BENEWAH COMMUNITY HOSPITAL

CODE OF CONDUCT

“We treat you like family!”

Dear Benewah Community Hospital Team Member,

First and foremost, we would like to thank you for choosing Benewah Community Hospital as a
place to share your passion and talents. Each member of our team, including yourself, are essential
to achieve our mission “To Provide Excellence in Healthcare and Wellness Services,” through
teamwork that is based on integrity, ethical behavior, respect, and professionalism.

Our Code of Conduct supports Benewah Community Hospital’s commitment to maintain a culture
of integrity. The fundamental building blocks of the culture of integrity are honesty, trustworthiness,
ethical behavior, and professionalism, which ensures we provide exceptional care and services to our
community.

Honesty – truthful, openness, and consistent

Trustworthiness – authentic, consistent, integrity, and compassionate
Ethical – truthful, fair, and honest
Professionalism – appearance, competence, reliability, and ethical

The Code of Conduct provides team members with best practices to use when making decisions in
our daily interactions with patients, vendors, providers, and each other.

As a team, we will take excellent care of our patients and community, achieving our motto: “We
Treat You Like Family!”

Sincerely,

Charles D. Lloyd, Jr., MBA/HCM, LNHA, LRCA, NCPT

Chief Executive Officer
Table of Contents
1 INTRODUCTION ................................................................................................................................................ 4
2 WHO WE ARE ..................................................................................................................................................... 4
3 PROVIDE QUALITY CARE AND SERVICES.................................................................................................. 5
4 CONFIDENTIALITY........................................................................................................................................... 6
5 EMERGENCY MEDICAL TREATMENT AND LABOR ACT ........................................................................ 7
6 DISCRIMINATION AND HARASSMENT FREE WORKPLACE ................................................................... 7
7 ACCURATE AND HONEST BILLING .............................................................................................................. 8
8 DOCUMENTATION ........................................................................................................................................... 9
9 RECORD RETENTION AND DESTRUCTION ................................................................................................. 9
10 PROTECTION OF ASSETS AND RESOURCES ............................................................................................... 9
11 KICKBACKS, REFERRALS, AND BRIBES ................................................................................................... 10
12 FUNDRAISING, GIFTS, GRATUITIES, AND BUSINESS COURTESIES .................................................... 10
13 MARKETING .................................................................................................................................................... 11
14 CONFLICT OF INTEREST ............................................................................................................................... 11
15 ENVIRONMENTAL HEALTH AND SAFETY ............................................................................................... 11
16 GOVERNMENT INVESTIGATIONS, ACCREDITATIONS, AND SURVEYS ............................................. 12
17 RESPONSIBILITY FOR REPORTING............................................................................................................. 12
18 NON-RETALIATION ........................................................................................................................................ 12
19 ENFORCEMENT OF THE CODE OF CONDUCT .......................................................................................... 13

Dept.: Compliance Page 3 of 14 Ver. #: 4 | Date Approved: 08/31/2020

 1 INTRODUCTION
Why Have a Code of Conduct? To promote conduct that is honest, ethical, and legal.
Benewah Community Hospital (BCH) is committed to promote honest, ethical, compliant and legal
behavior within our hospital. We encourage prevention, detection and resolution of conduct that does
not conform to our standards or Federal, State, and Local laws and requirements. Thus BCH has
developed a Compliance Program based on guidance provided by the Department of Health and Human
Services’ Office of the Inspector General.
One of the primary goals of the Compliance Program is to prevent and detect fraud, waste, and abuse.
The False Claims Act assists the federal and state governments in combating fraud and abuse and
recovering losses resulting from fraud in government programs, purchases and/or contracts. Healthcare
decision-making must be based on the patient’s medical needs, and not based on financial benefits to
the Hospital, personnel, or that of any other entity or individual.
The adoption and implementation of the Code of Conduct will significantly advance the prevention of
fraud, waste, and abuse while at the same time providing the highest level of compassionate, quality
healthcare to our patients.
In some instances, the Code of Conduct completely deals with the subject covered. However, in other
instances, the subject discussed is so complex that additional guidance is necessary. To provide this
additional guidance, we have developed policies and procedures.
Our Board of Trustees, Chief Executive Officer, providers, employees, volunteers, students, vendors, and
any other agents associated with BCH (collectively referred to as “personnel”) must review and attest to
adherence to the Code of Conduct to ensure that all actions are consistent with our values and
principles. The Code of Conduct should be considered a tool which should be used in all our daily
activities.
All personnel should strive to protect and promote patients’ rights, quality of care, hospital-wide
integrity, and ethical business practices.

If, at any time, you have questions, comments or suggestions regarding the Code of Conduct, or
your responsibilities under the Code of Conduct, please call the Compliance Officer at (208)245-
7676 or Human Resources at (208) 245-7662.

2 WHO WE ARE
Benewah Community Hospital is a county-owned, critical access hospital with a rural health clinic and
specialty clinic located in St. Maries, Idaho. For more than 50 years, we have been providing high quality
healthcare to individuals, families, and visitors in Benewah, Shoshone, and Kootenai counties. We offer
our patients a full range of diagnostic and therapeutic services providing high quality care in a rural
setting. Our personnel are dedicated to providing our patients with excellent care in a courteous,
respectful, and enthusiastic manner.
MISSION
To provide excellence in healthcare and wellness services.

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 VISION
 To continuously improve the overall health of our community through the provision of high
quality, affordable healthcare services.
 To serve as a leader in a collaborative effort with the community providing health education,
support services, and care for all citizens.
 To foster a culture of patient engagement by encouraging active patient participation in their
own plans of care as well as seeking patient input on future plans for this organization.
VALUES
Benewah Community Hospital:
 Recognizes that our patients, families, and community partners come first.
 Provides the highest quality patient-focused care along the continuum of life.
 Serves as a model rural health organization, incorporating the highest standards of care.
 Treats our patients, families, and community partners with dignity, respect, confidentiality, and
integrity.
 Maintains an environment that is safe, consistent, compassionate, and unbiased.
 Supports the emotional, physical, and spiritual needs of those we serve.
 Highly values the skills and contributions of our workforce, within a shared governance model.

3 PROVIDE QUALITY CARE AND SERVICES

Our primary purpose for existing is to provide comprehensive, quality healthcare appropriate to the
needs of our community, in a caring, empathetic manner. We recognize the importance of preventative
healthcare and focus on the promotion of a healthy lifestyle for the individual as well as the community.
All patients will be:
 Treated with respect and professionalism and in a manner, which preserves their dignity and
self-esteem;
 Involved in decisions about the delivery of their healthcare;
 Provided care and services in a timely and reasonable manner.
All personnel are responsible for providing healthcare services and products while complying with all
applicable laws, regulations, and standards, including state and federal regulations regarding patients’
rights. Only individuals who are qualified to conduct clinical assessments of prospective patients will do
so. BCH will seek out and employ only healthcare professionals with proper experience and expertise in
meeting the needs of our patients.
It is essential that all personnel bring knowledge of any deficiencies or errors in services to the attention
of someone in authority within the hospital who can properly assess and correct these problems. It is
everyone’s responsibility to provide only the best care to our patients.

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 4 CONFIDENTIALITY
Patient Information: Personnel shall maintain the confidentiality of patients’ protected health
information as required by the Privacy Policies and applicable laws and regulations including the Health
Insurance Portability and Accountability Act (HIPAA). This includes names, addresses, social security
numbers, and all patient health information. Personnel should not access patient information unless
there is a need to access the information because of job requirements. Refer to the HIPAA Privacy
policies and procedures for more specific information.

My aunt was admitted to our hospital. Is it okay if I look at her chart to let the family know
what is wrong with her and how she is doing? No. Any personnel who have been granted access to
the electronic health records, may only access the information required that they have a need to know
about to perform their job. This includes any information relating to treatment, payment and/or
healthcare operations.

Employee Information: Personnel shall treat personnel files, payroll information, benefits, and other
personal information as confidential. The Human Resource department will maintain employment files,
payroll information, disciplinary matters, and similar information in a confidential manner. Personnel
files are held in the strictest confidence with access allowed only on a need to know basis. For additional
information, review the Human Resource policies and procedures.

My sister is selling clothes on-line. Is it okay if I give her our disaster phone tree to text my co-
workers to let them know of sales she has at her on-line store? No, employee information should not
be given to anyone who is not considered part of BCH personnel since this is considered personal
information.

Passwords: All passwords and other personal security codes are to be kept confidential. Each person is
responsible for the actions resulting from the use of your accounts. Do not share passwords or let others
use your computer while you are logged in. For additional information, review the Information
Technology (IT) policies and procedures.
Proprietary Business Information: Confidential information includes information regarding hospital
financial data, strategic plans, statistical data, documents prepared in anticipation of litigation, and
communications with legal counsel to unauthorized persons such as competitors, suppliers, or outside
contractors without prior approval of administration. This includes customer lists, discounts, special
prices, or computer data.

I overheard someone in the hallway talking about how much money the hospital has in the
bank. Is it okay if I tell my spouse? No, financial data is considered proprietary information and
should not be shared with anyone outside our facility.

Intellectual Property: All personnel shall respect the intellectual property and copyright laws regarding
books, trade journals, magazines, computer software, and other applicable resources. Personnel shall
not copy computer software unless specifically allowed in the license agreement and/or authorization
has been received from the IT Department.

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 5 EMERGENCY MEDICAL TREATMENT AND LABOR ACT
BCH will provide appropriate emergency care to patients in accordance with state and federal laws,
including the Emergency Medical Treatment and Labor Act (EMTALA) and the relevant regulations
published by the Centers for Medicare and Medicaid Services (CMS). We will provide a medical
screening examination and stabilization to the best of our abilities to anyone who comes to the facility in
an emergency situation. If the patient’s needs exceed our capabilities, an appropriate transfer will be
arranged. We will provide emergency care to patients regardless of the patient’s ability to pay and
without delay as per our EMTALA Policy.

6 DISCRIMINATION AND HARASSMENT FREE WORKPLACE

BCH recognizes that the greatest strength of our organization lies in the efforts and talents of our
personnel, who create our success and our reputation. All personnel shall be treated with respect,
dignity, and courtesy. BCH will not tolerate intimidating and disruptive behaviors. Such behavior can
contribute to hostile work environments, medical errors, poor patient satisfaction, and adverse
outcomes, increase the cost of care, and cause good personnel to seek new positions elsewhere.
Safety and quality of patient care is dependent on teamwork, communication and a collaborative work
environment. Acceptable behavior is that which supports teamwork, a positive attitude, and good
communication and which follows the principles in our Code of Conduct.
Unacceptable behavior is any behavior that has a negative impact on the quality of care we deliver or
which can affect the safety of our patients, employees, providers and visitors, and may be either overt
or passive. Overt disruptive behavior includes intimidating behavior such as sexual harassment, verbal
outbursts and physical threats. Passive disruptive behavior includes refusing to perform assigned tasks
or quietly exhibiting uncooperative attitudes, such as reluctance or refusal to answer questions, return
phone calls or pages, condescending language or voice intonation, and impatience with questions. Overt
and passive disruptive behaviors undermine team effectiveness and can compromise the safety of
patients. All disruptive behaviors are unprofessional and will not be tolerated.
Personnel will strive to work collaboratively with colleagues and communicate respectfully to and about
others, and in a positive manner. We do not discriminate against any personnel on the basis of race,
color, religion, gender, ethnicity, sex, sexual orientation, age, marital status, genetic predisposition,
veteran status, or disability. We are committed to following the laws to promote fair employment and
equal treatment in hiring, placement, promotion, training, compensation, leave of absence, termination,
reduction in force, and disciplinary action.

We are all required to treat each other with respect at all times.

What are my options if I feel that I have been discriminated against? You should discuss your concerns
with your supervisor or department manager. If you are not comfortable discussing with him/her then
bring your concern to Human Resources or report it through the Anonymous Ethics Hotline 800-398-1496.

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 7 ACCURATE AND HONEST BILLING
It is critical to BCH’s success that we bill federal, state and private healthcare plans accurately, honestly,
with integrity and in compliance with the plan requirements. Medicare and Medicaid laws prohibit
reimbursement for billing for services not rendered; billing for undocumented services; falsifying cost
reports; billing for medically unnecessary services; assigning improper codes to secure reimbursement
or higher reimbursement; participating in kickbacks; and retaining an overpayment for services or items.
A violation of these laws may result in civil, criminal and/or administrative penalties, including monetary
penalties, imprisonment, and exclusion from participation in Medicare and Medicaid and a loss of
licensure status.
All Coders and Billers are committed to integrity in our coding, billing and collections requirements.
All Coders will consult the Official International Classification of Diseases (ICD 10-CM) codes, based on
the official version of the World Health Organization, which govern the use of codes and are required for
use by HIPAA.
All coders and billers will take steps to prevent the submission of claims for payment and
reimbursement of any kind that are fraudulent, abusive, inaccurate, or medically unnecessary, including,
but not limited to the following:
 Billing for items and service not provided to patient;
 Up coding for higher reimbursement than is supported by documentation;
 Submitting duplicate bills (more than one claim for the same service);
 Unbundling claims (submission of bills in a fragmented fashion to maximize reimbursement
if guidelines required the service be billed together);
 Inclusion of costs that are not allowable to be reimbursed in a cost report.
If a billing error is discovered, immediate steps will be taken to correct the error, alert the payer, and
promptly refund any payment not due. We have an obligation to promptly repay money we improperly
receive from third party payers within 60 days.

While coding services for a patient, I noticed that there was no documentation in the medical
record for a particular service. Should I still code and bill for this service under the assumption that
it was done? No. Coding and billing must reflect the actual services rendered to a patient based on
supporting medical documentation, including patient conditions and diagnoses, in the medical record.
An employee should never assume that a services was provided. If proper documentation is not
present in the medical record as required for billing purposes then the bill should not be submitted to
the payor for payment.

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 8 DOCUMENTATION
Personnel must ensure that all statements, submissions, and other communications within our
organization, to our patients, prospective patients, the government, accrediting bodies, regulatory
agencies, private healthcare plans, suppliers and other entities are truthful, accurate and complete. All
patient records, financial and accounting reports, expense reports, time sheets, and any other
documents must accurately and clearly represent the relevant facts and the true nature of the
transaction. No one may alter or falsify information on any record or document. Personnel who suspect
inaccurate documentation and/or record keeping must notify their supervisor and/or the Compliance
Officer immediately.

9 RECORD RETENTION AND DESTRUCTION

All personnel must protect the integrity of documents and records to ensure that records are
maintained in accordance with regulatory and legal requirements, and for the required length of time.
All records, both medical and business, including both written and computer-based information such as
email or computer files, shall be retained and/or destroyed in accordance with the Record Retention
and Destruction policy.

Why is accurate record keeping and storage so important? The law requires BCH to prepare and
retain a large number of forms and reports in connection with our business. All personnel must ensure
this is done in a complete and accurate manner.

10 PROTECTION OF ASSETS AND RESOURCES

All information concerning finances, operations, products, policies, customers, development plans,
computer programs and related information should be treated as proprietary and confidential. All
personnel have access to assets and resources so that we can do our jobs and advance BCH’s interest.
We must always protect our assets from loss, damage, carelessness, misuse, theft and waste, including
wasted supplies, equipment, space and capital. We should be as careful with resources as we would
with our own. Do not use proprietary information, physical assets, such as supplies or equipment, for
personal purposes or remove them from the premises without authorization; even just to “borrow”
them. Physical assets include, but are not limited to, vehicles and machinery, office supplies, medical,
cleaning and food supplies, tools, furnishings, television, computers and computer software, printers,
telephones, and all other types of equipment, including medical devices.
Personnel whose responsibilities include the management of departmental funds shall maintain internal
controls, record keeping, and shall exercise appropriate oversight. Any use of resources for personal
financial gain unrelated to BCH business is not permitted.

We are all required to:

 Protect BCH assets and proprietary information;
 Communicate efficiently and effectively;
 Not share insider information;
 Refer media requests to Human Resources or the Chief Executive Officer;
 Retain documents as required.

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 11 KICKBACKS, REFERRALS, AND BRIBES
The federal Anti-Kickback Statute (“Anti-Kickback Statute”) is a criminal statute that prohibits the
exchange (or offer to exchange), of anything of value, in an effort to induce (or reward) the referral of
federal healthcare program business.
The Sunshine Act, a.k.a. the National Physician Payment Transparency Program (Open Payments), is a
section of the Patient Protection and Affordable Care Act of 2010. It requires pharmaceutical and
medical device companies report certain payments made to providers or facilities to the Federal
government.
The Stark Law is a set of United States federal laws that prohibit provider self-referral, specifically a
referral by a provider of a Medicare or Medicaid patient to an entity providing designated health
services ("DHS") if the provider (or an immediate family member) has a financial relationship with that
entity.
**REMINDER: We will routinely screen personnel for their eligibility or exclusion with Medicare and
Medicaid programs.

I was discussing a referral with a medical supply company, they asked me to send them more
referrals, and they could possibly enter my name for a free all-expense paid trip to Disney Land. Is it
okay if I send them all the referrals for medical equipment? Absolutely not. This is a violation of the
Anti-Kickback Statute and subjects you, the hospital, and the medical supply company to criminal
penalties. You should report this to the Compliance Office immediately.

12 FUNDRAISING, GIFTS, GRATUITIES, AND BUSINESS COURTESIES

BCH will, from time to time, identify opportunities to utilize our reputation and relationships within the
local healthcare and business sectors as a means of giving back to the communities we serve through
charitable contributions, event sponsorships, volunteerism and facilitation of participation, donations,
and contributions by vendors, suppliers, service providers, groups, organizations, individuals,
philanthropists and the community at large. BCH does not intend to realize any gain or benefit beyond
the satisfaction of promoting improvement of the overall health, wellness and quality of life of the
persons that work and reside in the community in which we operate.
During the holidays especially patients, business associates, and others may give you a gift, such as
cookies, flowers, or candy. This gift should not influence, or reasonably appear to others to be capable
of influencing your business judgment in conducting affairs with the patient or business associate.
The exchange of cash of any amount will not be accepted. If a patient or other individual wishes to
present a cash donation, he/she should be referred to BetterCARE, Inc., the hospital’ s foundation, the
fundraising arm of BCH. The foundation was established to accept many forms of contributions and is
designed to help provide better care for our patients.

One of our suppliers offered me (4) tickets to the baseball game. The face value of each ticket is
$75. Can I accept the tickets? No. The offer of these tickets would not be an acceptable gift. In addition,
you must avoid the appearance that your decision to accept the tickets might be improperly influenced
for future business with the supplier. Entertainment, such as sporting, arts, culture or charitable events
must be part of a legitimate business activity and be within bounds of reason and a nominal value. The
face value of each ticket exceeds the nominal value of any permissible gift from a supplier.

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 13 MARKETING
BCH may use marketing and advertising activities to educate the public, provide information to the
community and increase awareness of Hospital services. BCH will present only truthful, and fully
informative information in these materials and announcements. All marketing and advertising must be
approved by the Administrative Team and must accurately reflect the services available and the level of
our licensure and accreditation status.

I have created a new brochure for our department and I want to start handing it out to patients.
Is it okay to start giving it to patients if my supervisor has approved it? Absolutely not. Prior to
anything being shared with the public the Administration Team must review it to ensure compliance with
laws and regulations as well as presenting the goals of the hospital.

14 CONFLICT OF INTEREST
We have a duty to place the interest of BCH ahead of our personal interests by avoiding both financial
and clinical conflicts of interest. A conflict of interest may occur if any person’s outside activities or
personal financial interests influence or appear to influence the individual’s ability to make objective
decisions in the course of him/her carrying out their responsibilities and obligations. Personnel should
always avoid such conflicts of interest or even the appearance of a conflict of interest.
BCH requires certain personnel to disclose financial interest that they (or their immediate family
member) may have that would interfere or affect the person’s responsibilities for or on behalf of BCH.
Completion of the Conflict of Interest Disclosure Form is a mandatory tool used to fulfill for this purpose.
Personnel should never use his/her position to profit personally or to assist others in profiting at the
expense of BCH. Anyone who fails to disclose actual or potential conflicts of interest will be subject to
disciplinary action up to and including termination.

15 ENVIRONMENTAL HEALTH AND SAFETY

BCH shall manage and operate its business in a manner that respects our environment and conserves
natural resources. Personnel shall:
 Comply with the Hospital’s Health and Safety Policies to ensure patients, visitors, the workforce,
and others are protected from unnecessary risks and unsafe conditions.
 Dispose of all waste in accordance with applicable laws and regulations and shall strive to utilize
resources appropriately and efficiently, including recycling when possible.
 Immediately report suspected violations of an environmental or occupational health and safety
law and shall work cooperatively with the appropriate authorities to remedy any environmental
contamination that may occur in the workplace.

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 16 GOVERNMENT INVESTIGATIONS, ACCREDITATIONS, AND SURVEYS
BCH and its personnel shall cooperate fully and promptly with appropriate government investigations
into potential violations of the law and to the efforts of our accrediting and surveying agencies.
Governmental and/or agency inquiries or requests should be promptly referred to the Compliance
Officer or Chief Executive Officer.
BCH promptly and thoroughly investigates reports of suspected illegal activities or violations of the
Compliance Program or the Code of Conduct. Personnel must cooperate with such investigations and
may not take actions to prevent, hinder, or delay discovery of an investigation. For example, personnel
must never alter or destroy records or documents requested in the course of an investigation, nor shall
personnel make a false or misleading statement on such documents or to an investigator. In addition,
personnel must never pressure any person to provide false information to, or to hide information from,
an investigator.

17 RESPONSIBILITY FOR REPORTING

Corporate Compliance is everyone’s responsibility. Therefore, all personnel are required to report their
good faith belief of any suspected or actual violation of the Code of Conduct, the Compliance Program,
or other policies, procedures, or applicable law. Sometimes it is unclear whether a particular activity or
situation may be a violation of the Code of Conduct or the Compliance Program. When this happens,
personnel should contact their supervisor or the Compliance Officer.
Reports of suspected or actual violations can be made in a number of ways as described below:
 Verbally or in writing to the employee’s supervisor or department manager
 Call the Compliance Officer at: 208.245.7676
 Report via the Anonymous Ethics Hotline at: 800.398.1496 or go to www.lighthouse-
services.com/bchmed 24 hours a day/7 days a week
 By mailing or emailing a concern or complaint to the Compliance Officer
Personnel who fail to report suspected or actual violations are themselves violating the Code of Conduct
and/or the Compliance Program and may be subject to disciplinary action, which could result in
personnel termination.

18 NON-RETALIATION
BCH is committed to fostering a workplace that is conducive to open discussions. To promote an open
culture, the Hospital has a strict Non-Retaliation and Whistleblower Policy to protect its personnel. This
means there will be no action of retaliation or retribution for an individual’s good faith actions in:
reporting of a violation or suspected violation; participating in an investigation pertaining to an alleged
violation, or in assisting with an investigation. Any manager, supervisor, or individual who commits or
condones any form of retaliation will be subject to discipline up to, and including termination. For more
information please see the above policy.

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 19 ENFORCEMENT OF THE CODE OF CONDUCT
Personnel must understand that they will be subject to discipline for violations of the Code of Conduct,
up to and including termination of employment or affiliation with BCH. The specific disciplinary action
depends on the nature and severity of the violation. BCH imposes sanctions in a consistent manner in
accordance with the Progressive Discipline policy.

Examples of violations of the Code of Conduct, which could result in disciplinary action, include:
 Participating in activities that violate the Code of Conduct;
 Encouraging others to violate the Code of Conduct;
 Failing to report suspected violations of the Code of Conduct; and
 For personnel who are supervisors or managers, failing to detect violations of the Code of
Conduct, if such violation should have been discovered in the reasonable course of the
Employee’s job responsibilities.

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 CERTIFICATION & ACKNOWLEDGMENT

 I have read the entire Code of Conduct. I have had the opportunity to ask any questions
with regard to its content, and I understand fully how the Code of Conduct relates to my
position.

 I hereby acknowledge my obligations and agreements to fulfill those duties and

responsibilities as set forth in the Code of Conduct and to follow these standards.

 I further certify that, throughout the remainder of my association/employment with

BCH, I shall continue to comply with the terms of the Code of Conduct.

 I understand that violations of the Code of Conduct may lead to disciplinary action, up
to and including termination.

___________________________________________
Signature

____________________________________________
Printed Name

____________________________________________
Department

____________________________________________
Date

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