

7.1 BoardofDirectors

TheBoardofDirectorsisultimatelyresponsibleforsupervisingtheworkoftheComplianceOfficerandadoptingandmaintainingthestandardsinthisCEPM.TheBoardofDirectorsisresponsiblefordelegatingresponsibilityandauthorityandforreviewingtheeffectivenessoftheCEP.ThespecificoversightresponsibilitiesoftheBoardofDirectorsare:

A. OverseeingallofthecomplianceeffortsofGoodShepherdHome;

B. Consultingwithadvisorsasnecessary;

C. CoordinatingwiththeComplianceOfficertoensuretheadequacyoftheprogram;

D. ReceivingperiodicreportsfromtheComplianceOfficerconcerningtheCEP;

E. Ensuring that appropriate correctivemeasures are instituted andmaintained in response to identifiedqualityissues;

F. Maintaining,andimprovingasappropriate,theCEPandthisCEPM;

G. ReviewingtheoverallperformanceofGoodShepherdHomeinlightoftheCEPandthisCEPM;

H. EnsuringthatGoodShepherdHomemeetsapplicablestandardsofbusiness,legal,andethicalcompliance;and

I. TakingactionasappropriateandnecessarytoensurethatGoodShepherdHomeconductsitsactivitiesincompliancewithapplicablelawandregulationsandsoundbusinessethics.

TheBoardofDirectorswillexerciseduecaretoensureitdoesnotdelegatesubstantialdiscretionaryauthoritytoanyindividualwhomitknows,orshouldhaveknown,throughtheexerciseofduediligence,hasthepropensitytoengageincriminal,civilandadministrativeviolationsundertheSocialSecurityAct.

7.2 ComplianceOfficer

TheComplianceOfficershallhavetheprimaryresponsibilityofdeveloping,implementingandoverseeingGoodShepherdHome’sCEP.TheComplianceOfficershallbeappointedbytheBoardofDirectors.TheComplianceOfficershallreceiveperiodictrainingincomplianceprocedures;havedirectaccesstotheBoardofDirectors;haveaccesstonecessaryrecordsanddocumentation,includingresidentrecords,billingrecords,andmarketingagreementsandrecords;andhaveauthoritytoconductinvestigations.TheComplianceOfficerwillconsultwithsupervisorsregardingcompliance issuesandassistsupervisors inrespondingtoreportsofsuspectednoncompliance.TheComplianceOfficershallberesponsiblefortakingstepstoensurethat:

A. TheCodeofConductisdistributedtoallemployees;

B. Employees receive education and training regarding the Code of Conduct and compliance policies andproceduresapplicabletotheirjobresponsibilities;

C. ThisCEPMisrevisedasneededtoreflectchangesinStateorFederallaw,privatepayorrequirements,orchangesinGoodShepherdHome’soperations;

D. Abackground check is conducted for all prospective employees, including a criminal background checkwhenapplicable,andadeterminationmadeofwhethertheprospectiveemployeeissubjecttosanctionsunderorexclusionfromtheMedicareand/orMedicaidprograms;


E. EmployeesaregivenappropriateCEPtraining,includinginformationregardingthedutytoreportsuspectedviolationsorquestionableconductandthemechanismforsuchreporting;

F. Hotlinecalls,correspondence,andotherreportsofsuspectedviolationsorquestionableconductaretreatedconfidentially(unlessspecificcircumstancesdictatetothecontrary);

G. Anappropriateinquiryorinvestigationisinitiatedwithrespecttoanyreportofasuspectedviolationorquestionableconduct,andcorrectiveand/oremployeedisciplinaryactionistaken,whereappropriate;

H. Reports are periodically provided to the CEO and the Board of Directors regarding material mattersinvolvingsuspectedviolationsorquestionableconduct,andonanasneededbasis;

I. PeriodicreviewsofvulnerableareasareconductedandthefindingsreportedtotheCEOandtheBoardofDirectors;

J. A report at least annually regarding the operation of the CEP is provided to the CEO and the Board ofDirectors;

K. Acompliancefilingsystemismaintained,includingalogofallcomplianceissuesraised,theresolutionofsuchissues,andactiontakeninresponse,ifany;

L. Specific compliance issues are assigned to individuals outside Good Shepherd Home for review, asappropriate,suchasLegalCounsel,accountants,qualityconsultants,etc.TheComplianceOfficerhastheauthorityandresponsibilitytoauthorizesuchreviews;

M. WithLegalCounsel,appropriatereportingandrepaymentofselfdiscoveredoverpaymentsoccurswithinareasonableperiod,butnolongerthansixty(60)daysfromthedateitisidentifiedasanoverpaymentorwhenthecostreportisdue,ifapplicable,whicheverislater;

N. ActivitiesoftheComplianceCommitteearecoordinatedtoassurethatalldutiesarefullyperformed;and

O. GoodShepherdHome’svendors,suppliers,andothercontractorsareinformedinwritingaboutitsCEP.7.3 ComplianceCommittee4

GoodShepherdHomehasestablishedaComplianceCommitteetoassisttheComplianceOfficerincarryingouthisorherduties,andtoassistwiththedevelopment,implementation,andoversightoftheCEP.TheComplianceOfficer and the Compliance Committeewill receive sufficient resources and authority to reasonably assurecompliancewithGoodShepherdHome’sstandards,policiesandprocedures.TheComplianceCommitteeshallbeappointedbytheComplianceOfficer,and,ataminimum,shallconsistofrepresentativefromthefollowingdisciplines:operations,humanresourcesandfinance/reimbursement.InadditiontootherresponsibilitiesrequestedorassignedbytheComplianceOfficer,theComplianceCommitteeshall:

A. AssisttheComplianceOfficerinanalyzingriskareasthatshouldbeaddressedinGoodShepherdHome’s

CEP,includinglegalrisks,operationalissues,andqualityofcareissues;

B. AssistinassessingGoodShepherdHome’spoliciesandprocedures,includingGoodShepherdHome’sCEPMandprogram,andindevelopingnewpoliciesoramendingexistingpolicies,asappropriate;

C. AssistinimplementingGoodShepherdHome’scompliancepoliciesandprocedures;

D. WorkwithGoodShepherdHome’sComplianceOfficerand staff todevelopand implement standardsofconduct;

4Asnotedabove,theRequirementsofParticipationforSNFsdonotspecificallyrequireacompliancecommittee,andGoodShepherdHomecouldelecttoremovethiselementoftheCEP.However,theOIGComplianceProgramGuidanceforNursingFacilities identifies thecompliancecommittee (alongwith theComplianceOfficer)asoneof thesevenelementsofaneffectivecomplianceprogram,and,therefore,werecommendestablishingsuchacommittee.


E. Assist the Compliance Officer in monitoring internal controls for carrying out Good Shepherd Home’spoliciesandproceduresandimplementingcorrectiveaction;and

F. AssisttheComplianceOfficerinemployeereportingandeducation.7.4 Supervisors

Supervisorsserveasafirstlineofcommunicationregardingcomplianceissuesforemployees.Supervisorsare“deputized”bytheComplianceOfficertorespondtoreportsofsuspectactivitywithintheirareaofsupervision.Ifasupervisorneedsdirectionorhasaquestionregardinghowtorespondtoareportofsuspectactivity,thesupervisorshouldseekguidancefromthenextlevelofGoodShepherdHome’schainofcommand,inaccordancewithGoodShepherdHome’sreportingprocedures.Additionally, supervisors are required and directed to report significant compliance issues up the chain ofcommandtotheComplianceOfficer.SupervisorsshouldexercisediscretionastowhetheracomplianceissueissosignificantastowarranttheattentionoftheComplianceOfficerbutwillerronthesideofreporting.Generally,systemicissues,issuesthatinvolvequestionsofethicalbusinesspractices,provisionofcarebyanunlicensedindividual,and/orlegalorbillingviolationsshouldbereportedtotheComplianceOfficer.Supervisors shall maintain policies and procedures that ensure that functions under their supervision areimplemented in compliance with law, and that employees under their supervision perform their duties incompliance with these policies and procedures and applicable law. Supervisors' performance of theseresponsibilitiesshallbeafactorintheirevaluations.Supervisorsmustbeavailabletodiscusswitheachemployeeundertheirdirectsupervision:

A. TheprinciplesunderlyingtheCodeofConduct;

B. ThatadherencetotheCodeofConductandtheCEPisaconditionofemployment;

C. ThatGoodShepherdHomeshalltakeappropriatedisciplinaryaction,includingterminationofemployment,forviolationoftheprinciplessetforthintheCEPandapplicablelawsandregulations;

D. ThatneitherGoodShepherdHomenoranyofitsemployeeswillretaliateagainstanyindividualforreportingasuspectedviolationorquestionableconductorassistinginaninvestigation;

E. ThenecessityandimportanceofparticipatinginongoingtrainingregardingGoodShepherdHome’sCEP;and

F. Thenecessityofcompletinganyrequiredaffirmationsofcompliance,andtoensurethatthosestatementsareacknowledgedandreturnedtoappropriatepersonnel.

7.5 LegalCounsel

TheComplianceOfficerand/ortheBoardofDirectorsmayconsultLegalCounselasnecessaryonissuesraisedbyreportsofsuspectedviolationsorquestionableconduct.LegalCounselmayberesponsiblefor:

A. ProvidingadviceregardingGoodShepherdHome’scompliancewithapplicablelaws;

B. Conductingandoverseeinginvestigationsofallegationsofcomplianceviolations;

C. ReviewingGoodShepherdHome’sCEPperiodicallyandasneeded;and

D. AssistinginanyneededrevisionstotheCEP.

Good Shepherd Home Code of Conduct

Documents

Transcript of Good Shepherd Home Code of Conduct