Covenant Health Code of Conduct - "Integrity is building trust with our patients and each other by being honest, ethical and consistent in what we ...
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Covenant Health Code of Conduct “Integrity is building trust with our patients and each other by being honest, ethical and consistent in what we say and do.”
Table of Contents Message from the President and CEO
Messages from the President and CEO and the Privacy and Security of Information . . . . . . . . . . . . . . . 12 Covenant Health is known for providing the communities we serve with quality
Chief Compliance Officer . . . . . . . . . . . . . . . . . . . . . . . . . 1 Patient Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 care delivered by professional and dedicated employees. We are proud of our
Company Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 reputation, which is built on a foundation of high ethical standards.
Covenant Health’s Mission, Vision and Values . . . . . . 2 Employee Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 I strongly reaffirm our commitment to conducting all aspects of our business
Covenant Health Pledge of Excellence . . . . . . . . . . . . . . 2 Information About Outside Entities . . . . . . . . . . . . . . 13 with integrity, and in compliance with the laws and regulations that govern us. It
is up to all of us – employees, administrators, and Board members – to uphold our
Information Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
reputation by acting in an ethical, fair and caring manner in all that we do, both
Standards of Business Conduct . . . . . . . . . . . . . . . . . . . . 2 Inside Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
internally and with people and organizations outside Covenant Health.
Lawful and Ethical Business Practices . . . . . . . . . . . . 2 Communications with Media or . . . . . . . . . . . . . . . . . 14 To guide our decisions and actions, we have developed the Covenant Health
Our Shared Responsibilities . . . . . . . . . . . . . . . . . . . . . . . 2 Outside Persons and Entities Code of Conduct, which has been approved by our Board of Directors. It is a
Raising Integrity Concerns and Seeking . . . . . . . . . . . 3 useful resource regarding ethical behaviors and decision making, and a valuable
Assistance Responsible Use of Assets . . . . . . . . . . . . . . . . . . . . . . . . . 14 information tool for the complex ethical, professional, and legal requirements which are part of the
Non-Retaliation for Reporting . . . . . . . . . . . . . . . . . . . . . 3 Protecting Company Assets . . . . . . . . . . . . . . . . . . . . . 14 healthcare environment. Please read it carefully.
Disciplinary Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Charitable Contributions . . . . . . . . . . . . . . . . . . . . . . . . . 14 All Covenant Health employees are responsible for understanding and following these policies and
Responsibilities of Management . . . . . . . . . . . . . . . . . . 4 Employee Solicitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 guidelines. Your commitment to doing so will help ensure that Covenant Health is the first and best
Responsibilities of Members of the . . . . . . . . . . . . . . . 4 Travel and Entertainment . . . . . . . . . . . . . . . . . . . . . . . . 15 choice for our patients to receive care, our physicians to practice and our employees to work.
Covenant Health Board of Directors Protecting the Assets of Others . . . . . . . . . . . . . . . . . . 15
Our Work Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Billing Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Jim VanderSteeg
Qualifications of Our Employees . . . . . . . . . . . . . . . . . . 5
President and Chief Executive Officer
Fair Treatment of Our Employees . . . . . . . . . . . . . . . . . . 5 Accuracy and Proper Handling of Records . . . . . . . . . 15
Drugs and Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Workplace Security, Safety and Health . . . . . . . . . . . . 6 Fair Competition/Antitrust and . . . . . . . . . . . . . . . . . . . 16
Marketing Practices Message from the Chief Compliance Officer
Patient Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Conducting Business with the Government . . . . . . . . 17
Conflict of Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Gifts, Business Courtesies and Payments to . . . . . 17 Covenant Health is committed to ethical business practices and complying with
Conflict of Interest Disclosure . . . . . . . . . . . . . . . . . . . . 8 Government Employees federal, state, and local laws. All Covenant Health team members play an important
role in upholding Covenant values in a complex ethical, legal, and regulatory health
Payments to or from Outside Sources . . . . . . . . . . . . . 8 Relationships with Vendors and Suppliers . . . . . . . 17
care environment.
Relationships between Covenant Health . . . . . . . . . . 8 Use of Funds and Accuracy of Records . . . . . . . . . . . 17
Covenant Health has instituted an Integrity-Compliance program as part of its
and Physicians Privacy and Security of Information . . . . . . . . . . . . . . 17 commitment to conducting its business and operations with integrity. This Code of
Outside Activities and Employment . . . . . . . . . . . . . . . 9 Cooperating with Government Investigations . . . . 17 Conduct is an essential part of the Covenant Health Integrity-Compliance program
Participation in Professional Societies . . . . . . . . . . . . 9 and outlines our commitment to professional and legal standards. Together with
and Vendor Seminars Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Covenant Health policies, it is intended to guide and direct all employees, officers,
Political Contributions and Activities . . . . . . . . . . . . 10 Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 board members, and others who work for or are associated with Covenant Health.
Distribution and Feedback . . . . . . . . . . . . . . . . . . . . . . . 18 The choices we make affect our organization. The Code and the Integrity-
Gifts and Business Courtesies . . . . . . . . . . . . . . . . . . . . . 10 Compliance program help us in making the right choices when confronted with difficult decisions. Please
General Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 FAQs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 read the Code carefully and completely. If any part of the Covenant Health Code of Conduct is unclear to
Permitted Gifts and Business Courtesies . . . . . . . . . 10 you, or if you have questions or concerns about a situation, there are a number of ways to seek assistance.
Prohibited Gifts and Business Courtesies . . . . . . . . 10 Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 First, you can direct a question or concern to your supervisor or manager. If, for any reason, you do not wish
to do so or your supervisor is not able to address your question or concern satisfactorily, you can contact
Gifts to or from Vendors, Suppliers . . . . . . . . . . . . . . . 11
Human Resources. If your question is still not satisfactorily addressed, or you do not wish to take either
and Outside Organizations
of these steps, you are always welcome to contact me at 865-374-8041. In addition, you can contact the
Gifts to or from Patients, Patients’ Family Covenant Health Integrity-Compliance Report Line at 1-888-731-3115 at any time.
Members, or Physicians . . . . . . . . . . . . . . . . . . . . . . . . . 11 Each of us has a personal obligation to identify and report compliance issues and uphold the standards
Relationships Among Covenant Health . . . . . . . . . . . 11 described in this Code. No retaliatory action will be taken against you for reporting a compliance problem or
Employees concern in good faith, either to the Report Line or through any other appropriate channel.
Thank you for your hard work and dedication.
Kathleen Flynn Zitzman
Chief Compliance Officer
Vers. 9.21
1 The Covenant Health Integrity-Compliance Office
can be reached at 1-865-374-8010 or through the
Integrity-Compliance Report Line at 1-888-731-3115.
Covenant Health Mission, Vision and Values
Mission It is also the personal responsibility of each employee • Discuss the issue with a higher-level manager. If you are
We serve the community by improving the quality of life through better health. to bring violations or suspected violations of this Code of not comfortable taking this step or still have concerns
Conduct to the attention of a supervisor, another member with the answer you get, take another step.
of management, Human Resources, or the Integrity- • Discuss the issue with Human Resources or Internal
Vision
Compliance department, either directly or through the Audit.
Covenant Health is committed to being the region’s Integrity-Compliance Report Line at 1-888-731-3115. • At any time when you have a question or concern, you
premier healthcare network by providing patient-centered Inquiries and reports may also be made in writing, either may contact the Integrity-Compliance department at
care that inspires clinical and service excellence, making by e-mail to Integrity-Compliance (IntegrityCompliance2@ 1-865-374-8010 or call the Covenant Integrity-Compliance
us the first and best choice for our patients, employees, covhlth.com), by secure message on the Integrity- Report Line at 1-888-731-3115. There is no need to take any
physicians, employers, volunteers and communities. Compliance page on the CovNet intranet, or by mail to: of the preceding steps before contacting the Integrity-
Compliance Department. Specifically, you need not
Covenant Health Integrity-Compliance Department
contact your supervisor, Human Resources, Legal or
Values 3003 Lake Brook Blvd., Suite 102
any other department before contacting the Integrity-
Working together in service to God, our values are: Knoxville, TN 37909
Compliance department. We are always interested in
• Integrity Whether you report your concerns by telephone or hearing from you.
• Quality in writing, you should provide as much detail as possible,
• Service including names, dates, times, location and the specific Non-Retaliation for Reporting
• Caring conduct you feel may violate the law or Covenant Health It is Covenant Health policy that no employee will be
policy. penalized for raising an ethical or compliance issue or
• Developing People
concern. Certain federal and state laws, such as the federal
• Using Resources Wisely False Claims Act, reinforce these protections for employees
Raising Integrity Concerns and Seeking Assistance
The Covenant Health Code of Conduct offers us who raise concerns.
Covenant Health Pledge of Excellence resources for addressing the complex ethical, professional Covenant Health has established a toll-free Report
Line and makes it available to all members of the Covenant
and legal requirements of our jobs. Considering the
following questions can help you make good decisions in Health team. Any Covenant Health employee, physician,
To fulfill Covenant Health’s vision and in order to make Covenant Health
complex circumstances: contract worker, patient, vendor or interested member
the best organization it can be, we pledge: of the community may call the Covenant Integrity-
Ask yourself: Compliance Report Line to ask questions concerning
The patient always comes first. • Does the action comply with the laws and regulations ethical or legal conduct, or to report any potentially
that apply to our business? improper action.
Excellence in everything we do.
• Is it consistent with Covenant Health’s values, policies The Report Line process allows individuals to report
We will do our part to make Covenant Health the first and best choice. and procedures? concerns anonymously if they wish.
• Is it consistent with the Covenant Health Code of To ensure the confidentiality of Report Line calls, the
Standards of Business Conduct Conduct?
• Does this action endanger a patient or other individual
Integrity-Compliance Report Line uses a “disappearing
switch” technology. This means that calls to the Line
under Covenant Health’s care? cannot be traced or produced on internal telephone line
Lawful and Ethical Business Practices conduct. Ignorance of the law and regulations is no • How would you feel after taking this action? reports. The only exceptions to this confidential system
Covenant Health is committed to conducting excuse for non-compliance. • How would it look to family, patients, friends and the occur in company Call Centers (for example, IT-Information
our business with honesty, fairness and integrity, in The Code cannot address every potential issue community? Technology Help Desk and KBOS-Knoxville Business Office
compliance with the laws and regulations that apply or situation that may arise and it is not intended Services). Employees in these areas who wish to make a
If you’re in doubt, ask for guidance! Keep asking until telephone inquiry or report should use phones outside the
to us. We depend on our employees and those who do to replace or supersede any Covenant Health
you get an answer that makes sense to you. It is always Call Centers.
business with us to help us fulfill this commitment. policy or procedure. All employees and associates
better to raise a question before taking an action that may The Covenant Health Integrity-Compliance Report
are responsible for reading, understanding and
be improper. Line is answered between the hours of 8 a.m. and 5 p.m.,
Our Shared Responsibilities complying with the Code, as well as other Covenant
This Code of Conduct defines our expectations Health policies and procedures. • Discuss the issue with your immediate supervisor. Monday through Friday. At other times, a voice mail
of all employees, physicians and those who do Any employee who acts outside the Covenant If you are not comfortable discussing it with your message will provide instructions for making a report or
business with Covenant Health. We expect all Health Code or Company policies will be held supervisor or still have concerns with the answer you getting additional assistance.
Board members, officers and employees to act personally accountable for the harm that he or she get, take another step.
with honesty and integrity at all times and to use causes to our patients, Covenant Health and our
Covenant Health resources to assist in business constituents.
2 3 The Covenant Health Integrity-Compliance Office
can be reached at 1-865-374-8010 or through the
Integrity-Compliance Report Line at 1-888-731-3115.
Our Work Environment
When you report a potential violation of the Code of could be found to violate any federal, state or local law, or Qualifications of Our Employees Conduct.” Examples of “inappropriate behavior” subject
Conduct to the Integrity-Compliance Office, the Chief the Code of Conduct, regardless of whether the conduct We will make reasonable inquiry into the background to this policy include violence and/or threats of violence,
Compliance Officer will ensure that an appropriate occurs at work or on personal time. of all candidates for employment, including temporary carrying weapons, alcohol intoxication or use of any illegal
investigation is conducted. All employees are expected This includes disciplinary action for failure to report employees. Covenant Health prohibits the hiring of drug or controlled substance while on Covenant Health
to cooperate fully during an internal investigation. another employee’s conduct that violates any law, individuals who have been convicted of certain crimes property or while using Covenant Health equipment or
Negligently or intentionally providing false or misleading regulation or the Code, as well as knowingly making a false or who are listed by a federal agency as ineligible for vehicles, and sexual or other harassment. No employee,
information to a Covenant Health investigator will report of a possible violation for the purpose of harming participation in federally funded programs. Upon consent director or physician shall be subject to discipline
result in disciplinary action, including termination of another individual. from the applicant, Covenant Health will conduct a for reporting instances of inappropriate behavior to
employment. background check that is appropriate to the level of your supervisor, a member of management, or Human
We will attempt to maintain the confidentiality of Responsibilities of Management responsibility of the position sought by the applicant. Resources. Retaliation, or the threat of retaliation,
reports and to protect the identity of those making Covenant Health managers and supervisors have All employees, independent contractors and privileged against any individual for reporting such behavior is
reports, as permitted by law. Unless otherwise required by a responsibility for ensuring high ethical standards and practitioners who are in positions that require professional strictly prohibited.
law, we will only inform those who need to know in order to actions by Covenant employees and associates. We expect licenses, certifications or other credentials are responsible While observing the standards of our professions,
help investigate, resolve or review these matters. our managers and supervisors to exercise responsibilities for maintaining the current status of their credentials and we expect members of our professional staff to exercise
We understand that employees may not want to report in a manner that is respectful of others. Under no complying with federal and state requirements that pertain good judgment and objectivity. Significant differences
concerns if they feel they may be subjected to retaliation circumstances will we sacrifice ethical and lawful behavior to their respective disciplines. Covenant Health will verify in professional judgment should be reported to your
or harassment. No Covenant Health supervisor, manager in the pursuit of business objectives. that these individuals have current licenses or credentials supervisor, a member of management, or Human
or employee is permitted to engage, or threaten to Management employees are expected to support as required. Resources.
engage, in retaliation or any form of harassment against implementation of the Code of Conduct. Examples of Employees, vendors, and privileged practitioners at We recognize and value the diversity of our employees,
an employee who reports a concern or who cooperates actions that demonstrate support include: Covenant Health facilities shall immediately advise in patients and communities, and view this diversity as
in an investigation or legal proceeding involving a • assuring that all current and new employees under your writing a member of Covenant Health management, who essential to our long-term success. Covenant Health
suspected violation. Any manager, supervisor or employee supervision are trained in the application of the Code; will notify Human Resources and Integrity-Compliance, prohibits discrimination in any work-related decision
who engages, or threatens to engage in retaliation or • demonstrating in your actions and words the importance of any termination, suspension, or restriction on any on the basis of race, color, religion, national origin, age,
harassment is subject to discipline, up to and including of continuing commitment to the Code and holding license or certification necessary to furnish services to gender, disability, veteran or citizenship status, or any other
dismissal on first offense. others accountable for living the values and behaviors patients or for job functions. Further, employees, vendors characteristic protected by law. All employment-related
This does not mean that an employee will be that support the Code; and and privileged practitioners at Covenant Health facilities decisions will reflect this commitment.
excused from the consequences of improper behavior • creating a workplace environment which encourages are required to report immediately to us if you become We recognize the unique work relationship between
or inadequate performance by reporting his or her own open communication and sharing of ideas and where ineligible to participate in federal healthcare programs or physicians (both those employed and those not employed
conduct. It does mean that the consequences of improper ethical concerns can be raised and openly discussed have been convicted of a criminal offense related to the by Covenant Health) and our employees, facilities and
behavior or inadequate performance will not be made without fear of retaliation. provision of healthcare items or services. programs. The privileges granted to physicians are
more severe because an employee has made the report governed by medical staff bylaws. Covenant Health
regarding his or her own behavior. Covenant Health Responsibilities of Members of the Covenant Health Fair Treatment of Our Employees promotes ethical conduct among all physicians who
considers prompt and forthright disclosure of any error a Board of Directors Covenant Health’s mission, to “serve the community by practice in Covenant Health facilities and programs.
constructive action by the employee. Covenant Health’s Board of Directors is strongly improving the quality of life through better health,” can only
committed to compliance with ethical and legal principles be accomplished through the dedication and contributions Drugs and Alcohol
Disciplinary Actions applicable to health system operations and is actively of all our employees and associates. We are committed to We expect our employees’ performance to be
The requirements of the Code apply to employees at involved in oversight of the Covenant Health Integrity- providing a professional work environment that fosters the unimpaired by substance abuse. Covenant Health prohibits
all levels of responsibility at Covenant Health, including Compliance program. The Board is routinely informed development of teamwork and excellence in leadership. the use, possession or distribution of any illegal substance
senior management. The Company will take disciplinary about how Covenant Health addresses compliance issues, We strive to hire, motivate, develop and retain people with on Covenant Health property (including parking areas), as
action as appropriate under the circumstances, up to and and the Board is guided by the Code of Conduct in carrying the skills and abilities needed to reach our goals and the well as the abuse of legal drugs or alcohol while performing
including termination of employment, for conduct that out its governance obligations. behaviors that reflect our values. your duties as an employee of Covenant Health. This
It is the policy of Covenant Health that all individuals includes time spent traveling on behalf of Covenant Health
within our facilities, and all individuals engaged in activities and while on relief, lunch or dinner breaks after which you
on behalf of Covenant Health should be treated with return to your work activities. Anyone who consumes illegal
courtesy, respect and dignity. All employees, directors and drugs or alcohol on Covenant Health property, or who
physicians shall refrain from engaging in inappropriate comes to work while under the influence of illegal drugs
behavior as defined by various Covenant Health Human or alcohol will be subject to disciplinary action, up to and
Resources policies under the category of “Standards of including termination.
4 5 The Covenant Health Integrity-Compliance Office
can be reached at 1-865-374-8010 or through the
Integrity-Compliance Report Line at 1-888-731-3115.This policy does not restrict the use of legally obtained Except as otherwise permitted by Tennessee law, gender, disability, veteran or citizenship status, or any • We shall maintain accurate medical records and other
medications or prescriptions as directed by a medical weapons, including firearms, are not allowed in Covenant other characteristic protected by law. documentation to meet all requirements of medical
professional; however, you may not operate a vehicle or Health facilities or on Covenant Health premises. • In an emergency situation, or if the patient is in labor, we staff bylaws, Covenant Health and work unit policies,
equipment on behalf of Covenant Health when using a legally Threats of violence are prohibited, as are any other will provide an emergency medical screening examination accreditation standards, and applicable laws and
prescribed medication that may impair your ability to operate practices or conditions that could contribute to injury. and necessary stabilization treatment without regard to regulations. This standard applies to electronic as well as
the vehicle or equipment safely. Nor does this policy restrict We expect our employees to correctly dispose of all the patient’s ability to pay. We will not delay this screening paper records.
the consumption of alcoholic beverages at a social function medical waste, environmentally sensitive materials and and necessary stabilization treatment in order to seek • As health services providers on whom people depend for
approved or sponsored by Covenant Health, provided prior hazardous materials. You must also ensure that drugs, financial and demographic information. their health and safety, we must take note of deficiencies
permission to serve alcoholic beverages has been granted by pharmaceuticals and hazardous materials are safely stored • Our health services and products will comply with all or errors, even those that seem small or insignificant, and
a Company senior or executive vice president. and inventoried, and that any missing supplies of these applicable laws and regulations, and will conform to report these as appropriate.
All potential new hires at Covenant Health are required materials are promptly reported. standards of professional practice including the standards • Any employee who has concerns about the safety or
to pass a drug test prior to employment. After employment, Diversion of narcotic and psychotropic substances, of appropriate professional associations, societies and quality of care provided by Covenant Health should
the Company reserves the right to require testing for the as well as pharmaceuticals, from their legitimate use is a certifying, licensing or accrediting organizations. report these concerns, following the guidelines outlined
use of illegal drugs on a random basis or when there is criminal violation and will not be tolerated. Examples of • All research, investigations and clinical trials in this Code of Conduct, “Raising Integrity Concerns
reason to suspect that an employee’s work performance is unlawful drug diversion include prescription forgery or undertaken by our physicians and professional staff and Seeking Assistance.” Employees may contact the
being influenced by substance abuse. alteration, theft of prescriptions or physician prescription will conform to high ethical standards and comply Integrity-Compliance department at 1-865-374-8010 or
Covenant Health reserves the right to impose order forms, falsifying narcotic logs, failure to administer with Company policies, federal and state laws, and call the Covenant Integrity-Compliance Report Line at
disciplinary action, up to and including termination, for the prescribed pharmaceuticals to a patient, diverting a regulations. All human subject research must be 1-888-731-3115. Again, it is the policy of Covenant Health
use of illegal drugs on non-working time. Off-the-job illegal prescribed pharmaceutical from a patient to another performed in conjunction with an Institutional Review that retaliation against any employee for having reported
drug use can adversely affect your job performance or person and theft of pharmaceutical samples from a Board. Patients will be informed of alternative services, a concern to the Integrity-Compliance department
jeopardize the safety of other employees or the public. Off- physician’s office. If you have knowledge of the diversion as well as the risks and expected benefits of the or the Report Line is strictly prohibited. Any manager,
the-job illegal drug use can also jeopardize patients’ or the of drugs from legitimate purposes, you have an obligation research, investigation or clinical trial. The refusal of supervisor or employee who engages in, or threatens
public’s confidence in Covenant Health and our employees. to report such information to the appropriate Covenant a patient to participate in a research study will not to engage in, retaliation or harassment is subject to
We reserve our right to require testing for use of illegal Health authority, such as a senior or executive vice compromise his/her access to services. discipline, up to and including dismissal on first offense.
drugs or alcohol. president, Human Resources, or the Covenant Health Chief
Workplace Security, Safety and Health
Compliance Officer. Employee reports of suspected drug
diversion will be treated with confidentiality. Failure to Conflict of Interest
Because of our commitment to our employees, report suspected drug diversion will result in disciplinary
patients, visitors, volunteers, students and clients, we shall action, including termination of employment. If we allow considerations of personal gain or benefit to your family members, which includes any person who
make our business environment one that fosters privacy, The Company reserves the right to establish policies/ to influence our conduct on behalf of Covenant Health, is related by blood or marriage or whose relationship with
security and comfort. Covenant Health facilities must rules in the interest of patient safety, such as those then we are in violation of Company policies and guidelines you is similar to that of persons who are related by blood
comply with all policies, procedures, laws and regulations, concerning employee TB tests and flu shots that are a regarding conflict of interest. A conflict of interest occurs or marriage.
standards and reporting requirements applicable to the condition of employment. if an outside interest or activity, or relationship with a third
health, safety and environmental aspects of Covenant party, influences, or appears to influence, your ability to A Conflict of Interest May Exist If:
Health operations. exercise objectivity or meet your job responsibilities for • You have a significant financial interest in an organization
Covenant Health. The appearance of a conflict of interest that has business relationships with the Company.
Patient Care is included because those on whom our success depends
may judge our conduct by its appearance. Therefore, you
• You have a significant interest or part in another business
that competes directly with the Company.
may not use your position as an employee or director of • You have an employment or consulting agreement with
At Covenant Health, we have developed standards that • In assessing the needs of our patients, we will seek input Covenant Health to profit personally or to assist others in an organization that has business relationships with or
support our commitment to providing high quality patient from our patients, their families, professional staff, and profiting in any way at the expense of Covenant Health. competes with the Company.
care and safeguarding patient rights. These standards referral and payer sources. If a member of your family works for a direct competitor • You are in direct or indirect competition with Covenant
include, but are not limited to, the following principles: • Each patient will be provided information about of Covenant Health and is in a position to influence decisions Health in the purchase or sale of property, property rights
• We treat all patients with compassion, personal dignity patient rights and notice of our privacy practices. affecting Covenant Health, you must disclose this situation or interest in property.
and respect, and provide high quality care that is This information includes the rights of the patient to on a Conflict of Interest form to your manager, Human • You are involved in an outside activity that conflicts
necessary and appropriate according to the specific be involved in the planning of his/her care, as well as Resources, and the Integrity-Compliance Office. with your obligations to Covenant Health. (See section
needs of our patients. rights related to his/her protected health information While this Code cannot cover every potential situation on “Outside Activities and Employment” for more
• Only qualified individuals may practice in Covenant maintained by Covenant Health. or issue that may be a conflict of interest, the following information.)
Health facilities and programs and only qualified • We will not discriminate in any patient care decision are examples of situations where you may be in violation • You accept gifts or business courtesies that are
professionals will conduct clinical assessments. on the basis of race, color, religion, national origin, age, of this policy. These principles apply not only to you, but inappropriate or in violation of Company policy or the law.
6 7 The Covenant Health Integrity-Compliance Office
can be reached at 1-865-374-8010 or through the
Integrity-Compliance Report Line at 1-888-731-3115.• You use (or propose to use) Company assets to purchase Payments to or from Outside Sources to physicians, recruit physicians to the community, employ outside activity that prevents you from meeting your job
services, equipment, or supplies because of a personal No Covenant Health employee shall, directly or physicians, and/or arrange for physicians to serve in responsibilities or compromises your objectivity in making
financial relationship with the vendor, or because it indirectly, engage in any corrupt business practice, leadership positions in the organization) are aware of the business decisions on the Company’s behalf would be
benefits you or a family member personally. including bribery, kickbacks, or payoffs. A “bribe” or requirements of the laws, regulations, and policies that deemed to impact your job performance negatively. You
• As a Covenant Health executive, senior officer, manager “kickback” is any payment or item of value offered with address relationships between Covenant Health providers also must abstain from using or discussing proprietary
or supervisor, you participate in the hiring or supervision the intent to influence a decision on grounds not directly and physicians. business information (e.g., business plans or forecasts)
of a family member. related to business merits. Any arrangement with a physician (or a physician’s or patient information in connection with such outside
• You are in a position to make or influence a Covenant Offering payments or other items of value to physicians immediate family member) must be properly structured activities. You should ensure any notes or minutes reflect
Health decision in favor of a company for which your or other parties to influence the flow of referrals or and administered to ensure compliance with legal the abstention.
spouse or other family member is acting as a salesperson business to Covenant Health may be a bribe or kickback requirements. Most physician arrangements must be in Outside activities cannot involve the use of
for the product or service being purchased. and is prohibited. For example, we do not charge physicians writing and approved by the Integrity-Compliance Office Covenant Health proprietary business information
• You are in a position to make or influence a Covenant lower rents, provide free nursing, or other staff services in and legal counsel. Failure to meet all requirements of or patient information. Non-Covenant materials may
Health decision in favor of a company where you were exchange for referrals to Covenant Health facilities. applicable laws and regulations can result in serious not be distributed in the Covenant Health workplace
formerly employed or have continuing interests, e.g., You may not offer, solicit, or receive payments in any consequences. Contact the Integrity-Compliance Office during working time. “Working time” is when either the
retirement plans, stock options, etc. form in return for referrals, or to induce referrals of patients, with questions about compensation or other financial employee distributing materials or the employee to whom
goods or services. Further, in making patient referrals to relationships with physicians and their immediate family the distribution is directed is or should be engaged in
Conflict of Interest Disclosure another provider, you must not consider the volume or members. performing work tasks and does not include time when an
At any time during your employment, if you believe value of referrals that the provider has made, or may make, employee is on duty but is not expected to be performing
a conflict of interest exists, you must disclose it to your to Covenant Health. Outside Activities and Employment work tasks, such as breaks or meal periods.
supervisor and complete a Conflict of Interest Disclosure Nor may you offer payment or make payment in any Covenant Health is proud of our many employees Employees who are involved in outside employment
Form as soon as you become aware of the potential form, including kickbacks, bribes or rebates, in return for who are active within the communities we serve. When or entrepreneurial businesses may not market their
conflict. If you are unsure whether a particular activity or referring or recommending an individual to a Covenant you are involved in outside activities, which may include businesses, products or services in the Covenant Health
situation represents a potential conflict of interest, treat Health facility for services. outside employment, directive, managerial or consultative workplace.
the situation as if a conflict definitely exists and consult Covenant Health will comply with applicable laws services, civic or charitable affairs, it is important that Covenant Health employees may not, as an outside
your supervisor, another member of management, Human regarding agreements with agents or consultants, your activities not create an actual or potential conflict activity, provide any product or service that Covenant
Resources, or the Integrity-Compliance department. Failure including physicians. Agreements must be in writing on of interest with your Covenant Health employment. Health has, or is planning to have, available on the market.
to disclose an actual or potential conflict of interest may the Company’s standard forms or other forms/contracts Therefore, it is Covenant Health policy that these activities Nor may employees, on their non-work time, provide
result in disciplinary action, up to and including termination as approved by Executive Leadership and/or legal counsel be disclosed, preferably before the actual acceptance Covenant Health customers with services that are normally
of employment. and must clearly and accurately set forth the services to be of the commencement of work. All employees (full time, provided by Covenant Health employees.
Executive Leadership, in conjunction with the Board performed, the basis for earning any fee, and the applicable part time and occasional) will be asked to review and sign
of Directors, will investigate circumstances in which a rate or fee. Payments under these agreements must be the Outside Employment/Activities Disclosure Form in Participation in Professional Societies and Vendor
conflict of interest may exist to determine if such conflict reasonable and in an amount that is appropriate for the accordance with procedures outlined in Covenant Health’s Seminars
is detrimental to Covenant Health. If so, appropriate action value of the services rendered. Covenant Health agents, policy on Outside Employment/Activities Disclosure. We encourage employees to broaden their knowledge
will be taken to ensure that the employee disassociates consultants and other third parties are prohibited from Management employees and employed physicians and competence by participating in professional society
himself or herself from the conflicting activity. Failure to do making any payment on behalf of the Company that would are expected to give their full-time effort and energies meetings and seminars. However, since we must be
so will result in termination from employment. be improper when made by a Covenant Health employee. to their priorities at Covenant Health. Therefore, in most careful that payment for this participation, whether in the
Members of the Covenant Health Board of Directors, Federal law limits the cumulative value of gifts and instances, outside employment, including consultation and form of an honorarium or paid travel and lodging, does
Executive Leadership Team, and designated members of other payments to referring sources, including physicians. individual service agreements, is prohibited. In no case will not constitute a conflict of interest with the interests
management will be required to complete a Conflict of Any question about gifts or payments to physicians it be allowed without the express permission of the Chief of Covenant Health or an improper payment, prior
Interest Disclosure Form at least annually or periodically as and referring sources should be directed to the Chief Administrative Officer/President of the operating unit, and approval must be obtained from your manager, Human
requested by the Company. Compliance Officer. Covenant Health’s Executive Leadership Team. Resources and the Integrity-Compliance Office. Under
Upon hire and annually thereafter, employees may It is the policy of Covenant Health to permit its non- no circumstances is it acceptable for payment to include
be required to complete a Conflict of Interest Disclosure Relationships between Covenant Health and Physicians management employees to engage in outside employment a Covenant employee’s spouse or other guests. If the
Form disclosing any activity or significant interest that Federal and state laws and regulations govern or activities (e.g., volunteering or serving on a board) approved activity occurs during your paid work-time, any
may constitute a conflict of interest with Covenant Health. relationships between health care providers and physicians as long as there is no associated conflict of interest honorarium for your participation must be made payable
Approval will be granted to engage in those activities or who may refer patients to health care providers. It is or interference with the employee’s responsibilities to to Covenant Health. If the activity occurs during your
interests that, in the view of Company management, do not important that Covenant staff who interact with physicians Covenant Health. Outside activities, whether with or unpaid time off and Covenant Health does not pay your
create a conflict of interest. (particularly those Covenant staff who make payments to without compensation, must not negatively impact your expenses for the activity, you may retain any honorarium
physicians for services rendered, provide space or services job performance for Covenant Health. For example, an earned for an approved activity. Covenant employees
8 9 The Covenant Health Integrity-Compliance Office
can be reached at 1-865-374-8010 or through the
Integrity-Compliance Report Line at 1-888-731-3115.who are not faculty participants at professional meetings personal political contributions and communicate your Gifts to or from Vendors, Suppliers and Outside It is Covenant Health’s policy to pay travel and lodging
and seminars may not accept compensation for their personal beliefs to candidates and elected officials. Organizations expenses for any vendor-sponsored event. The vendor may
time spent at such events. However, it is against Company policy and may be illegal to: Covenant Health employees and their families cover only training-related expenses and meals offered
Employees who need to attend vendor-sponsored • include, directly or indirectly, any personal political generally are prohibited from soliciting or accepting gifts, during the educational portion of the day. Any exception
training or who must travel to evaluate potential contributions on your expense account, or in any other way loans, entertainment, or anything of value from a person or must be approved by the Chief Compliance Officer.
equipment purchases, etc., must have the travel that causes the Company to reimburse you for that expense; organization that does business or may seek to do business If an outside party offers to enter into such an
approved by their manager, Human Resources and • use Company property or facilities or the work time of with Covenant Health. arrangement, contact the Integrity-Compliance Office to
Integrity-Compliance. If approved, travel, lodging, and Company employees for any political activity, except as You may never offer, give or accept any of the following: determine whether the activity complies with Company
expenses will be paid by Covenant Health. Only expenses approved by executive management; cash or cash equivalents, such as checks, stocks/bonds, policy and the law. Such offers may not be accepted unless
associated with the actual day(s) of training may be paid • use funds of the non-profit business units or of money orders or loans. approved by the chief administrative officer of the entity in
by the vendor. Covenant Health itself to make political contributions. Also, vendors, suppliers, and outside organizations which you work or the Chief Compliance Officer.
If you plan to run for political office of any type, that provide any items or services billable to governmental
Political Contributions and Activities contact the Executive Leadership Team to determine if a health care programs, may not furnish free meals, drinks, or Gifts to or from Patients, Patients’ Family Members, or
While the Company encourages all employees to potential conflict of interest exists. Holding political office other gifts to Covenant Health employees or departments. Physicians
vote and be active in the political process, you may do must not interfere with your job performance or conflict This includes meal or gift offers from pharmaceutical, You may not solicit or accept gifts, tips, or any items
so only during non-work time and as individuals, not with your responsibilities to Covenant Health. device, and equipment manufacturer representatives on or merchandise of value from Covenant Health patients,
as representatives of Covenant Health. You may make and off Covenant Health premises. patients’ family members, or physicians or other outside
The exception to this policy is that occasional gifts of third parties. You may never accept any of the following:
perishable or consumable items offered to a department cash or cash equivalents, such as checks, gift cards, gift
Gifts and Business Courtesies or group (for example, a food basket given to a department certificates, stocks/bonds, money orders or loans.
as a holiday gift) are acceptable when they are part of the Employees or departments may accept occasional gifts
Covenant Health is committed to ensuring that all Permitted Business Courtesies community business standard. These items are not subject of perishable or consumable items only. For example, if a
gifts and business courtesies, given and received, are • Except as otherwise prohibited by this Code of Conduct to any price limitation. patient or patient’s family desires to show appreciation to
appropriate and within the limits of the law. It is your or Covenant Health policy, you are permitted to give There may be times when an individual or organization a department, it is acceptable for them to provide a gift of
responsibility to know and comply with Company policies, individuals other than patients occasional approved gifts of with whom you do business, or are contemplating doing food or a meal for the department during work hours at the
as well as applicable laws and regulations. small value which would not be mistaken for anything other business, extends an invitation to an event such as a meal department’s location.
than a sign of respect or friendship. or sporting or theatrical event, in order to further or develop Other gifts must be reported to your manager, Human
General Principles Note: Expenses for gifts given as a business courtesy a business relationship. It is Covenant Health policy that we Resources, or the Integrity-Compliance office, which will
There are times when offering or accepting gifts by an employee or department of Covenant Health must will not accept such invitations from any outside individual evaluate what action is to be taken with that gift. Integrity-
and business courtesies is appropriate and can create be properly recorded in the appropriate Covenant Health or organization, regardless of the dollar value, without prior Compliance may recommend options such as donating
goodwill and positive working relationships. However, it is books and records. written approval of the senior executive of a Covenant the gift to Covenant Health’s Office of Philanthropy or We
Covenant Health policy that gifts and business courtesies Health entity or the Chief Compliance Officer. Care fund.
not be used to gain special advantage or unduly influence Prohibited Business Courtesies Likewise, expenses for travel costs or overnight lodging Do not offer or provide to a patient who is a
employees, patients, suppliers or others doing business • You may not offer, give or accept gifts, meals, may not be financed by the individual or organization Medicare or Medicaid beneficiary a gift of more than $15
with Covenant Health. entertainment or any item of value that would or might extending the invitation without prior written approval from in value that could be viewed as an inducement for the
The basic principle for accepting gifts, meals or other appear to influence the business decisions of others. the senior executive of the entity or the Chief Compliance patient to choose a particular provider or supplier of any
items of value is: Never accept anything for yourself, a • You may not solicit gifts or business courtesies under any Officer. Under no circumstances will expenses for an item or service paid by a federal healthcare program.
family member, or anyone else that might be viewed as circumstances. employee’s spouse or other guests be covered. Cash or cash equivalents must never be offered. All
actually or potentially influencing your objective judgment • You may never offer, give or accept any of the following: Covenant Health employees and their family such gifts may not exceed $75 in the aggregate on an
on behalf of Covenant Health. cash or cash equivalents, such as checks, stocks/bonds, members may be approached by outside parties such annual basis.
The basic principle for offering or giving gifts, meals money orders or loans. as pharmaceutical manufacturers, computer vendors Certain exceptions can apply; for instance, this
or other items of value is: Never offer or give a gift, meal • You may not participate in contests or gift giveaways or physicians offering cash or other items or services restriction generally does not apply to gifts to Covenant
or other item of value that might be viewed as actually or (such as radio call-in contests) while on duty. of value as an inducement for special treatment or for Health Chaplain’s Funds or other health system patient
potentially intended to influence the objective business • Your friends and family members may not give or accept information related to Covenant Health business activities. assistance funds for current or future patients. Contact the
judgment of anyone with whom Covenant Health does prohibited gifts, meals or entertainment where it may Examples include free seminars in disease management, Integrity-Compliance Office for additional information and
business. appear that you are the intended recipient or giver. offers to provide research data at no cost to Covenant assistance.
As a general rule, gifts or business courtesies may • You may not give or offer any gift, meal or entertainment Health or free travel to attend industry-related meetings.
only be given or accepted on an infrequent basis and that benefits a party indirectly, such as a gift to a person’s You may believe these offers are only to benefit Covenant Relationships Among Covenant Health Employees
only if reasonable and appropriate to the occasion and in family or an organization in which the person/business Health in our business. However, these offers may be unfair We recognize that employees may wish to exchange
accordance with Covenant Health policy and the law. has a personal interest. business practices. gifts of small value that are purchased with personal
10 11 The Covenant Health Integrity-Compliance Office
can be reached at 1-865-374-8010 or through the
Integrity-Compliance Report Line at 1-888-731-3115.funds for special occasions such as birthdays, holidays, These gifts also should not improperly influence or create Employee Information Information Security
weddings, baby showers, or standard calendar observances the appearance of influencing an employee’s decisions Covenant Health will not release confidential Covenant Health employees are prohibited from
for business and healthcare professionals. This is regarding Covenant Health business, or the working employee information without proper authorization, disabling or circumventing any Company security
acceptable, provided that gift giving is voluntary and relationship between employees or between an employee or unless required by law. External inquiries from controls protecting our information systems, such as
follows the General Principles for giving/accepting gifts. and a supervisor. Gift cards are discouraged. a prospective employer or third party conducting passwords, firewalls, encryption, and screen-blanking
background checks regarding an employee’s salary, mechanisms.
Privacy and Security of Information performance information, address and telephone number,
or other employment-related information should be
It is your responsibility to use passwords and security
codes responsibly. You may never participate in or allow
directed to Covenant Health Human Resources. someone else to have unauthorized access to Company
All of us at Covenant Health have a responsibility Covenant Health has adopted very specific privacy Many employees have access to confidential systems, or to confidential information concerning
to safeguard the confidential and private information and security policies, including policies related to employee information in the normal course of business patients, clients, the Company or outside entities.
that is entrusted to us by the Company and those with computer use and electronic communications using (e.g., Social Security numbers, medical information, tax You may never install, download or copy any software,
whom we do business. There are specific laws and mobile phones, personal devices, social media, and other records, banking information and Human Resources files). including any from the internet, unless the software
regulations such as the Health Insurance Portability internet communications, to protect our patients’ personal You must make sure that any time you access or use this is specifically approved and appropriately licensed by
and Accountability Act and its regulations (“HIPAA”) and health care information. For more information about type of confidential employee information, you take the Covenant Health. Furthermore, you may not copy a
that govern safeguarding the privacy of information, the Company’s privacy policies, please contact your local appropriate steps to ensure its confidentiality. software package for use on more than one Company
and we are committed to upholding these requirements. Covenant Health Privacy Officer, the Centralized Privacy Altering your own employee records or the records computer or for use on your personally owned computer
All employees are required to complete an annual Office or the Integrity-Compliance Office. of your family members or fellow employees or any unless you have received specific permission to do so from
confidentiality agreement. other individual for any reason outside your normal job the Company.
The basic principle for safeguarding information Company Information responsibilities is a violation of this Code and Company If you have or use Company mobile computing
is that unless you have specific authorization, do not Confidential information about Covenant Health’s policy. equipment, you should secure the equipment with a
disclose confidential and private information to others, operations and strategies is a valuable Company It is important to remember that Covenant Health security device approved by the Company. When you are
including Covenant Health employees, except on a “need asset. Every employee must protect our organization’s owns all electronic information created by employees not using this equipment, you should keep it in a secure
to know” basis for business or job-related responsibilities confidential and proprietary information from accidental or using Company equipment, and users of such equipment location to avoid theft.
and with the agreement of the recipient to treat the unauthorized modification, destruction and/or disclosure. and Covenant Health information systems shall have The Company has very detailed security policies and
information as confidential and private. If you suspect This includes Covenant Health information in all its forms no expectation of privacy relative to data transmitted, procedures that every employee must follow. If you have
a breach or misuse of patient or Company information, (written, verbal or electronic) that is generally not available accessed, or maintained via such equipment and systems. any questions about information security issues, contact
report such occurrence immediately to your supervisor to or known by the public. Common examples of this type This means the Company has the right to search all the Human Resources department or Integrity-Compliance
and the Integrity-Compliance Office. Employees who of information include business and marketing plans, electronic files, monitor employee phone calls made Office, which will notify the appropriate Executive
fail to comply with policies concerning the privacy and customer lists, sales and marketing data, research and on the premises and review other employee electronic Leadership Team member.
security of information are subject to disciplinary action technical data, strategies, provider fee arrangements, and communication without giving advance notice or obtaining
by the Company, and may be subject to legal action by law information pertaining to our subcontractors, vendors, new an employee’s specific consent to do so. Inside Information
enforcement authorities. products and services. You should also be careful not to If you have any specific questions or concerns Inside information is information about Covenant
Any situation or question regarding the privacy and disclose such information in public places or in situations regarding employee information or employee use of Health or its activities that is not generally available to the
security of patient, employee or Company information that where it might be passed inadvertently to someone else. Covenant Health electronic equipment, please contact public. Examples include physician recruitment activities,
is not covered in this section should be referred to the Information obtained, developed or produced by Human Resources. new products or services, or plans for new acquisitions or
Integrity-Compliance Office. Covenant Health and its employees, and information company mergers, to name a few. You may not disclose or use
supplied by outside consultants or vendors for the benefit Information About Outside Entities confidential Company information for your personal profit or
Patient Information of Covenant Health is confidential. Materials, both written We must also safeguard confidential information advantage, nor for the profit or advantage of anyone else.
Every employee must protect the confidentiality of any and electronic, that have been copyrighted by the Company we receive from or about any other company, including Inside information also can be information about
personal information that identifies a patient, customer or by others must be acknowledged and safeguarded. You our competitors, vendors and providers. You may not other companies that has not been made public. This
or member such as name, date of birth, Social Security are responsible for knowing and complying with Company use confidential or proprietary information from other information can be misused if it could be viewed as
number, or medical information. Do not use, disclose policy that restricts the use of these materials. companies or individuals without specific written a factor in determining whether or not to trade in a
or discuss with others such confidential information Should you end your employment or contractual authorization. While you may obtain information about an company’s stock. It is a violation of law to use inside
unless it is necessary to serve the patient, customer or relationship with the Company, you may not take any outside entity that is publicly available, this information information or to provide such information to someone
member, or is required by law. In accordance with federal confidential or proprietary Company information with you, may be used only when it is appropriate and does not else in order to purchase or sell stock, and you may not
and state privacy and security laws regarding Protected nor disclose confidential information to persons who do violate any applicable law or Covenant Health policy. buy or sell stock, bonds, options or other securities based
Health Information (“PHI”), confidential information may not have a need to know that information. Nor may you use If you have any question about how or when to use on inside information.
only be released to persons authorized by law or by the Company information for your own personal gain or for the or disclose information about another entity, consult the This policy applies to securities transactions by
appropriate written authorization. gain of another person or company. Chief Compliance Officer before acting. directors, employees and agents, and their immediate
12 13 The Covenant Health Integrity-Compliance Office
can be reached at 1-865-374-8010 or through the
Integrity-Compliance Report Line at 1-888-731-3115.You can also read
