St. Mary’s Healthcare is committed to providing the highest quality care to our patients and conducting our business with integrity and in compliance with applicable Federal and state laws and regulations. To this end, we have a Compliance Program in place that we expect all employees and all persons and entities with which we contract or who maintain staff privileges to comply.
As part of our Compliance Program, we have our Standards of Conduct that provides general guidance relating to conducting business with honesty and integrity. These Standards also provide certain compliance guidance regarding referral activities, the provision of services, and the billing of those services. The Compliance Program provides a mechanism which allows us to identify potential compliance risk areas, address questions and concerns, and implement corrective action, as necessary. We have appointed a compliance responsibility officer to oversee the day-to-day activities of the Compliance Program and to perform appropriate audits.
In addition, as a participant and the Medicaid program, we are required to comply with the terms and conditions of the Deficit Reduction Act of 2005 (the “Act”). In accordance with the Act, we are required to establish written policies for all employees and contractors and agents that provide detailed information about the Federal False Claims Act, Federal administrative remedies for false claims and statements, the New York State false claims provisions, state penalties (both civil or criminal) for false claims and statements and whistleblower protections under such laws, and the role of these laws in preventing and detecting fraud, waste, and abuse in Federal health care programs.
We appreciate your continued cooperation with our compliance Program. We also welcome you to take a moment and browse the many areas associated with our corporate compliance program such as quality initiatives, infection prevention, patient safety office, care enhancement team and Patient Bill of Rights.
If you have any questions about our Compliance Program, or if you desire additional information please feel free to call our Compliance Officer at – (518) 770-7528.
Code of Conduct
This Code of Conduct is meant for all employees, physicians, volunteers, and other representatives of St. Mary’s Healthcare, as well as vendors, suppliers, and independent contractors. The reason for the Standards of Conduct is to create and communicate our expectations in promoting an ethical environment and demonstrates St. Mary’s Healthcare’s system-wide emphasis on compliance with all policies and procedures, as well as state, federal, and administrative regulations. In a work environment safety and quality thrive when that teamwork and respect for others is the standard.
All persons associated with St. Mary’s Healthcare have an obligation to conduct themselves in ways that merit the trust and confidence of peers, as well as the general public. It is expected that these Standards of Conduct will be discussed and applied to the entire spectrum of responsibilities of all health professionals, including but not limited to, management, clinical and administrative staff, licensed independent practitioners, governing body members, employees, volunteers, and independent contractors.
St. Mary’s Healthcare Standards of Conduct
Legal Compliance: St. Mary’s Healthcare shall strive to ensure all activities are in compliance with all state, federal, local, and administrative regulations.
Confidentiality: All employees shall actively protect and safeguard confidential, sensitive, proprietary information, and protected health information in a manner designed to prevent the unauthorized disclosure of such information, in accordance with HIPAA and Hi-Tech laws.
Business Ethics: St. Mary’s Healthcare commits to the highest standards of business ethics and integrity.
Intimidating and/or Disruptive Behavior: The expectation is that all employees, physicians, volunteers, and other representatives of St. Mary’s Healthcare are held to the highest standards of conduct in all areas related to their employment. Inappropriate conduct of any kind, including but not limited to, disruptive, discourteous, disrespectful, abusive behavior, or any other behavior deemed inappropriate will be subject to disciplinary action based on the circumstances of the situation.
Response and Discipline: St. Mary’s Healthcare is committed to creating and fostering a culture in which compliant behavior is encouraged and supported. Those who violate St. Mary’s Healthcare’s standards of conduct, compliance policies and procedures, or any law, rule, or regulations under which St. Mary’s Healthcare operates will be subject to disciplinary action.
Code of Compliance: To keep in mission and values of St. Mary’s Healthcare.
St. Mary’s Healthcare and its subsidiaries and affiliated entities (collectively referred to as the “Organization”), have instituted a Compliance Program to ensure that all of our business practices are in compliance with the applicable Organization policies and procedures and applicable civil and criminal laws, rules, and regulations.
A key element of the Organization’s Compliance Program is the ability of employees to express problems, concerns, or opinions without fear of retaliation or reprisal. At the same time, employees have an affirmative duty to report issues or concerns that come to their through the appropriate channels. Failure to do so can result in disciplinary action up to and including termination.
In addition to reporting potential compliance issues, employees can participate in the Compliance Program by assisting in the investigation of compliance issues, performance of self-evaluations and audits, implementation of remedial actions and/or by reporting to appropriate officials as provided in Labor law §§ 740 and 741.
The Organization will not take disciplinary or retaliatory action against an employee who in good faith raises a compliance concern or otherwise participates in the Compliance Program. Retaliation in any form by any individual associated with the Organization is strictly prohibited and is itself a serious violation of the Standards of Conduct.
Our Compliance Program’s Standards of Conduct sets general directives for all personnel associated with the Organization to act in a lawful manner and to avoid dishonest behavior and even in the appearance of impropriety.
Corporate Compliance Hotline – 1-800-707-2198 or 518-841-7128
St. Mary’s Healthcare Corporate Compliance provides the Hotline as a service to its directors/trustees, officers, managers, employees, medical staff, contractors, volunteers, patients, and family members to confidentially report information regarding suspected misconduct, fraud and abuse, or any other legitimate concerns. Information provided to the Hotline is treated confidentially and privileged to the extent permitted by applicable law.
Discrimination is against the law!
St. Mary’s Healthcare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. St. Mary’s Healthcare does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
St. Mary’s Healthcare:
Provides free, timely aids and services to people with disabilities to communicate effectively with us, click here to view a chart of languages commonly spoken in our community, such as:
• Qualified sign language interpreters
• Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free, timely language services to people whose primary language is not English, such as:
• Qualified interpreters
• Information written in other languages
If you need these services, notify your care provider.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services 200 Independence Avenue, SW • Room 509F, HHH BLDG
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html