2832 Booklet 1/31/13 12:55 PM Page 42 Code of Conduct2600 Belmont Avenue Philadelphia, PA 19131...

2600 Belmont Avenue

Philadelphia, PA 19131

215.581.0731

www.inglis.org

Revised September 12, 2006

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Code ofConduct

The Inglis Ethics and Compliance Plan and Code of Conduct

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You may call the Inglis ComplianceLine 24 hours a day at 1.866.368.1902

Conclusion

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As a team member, your duty to Inglis is to ensure that the organization is doing

everything practical to comply with applicable laws. You are expected to satisfy

this duty by performing your responsibilities in accordance with these

laws and other professional standards and by complying with the

Three-Step Reporting Process. If you fail to perform your professional dutiesor, if you suspect a violation and do not report it, you will face disciplinary action,

up to and including termination. In some cases, you may even face legal action.

Upholding the Inglis standards is a responsibility we take very seriously.

Thank you for doing your part to help us maintain the integrity of Inglis and for

renewing your own commitment to act with integrity.

You may call the Inglis ComplianceLine 24 hours a day at 1.866.368.1902 (40

Conclusion

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Inglis’ Code of Conduct

The Compliance Process

Dear Team Members,

Inglis has hundreds of team members, including our Board, staff, contractors and vendors

with many different kinds of jobs, but we all share common values: we are caring,

professional and committed to excellence in our work, every day. This fundamental

principle is true for every team member at Inglis, from the Board and upper management

to all levels of staff.

We all have a responsibility to our clients. Even if we do not provide direct client care,

the choices we make and the actions we take affect all of our clients, their families and

the government. We want to give our best to all of our clients, all of the time. We must

hold ourselves accountable, individually and as a high-quality service provider, for the

integrity of our decisions and actions, every day.

Our Code of Conduct is an integral part of Inglis’ commitment to an ethical work

environment. It highlights our standards of proper legal, ethical and professional

behavior and describes how team members can communicate any legal, ethical or

quality concerns so they can be swiftly resolved.

Our Code of Conduct is not meant to cover every possible situation. You are expected

to use your own good judgment and abide by the standards of your profession as well.

If you have any questions about this Code of Conduct and the Inglis Corporate Ethics

and Compliance Plan, you are encouraged to talk to your supervisor.

Each of us is a vital link in ensuring the integrity of Inglis. Inglis’ commitment to

excellence is the foundation of our organization and the strength that makes it

successful. We all have a duty to fulfill our ethical, legal and professional responsibilities.

Thank you for doing your part by following Inglis’ Code of Conduct as you go about

your daily work activities.

Sincerely,

The Inglis Foundation Board of Directors and Chief Executive Officer

1

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You may call the Inglis ComplianceLine 24 hours a day at 1.866.368.1902 (

MISSION AND SCOPE

Inglis is committed to the ethical care, treatment and quality of life for our

clients. To fulfill this pledge we make every endeavor to design our services to

be responsive to resident and client needs in a changing healthcare environment.

Our Mission

Inglis enables people with disabilities – and those who care

for them – to achieve their goals and live life to the fullest.

SCOPE

The Code of Conduct is the foundation of the Ethics and Compliance Plan. The

Code applies to team members at every level of the organization. References in

the plan to “team members” mean employees, officers and directors of all

boards of related entities, independent contractors, subcontractors and vendors

who may provide or are involved with healthcare or billing. Throughout this

handbook, we have tried to use language and references that apply to each of

Inglis’ lines of business. The term “client” refers to individuals who receive the

various types of healthcare, housing, services and products Inglis provides.

Inglis Entities

Inglis House

Inglis Housing Corporation

Inglis Community Employment Services

Inglis Adult Day Services

Inglis Care Management

The Code of Conduct is supported by the policies and procedures of Inglis and itsrelated entities.

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If you observe or suspect a situation that you believe may be unethical,illegal, unprofessional or wrong, including but not limited to substandard care, altered or falsified medical records, inaccurateclaims, improper payments, or questionable accounting matters, or ifyou have any clinical, ethical or financial concern, you must report itusing the Three-Step Reporting Process. When you make a report,you are acting in accordance with the law and in an ethical manner.Remember, the law mandates that you report known or suspectedinstances of abuse.

It is your responsibility to study the Code of Conduct and

information you receive about the Ethics and Compliance Plan,

to attend required training programs and

to comply at all times with your ethical,

professional and legal responsibilities.

39You may call the Inglis ComplianceLine 24 hours a day at 1.866.368.1902

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The Ethics and Compliance Plan is critical for Inglis’ continued success. You are crucial to ensuring the integrity of Inglis and its entities. The Ethics and Compliance Plan and Code of Conduct setstandards for the legal, professional and ethical conduct of business.Some key points to remember are:

• Inglis and all of its team members are committed to personal and organizational

integrity, to act in good faith and to be accountable for our actions.

• The Ethics and Compliance Plan and Code of Conduct prepare us to deal with

the growing complexity of ethical, professional and legal requirements of

delivering healthcare, housing, services and products.

• The Ethics and Compliance Plan is an ongoing initiative designed to foster a

supportive work environment, provide standards for clinical and business

conduct and offer education and training opportunities for team members.

The success of the Ethics and Compliance Plan depends on our commitmentto act with integrity, both personally and as an organization. It is your responsibility to study the Code of Conduct and information you receiveabout the Ethics and Compliance Plan, to attend required training programs and to comply at all times with your ethical, professional andlegal responsibilities. You are required to perform your duties as directedby the regulations and standards that govern your profession.

Conclusion


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3

Introduction ..........................................................................................4

The Three-Step Process:Inglis ComplianceLine ........................................................................10

Care Excellence: Our First PriorityClients’ Rights ....................................................................................12 Abuse and Neglect ..............................................................................13Client Confidentiality ..........................................................................15 Client Property ..................................................................................15 Providing Quality Care ........................................................................16 Gifts ..................................................................................................19

Professional Excellence:Standards and Responsibility ..............................................................20 Hiring and Employment Practices ......................................................20 Team Member Screening ....................................................................21 Team Member Relations......................................................................22 Workplace Safety................................................................................22 Drug and Alcohol Abuse......................................................................23Organizational Relations......................................................................24Use of Inglis Property ........................................................................26 Computers and the Internet ................................................................26 Vendor Relationships ..........................................................................26

Regulatory Excellence:Compliance with Federal and State Laws ............................................28 Billing and Business Practices ............................................................28 Referrals and Kickbacks......................................................................32 Copyright Laws ..................................................................................33 Financial Practices and Controls ........................................................33 Competitive Practices and Antitrust Laws ..........................................34 Government Investigations ..................................................................35 Disciplinary Action ..............................................................................36Inglis Ethics and Compliance Team......................................................37

ConclusionCommitment to Ethics and Compliance ..............................................38

Table ofContents

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The Code of Conduct is the foundation of the Ethics and CompliancePlan. The Code is a guide to appropriate workplace behavior; it willhelp you make the right decisions if you’re not sure how to respondto a situation. The Code of Conduct applies to everyone at Inglis –from entry-level team members to upper management, the officersand directors, contractors and vendors.

Inglis and its team members must comply with both the spirit and the letter of

all federal, state and local laws and regulations that apply to the healthcare and

other services that Inglis provides, as well as all laws that apply to Inglis business

dealings. Violations of these laws and regulations can result in severe penalties,

for Inglis entities and individual team members including financial penalties, exclusion

from participation in government programs and in some cases imprisonment.

As Inglis team members, we share a commitment to legal, ethical and professional

conduct in everything we do. We support these commitments in our work each

day, whether we care for clients, order supplies, prepare meals, keep records,

take physician’s orders, pay invoices or make decisions about the future of our

organization. The success of Inglis as a provider of healthcare, housing, services

and products depends on us – our personal and professional integrity, ourresponsibility to act in good faith and our obligation to do the right things for

the right reasons. The Ethics and Compliance Plan provides principles, standards,

training and tools to guide you in meeting your legal, ethical and professional

responsibilities. As a team member, you are responsible for supporting the Ethics

and Compliance Plan in every aspect of your workplace behavior. Your regular

performance review includes understanding and adhering to the Ethics and

Compliance Plan as it applies to your job.

Introduction


Inglis’ Code of Conduct

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INGLIS ETHICS AND COMPLIANCE TEAM

Inglis has created a team that is responsible for the company’s compliance activities. Led by the Ethics and Compliance Officer, theteam includes managerial compliance liaisons who implement andmonitor Inglis’ ethics and compliance activities throughout eachentity.

Ethics and Compliance Officer and Staff

Inglis’ Ethics and Compliance Officer oversees the organization’s compliance

activities. He or she coordinates and communicates the design, implementation

and monitoring of the Ethics and Compliance Plan.

The Inglis Ethics and Compliance Committee

Each Inglis entity has a compliance liaison who works with management to

ensure adherence to the policies, procedures and laws that govern its business

activities. Composed of Inglis’ senior management team and compliance liaisons

from various departments and entities, this committee makes final decisions

on Inglis’ Ethics and Compliance Plan and provides increased oversight for the

company. The activities and recommendations of the Inglis Ethics and Compliance

Committee are reviewed and addressed by the Ethics and Compliance

Committee of the Board of Directors.

Compliance Questions

The laws applicable to Inglis’ operation are numerous and complicated. When a

team member is not sure whether a particular activity or practice violates the

law or the Ethics and Compliance Plan, the team member should not – under

any circumstances – “guess” as to the correct answer. Instead, the team member

must immediately seek guidance from his or her department supervisor or

report to the Ethics and Compliance Office. Inglis team members will not be

penalized for asking compliance-related questions. Indeed, Inglis is intent on

maintaining a culture in which every team member is comfortable asking the

questions necessary to ensure that he or she understands the duties imposed on

him or her by this Code of Conduct, Inglis’ Ethics and Compliance Plan and other

applicable federal and state laws.

You may call the Inglis ComplianceLine 24 hours a day at 1.866.368.1902 37

Regulatory Excellence

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DISCIPLINARY ACTION

Inglis will take disciplinary action against any team member who fails to act in

accordance with this Code of Conduct, Inglis’ Ethics and Compliance Program

and affiliated Policies and Procedures and applicable federal and state laws.

Disciplinary action will range from a verbal warning to termination of employment.

The severity of discipline will be determined by members of senior management,

including the Ethics and Compliance Officer (and the team member’s department

supervisor, as appropriate) after consideration of a number of factors, including

but not limited to:

• the nature and severity of the violation

• the effect of the violation on Inglis and its clients

• whether the violation was committed intentionally, recklessly, negligently or

accidentally

• whether the team member has committed any prior violations

• the discipline imposed for similar past violations

• whether the team member was directly involved in the violation

• whether the team member self-reported his or her misconduct

• whether (and the extent to which) the team member cooperated with Inglis

in connection with investigation of the misconduct

Where appropriate, Inglis may also take disciplinary action against department

supervisors who failed to detect or report misconduct on the part of team

members under their supervision. Inglis shall document any disciplinary action

taken for violation of this Code of Conduct, Inglis’ Ethics and Compliance Plan

and affiliated Policies and Procedures and other applicable federal and state

laws, as well as the reason for such disciplinary action.



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This handbook describes Inglis’ Code of Conduct. It supplements your Team

Member Handbook and the specific policies and procedures that apply to your

job. The Code of Conduct discusses the importance of:

• Care Excellence – providing quality, compassionate, respectful and clinically

appropriate care.

• Professional Excellence – maintaining ethical standards of healthcare and

business practices.

• Regulatory Excellence – complying with federal and state laws, regulations

and guidelines that govern the healthcare, housing, services and other products

we provide.

Every team member is required to read this handbook and sign and return the

Ethics and Compliance contract to annually confirm their understanding of the

Inglis Code of Conduct. The signed Commitment to Ethics and Compliance will

become part of your permanent employment record. Contractors and vendors

are also required to acknowledge and sign the Commitment to Ethics and

Compliance in order to provide goods and services to Inglis.

As a team member, you are responsible

for supporting the Ethics and

Compliance Plan in every aspect of

your workplace behavior.

5

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SAMPL

E

I certify that I have read and am familiar with the Inglis’ Ethics and Compliance Plan

and also understand the Code of Conduct. Furthermore, I agree to abide by the Code of

Conduct during the entire term of my employment. I acknowledge that I have a duty

to report any alleged or suspected violation of the Code of Conduct or the Ethics and

Compliance Program to the Ethics and Compliance Officer. Unless otherwise noted

below, I am not aware of any possible violation of the Code of Conduct or the Ethics

and Compliance Plan. I also certify that I have not been convicted of, or charged

with, a criminal offense related to healthcare or other services that Inglis provide nor

have I been listed by a federal or state agency as debarred, excluded or otherwise

ineligible for participation in federally funded programs.

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Further, I certify that I am not aware of any additional circumstances, other than

those disclosed above, that could represent a potential violation of the Ethics and

Compliance Program or the Code of Conduct. I will report any potential violation of

which I become aware promptly to the Ethics and Compliance Officer. I understand

that any violation of the Ethics and Compliance Program, the Code of Conduct or any

other Inglis compliance policy or procedure is grounds for disciplinary action, up to

and including discharge from employment.

Please check the appropriate box:

� I certify that this is my initial review of this Code of Conduct.

� I certify that this is my annual review of this Code of Conduct.

____________________________________________________________________Date Signature

____________________________________________________________________Position Print/Type Name


Commitment to Compliance

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GOVERNMENT INVESTIGATIONS

Inglis is committed to cooperating with all governmental inquiry, audits or

investigations. Inglis has specific policies and procedures that provide more

detailed information on how to respond in these situations.

If someone who claims to be an investigator or inspector contacts you at work,

immediately tell your supervisor or the Ethics and Compliance Office that you

need advice about a possible investigation. The Ethics and Compliance Office

can verify the investigator’s credentials, determine whether the contact is legitimate

and help you follow the proper procedures for cooperating with the investigation.

In some cases, government investigators or inspectors, or people presenting

themselves as such, may contact you outside the workplace. Again, you may

contact the Ethics and Compliance Office before speaking to them.

You have a legal right to contact an attorney before you respond to an

investigator’s questions. Contacting an attorney or the Ethics and Compliance

Office before talking with an investigator does not in any way suggest improper

conduct.

In complying fully with Inglis’ policies, you must not:

• lie or make false or misleading statements to any government investigator or

inspector

• destroy or alter any records or documents in anticipation of a request from

the government or court

• attempt to persuade another team member or any person to give false or

misleading information to a government investigator or inspector

• be uncooperative with a government investigation

If you receive a subpoena or other written request for information from the

government or a court (such as a civil investigation demand), contact the Ethics

and Compliance Office before responding.



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COMPETITIVE PRACTICES AND ANTITRUST LAWS

Antitrust laws and unfair competition laws protect Inglis and other companies

from unfair trade practices and promote fair competition. These laws are based

on the belief that individuals and businesses acting independently serve the

economic good of all. These complex laws prohibit, among other things:

• illegal or deceptive marketing activities

• price-fixing arrangements with competitors

• any activities that limit open business competition

All team members must strictly comply with the letter and spirit of all applicable

federal and state antitrust laws. All officers, team members or agents of Inglis

or any of its affiliates must comply with this standard of conduct and authorize,

direct, approve or condone such conduct by others.

Inglis team members faced with situations that appear to be questionable under

antitrust and trade regulation laws should consult with their supervisor for

guidance. Any questions about interpretations of antitrust and trade regulation

laws should be discussed with the Ethics and Compliance Office.

An Inglis team member who suspects that a violation of antitrust and trade

regulation laws has occurred should disclose that situation to the Ethics and

Compliance Officer or use the Three-Step Reporting Process.

LICENSURE AND CERTIFICATION

Inglis is committed to ensuring that only qualified professionals treat Inglis

clients. Practitioners and other professionals treating Inglis clients must abide

by all applicable licensing, credentialing and certification requirements.

VOLUNTARY DISCLOSURE

It is the policy of Inglis to voluntarily report fraudulent conduct it uncovers that

affects any federal or state healthcare or housing program.



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SAMPLE

A Shared Responsibility

Because we are in the business of caring and providing services for others, it

is critical that each of us adheres to appropriate standards of behavior.

As individuals and as a company, we are responsible to many different groups.

We must act ethically and responsibly in our relations with:

• residents, clients, tenants and their families

• colleagues and coworkers

• volunteers and nonaffiliated colleagues

• healthcare payors, including federal and state governments

• regulators, surveyors and monitoring agencies

• physicians

• vendors and suppliers

• business associates

• communities we serve

Any compromise in our standards could harm our clients, our coworkers and our

organization. Like every organization that provides healthcare, housing, services

and products, we do business under very strict regulations and close oversight.

Fraud and abuse are serious issues. Sometimes even an innocent mistake can have

significant consequences that could result in substantial penalties to Inglis and

ourselves.

You are required to complete training on the Code of Conduct and the Ethics and

Compliance Process as a condition of employment at Inglis, and you must

follow the Code to remain employed. The Code of Conduct sets forth mandatory

standards. There is no justification for departing from the Code of Conduct ,

no matter what the situation may be. Every team member is responsible forensuring that they comply with the Code and all Inglis policies and procedures. A

team member who violates any of these standards and/or policies and procedures

will be subject to discipline up to and including termination of employment.


Commitment to Compliance Introduction

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?1. Do I behave ethically in all my daily activities?

2. Would I be ashamed or uncomfortable to tell my family what I do at work?

3. Have I justified or rationalized doing something I know is wrong? Have Imade excuses for myself by saying “everybody does it” or “no one will find

out” or “I’m angry at my supervisor so I have a right to cross the line?”

A Personal Obligation

As we each are responsible for following the Code of Conduct in our daily work,

we also are responsible for enforcing it. This means that you have a duty to

report any problems you observe or perceive, regardless of your role at Inglis.

As a team member, you must help ensure that Inglis is doing everything practical

to comply with applicable laws. If you observe or suspect a situation that you

believe may be unethical, illegal, unprofessional or wrong, or if you have a clinical,

ethical or financial concern, you must report it. You are expected to satisfy thisduty by complying with the Three-Step Reporting Process (described on page10) and Pennsylvania-required reporting obligations. In fact, if you suspect a

violation and do not report it, you could face disciplinary action. This disciplinary

action could include verbal warnings, suspension or termination. In some cases,

you may even face legal action. Upholding Inglis’ standards is a shared

responsibility we take very seriously.

QUESTIONS TO ASK YOURSELF?


Introduction

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??

COPYRIGHT LAWS

Print and electronic materials are protected by copyright laws. These laws

ensure that the people who created these materials receive proper credit and

compensation for their work. Inglis team members are expected to respect these

laws. Do not reproduce electronic or print material without written permission

from the writer or publisher.

FINANCIAL PRACTICES AND CONTROLS

Inglis must ensure that its financial and operating information is current and

accurate as an important means of protecting its assets. All team members must

make sure that all information we give to Inglis’ bookkeepers, accountants,

reimbursement staff, internal and external auditors and compliance staff is

accurate and complete. We must also comply with federal and state regulations

when maintaining accounting records and financial statements and cooperate

fully with internal and external audits.

QUESTIONS TO ASK YOURSELF

1. Have I declined any gifts or presents offered to me by a vendor or supplier?

2. Have I made all decisions about physician referrals based on the best interests of my clients?

3. Have I looked after the interests of our clients, including our largest client,the federal government?



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?? QUESTIONS TO ASK YOURSELF

1. Have I provided complete, honest and accurate documentation of the workI do?

2. Have I followed all company policies and government regulations in my dailyactivities?

3. Have I asked for help from a supervisor if there is a discrepancy I don’tunderstand?

REFERRALS AND KICKBACKS

Inglis team members, facilities and related entities often have close associations

with local healthcare providers and other referral sources. To demonstrate ethical

business practices, we must make sure that all relationships with these

professionals are open, honest and legal.

Inglis accepts client referrals based solely on clinical needs and our ability to

provide the services required by the client. Inglis makes referrals based solely on

clinical needs and the recipient’s ability to provide the identified services. We

never solicit, accept, offer or give kickbacks of any kind.

A kickback is an item or service of value including cash, goods, supplies, gifts,

“freebies” or bribes that is received in exchange for a business decision, such as

a client referral. Accepting kickbacks is not only against Inglis’ policies and

procedures but also against the law. To assure adherence to ethical standards

in our business relationships, team members must:

• verify all business arrangements with physicians or other healthcare vendors

in a written document that has been approved by Inglis’ legal counsel.

• comply with all state and federal regulations when arranging referrals to

physician-owned businesses or other healthcare providers.

Team members cannot request, accept, offer or give any item or service that is

intended to influence – or even appears to influence – a healthcare service paid

for by any private or commercial healthcare payor, or federal or state healthcare

program, including Medicare and Medicaid, or other providers.



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Waivers

Any request for a waiver of any provision of this Code of Conduct by any team

member, other than Executive Officers, must be in writing and addressed to the

Ethics and Compliance Officer, who has the sole and absolute discretionary

authority to approve any such waiver. Any request for a waiver of any provision

of this Code of Conduct by an executive officer or a senior financial officer

(including Inglis’ chief financial officer, controller, or persons serving in similar

functions) must be in writing and addressed to the Ethics and Compliance Officer

and the Inglis Foundation Board of Directors, which has the sole and absolute

discretionary authority to approve any such waiver.


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INGLIS COMPLIANCELINE

Inglis has a specific communication process for reporting complianceissues. Use the Three-Step Reporting Process whenever you have aquestion or concern. You should seek answers until your questionsare resolved. Remember, as an Inglis team member, you must promptlyreport actual or potential wrongdoing you observe or suspect. Yourreports may involve possible violations of law, regulations, policiesand procedures or the Code of Conduct.

The Three-Step Reporting Process

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

2. If you are not comfortable talking with your supervisor or are not satisfiedwith the response you receive, talk to another member of the management

team or someone from Human Resources.

3. If you still have a concern, contact a member of the Inglis compliance teamor the Ethics and Compliance Department directly. If none of the above

steps resolves your questions or concerns, or if you prefer, call the toll-freeINGLIS ComplianceLine at (866) 368-1902 for assistance. All calls areconfidential and you may call anonymously if you choose. Concerns can also

be registered directly via the ComplianceLine access located on the Inglisintranet.

The INGLIS ComplianceLine is staffed by a company that specializes in providing reporting services. You may call this line anonymously anytime, 24

hours a day, 7 days a week. Every call is investigated by a Human Resources,

Ethics and Compliance, or assigned professional with expertise in the reported

issue. You must provide enough information to start the investigation process.


The Three-Step Process

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Charitable Contributions

Inglis may contribute to charitable organizations provided that Inglis’ contribution

is not, and cannot be seen as, an attempt to induce referrals. Except for Inglis-

sponsored events, team members may not solicit each other for charitable

contributions. All solicitations for Inglis-sponsored events should occur away

from resident/client care areas.

DOCUMENT CREATION, USE AND MAINTENANCE

Every team member is responsible for the integrity and accuracy of Inglis’

documents, records and e-mails including, but not limited to, client medical

records, billing records and financial records. No information in any record or

document may ever be falsified or altered.

Financial Records

In the performance of their duties, team members may have access to, receive

or be entrusted with confidential and/or proprietary information, that is owned

by Inglis (or its affiliates, agents, or consultants), and that is not presently

available to the public.

Examples of confidential business information include earnings estimates,

expansions or curtailment of operations, an increase or decline in business, a

merger or acquisition proposal or agreement, borrowings, potential or threatened

litigation, litigation strategy, unusual management developments, purchases or

sales of substantial assets, business plans, development plans, marketing strategies,

organizational plans, financial management, training materials, fee schedules,

departmental performance metrics and administrative policies.

Team members must not disclose internally or externally, either directly or

indirectly, confidential information except on a need-to-know basis and in the

performance of their duties on behalf of Inglis. Team members must never

disclose confidential information externally unless expressly directed to do so by

legal counsel. Upon termination of employment with Inglis, a team member

must promptly return all confidential information to Inglis.

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Research

All research activities performed within Inglis are to be coordinated or approved

by the appropriate individuals. All research activities shall follow appropriate

rules and regulations.

Fair Dealing

All Inglis team members must deal fairly with Inglis’ clients, suppliers, competitors

and team members. No team member, senior manager or director shall take

unfair advantage of anyone through manipulation, concealment, abuse of

privileged information, misrepresentation of material facts, or any other unfair

dealing practice.

Protection and Proper Use of Inglis Assets

All Inglis team members must protect the assets of Inglis and ensure their

authorized and efficient use. Theft, carelessness and waste have a direct impact

on Inglis’ viability. All of Inglis’ assets must be used solely for legitimate business

purposes.

Political Contributions

Inglis must comply with all federal, state, and local laws governing political

activities. In particular, federal law prohibits a corporation from making

contributions or expenditures in connection with a federal election. This prohibition

is broadly construed to include in-kind contributions, such as the use of corporate

centers or any other donation of goods and services for which fair market value

compensation is not obtained. Team members must not engage in individual

election-related activities in the workplace.

A contribution of Inglis funds to state or local campaigns may only be authorized

by the chairman of the appropriate Inglis Board, or the chief executive officer,

and only if such contribution complies with all applicable laws.

From time to time, Inglis may invite team members and clients to make personal

contact with government officials or to write letters voluntarily expressing their

concerns or their position on a particular issue. In addition, some team members

regularly have contact with government officials. In these situations, team members

must comply with all applicable laws and regulations. If a team member has any

questions about contacting a government official, he or she should contact the

Ethics and Compliance Officer.



2832 Booklet 1/31/13 12:55 PM Page 30

During this investigation, your name (if you provide it) will be kept confidential

as much as possible; until or unless it may become necessary to reveal your identity

to resolve the issue fully.

You can make a report in good faith to the INGLIS ComplianceLine without fearof reprisal, retaliation or punishment for your actions. Anyone, including a

supervisor, who retaliates against a team member for contacting the INGLISComplianceLine or reporting compliance issues in another manner will be disciplined, subject to possible termination.

A team member should never think that an actual or suspected compliance

violation is not his or her problem, even if that team member has not participated

in the action. Each and every team member is required to report all actual or

suspected violations of law or Inglis policy so that Inglis can investigate and take

the necessary corrective action.

When should I call the INGLIS ComplianceLine?

You should call the INGLIS ComplianceLine any time you are aware of an illegal,irresponsible or ethically questionable situation and feel that you cannot go to your

supervisor or a human resources representative with the issue. Remember that

it is part of your responsibility as an Inglis team member to report suspected

wrongdoing when you have knowledge.

INGLIS ComplianceLine

(866) 368-1902

INGLIS COMPLIANCE OFFICE

(215) 581-0731

You can make a report in good faith to the

INGLIS ComplianceLine without fear

of reprisal, retaliation or punishment for

your actions.


The Three-Step Process

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CLIENTS’ RIGHTS

At Inglis, our healthcare providers’ most important job is providing quality care

to our clients. This means offering compassionate support to our clients and

working toward the best possible outcomes while following all applicable rules

and regulations. Clients receiving healthcare and other services have clearly

defined rights. To honor these rights, we must:

• make no distinction in the admission, transfer or discharge of a client, or in

the care Inglis provides, on the basis of race, gender, age, religion, national

origin, disability, color, marital status, veteran status, medical condition,

other protected-class status, insurance or financial status.

• treat all clients in a manner that preserves their dignity, autonomy,

self-esteem and civil rights.

• protect every client from physical, emotional, verbal or sexual abuse or neglect.

• protect all aspects of client privacy and confidentiality.

• respect clients’ personal property and money and protect it from loss, theft,

improper use and damage.

• respect the right of clients and their legal representatives to be informed of

and participate in decisions about their care and treatment.

• respect the right of clients and/or their legal representatives to access their

medical records as requested.

• recognize that clients have the right to consent to or refuse care and the right

to be informed of the medical consequences of such refusal.

• protect the client’s right to be free from physical and chemical restraints.

• respect the client’s right to self-determination and autonomy.

Care Excellence: Our First Priority

2832 Booklet 1/31/13 12:55 PM Page 12

Prohibited practices include but are not limited to:

• billing for services or items that were not provided or costs that were not

incurred.

• duplicate billing – that is, billing for the same item or service more than

once.

• billing for items or services that are not medically necessary.

• assigning an inaccurate code or client status to increase reimbursement.

• providing false or misleading information about a client’s condition or

eligibility.

• failing to identify and refund credit balances.

• submitting bills without supporting documentation.

• soliciting, offering, receiving, or paying a kickback, bribe, rebate or any other

remuneration in exchange for referrals.

• unlawfully inducing business associates.

If you observe or suspect that false claims are being submitted or have

knowledge of a prohibited practice, you must immediately report the situation

to a supervisor, the Ethics and Compliance Officer or the ComplianceLine.

Corporate Opportunities

All Inglis team members are prohibited from (a) taking for themselves personally

opportunities that are discovered through the use of Inglis property, information

or position; (b) using Inglis property, information or position for personal gain;

and (c) competing with Inglis. Team members, senior managers and directors

owe a duty to Inglis to advance its legitimate interests when the opportunity to

do so arises.

A billing clerk calls a therapist to confirm a

treatment procedure that was entered twice

on a billing document …A marketing director

declines concert tickets.



2832 Booklet 1/31/13 12:55 PM Page 29

COMPLIANCE WITH FEDERAL AND STATE LAWS

Because we are in healthcare, housing, services and products and other regulated

businesses, we must follow the many federal, state and local laws that govern

those industries. Keeping up with the most current rules and regulations is a big

job – and an important one. Inglis team members are responsible for learning

and staying current with the federal, state and local laws, rules and regulations,

as well as the policies and procedures that apply to their jobs. Managers must

review regulations with team members to make sure they understand and comply

with them.

BILLING AND BUSINESS PRACTICES

Inglis is committed to operating with honesty and integrity. Therefore, Inglis

team members must ensure that all statements, submissions and other

communications with clients, prospective clients, the government, suppliers and

other third parties are truthful, accurate and complete.

Inglis is committed to ethical, honest billing practices, and we expect every team

member to be vigilant in maintaining these standards at all times. Inglis will not

tolerate any deliberately false or inaccurate billing. Any team member who

knowingly submits a false claim, or provides information that may contribute to

submitting a false claim such as falsified clinical documentation, to any payor –

public or private – is subject to termination. In addition, legal or criminal action

may be taken.



2832 Booklet 1/31/13 12:55 PM Page 28

ABUSE AND NEGLECT

Inglis will not tolerate any type of client abuse or neglect – physical,emotional, verbal or sexual. Clients must be protected not only fromteam members, but also from other clients, volunteers, agency staff,family members, legal guardians, friends or any other person. Thisstandard applies to all clients at all times. The state of Pennsylvaniadefines abuse as the following:

Abuse – The infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain or mental anguish, or deprivation

by an individual, including a caretaker, of goods or services that are necessary

to attain or maintain physical, mental and psychosocial well-being. This presumes

that instances of abuse of all clients, even those in a coma, cause physical harm,

or pain or mental anguish. The term includes the following:

Verbal abuse – Any use of oral, written or gestured language that willfullyincludes disparaging and derogatory terms to clients or their families, or within

their hearing distance, regardless of their age, ability to comprehend or disability.

Examples of verbal abuse include:

• Threats of harm

• Saying things to frighten a client, such as telling a client that the client will

never be able to see his family again


A nurse pulls the privacy curtain before starting a procedure…A

CNA goes to the nurses’ station to give an update on a client’s

condition so visitors do not overhear her…

A nurse thoroughly explains a change in

treatment to a client and his family…


2832 Booklet 1/31/13 12:55 PM Page 13

Sexual abuse – Includes sexual harassment, sexual coercion or sexual assault.

Physical abuse – Includes hitting, slapping, pinching and kicking. The term alsoincludes controlling behavior through corporal punishment.

Mental abuse – Includes humiliation, harassment, threats of punishment ordeprivation.

Involuntary seclusion – Separation of a client from other clients or from hisor her room or confinement to his or her room (with/without roommates)

against the client’s will, or the will of the client’s legal representative. Emergency

or short term monitored separation from other clients will not be considered

involuntary seclusion and may be permitted if used for a limited period of time

as a therapeutic intervention to reduce agitation until professional staff can develop

a plan of care to meet the client’s needs.

Neglect—The deprivation by a caretaker of goods or services which are

necessary to maintain physical or mental health.

Any team member who abuses or neglects a client is subject to termination. In

addition, legal or criminal action may be taken. Abuse and neglect must be reported

immediately to your supervisor or other member of management under the

mandatory reporting requirements in the state of Pennsylvania. DO NOT call the

ComplianceLine for issues of abuse and neglect. REPORT THEM IMMEDIATELY.



2832 Booklet 1/31/13 12:55 PM Page 14

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• maintain Inglis’ standards for the products and services they provide to

Inglis and our clients.

• comply with all of Inglis’ policies and procedures as well as the laws and

regulations that apply to their business or profession.

• maintain all applicable licenses and certifications and have current

documentation of that information available.

• require that their team members comply with Inglis’ Code of Conduct and the

Ethics and Compliance Plan and training, as appropriate.

MARKETING AND ADVERTISING

Inglis uses marketing and advertising activities to educate the public, increase

awareness of our services and recruit new team members. These

materials and announcements, whether verbal, printed or electronic will present

only truthful, informative, non-deceptive information.


1. Have I ever “borrowed” an Inglis vehicle for personal use?

2. Have I copied company-purchased software for my home computer?

3. Am I using the Internet at work primarily for business purposes only?

4. Have I been honest and accurate when describing the services Inglis provides?

5. Does my holiday job at a department store interfere with my scheduled workhours at Inglis?

6. Are any of my family members involved in business activities that couldaffect my duties as a team member?

7. Have I ever shared information – about an Inglis client, a team member, anew program, a change in Inglis management or another event – with people

outside Inglis who could use the information for their own benefit?


?

Professional Excellence

2832 Booklet 1/31/13 12:55 PM Page 27

USE OF INGLIS PROPERTY

Inglis property – everything from office supplies and computers to company

vehicles – represents a significant expense and should only be used for legitimate

business purposes. We all must make sure that we:

• use Inglis property only for company business, not personal use.

• exercise good judgment and care when using Inglis supplies, equipment and

other property.

• respect copyright and intellectual property laws; never copy or download

software.

COMPUTERS AND THE INTERNET

Team members are expected to use Inglis computers, e-mail and Internet

systems appropriately. Computer, Internet and e-mail usage is defined by Inglis

policy and procedure. A team member who violates the computer, Internet and

e-mail usage policy shall be subject to discipline, up to and including termination.

Employees are not permitted to use the Internet for improper or unlawful activity

– including visiting pornographic, gambling or other inappropriate sites – or to

download or play games on Inglis computers. Internet use can be tracked, and

Inglis can and will monitor how team members use their time on the Internet.

Abuse of Internet access is grounds for discipline up to and including termination.

VENDOR RELATIONSHIPS

We take responsibility for being a good client and dealing with vendors honestly

and ethically. Inglis is committed to fair competition among prospective vendors

and contractors for our business. Arrangements between Inglis and its vendors

must always be approved by management. Certain business arrangements such

as Business Associate Agreements must be detailed in writing and approved by

management and the Ethics and Compliance Office. Inglis encourages vendors to

adopt their own comparable ethical standards in their businesses. In addition,

contractors or vendors who provide client care, reimbursement or other services

to beneficiaries of federal and or state healthcare programs are subject to

Inglis’ Ethics and Compliance Plan and must:



2832 Booklet 1/31/13 12:55 PM Page 26

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CLIENT CONFIDENTIALITY

Every team member must treat all client information, including any documents

or records that contain client-identifying information (such as the names of

clients, their social security numbers, home addresses, telephone numbers, medical

histories, treatment histories, financial information and insurance information),

medical records and charts, as confidential. Team members must use and

disclose medical, financial or personal information only in a manner consistent

with Inglis’ privacy policies and procedures and state and federal law.

Confidentiality is more than a courtesy – it is the law.

CLIENT PROPERTY

Team members must respect clients’ personal property and protect it from loss,

theft, damage or misuse. Team members who have access to property or funds

must maintain accurate records and accounts.


1. Do I behave ethically in all my daily activities?

2. Do I give clients the privacy I would want for myself?

3. Do I make every effort to protect the confidentiality of our clients’ healthand financial information?

4. Have I ever seen anyone injure or insult a client? Did I report it?

5. Do I make sure that I am not overheard when I discuss a client?

6. Am I careful to keep my personal feelings or situation from interfering withclient care?

7. Do I talk to clients with respect? Do I talk about clients with respect?

8. Have I made sure that all clients’ property is kept secure?

9. Do I treat my clients the way I would want my own family treated?



2832 Booklet 1/31/13 12:55 PM Page 15


PROVIDING QUALITY CARE

As an organization our primary commitment is to provide the care, services and

products necessary to help each client reach or maintain his or her highest

possible level of physical, mental and psychosocial well-being. Each Inglis entity

has policies and procedures to achieve this goal. You will learn about the specific

policies and procedures for your job as part of your employment orientation

and training.

To meet the Inglis quality of care standards, we:

• Accurately assess the individual needs of each client and develop

interdisciplinary plans that meet those assessed needs.

• Constantly review goals and plans of care to ensure that our clients’ ongoing

needs are being met.

• Provide only medically necessary, physician prescribed services and products

that meet the client’s clinical needs.

• Confirm that services and products (including medications) are within

accepted standards of practice for the client’s medical condition.

• Ensure that services and products are reasonable in terms of frequency,

amount and duration.

• Measure clinical outcomes and client satisfaction to confirm that quality

care goals are met.

• Provide accurate and timely clinical and financial documentation and

record-keeping.

• Ensure that client care is given only by properly licensed and credentialed

providers with the appropriate background, experience and expertise.

• Periodically review client care policies and procedures and clinical protocols

to ensure that they meet current standards of practice.

16


2832 Booklet 1/31/13 12:55 PM Page 16

Conflict of Interest

A conflict of interest exists any time your loyalty to the company is, or even

appears to be, compromised by a personal interest. There are many types of conflict of interest and these guidelines cannot anticipate them all; however, here are some examples:

• financial involvement with competitors, vendors or others that would cause

you to put their financial interests ahead of Inglis: for example, a partnership

in a local bakery that provides bread to an Inglis facility.

• an immediate family member who works for an Inglis vendor, contractor,

client or competitor, and who is in a position to influence your decisions

affecting business at Inglis: for example, a brother who owns a laundry service

that wants to do business with Inglis.

• participating in transactions that put your personal interests ahead of Inglis’

or cause loss or embarrassment to Inglis: for instance, allowing a family

member to use a company van.

• taking a job outside the company that overlaps with your normal working

hours at Inglis or interferes with your job performance: for example, making

telephone calls on behalf of another employer while on the job at Inglis.

• working for Inglis and also for a vendor that provides goods or services to

Inglis at the same time: for example, having a job as an Inglis bookkeeper

while also working for a temporary staffing agency as a bookkeeper for

Inglis.

All team members must ensure that they remain free from actual or perceived conflicts of interest.



2832 Booklet 1/31/13 12:55 PM Page 25

Organizational Relations

Professional excellence in organizational relations includes:

• maintaining company privacy and keeping Inglis’ proprietary information

confidential.

• avoiding outside activities or interests that conflict with responsibilities to

Inglis and reporting such activity or interest prior to and during employment.

• allowing only designated management staff to represent the company to the

public or media.

• obtaining written approval from a corporate officer before making a charitable

contribution to another organization in Inglis’ name.

• requiring that all Inglis entities comply with the licensing and certification

laws that apply to their businesses.

Proprietary Information

In the performance of their duties, team members may have access to, receive

or be entrusted with confidential and/or proprietary information, that is owned

by Inglis (or its affiliates, agents, or consultants), and that is not presently available

to the public. This type of information should never be shared with anyone outside

the company without authorization.

Examples of proprietary information that should never be shared include:

• client and team member data and information

• details about clinical programs, procedures and protocols

• policies, procedures and forms

• training materials

• current or future charges or fees or other competitive terms and conditions

• current or possible negotiations or bids with payors or other clients

• compensation and benefits information for staff

• costs or any kind of financial information

• market information, marketing plans or strategic plans

• technical information, research and development strategies and clinical

research data

• any other information that would not be given to a competitor



2832 Booklet 1/31/13 12:55 PM Page 24

Medical Director/Physician Services

Inglis is committed to providing comprehensive, medically necessary services for

its clients. The medical director provides oversight to physicians and other

medical services as defined by state and federal regulations. Inglis compensates

the medical director at a fair market value for the services he/she renders. The

medical director oversees care and treatment policies and is actively involved in

the quality improvement committee.



2832 Booklet 1/31/13 12:55 PM Page 17

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1. Did I provide all the care and treatments required by my client’s plan of care?

2. Have I documented my client’s care and treatments accurately and completelyand in a timely manner?

3. Have I recommended only treatments that are necessary for the client’smedical condition?

4. Have I communicated care and treatment to the client in a manner thathe/she is able to understand and enabled him or her to make an informed

decision?

5. Do I make sure my license or certification is up-to-date and that I am staying up-to-date with any requirements for training and education?

6. Do I ask the physician for clarification if I do not understand an order?

7. Do I respond promptly to clients’ requests for care?

18


2832 Booklet 1/31/13 12:55 PM Page 18

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DRUG AND ALCOHOL ABUSE

Inglis is committed to maintaining a workforce dedicated to and capable of

providing quality client services and performing other applicable duties. To that

end, Inglis prohibits team members from consuming any substance that impairs

their ability to provide quality services or otherwise perform their employment

duties.

Team members may never use, sell or bring on company property alcohol,

illegal drugs and/or narcotics or report to work under the influence of alcohol,

illegal drugs and/or narcotics. For team members who appear to have work

performance problems related to drug or alcohol use, Inglis will conduct drug

and alcohol screening and take appropriate action if necessary. At the discretion

of the responsible senior manager, moderate consumption of alcoholic beverages

may be permitted at company-sponsored meetings or events.

Inglis prohibits illegal, improper or unauthorized use of any controlled substance

that is intended for a client. If a team member becomes aware of any improper

diversion of drugs or medical supplies, the team member must immediately

report the incident to his or her department supervisor, or the Ethics and

Compliance Officer.


1. Do I treat all team members with equal respect and courtesy?

2. Am I uncomfortable with a coworker because he or she makes inappropriateremarks or tells off-color jokes? Could any of my coworkers be uncomfortable

with me for the same reason?

3. Have I worked with anyone who seems to be under the influence of alcoholor drugs? Have I reported it?



2832 Booklet 1/31/13 12:55 PM Page 23

TEAM MEMBER RELATIONS

To maintain an ethical, comfortable work environment, all Inglisteam members must:

• refrain from any form of sexual harassment or violence in the workplace.

• treat all colleagues and coworkers with equal respect, regardless of their

national origin, race, color, religion, sexual orientation, age, gender, gender

identity or disability.

• protect the privacy of other team members by keeping personnel information

confidential and allowing only authorized individuals access to the information.

• not supervise or be supervised by an individual with whom they have a close

personal relationship.

Workplace Violence

Every Inglis team member has the right to work in a safe environment. Violence,

abuse or aggressive behavior will not be tolerated at Inglis. Therefore, team

members must not engage in violent acts, threaten to engage in violent acts, or

bring a weapon to the workplace (this includes parking lots).

Inglis’ policy against workplace violence will be enforced for all team members,

whether on Inglis property, while performing any job-related duties for Inglis, or

at any Inglis-sponsored event, on or off Inglis premises.

WORKPLACE SAFETY

Maintaining a safe workplace is critical to the well-being of our clients, visitors

and coworkers. That is why Inglis has developed policies and procedures that

describe the company’s safety requirements. Every Inglis team member should

become familiar with safety regulations and emergency plans regarding fire and

disaster in their work area.

In addition to company policies, we must abide by all environmental laws and

regulations. You are expected to follow company safety guidelines and to take

personal responsibility for helping to maintain a secure work environment. If you

notice a safety hazard, you must take action to correct it if you can, or report

it to your supervisor immediately.



2832 Booklet 1/31/13 12:55 PM Page 22


Care Excellence: Our First PriorityGIFTS

Legal and Inglis restrictions focus on gifts or entertainment that are intended

to, or that give the appearance of attempting to, compromise the objectivity

of healthcare, housing, services and products decisions (e.g., weekend trips,

elaborate dinners, or similar benefits). More modest expressions of goodwill,

which are consistent with industry and local business practices, are acceptable

(e.g., holiday gift baskets, modest lunches or dinners where business is discussed).

Where modest gifts or entertainment are appropriate, good judgment should be

followed. All gifts and entertainment should fall within the bounds of moderation

and common business courtesy and have a valid business purpose (e.g., a

business lunch).

A pattern of giving or receiving gifts is prohibited if the frequency or total value

of the gifts exceeds reasonable limits. As a guideline, gifts should not exceed $50

per person, per event. If a client wants to give a gift, the client must be advised

that the gift should either be one that can be shared by all team members or be

a gift made to an Inglis charitable fund.

2832 Booklet 1/31/13 12:55 PM Page 19

STANDARDS AND RESPONSIBILITY

The clinical assessment for the client is completed accurately andpromptly…A billing clerk rechecks questionable codes and charges tomake sure they are accurate on a claim form… A certificate of medicalnecessity is obtained before an ambulance is ordered…A physical therapist accurately charts treatment procedures and associatedtreatment time…

The professional, responsible and ethical behavior of every Inglis team member

reflects on the reputation of our organization and the services we provide.

Whether you work directly with clients or in other areas that support client services,

you are expected to maintain our standards of honesty, integrity and professional

excellence, every day.

HIRING AND EMPLOYMENT PRACTICES

As an organization, Inglis is committed to fair employment practices. When

hiring and evaluating team members, Inglis:

• complies with federal, state and local Equal Employment Opportunity laws,

hiring the best-qualified individuals regardless of race, color, age, religion,

national origin, gender, gender identity, sexual orientation or disability. All

promotions, transfers, evaluations, compensation and disciplinary actions

also follow this policy.

• conducts employment screenings to protect the integrity of our workforce

and the welfare of our clients and team members.

• requires all team members who need licenses or certifications to maintain

their credentials in compliance with state and federal laws; documentation

of current licenses or certifications must be provided.



2832 Booklet 1/31/13 12:55 PM Page 20

TEAM MEMBER SCREENING

Inglis is prohibited by federal law from employing or retaining or contracting

with anyone who is excluded from any federal or state funded programs. Inglis

has implemented screening procedures conducted prior to hire and a minimum

of annually thereafter, to identify such individuals. These standards also apply to

temporary healthcare workers. Inglis policies and procedures are intended to

ensure that Inglis does not contract with, employ or bill for services ordered,

rendered or supervised by anyone:

• confirmed with a positive drug test

• convicted of a violent crime, including assault, abuse or rape

• convicted of a criminal offense related to healthcare, including fraud, neglect

or abuse of clients

• convicted of a felony in the preceding seven years

• convicted of an offense considered exclusionary by state statute, regulation

or standard

• excluded from or ineligible to participate in federal healthcare programs

• disbarred or excluded by a duly authorized licensing agency

• listed on the Federal Terrorist List maintained by the Department of Treasury,

Office of Foreign Asset Control

As long as they are employed at Inglis, team members must immediately report

to their supervisors if they are convicted of an offense that would preclude

employment in a healthcare facility; if action has been taken against their

license; or if they are excluded from participation in any federal healthcare

program. Any Inglis team member who is alleged to have committed a serious

criminal act will be suspended or, if convicted of a felony, will be terminated.

Whether you work directly with clients or in

other areas that support client care, you are

expected to maintain our standards of honesty,

integrity and professional excellence, every day.



2832 Booklet 1/31/13 12:55 PM Page 21

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