Code of Conduct Compliance. Quality. Integrity.
Cape Cod Healthcare
Mission. Vision. Values.
Our Mission | The reason we’re here.
To coordinate and deliver the highest-quality, accessible health services, which enhance the health of all Cape Cod residents and visitors. What began as a community hospital over 100 years ago with the creation of Cape Cod Hospital, has grown to become Cape Cod Healthcare, a comprehensive and sophisticated healthcare system that has expanded medical care across Cape Cod and beyond. Today, with two acute care hospitals, seven Urgent Care centers, a Level III trauma center, a primary and specialty care network, homecare and hospice services, a skilled nursing and rehabilitation facility, an assisted living facility and numerous health programs, Cape Cod Healthcare has become a commu- nity leader providing exceptional care for those who live in or visit this unique region. It takes a special team to fulfill this mission, and our team lives up to and supports our mission continually.
Cape Cod Healthcare | Code of Conduct
Table of Contents Introduction Messages . ....................................................................... 1 Training Requirements ........................................................................ 3 (A) Employees (B) Physicians (C) Monitoring Workplace Environment ...................................................................... 4 (A) Non-Discrimination (B) Anti-Harassment (C) Violent Behavior/Illegal Activities (D) Environmental Safety Anti-Trust Laws and Competitive Conduct .................................... 5 (A) Physicians (B) Employees (C) Examples of Potentially Anti-Competitive Conduct Suppliers and Competitors ................................................................. 6 Physician Recruitment . ....................................................................... 6 Kickback .................................................................................................. 7 No False Claims . ................................................................................... 8 Research Compliance .......................................................................... 8 (A) Research Misconduct (B) CCHC’s Institutional Review Board Emergency Services and Patient Transfers . .................................. 9 Conflict of Interest .............................................................................. 10 (A) Employees (B) Non-Employed Physicians Confidential Information . .................................................................. 10 (A) General Obligations (B) Confidentiality of Patient Information Social Media ......................................................................................... 11 Skilled Nursing . ................................................................................... 11 Clinical Laboratory .............................................................................. 11 Assets and Resources ........................................................................ 11 Documentation (Proper recording) ................................................. 12 Political Contributions . ...................................................................... 12 Gifts, Favors and Entertainment ..................................................... 13 Fundraising ........................................................................................... 13 Government Investigation ................................................................. 14 Record Retention ................................................................................ 15 Reporting Requirements . .................................................................. 15 (A) Reporting (B) Non-Retaliation Compliance Reviews and Audits . ................................................... 16 Enforcement and Discipline ............................................................. 16 Acknowledgement ............................................................................... 17 Corporate Compliance Office ........................................................... 17
Our Vision | The goal as we look ahead to a promising future. We will be the health service provider of choice for Cape Cod residents and visitors by achieving and maintaining the highest standards in healthcare delivery and service quality. To do so, we will partner with other health and human service providers as well as invest in needed medical technologies, human resources and clinical services. Above all, we will help identify and respond to the needs of our community. In pursuit of excellence The healthcare industry continues to evolve every day. We continually seek ways to navigate and adjust to these changes. Strategic clinical affiliations with entities like Beth Israel Lahey Health, Boston Children’s Hospital, Dana-Farber Cancer Care Collaborative and others have supported our mission by enabling us to advance the breadth and depth of our clinical services while remaining an independent healthcare system. The Barbey Pavilion at Cape Cod Hospital is a transformative step which redefines future clinical care on the Cape with advanced, specialized medicine. Investments in state-of-the-art technology, accessible and modern facilities and the expert team that comprises Cape Cod Healthcare are key facets in our evolution. Our commitment to our community is at the core of everything we do — we will continue to work alongside community partners to identify the Cape’s greatest health needs and help improve the health, well-being and quality of life for all in our region. Our Values | The principles that guide every aspect of our work. Compassion – To be compassionate, respectful and professional in the way we deliver care Quality – To be relentless in pursuing the highest standard of quality through continuous improvement, emphasizing the power of teamwork Transparency – To be honest, ethical and open in all our relationships Resourcefulness – To be responsible stewards of the community’s resources by working efficiently and cost-effectively Inclusion – To serve all without regard to sex, race, creed, residence, national origin, sexual orientation or ability to pay
Cape Cod Healthcare | Code of Conduct
A Message from CCHC President and CEO and the Chairperson of the Board
A Message from the Chief Compliance Officer
Welcome to Cape Cod Healthcare’s Code of Conduct. As a valued member of our team—whether you serve within one of our affiliates, service lines, or clinical departments—your commitment to ethical behavior and legal compliance is essential to our mission. This Code outlines the standards we expect all employees, physicians and representatives to uphold. It is your responsibility to read, understand and follow the provisions of the Code, as well as any supplemental policies and procedures specific to your role or the CCHC affiliate for which you work. The Code is designed to align with CCHC’s broader policies and procedures. In the event of any inconsistency, the standards in this Code will take precedence and should guide your actions. If you ever have questions about how to interpret or apply the Code—or any other CCHC policy—I encour- age you to speak with your supervisor, manager or reach out directly to the Corporate Compliance Office. Physicians are also expected to comply with the Code in accordance with applicable laws, Medical Staff governance documents and professional ethical standards. Ethical and compliance-related concerns are best addressed early. If you are involved in business dealings or decisions that raise questions, please consult the Compliance Office proactively. If you witness or suspect any activity that may be criminal, fraudulent or otherwise unethical, you are obligated to report it using the procedures outlined in this Code. CCHC strictly prohibits retaliation against anyone who reports concerns in good faith. Together, we can maintain a culture of integrity, accountability and excellence in everything we do.
Dear Colleagues, At Cape Cod Healthcare, our commitment to excellence begins with integrity. As a healthcare system dedicated to serving our community with compassion and professionalism, we must hold ourselves to the highest standards of ethical and lawful conduct. This Code of Conduct is more than a policy document—it is a reflection of our shared values and a guide to help each of us navigate the responsibilities we carry in our roles. Whether you work within one of our hospitals, an affiliated practice or a specialized service line, you play a vital role in upholding the trust our patients and partners place in us. It is your responsibility to read, understand and follow the provisions of this Code, along with any additional compliance policies and procedures specific to your area. These standards apply to all of us—employees, physicians, contractors and representatives, and failure to comply may result in disciplinary action. If you ever have questions or concerns, I encourage you to speak with your supervisor or our Chief Compliance Officer. Open communication and early consultation are key to maintaining a culture of accountability and respect. Thank you for your continued dedication to our mission and values. By embracing this Code and living it out in your daily work, you help ensure that Cape Cod Healthcare remains a trusted, ethical and patient-centered organization. I am proud to work alongside you in service to our community.
Sincerely,
Sincerely,
Michael Main Vice President, Chief Compliance Officer
Robin Devereaux Chairperson of the Board
Michael K. Lauf, MBA President and Chief Executive Officer
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Training Requirements To ensure that all employees and physicians understand their compliance obligations, Cape Cod Healthcare (CCHC) has established a comprehensive compliance training program. (A) Employees • New Employees : All new employees, including employed physicians, receive compliance training during orientation. Training covers the Code’s goals, standards and objectives, and introduces CCHC’s Compliance Program. Each new employee must sign a written acknowledgement agreeing to abide by the Code. • Active Employees: All employees must complete follow-up compliance training at least once per year. Training may be delivered through live sessions, recordings, webcasts, written materials, mandatory education modules or interactive computerized modules. • Mandatory Participation: Annual compliance training is required and is part of each employee’s performance evaluation. Additional training may be assigned based on role, disciplinary needs or remedial action plans. (B) Physicians • Non-Employed Physicians: Encouraged to participate in CCHC’s compliance training programs. Whenever possible, training will be offered for risk management credits required for licensure and reappointment. • Medical Staff Requirements: Compliance education is mandatory for all physicians—employed or non-employed— as part of initial credentialing and ongoing reappointment. Additional training may be required to meet government obligations. • Commitment to the Code: Non-employed physicians must agree to abide by the Code and compliance policies as part of credentialing. (C) Monitoring • The Chief Compliance Officer (or designees) is responsible for developing, coordinating and monitoring all compliance training sessions. • Written records of all training sessions and attendance must be maintained to ensure accountability.
Workplace Environment Cape Cod Healthcare (CCHC) is committed to maintaining a healthy, safe and productive environment for employees, physicians, vendors, patients and visitors. Everyone must comply with all applicable federal, state and local health and safety laws.
(A) Non-Discrimination • Treat all individuals with honesty, dignity and respect. • Discrimination or exclusion based on race, color, national origin, citizenship, religion, creed, sex, sexual orientation, gender identity, age or disability is prohibited. • Remarks, gestures, slurs or jokes that demean others are not tolerated. (B) No Harassment or Sexual Misconduct • CCHC prohibits all forms of harassment, sexual misconduct and abusive behavior. • Conduct that creates a sexually intimidating or offensive environment will not be tolerated. • Racial, religious or disability-related slurs are strictly prohibited. • Retaliation against individuals who file complaints or cooperate in investigations is forbidden and may result in termination. • Questions about policies or complaint procedures should be directed to the Senior Vice President of Human Resources.
(C) Violent Behavior and Illegal Activities • Violence or threats of violence are prohibited on CCHC property. • Firearms or weapons may not be possessed or stored in any facility. Report violations immediately to a supervisor or the Executive Director of Security . • Alcohol, illegal drugs or controlled substances may not be possessed, used or distributed on CCHC property. • Employees may not work or remain on premises while impaired or intoxicated, except to seek medical assistance. • Alcohol may be permitted at approved events but must be consumed responsibly and in moderation. • CCHC may investigate suspected misconduct, including theft, drug or weapon possession, or other prohibited activities. Employees must cooperate fully in such investigations. (D) Environmental Safety • CCHC is committed to clean, safe and accessible facilities and to sound environmental practices. • Report hazardous conditions immediately to a supervisor, the Director of Facilities or the Chief Compliance Officer . • Hazardous substances, medical waste and infectious materials must be handled and disposed of safely and lawfully. • Employees must be familiar with and prepared to implement relevant safety and emergency procedures.
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Anti-Trust Laws and Competitive Conduct Cape Cod Healthcare (CCHC) is committed to full compliance with federal and state antitrust laws, which are designed to preserve fair competition and protect the competitive process. Free and open competition ensures patients receive better care and more efficient services at lower cost.
Suppliers and Competitors
Cape Cod Healthcare (CCHC) is committed to treating everyone it does business with honestly and fairly.
• No Misrepresentations: Never misrepresent CCHC’s business, services or practices. Correct misunderstandings promptly. • Fair Comparisons: Ensure that any comparisons with competitors are accurate and fair. • Cost and Pricing Data: When disclosure is required by law, provide current, accurate and complete cost or pricing information. • Contract Proposals and Negotiations: All data used in proposals, negotiations or shared with supervisors, employees, customers or suppliers must be accurate, complete and relevant.
(A) Physicians • Non-employed physicians should consult their own legal counsel before engaging in any activity that could be construed as anti-competitive. • All physicians practicing within CCHC are expected to comply with antitrust laws at all times. (B) Employees • Employees, including employed physicians, must comply fully with antitrust laws in carrying out CCHC’s business. • Violations can result in substantial penalties, including fines and imprisonment, imposed on both CCHC and individuals. (C) Examples of Potentially Anti-Competitive Conduct Certain agreements or conduct that restrict competition may be illegal, including: • Price fixing or agreements to divide markets. • Setting predatory prices to drive competitors out of business. • Boycotts or agreements with suppliers/distributors not to deal with competitors. • Conditioning the sale or lease of one product on another (tying/bundling). • Reciprocal dealing arrangements. Employees must consult and obtain prior written approval from the Chief Compliance Officer or Chief Legal Officer before considering any arrangement that could raise antitrust concerns.
Business Conduct Guidelines • Do not suggest boycotts or refusals to deal with competitors, suppliers, payors or contractors. • Termination of long-time suppliers or payors must be reviewed in advance with Compliance or Legal. • Competitor information should be obtained only through proper, publicly available channels—not directly from competitors or through improper means. • Avoid discussing pricing, payor lists, costs, profits, market shares, distribution practices or other proprietary information with competitors. • If a competitor raises such topics, object immediately, end the discussion and report the incident to the Chief Compliance Officer or Chief Legal Officer.
Physician Recruitment
• Recruiting and retaining physicians at Cape Cod Healthcare (CCHC) requires strict compliance with applicable laws, including the Anti-Kickback Statute , the Stark Law and IRS rules governing the tax-exempt status of CCHC and its affiliates. • Written Agreements: All recruitment packages and commitments must be documented in writing and consistent with CCHC’s established guidelines and policies. • Legal Review: New or unique recruitment arrangements must be reviewed and approved in writing by the Chief Compliance Officer and/or Chief Legal Officer before becoming binding. • Acceptable Support: Support for new physicians is permissible if: - There is a documented need for the physician’s specialty in CCHC’s service area. - Compensation is reasonable and consistent with fair market value. - Support is provided to encourage relocation, not tied to referral volume or value. • Income Guarantees: These present special compliance issues and must be reviewed and approved in writing by the Chief Legal Officer. • Employed Physicians: Compensation arrangements must remain consistent with fair market value. For highly compensated individu- als, terms must be reviewed and approved by the Compensation Committee of the Board of Trustees .
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Kickback
No False Claims It is illegal to submit false claims for reimbursement. Cape Cod Healthcare (CCHC) strictly prohibits any employee, provider or representative from knowingly presenting—or causing to be presented—a false or fraudulent claim to patients, Medicare, Medicaid, other government health programs or private payors. Likewise, no false statements or records may be used to obtain reimbursement. Standards for Claims All claims must: • Be submitted only when services were actually provided and medically necessary. • Accurately reflect charges for services rendered. • Properly document the procedures performed. • Comply with all applicable regulatory requirements. Examples of Violations • Billing for services not rendered or inaccurately described. • Billing for services that were not medically necessary or appropriate. • Falsifying plans of care or Certificates of Medical Necessity. • “Upcoding” diagnoses or entering false/misleading information to obtain excessive or impermissible payments. Training and Reporting • Personnel involved in preparing or submitting claims will receive ongoing training, including mandatory annual updates. • If you suspect improper claims are being submitted to Medicare, Medicaid, other government programs or private payors (e.g., Blue Cross), you must report the concern to the Chief Compliance Officer.
Research Compliance
Cape Cod Healthcare (CCHC) participates in Medicare, Medicaid and other government healthcare programs, and must comply with strict federal and state laws governing referrals and financial arrangements.
CCHC is committed to advancing medicine and medical technologies while ensuring strict compliance with ethical and legal standards. (A) Research Misconduct • All employees, medical staff, students, fellows, guest researchers and collaborators must report observed, suspected or apparent research misconduct immedi- ately to the Chief Compliance Officer. • If uncertain whether an incident qualifies as miscon- duct, consult the Chief Compliance Officer. • Cooperation in reviews, investigations and corrective actions is required. (B) Institutional Review Board (IRB) The IRB oversees all human subject research at Cape Cod Hospital, Falmouth Hospital, affiliated practices and ancillary facilities. Responsibilities include: • Ensuring compliance with applicable laws and regulations. • Providing education and training on ethical require- ments and CCHC research policies. • Managing conflicts of interest for IRB members and investigators. • Acting as the Privacy Board for research conducted within CCHC. Medicare and Billing Compliance • Medicare has specific requirements for coverage of clinical trial services. • The Chief Compliance Officer works with research staff, coders and patient accounts to ensure billing practices meet Medicare and other payor requirements. • Regular reviews prevent submission of claims for: - Items/services paid for by research sponsors. - Non-covered items under Medicare. - Trials that do not qualify as “qualified clinical trials.”
Anti-Kickback Laws • These laws prohibit offering, soliciting or receiving money or any benefit in exchange for patient referrals or to induce the purchase of goods or services. CCHC policy strictly forbids: • Offering or receiving anything of value to induce patient referrals or purchases. • Routine waivers of co-payments or deductibles. • Any arrangement that could be perceived as a bribe, kickback or rebate.
Prohibited Practices Examples of violations include: • Paying physicians or referral sources to induce patient referrals. • Compensating physicians for duties not actually performed. • Failing to require contracted physicians to devote time to agreed duties. • Paying compensation above fair market value. • Terminating contracts based on referral volume. • Providing grants, directorships, consulting or marketing agreements intended to generate referrals. Oversight and Documentation • All agreements involving compensation or referrals must be in writing and approved by CCHC’s legal counsel before becoming binding. • Arrangements are subject to periodic review to ensure compliance and fair market value. Guidance and Reporting Because this is a complex area of law, employees must exercise caution in transactions involving referral sources, healthcare providers or suppliers. Consult CCHC policies, the Chief Compliance Officer or the Chief Legal Officer for guidance. If you suspect an improper arrangement or violation of law, report it immediately to the Chief Compliance Officer or Chief Legal Officer.
Stark Law (Physician Self-Referral) The Stark Law prohibits:
• Physicians from referring patients for certain desig- nated health services to entities in which they or their family members have a financial interest. • Entities like CCHC from billing for services provided as a result of prohibited referrals. • CCHC requires strict compliance with the Stark Law in all physician financial arrangements.
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Emergency Services and Patient Transfers Cape Cod Healthcare (CCHC) provides emergency care to all individuals, regardless of ability to pay, at Cape Cod Hospital and Falmouth Hospital. Medical Screening & Care • Every patient must receive a prompt medical screening exam. • Emergency care cannot be delayed to assess insurance or financial status. • Patients with emergency medical conditions—including active labor, psychiatric disturbances or acute substance use—must be treated until stabilized. Transfers • Transfers of unstable patients are permitted only if a physician certifies the benefits outweigh the risks, the receiving hospital is qualified and has agreed to accept, and appropriate space is available. • Prior to transfer, necessary treatment must be provided to minimize risks, including care for pregnant individuals and unborn children. • Transfers must be performed by qualified personnel with appropriate transportation, life support measures and complete medical records sent to the receiving facility. Reporting Requirements • Suspected inappropriate transfers must be reported immediately to a supervisor, the Chief Compliance Officer or the Chief Medical Officer. • Receiving hospitals must report suspected violations within 72 hours. • On-call physicians who fail to appear in a timely manner to provide stabilizing treatment must also be reported.
Conflict of Interest
Confidential Information
CCHC employees and physicians must always act in the best interests of the organization, our patients and our mission—not for personal gain. Employees Employees (including employed physicians) must avoid interests, influences, or relationships that conflict—or appear to conflict—with CCHC’s best interests. This applies to their own interests, those of immediate family members and anyone acting on their behalf. Examples of potential conflicts include: • Employment, directorship or ownership in a CCHC competitor, supplier or payor • Consulting relationships with competitors, suppliers or payors • Outside business activities that compete with CCHC • Significant outside activities that impair job performance • Supervising or evaluating a close relative, significant other or household member Any such relationships or activities must be disclosed in writing to a supervisor or manager. When in doubt, consult the Compliance Officer or disclose the interest. Employed Physicians Physicians must also avoid interests or relationships that conflict— or appear to conflict —with CCHC’s best interests, including those of immediate family members. Examples include: • Employment, directorship or ownership in a competi- tor, supplier or payor • Consulting relationships with competitors, suppliers or payors • Outside activities that could inappropriately affect— or appear to affect — responsibilities at CCHC Such relationships or activities must be disclosed in writing to the Chief Compliance Officer. When uncer- tain, physicians should consult the Chief Compliance Officer or err on the side of disclosure.
Cape Cod Healthcare (CCHC) requires all employees, medical staff and representatives to safeguard Confidential Information at all times. Confidential Information includes non-public business, financial, patient, fundraising and marketing information, as well as personnel records, salary and benefit data, and patient-specific information. These obligations continue even after your relationship with CCHC ends. General Obligations • Do not disclose Confidential Information outside CCHC without written authorization. • Use Confidential Information only for legitimate CCHC business purposes, never for personal gain. • Avoid discussing Confidential Information in public or with unauthorized individuals (including family or friends). • Protect confidential and proprietary information provided by third parties (vendors, partners) with the same care. Patient Information • CCHC is committed to protecting patient privacy under HIPAA , the HITECH Act and applicable state and federal laws. • Employees, medical staff and business associates must comply with CCHC’s privacy and security policies and the standards in its Notice of Privacy Practices . • Medical records and Protected Health Information (PHI) must only be accessed, used or disclosed as permitted by law and policy. • Any suspected data breach or unauthorized disclosure of PHI must be reported immediately to the Chief Compliance Officer , Privacy Officer or Chief Legal Officer . • All personnel are required to cooperate fully in investi- gations of such matters.
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Social Media When your social media content or public statements reflect an affiliation with Cape Cod Healthcare (CCHC), you must not: • Post harassing, defamatory or discriminatory comments about co-workers or colleagues. • Reference any CCHC patient or patient condition. • Imply that you are authorized to speak on behalf of CCHC (all statements must be personal). • Share CCHC confidential or proprietary information. • Publish false or misleading content about CCHC, its executives, employees, physicians, patients or services. • Use CCHC logos, trademarks or images of its facilities, employees, or representatives. Skilled Nursing • As a Medicaid-participating skilled nursing facility, the JML Care Center must comply with the federal Nursing Home Reform Act (NHRA) , which estab- lishes standards for resident quality of life, required services, management of personal funds and other resident rights. These requirements are enforced by both the state Medicaid agency and the federal government. • Any deficiencies related to NHRA compliance should be reported promptly to the Chief Compliance Officer or JML’s Executive Director so corrective action can be taken. JML and CCHC are committed to strict com- pliance with all state and federal licensing requirements and to maintaining the dignity of every patient. • Effective June 14, 2012 , JML implemented its own Corporate Compliance and Ethics Program to prevent and detect criminal, civil and administrative violations and to promote quality care for residents and families. This program supplements and aligns with CCHC’s Code of Conduct. More information is available from JML’s Executive Director or Chief Compliance Officer.
Clinical Laboratory
Documentation (Proper recording) Cape Cod Healthcare (CCHC) requires strict compliance with generally accepted accounting principles and established internal controls in recording all assets and transactions. • No Undisclosed Funds or Assets: Secret or unrecorded accounts are prohibited. • Honest and Accurate Reporting: All transactions—including payments, expense accounts, time records, and reimbursement requests—must be recorded truthfully, timely and completely. False or misleading entries are strictly forbidden. • Supporting Documentation: Payments on CCHC’s behalf must be supported by adequate documentation and used only for the purposes reflected in that documentation. • Prohibited Practices: Employees and providers may not engage in undisclosed or unrecorded transactions, falsify or conceal information, create false documents, or participate in bribes, kickbacks or political contributions on CCHC’s behalf. • Accountability: Failure to promptly report violations of these standards to the Chief Compliance Officer may result in disci- plinary action, up to and including termination. Political Contributions • Cape Cod Healthcare (CCHC) conducts all fundraising through the Cape Cod Healthcare Foundation (“the Foundation”). The Foundation is responsible for complying with all state and federal registration, record-keeping and reporting requirements. • All solicitations of charitable contributions for CCHC must be carried out under the Foundation’s supervision and direction. No employee, physician or other individual is authorized to use CCHC’s name in fundraising activities unless the Foundation has provided prior approval. • It is strictly prohibited for any employee or representative to make false, deceptive or misleading statements in connection with fundraising or the sale of goods or services benefiting CCHC. In addition, federal law generally prohibits the use or disclosure of patient Protected Health Information (PHI) for fundraising purposes without the patient’s written authorization. Employees must consult with CCHC’s Privacy Officer before initiating any fundraising activities that could involve PHI.
• In October 1998, Cape Cod Healthcare (CCHC) established a service-line specific compliance program for its clinical laboratory services (“C-Lab”). The program was created to ensure the quality of C-Lab’s services and to prevent and detect illegal or unethical activities involving patients, customers and referring physicians. • The C-Lab compliance program is designed to supplement and remain consistent with CCHC’s overall Code of Conduct. More information about the program is available from C-Lab’s Compliance Officer.
Assets and Resources
• CCHC’s materials, supplies, facilities and equipment must be used solely for CCHC business purposes. Employees may not use CCHC resources—including the internal email system—for personal convenience or profit during work time. • All staff are expected to comply with CCHC’s policies on social media use during work hours. Use of CCHC assets for any unlawful or improper purpose is strictly prohibited. • Bribes, kickbacks or similar payments or remunera- tion may never be offered or accepted in connection with CCHC business.
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Gifts, Favors and Entertainment Employees and representatives of Cape Cod Healthcare (CCHC) must not accept anything of value from individuals or organizations doing business with CCHC—or whose services are subject to CCHC’s review—if the gift or favor is, or could appear to be, offered in exchange for favorable treatment.
Government Investigation Cape Cod Healthcare (CCHC) will cooperate fully with government investigations, but all cooperation must be coordinated through appropriate CCHC representatives and legal counsel. Government inquiries often arise from complaints that agencies are legally obligated to investigate. While the government has the right to conduct investigations, CCHC has the right to insist that they be carried out in an orderly, proper and lawful manner. If you are contacted in connection with an investigation, you should: • Confirm the investigator’s identification and obtain a business card. • Determine the general subject of the inquiry without providing details, documents or data. • Immediately contact CCHC’s Chief Legal Officer, who is available 24/7 through the Cape Cod Hospital operator, to determine next steps. The following is a list of some of the state and federal agencies that might be involved in an investigation at CCHC: • United States Department of Justice (DOJ) • United States Department of Health and Human Services (HHS) • Federal Bureau of Investigation (FBI)
• Nominal Items Only : Acceptable items of nominal value include pens, notepads, mugs or similar promotional items generally priced under $100. • Meals and Entertainment: May be accepted only if unsolicited, infrequent, reasonable in scope and cost and directly connected to legitimate business discussions. • Travel and Lodging: Reimbursement or compli- mentary lodging/travel requires advance written approval from your supervisor or manager. Discounts or promotional premiums available to the general public (not specific to CCHC employees) may be accepted. Fundraising • Cape Cod Healthcare (CCHC) conducts all fund- raising through the Cape Cod Healthcare Foundation (“the Foundation”). The Foundation is responsible for complying with all state and federal registration, record-keeping and reporting requirements. • All solicitations of charitable contributions for CCHC must be carried out under the Foundation’s super- vision and direction. No employee, physician or other individual is authorized to use CCHC’s name in fundraising activities unless the Foundation has provided prior approval.
• When in Doubt: If accepting a gift or favor could cause embarrassment to you or CCHC if publicly disclosed, decline it and consult your supervisor or the Chief Compliance Officer. • Bribes and Kickbacks: Offers of money or anything of value that could be viewed as a bribe or kickback must be refused and promptly reported to the Chief Compliance Officer.
• Massachusetts Board of Registration in Medicine • Massachusetts Department of Public Health (DPH) • Office for Civil Rights (OCR) • United States Department of Labor (DOL) • Medicare Administrative Contractors/DMERCs (MACs) • Massachusetts Medicaid Fraud Control Unit (MFCU) • United States Attorney’s Office (USAO) • Massachusetts Board of Registration in Nursing
• HHS Office of the Inspector General (OIG) • Occupational Safety and Health Administration (OSHA) • United States Coast Guard • Drug Enforcement Administration (DEA) • Massachusetts Attorney General’s Office
• It is strictly prohibited for any employee or representa- tive to make false, deceptive or misleading statements in connection with fundraising or the sale of goods or services benefiting CCHC. In addition, federal law generally prohibits the use or disclosure of patient Protected Health Information (PHI) for fundraising purposes without the patient’s written authorization. Employees must consult with CCHC’s Privacy Officer before initiating any fundraising activities that could involve PHI.
• You are not obligated to speak with investigators if you choose not to, and you are entitled to have representation present. CCHC will arrange for the Chief Legal Officer or another appropriate representative to attend any interview or meeting at no cost to you, even if you are no longer employed by CCHC. • Under no circumstances should you destroy, alter or falsify records; provide misleading information or attempt to influence others to do so. Such actions may result in civil or criminal penalties for both CCHC and individuals involved. • If employees, physicians, suppliers or members of the press inquire about an investigation, do not discuss the matter. All press inquiries must be referred to the Chief Legal Officer, and the only appropriate response is to direct questions to that office. • Finally, nothing in this Code of Conduct prevents you from communicating directly with government authorities to make a good faith report of suspected violations of law or regulation, or from testifying or participating in legal proceedings related to such matters.
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Record Retention Cape Cod Healthcare (CCHC) has established a Record Retention Policy to ensure compliance with legal requirements, maintain accessibility of critical records and minimize the costs of record keeping and handling. The policy defines which records must be maintained, the length of time they are retained and the proce- dures for storing and controlling them. For purposes of this policy, the term “records” is broadly defined. It includes all forms of documentation and data, such as correspon- dence, memoranda, notes, drafts, publications, invoices, ledgers, journals, notebooks, diaries, accounts, reports, surveys, statistical compilations, work papers, calendars, appointment records, voice recordings, computer servers and backup tapes, disks, flash drives, portable media, printouts and any other written or recorded information. A copy of the Record Retention Policy is maintained within the CCHC APPS under the “Record Retention” section of policies and procedures. Reporting Requirements Cape Cod Healthcare (CCHC) requires all employees and medical staff to promptly report any suspected criminal, fraudulent or illegal activity, or any conduct that violates the Code of Conduct. Concerns involving senior leadership—including the President/ CEO, CFO, Chief Legal Officer or Chief Compliance Officer—must be reported directly to the Chairperson of the Board of Trustees. Ignoring or concealing a possible violation is never acceptable, as silence may allow misconduct to continue or worsen.
How to Report?
Compliance Reviews and Audits The Chief Compliance Officer is responsible for coordinating periodic internal compliance reviews and audits, including those identified through CCHC’s Risk Assessment Policy. These reviews examine CCHC’s adherence to legal require- ments, internal policies and procedures designed to detect areas of concern, as well as business practices that may pose legal risks. CCHC personnel are expected to fully participate and cooperate in these reviews under the direction of legal counsel, the Chief Compliance Officer or external consultants engaged by CCHC. At the conclusion of each review, findings are reported to the Chief Compliance Officer shared with senior management as appropriate and presented to the Compliance Committee for further review and action.
Reporting Options • Chief Compliance Officer: Call 508-862-5621, email complianceoffice@capecodhealth.org, or written report (anonymous or named) via internal mail or U.S. mail. • Third-Party Vendor (Navex): Confidential, anony- mous reports by phone (1-800-892-9205), online at capecodhealthcare.ethicspoint.com or via mobile intake at capecodhealthcaremobile.ethicspoint.com. • Internal Channels: Speak with your supervisor, any CCHC Officer or a member of the Chief Compliance Officer (oral or written, anonymous or named). • All reports are reviewed promptly, shared with the Chief Compliance Officer, and addressed by the Compliance Committee. The Chief Compliance Officer provides updates to the Board of Trustees at each meeting. Non-Retaliation Cape Cod Healthcare (CCHC) is committed to ensur- ing that all individuals feel safe and comfortable raising concerns or asking questions about the Code of Conduct, CCHC policies or applicable laws. Retaliation of any kind against someone who makes a good faith compliance report will not be tolerated. A good faith report means that, to the best of the reporter’s knowledge, the information provided is accurate, truthful and complete. Any individual who retaliates—or attempts to retaliate— against someone who has reported a compliance issue in good faith will be subject to disciplinary action, up to and including termination, in accordance with CCHC policies and applicable law. Similarly, knowingly making a false accusation, or being uncooperative or untruthful during an investigation, will also result in disciplinary action, which may include termination.
Enforcement and Discipline
Cape Cod Healthcare (CCHC) enforces the compliance standards outlined in this Code, related policies, procedures and training materials. When violations occur, CCHC will take timely and appropriate corrective action to prevent recurrence. Responses may include: • Individual discipline or termination • Additional or remedial training and communications • Policy or billing changes • Disclosure to payers, including government programs • Return of inappropriate payments Discipline may also be imposed for failing to detect or report an offense. The type and level of discipline will reflect the seriousness of the circumstances, investigation findings and will remain consistent with applicable laws and CCHC policies.
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Acknowledgement CCHC views your actions under the Code as key indicators of your judgment and professional competence. • Compliance with the Code and related policies affects your eligibility for employment or privileging. • Adherence is also considered in decisions about compensation and promotions. • You are required to acknowledge that you have received, read and understood the Code. • These acknowledgments become a permanent part of: - Personnel records for employees - Credentialing files for non-employed Medical Staff across the system
Corporate Compliance Office Contacts • Chief Compliance Officer: 508-862-5621 | 508-360-1906 • Corporate Compliance Office: complianceoffice@capecodhealth.org • Compliance Reporting Line: 1-800-892-9205 (confidential voicemail) • CCHC Corporate Disclosure Program website: capecodhealthcare.ethicspoint.com
17 | Cape Cod Healthcare
12.2025 | CCHC
1.2026 | CCHC
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