Ethics

PURPOSE

To describe Shepherd Center’s ethical standards applicable to all professional and business conduct.

POLICY

Shepherd Center and affiliates committed to the establishment and implementation of ethical practices with all customer groups which we serve. This is accomplished through the application of our Ethics in Business Program and relevant policies and procedures in Shepherd Center All Center policy manual. These include policies and practices related to Patients’ Rights and Responsibilities, Patient Care, Informed Consent, Patient Complaints, Confidentiality, Mission, Philosophy, Values, Ethics Committee, Grievance Procedures, Business Practices, Internal and External Auditing, Financial Management and Marketing.

A. Professional Behavior

Personnel are expected to adhere to professional standards of practice related to the specific professional licensing and accrediting organizations for their discipline of practice. A copy of Professional Practice Standards is maintained by departmental management. Staff not governed by professional practice standards abide by behavioral guidelines outlined in Shepherd’s Employee Handbook. Ethical conduct is reviewed with personnel during orientation, monitored on an ongoing basis and reviewed during periodic performance evaluations.

B. Business Practices

Shepherd Center and all affiliates abide by the Ethics in Business Program. The code of this program is “Conducting Business with Honesty, Fairness and Integrity”. These standards are maintained through truthfulness, the absence of deception or fraud and full intent to follow and respect all applicable laws and regulations. Every employee, irrespective of facility, location or position is expected to act with the highest degree of integrity.

C. Marketing Practices

All referral development activities, including promotional materials, reflect the organization’s mission, philosophy and value statements. All promotional materials, events and interactions truthfully and accurately represent our program capabilities, outcomes and populations served. All marketing activities are focused on Shepherd Center program, taking particular care to emphasize our benefits and not the deficiencies of a competitor, nor exploit patient/family fears as a motivating factor. Marketing funds are used modestly when sponsoring specific marketing activities in maintaining or developing customer relationships.

All pre-admission patient and family contacts are at the invitation or informed consent of the patient, family and/or professional. All contacts with the patient and family will cease after selection of an alternate facility unless requested otherwise.

D. Endorsements and Testimonials

Responsibility for controlling the use of the name and logo of Shepherd Center and
affiliates or employees in any type of advertisement or non-editorial material prepared by
suppliers (vendors) of products, services or equipment will be with the Media Relations
Manager and the Chief Compliance Officer. Employees contacted by media or companies not directly affiliates with Shepherd Center to represent the Center, should receive permission from the Media Relations Manager and in some cases the Chief Compliance Officer. No employee representing Shepherd Center shall perform an endorsement or testimonial for any reason with the promise of expectation of monetary or "value in kind" being offered for such services. Any endorsement or testimonial approved by the Media Relations Manager will be honest and not derogatory to any company or their product. Employees are not allowed to make any comparisons between companies or their products.

E. Violations

Any perceived violation of ethical practices are processed through formal channels outlined in referenced policies, professional board practices and/or legal system.

CODE OF ETHICAL CONDUCT

The staff of Shepherd Center and affiliates have developed and abide by a code of ethical
conduct. This code of conduct is intended to guide staff behavior and interactions with all
customers. It has, as it’s primary goal, the welfare and protection of the individuals and families
with whom staff work. It is the individual responsibility of each staff member to aspire to the highest possible standards of conduct. The staff respect and protect human and civil rights, and do not knowingly participate in or condone unfair discriminatory practices.

A. Competence

All staff strive to maintain high standards of competence in their work. They recognize
the boundaries of their particular abilities and the limitations of their expertise. They provide only those services and use only those techniques for which they are qualified by education, training, or experience.

B. Integrity

Staff are honest, fair and respectful of others. In describing or reporting their qualifications, services, products, or fees, they do not make statements that are false, misleading or deceptive. Staff strive to be aware of their own belief systems, needs and limitations and the effect of these on their work.

C. Professional Responsibility

Staff uphold professional standards of conduct, clarify their professional roles and obligations, accept appropriate responsibility for their behavior and adapt their methods to the needs of different populations. Staff consult with, refer to or cooperate with other professionals and institutions to serve the best interests of their patients. Clinical decisions (including tests, treatments, and other interventions) are based on Carepaths and identified health care needs. Research will adhere to the Public Health Service’s regulations for responding to allegations of research.

D. Respect for People’s Rights and Dignity

Staff respect the fundamental rights, dignity and worth of all people. An environment that respects the patients' dignity and encourages a strong self-image is continuously fostered at Shepherd. They respect the rights of individuals to privacy, confidentiality, self-determination, and autonomy. Staff are aware of cultural, individual and role differences, including those due to age, gender, race, ethnicity, national origin, religion, sexual orientation, disability, language and socioeconomic status. To support the patient's right to access protective services, a list of such services including how to contact the agency will be provided to any patient who requests it. (See Abuse - Neglect policy attachment, or access www.unitedwayatl.org, or dial 211).

E. Maintaining Expertise

Staff who engage in assessment, therapy, teaching or other professional activities maintain a reasonable level of awareness of current scientific and professional information in their fields and undertake ongoing efforts to maintain competence in the skills they use.

F. Documentation

Staff appropriately document their professional work in order to facilitate provision of services later by them or by other professionals, to ensure accountability and to meet other requirements of the facility or the law. Staff create, maintain, disseminate, store, retain and dispose of records and data relating to their practice in accordance with hospital policy and applicable law. Staff ensures all business records are accurate and complete and will contain no false or misleading information.

G. Admissions and Discharge

Shepherd Center does not discriminate on admission criteria for race, religion, age, sex, or the ability to pay. Admission criteria are based primarily on clinical decisions and discharge plans. Discharge criteria are based upon clinical guidelines and realistic expectations of the patient and caregivers. Financial assistance and counseling are available to all patients and families.

H. Billing and Fees

Shepherd Center and all affiliates will bill only for services actually rendered. Services rendered must have appropriate documentation and be accurately coded. All billing must comply with requirements of state and federal payers and conform to all contractual agreements. The Ethics in Business Program at Shepherd operates on the guiding principle, “Without appropriate documentation, the service has not been rendered”. No medical record may be amended for covering up errors or obtaining non-entitled payment. All fees for service are appropriate for the service rendered and are set and authorized by Directors and Vice Presidents. No staff member may exploit the recipient of service or payor for fee for service. No staff member or representative will agree or attempt to agree to fix prices or fees for any reason. The policies and procedures that address the use of services and financial incentives are available on request to all patients, clinical staff, licensed independent practitioners and hospital personnel.

I. Improper Use of Funds

Shepherd Center and affiliates strongly prohibit any type of payment or consideration of value offered with the intent to influence a decision on grounds not directly related to business merits. Prohibited inducements include gifts or considerations to government employees, politicians, physicians or any other party who are in a position to influence patient referrals.

J. Reporting and Resolution of Non-Business Related Ethical Violations

When staff believe that there may have been a (non-business related) ethical violation by another staff member, they attempt to resolve the issue by bringing it to the attention of the individual if an informal resolution appears appropriate and the intervention does not violate any confidentiality rights. Staff exercise professional judgment in notifying management of their perceptions. If any apparent ethical violation is not appropriate for informal resolution or is not resolved properly in that fashion, staff may take further action through the organizational management structure, human resource department and/or hospital grievance procedure.

K. Reporting and Resolution of Business Related Ethical Violations

Reporting of ethical problems that are business related are to follow the notification policy in the Ethics in Business Program. The employee may report the violation to their immediate Supervisor, Director or anonymously to the 24 hour “Compliance Line."

L. Confidentiality

Information obtained, developed or produced by Shepherd Center and affiliates and information about Shepherd customers is totally confidential. This information should not be disclosed outside the professional confines of Shepherd Center, unless there is specific written permission of authorization.

M. Conflicts Between Ethics and Organizational Demands

If the demands of the organization conflicts with the Code of Ethics, staff clarify the nature of the conflict, make known their commitment to the Code of Ethics and to the extent feasible, seek to resolve the conflict in a way that permits the fullest adherence to the Code of Ethics.

Please see our list of Policies and Procedures that relate to Ethics:

Ethics Committee/Service
Code of Ethical Conduct
Advisory Opinion Program
Objectives for Ethics in Business Program
Management Responsibility with the Ethics in Business Program
Employee Responsibility with the Ethics in Business Program
Excluded Providers
Vendor/Contractor Responsibility for Ethics in Business Program
24-Hour Compliance Line Notification
Reporting of Suspected or Known Fraud, Waste and Abuse
Falsification of Documents
Combating Waste, Fraud, Abuse; Ability to Report Wrongdoing for Federal/Georgia Beneficiaries
Standards for Ethics in Business Program
Anti-Kickback and Self-Referrals
Making Purchasing Decisions Outside Officials Channels
Auditing and Monitoring for Compliance
Professional/Courtesy Discounts
Ethics in Business Compliance Committee
Physician Incentive Compensation
Statement of Purpose for Ethical Practice and Conduct
Employee Attestation Statement
Housing Arrangements for Families and Federally Funded Healthcare Patients
Business Courtesies
Gifts