CC-160103303-2021-02-Code of Conduct Brochure-FIN | Page 14


Patient Care Standards

Patient Rights and Responsibilities
We consider our patients ’ families our partners in their child ’ s care . We encourage respect for the personal preferences and values of each individual . Patients and / or families have rights and responsibilities that are posted throughout the Children ’ s Colorado locations , on the intranet PPRR brochure - English ; PPRR brochure - Spanish , on childrenscolorado . org .
We respect the rights of patients , parents , and / or legally authorized representatives to make healthcare decisions . When clinical decisions are in conflict and a choice needs to be made , patients , families , and team members can request an ethics consultation with the Ethics Committee 24 / 7 via the hospital operator ( 720-777-1234 ) or OneCall ( 720-777-3999 ).
Admission , Transfer , Discharge / Non-Discrimination
We admit , transfer , and discharge patients based on medical appropriateness . We do not discriminate against patients or their visitors on the basis of age , race , ethnicity , national origin , ancestry , sex , creed , religion , pregnancy , disability ( mental and physical ), marital status , genetic information , gender expression , sexual orientation , veteran status , insurance status , ability to pay , or other protected classification to the extent required by relevant laws . ( Non-Discrimination of Patients )
Patient Safety
We commit to a culture of safety through our behaviors , initiatives , and programs . We strive to provide our patients , families , team members , visitors , and community with a safe environment in which to heal , work , and visit . We focus on the continuous enhancement of safety and improvement of patient care by the identification , analysis , and reduction of risks .
Informed Consent
We adhere to our General and Informed Consent policy that defines who can legally provide consent and outlines the informed consent process . Our policy provides clarification of procedures that require informed consent in compliance with Colorado Consent Law and other various regulatory and accrediting bodies . ( Consent : General and Informed )
Emergency Medical Treatment and Labor Act ( EMTALA )
EMTALA is a federal law that governs the treatment of all individuals and / or transfer of an individual who presents to a hospital that participates in federal and state healthcare programs , regardless of the individual ’ s insurance status or ability to pay .
EMTALA requires Children ’ s Colorado to conduct a Medical Screening Exam ( MSE ) on all patients who present to an Emergency Department to assess whether an Emergency Medical Condition ( EMC ) exists . EMTALA also applies if an individual presents anywhere on hospital property if the individual requests examination or treatment for an EMC , or if a prudent layperson observer would believe that the individual is suffering from an EMC . If a patient is determined to have an EMC , EMTALA requires Children ’ s Colorado to stabilize the patient and treat the EMC ( e . g ., a pregnant woman in labor or an adult experiencing a Code Blue event ). If Children ’ s Colorado is unable to stabilize a patient within its capability , or if the patient requests , an appropriate transfer to another facility will be implemented . ( EMTALA — Emergency Medical Treatment and Labor Act )
CODE OF CONDUCT CHILDREN’S HOSPITAL COLORADO Fraud, Waste and Abuse continued Compliance and Business Ethics (CaBE) False Claims Purpose/Infrastructure The False Claims Act aims to deter fraudulent billing. It is used to discipline health care providers who knowingly submit false claims or knowingly make false statements to Medicare, Medicaid, or other federal health care programs, or knowingly retains an overpayment more than 60 days. The Act provides for civil penalties of at least $5,500 per claim up to $11,000 per claim, plus three times the amount of damages, and potential exclusion from participation in Medicaid and other health care programs. Colorado and most other states where Children’s Colorado’s patients live also have state laws prohibiting the submission of false claims. The False Claims Act includes a qui tam (whistleblower) provision that allows a private person to bring a lawsuit in the name of the United States if he or she has personal knowledge of a false claim. The claim must be presented to the government, which has 60 days to decide whether to intervene and pursue the action. If the government declines to proceed, the individual may independently pursue legal action. The Exclusion Authorities The Office of the Inspector General (OIG) has authority to exclude individuals from participating in federal health care programs, including Medicaid, for various reasons. Generally, federal health care programs will not pay for items or services furnished, ordered, prescribed, or supplied by an excluded individual or entity. We routinely conduct exclusion checks to ensure vendors, team members, and applicants are not prohibited from participating in federal or state healthcare programs. (Background Checks) The Civil Monetary Penalties Law The Civil Monetary Penalties Law authorizes the OIG to impose civil penalties for violations of the Anti-Kickback Statute and the Stark Law as well as a range of other violations. These violations include, but are not limited to, the following: • Submitting false claims • Failing to provide an adequate medical screening examination for patients who present to a hospital emergency department with an emergency condition or in labor • Making false statements on applications or contracts to participate in a Federal health care program CaBE supports Children’s Colorado activities in accordance with Children’s Colorado’s mission, values and ethical and legal obligations. CaBE is tasked with ensuring all Children’s Colorado team members and those providing services on behalf of Children’s Colorado understand the important role they play in Children’s Colorado’s compliance efforts and what they must do to adhere to rules and regulations set forth by governing agencies and to uphold this Code of Conduct. CaBE activities are intended to be constructive and provide Children’s Colorado with an opportunity to prevent and detect noncompliant behavior, to resolve noncompliant conduct, and to take actions necessary to prevent future noncompliance. Primary oversight of Children’s Colorado's CaBE efforts rests with the Children’s Colorado Board of Directors. The Board has delegated day-to-day operational responsibilities for CaBE to the Corporate Compliance Officer and the Corporate Compliance team. (Corporate Compliance) Open Lines of Communication for Reporting Concerns CaBE promotes adherence to applicable federal, state, and local laws as well as Children’s Colorado’s policies and procedures. If you have concerns regarding a potential violation of any law, regulation, policy, and/or procedure, you are expected to take action. Reports can be made anonymously and securely. Children’s Colorado has a non-retaliation policy meaning there will be no retaliation or corrective action against any team member who reports a suspected violation in good faith. (Corporate Compliance Hotline) How to report a concern: • Consult with your direct supervisor/manager. • Speak with the next level of management such as your department or division head. • Call the Compliance and Business Ethics Program (720-777-2566). • Call the Compliance Hotline which is available 24/7 (1-866-568-5420). • Report through the Compliance Hotline via the intranet ( Communication, Training and Education Response and Prevention CaBE offers educational trainings regarding various compliance issues to team members throughout the year. In addition, all team members are required to complete initial compliance training during new hire orientation, and annual refresher compliance training. Violations of the law, Children’s Colorado policies, and the principles of our Code of Conduct will not be excused or tolerated for any reason. Appropriate corrective action will be taken by Children’s Colorado to address incidents of non- compliance, which may include disciplinary action against any individuals responsible for misconduct. Auditing and Monitoring CaBE conducts or directs periodic audits of departments to assess compliance with laws, regulations, standards, and policies. Occasionally, external auditors assist with the auditing process. While Corporate Compliance and leadership develop an annual auditing and monitoring plan, additional audits can be performed as needed. Audit results are provided to key stakeholders and involved personnel when appropriate. 14 Responsible Conduct of Research The Research Compliance Office, a part of CaBE, devotes itself to upholding the highest standard of ethical principles and research integrity to ensure that research abides by applicable federal laws, regulations, state codes, and institutional policies governing human subject research. Research Compliance strives to foster a commitment to ethical and legally compliant conduct so that the clinical research enterprise embodies Children’s Colorado’s mission and values. 15