2014 catholic health orientation
DESCRIPTION
New associates to Catholic Health must review this presentation before attending orientation.TRANSCRIPT
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This material must be reviewed prior to attending your General Orientation class.
Please ask any related questions at your General Orientation class.
Welcome to the 2014 Welcome to the 2014 Catholic Health System Catholic Health System Online Orientation Component Online Orientation Component
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Leonardo Sette‐Camara, Esq Compliance &Privacy Officer
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To prevent, find and correct violations of CHS standards, governmental laws, regulations and rules
To promote honest, ethical behavior in the day-to-day operations
To understand the ethical, professional, and legal obligations associates have and our role in meeting those obligations
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As healthcare professionals and providers, we are dedicated to caring for and
improving the health and well being of the people we serve in the community
Compliance means “doing the right thing”
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Attain compliance by:
Embracing our Mission and Values
Adherence to Policies and Procedures
Found in Compliance 360
Maintaining high standards of business and ethical conduct
Delivering high quality patient care
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Standards of Conduct & Ethical ConductDeal openly and honestly with othersMaintain high standards of conduct in accordance to the CHS Mission, directives of the Catholic Church, and applicable federal, state and local laws and regulations
Conflict of InterestWe have a responsibility to act on the best interests of Catholic Health. We need to avoid situations that lead to actual or perceived conflicts of interest
Documentation and BillingMust be accurate and complete
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Associate Compliance Guidebook
Provides information on the Standards of Conduct and is available on CHS website.
An observation of failure to follow Standards of Conduct, Policies or Procedures, or observation of an error requires reporting.
Associates can face disciplinary action and even termination for failure to report such events.
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All associates are expected to follow standards for
Legal and Regulatory Compliance
Business Ethics
Conflict of Interest
Appropriate Use of Resources
Confidentiality
Professional Conduct
Responsibility
And follow the Code of Ethics
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Enhance the Patient Experience
Have a questioning attitude
Pay attention to details
Follow the rules
Be accountable for your actions
Providing high quality services
and upholding patient rights
supports the Compliance Program.
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Compliance policies and procedures are available on
Compliance 360 (or in an on-site reference manual)
and apply to all CHS associates.
Additional compliance policies are also applicable to:
Home Care
Clinical Laboratory
Physician Practices
Nursing Facilities
Coding and Billing
Home Health Agency
PACE Program
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It is fraudulent to either document services that were
not performed or to submit claims for services without
appropriately documenting those services
Missing clinical notes (dates, signatures, orders, care or service rendered) or test resultsIncomplete or illegible documentsImproper billing and coding
can be interpreted as fraud or abuse and lead to a false claim with the government resulting in penalties
Reimbursement can only be sought for services or itemsthat have been provided and appropriately documented.
If it’s not documented, it’s not done.
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It is a crime to knowingly make a false record, file, or
submit a false claim with the government for payment.
A false claim can include billing for service that:
Was not provided or documented
Was not ordered by a physician
Was of substandard quality
Improperly coded or billedIt is also unlawful to improperly retain overpayments.Allows for Qui Tam Relator – notification to
government with protection (Whistleblower provision)
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Government Sanctions
Individuals or entities can be excluded from participation in Medicare and Medicaid programs.
CHS must not submit any claims to Medicare and/or Medicaid in which a sanctioned individual or entity provided care or services.
If an associate/provider is sanctioned,he/she must provide notification immediately
to the Compliance Officer.
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If working on behalf of CHS, do your actions or activities
result in personal gain or advantage, potential adverse
effect for CHS or the potential to interfere with professional
judgment, objectivity or ethical responsibilities?
Potential Conflicts of Interest Relationships includefinancial relationship for yourself or your
immediate familymember or secondary employment
ConsultantSpeakers’ BureauAdvisory PanelAdministrative positions with Pharm or DMEThird Party PayorOther entities doing business with CHS
All potential Conflicts of Interest must be reported.
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Associates may NOT accept any cash gifts or cash equivalent gifts (gift cards) from any person or business conducting or seeking to conduct business with CHS
Prior to receiving work-related
Gifts
Social or entertainment events
Free meals
Associates must consult with their supervisor.
See CHS Policy for further information.
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Ensures that limited English proficiency or hearing impaired persons utilizing CHS services are able to understand and communicate with CHS associates and physicians
Provided FREE of charge to the patient
Mandatory service by law
Documentation is vital to compliance
Language Assistance Program Policy is found in Compliance 360
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HEALTH
INSURANCE
PORTABILITY
ACCOUTABILITY
ACT
and HITECH
Health/Information Technology for Economic and Clinical Health Act
Privacy and Security Policies are found in Compliance 360
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Individually identifiable health information
Also known asProtected Health Information
(PHI)
Transmitted or maintained in any form or medium
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NamesFull face photosMedical Record NumberHealth Plan NumberAccount NumbersCertificate/License NumbersVehicle IdentifiersE-mail and web addresses
Biometric IdentifiersGeographic subdivisions smaller than a stateAll elements of dates related to birth date, admission, discharge, or date of death, ages over 89Telephone and fax numbersSocial Security Number
Any other unique identifying data
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Be aware of surroundingsBe conscious of who is in the immediate area when discussing sensitive patient information or at your computer terminal (lower your voice)
Secure area when not attendedClose out of computer screens containing PHI before leaving the areaClose medical records/chart when not in useDo not allow other associates to utilize your ID and passwordReport theft or loss of computer devices immediately
Correct Disposal of PHI (shred bin)
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TelephonesBe careful with phone call pertaining to patient information
Fax Machines and ScannersPick up faxed or printed PHI immediatelyUse fax cover sheet, verify # and receiptScan PHI only to CHS e-mail accounts
E-MailMake sure to encrypt if being sent outside CHSCareful forwarding and replying
MailDouble check name/address and material prior to sending
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Curiosity can be a normal human trait …
However accessing health information on yourself, family members, friends, co-workers, persons of public interest or any others that you are not involved in the care of or
Disclosing PHI inappropriately
Are … VIOLATIONS of HIPAA
Individuals do NOT have the right to look up their own health records.
Your computer use can be monitored.
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Fraud and Abuse
Fraud Defined: An intentional deception or misrepresentation that could result in some unauthorized benefit to a person or Catholic Health
Abuse Defined: Practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary cost, or in reimbursement of services that are not medically necessary or that fail to meet professionally recognized standards for health care
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Documentation issues
Improper billing and coding
Offering or receiving kickbacks, bribes, or rebates
The service has not been rendered by the identified provider, to the identified person, or on the identified date
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Lack of integrityEthical incidentsTheft or misuse of servicesImproper political activityBreech of corporate confidentialityImproper use of proprietary informationEnvironmental health and safety issuesDishonest communication (spoken or documents)Improper business arrangementsFailure to follow Record Retention policyReceipt of incentives for patient referrals
The Associate Guidebook or your supervisor can provide additional info.
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Immediate supervisor or appropriate department
Higher level manager
Compliance OfficerNancy Sheehan, Esq.
821-4469
Also available 24/7Compliance Line 1-888-200-5380
Confidential and Anonymous (if desired)
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Behavior issues
Human Resource policy violations
Union contract matters
… Should be reported to Human Resources
Policies on Compliance 360 include:
Corrective Action
Fair Treatment Review
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Protects associates from adverse action when they do the right thing and report a genuine concern
Reckless or intentional false accusations by CHS associates are prohibited
Reporting the possible violation does not protect the constituent from the consequences of their own violation or misconduct
Associates have a duty to report HIPAA/Compliance concerns
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Upholding CHS Mission and Values
Adhering to Code of Conduct, Policies and Procedures and the Law
Completing education and employment requirements
Constant monitoring for concerns
Duty to report concerns and support non-retaliation
During an investigationBe truthful
Preserve documentation or records relevant to ongoing investigations
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For associate and CHS managers/supervisors/administrators
Fines and Prison sentences
Corrective action - Includes termination of employment for violations or failure to report concerns
For Catholic Health System
Exclusion from government funded insurance programs (Medicare/Medicaid)
Fines
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Putting words into action …
“We judge ourselves based on our intentions … Others judge us based on our actions.”
Adhere to the CHS code of conduct, policies and procedures, and other standards
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Duty to report Compliance/HIPAA concerns as soon as aware of situation
Do the right thing …
Apply ethical decision making
If uncertain …
Always Seek Knowledge (A.S.K.)
Use Associate Booklet on CHS website as a reference
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Compliance/HIPAA Privacy Officer Nancy Sheehan, Esq 821-4469
CHS HIPAA Hotline 862-1790
Compliance Hotline 1-888-200-5380 (available 24/7)
All reports are confidential.
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Risk Management is the
systematic review of events
that present a potential for
harm and could result in
loss for the system.
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Review Identification
Review Occurrence Reports
Review Patient/Visitor Complaints
Participate in Root Cause Analysis
Review concerns expressed by CHS staff
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Loss Prevention
Educational programs through CHS University
Department specific in-services
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Claims Management
Investigating and reporting occurrences and claims made to insurance carriers
Assist with discovery requests for lawsuits
Process Summons, Complaints and Subpoenas
** NOTIFY RISK MANAGEMENT IMMEDIATELY UPON RECEIPT
OF A WORK RELATED SUMMONS OR SUBPOENA
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Claims Management - Continued
Within CHS, a process server is to be directed to Administration of the facility
in order to serve a Summons or Subpoena. (HIM may accept subpoenas for hospital records.)
*** INDIVIDUAL DEPARTMENTS SHOULD NOT ACCEPT, EVEN IF IT IS FOR SOMEONE IN THE DEPARTMENT.
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Risk Financing
Obtaining and maintaining appropriate insurance coverage:
HPL (Healthcare Professional Liability)
GL (General Liability)
D&O (Directors and Officers)
Property and Casualty
Auto
Crime
Fiduciary (Finance)
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An occurrence is an event that
was unplanned, unexpected and
unrelated to the natural course of
a patient’s disease process or
routine care and treatment.
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Patient harm/potential harm like falls, medication errors
Visitor injury
Patient related equipment “failure”
Security issues like elopement, crime, altercations
Lost or damaged property
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Enhance the quality of patient care
Assist in providing a safe environment
Quick notice of potential liability
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Any associate or physician who discovers,
witnesses or to whom an occurrence is reported,
is responsible for documenting the event
immediately by means of the
Occurrence Report.
Anyone who requires assistance should contact
the department manager.
DO NOT MAKE COPIES OF AN
OCCURRENCE REPORT.
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The completed Occurrence Report
is to be forwarded to
the Department Manager
who will investigate the occurrence
and forward to Quality & Patient
Safety Department who will
forward to Risk Management.
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Patient and visitor safety are assessed from both clinical and environmental perspectives
Notify Quality & Patient Safety of patient occurrences
Notify Security of visitor or property occurrences
Risk Management will be notified and will participate in evaluation of occurrence
Risk Management will report occurrences to insurance carrier in cases of potential liability
Risk Management will manage claim as indicated
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Date (MM/DD/YY) and time (military)
State facts, be clear and concise
Your own observations
If event described to writer, use quotes or “according to …”
Do not place blame in the record
DO NOT REFER TO OCCURRENCE REPORT IN THE MEDICAL RECORD
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EMTALA is the Emergency Medical Treatment and Active Labor Act (aka COBRA)
EMTALA provides a guideline for safely and appropriately transferring patients in accordance with Federal regulations.
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The law provides for a medical screening exam (MSE) to all individuals seeking emergency services on hospital property. Hospital property includes the driveway, parking lot, lobby,
waiting rooms and areas within 250 yards of the facility.
If an emergency medical condition is found, it will be stabilized within the hospital’s ability to do so, prior to the
patient’s transfer or discharge.
If a patient does not have an emergency medical condition, EMTALA does not apply.
*** IMPORTANT: NEVER SUGGEST THAT
A PATIENT GO ELSEWHERE FOR TREATMENT
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Fair and Accurate Credit Transactions Act of 2003
or“RED Flag Rules”
Hospitals that maintain covered accounts must develop and implement written
policies and procedures to identify, detect, prevent, and mitigate identity theft.
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Alerts, notifications, warnings
Presentation of suspicious information
Suspicious activity
Notice from patient, law enforcement, etc.
** Patient Access, Health Information, Finance, I.T. departments primarily involved.
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You can help reduce opportunities
for Identity Theft by keeping
PHI confidential and out of public view.
If you believe someone is presenting
suspicious documents or acting in a
suspicious manner, notify your supervisor
who will notify Risk Management.
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Carol Ahrens, RN, BSN 821-4462Director, Risk Management
Joanne Ricotta, RN, BSN 821-4463Risk Management Coordinator
Linda McGavin 821-4467Risk Management Technical Assistant
Amy Maurer 821-4468Legal Services Administrative Assistant
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Violence can have a negative effect on an organization as reflected by:
Low morale
Increased job stress
Increased worker turnover
Reduced trust of management or co-workers
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Contact with violent people or those with history of violence
Contact with those under the influence of drugs and/or alcohol
Contact with people having psychotic diagnoses
Contact while transporting patients
Contact with people perceiving a long wait for service
Working alone
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Watch for signals of impending violence:
Verbally expressed anger and frustration
Body Language such as threatening gestures
Signs of drug or alcohol use
Presence of weapons
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Assess current demeanor when you enter a room or begin to relate to a patient or visitor
Be vigilant throughout the encounter
Don’t isolate yourself with a potentially violent person
Keep an open path for exiting
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NIOSH (National Institute for Occupational Safety
and Health) defines workplace violence as violent
acts (including physical assaults and threats of
assaults) directed toward persons at work or on
duty.
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Threats: Expressions of intent to cause harm, including verbal threats, threatening body language, and written threats.
Physical Assaults: Attacks ranging from slapping and beating to rape, homicide, and use of weapons such as firearms, bombs, or knives.
Muggings:Aggravated assaults, usually conducted by surprise and with intent to rob.
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Workplace violence in hospitals usually results
from patients and occasionally from family
members who feel frustrated, vulnerable,
and out of control.
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Violence takes place
During times of high activity such as meal time or visiting hours or patient transportation
When service is denied
When a patient is involuntarily admitted
When limits are set regarding eating, drinking, tobacco use or alcohol use
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Hospital personnel having direct contact with
patients and families are at increase risk.
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An elderly patient verbally abused a nurse and pulled her hair when she prevented him from leaving the hospital to go home in the middle of the night.
An agitated psychotic patient attacked a nurse, broke her arm, and scratched and bruised her.
A disturbed family member whose father had died in surgery walked into the E.D. and fired a handgun, killing a nurse and an EMT and wounding a physician.
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Anywhere in the hospital, but it is most frequent in the following areas:
Emergency Departments
Any Critical Care area
Waiting Rooms
Geriatric Units
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Violence can have a negative effect on an organization as reflected by:
Low morale
Increased job stress
Increased worker turnover
Reduced trust of management or co-workers
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Contact with violent people or those with history of violence
Contact with those under the influence of drugs and/or alcohol
Contact with people having psychotic diagnoses
Contact while transporting patients
Contact with people perceiving a long wait for service
Working alone
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Watch for signals of impending violence:
Verbally expressed anger and frustration
Body Language such as threatening gestures
Signs of drug or alcohol use
Presence of weapons
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Assess current demeanor when you enter a room or begin to relate to a patient or visitor
Be vigilant throughout the encounter
Don’t isolate yourself with a potentially violent person
Keep an open path for exiting
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Present a calm, caring attitude
Don’t match the threats
Avoid giving commands
Acknowledge a person’s feelings
Avoid behavior that may be interpreted as aggressive
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Remove yourself from the situation
Call Security or 911 for HELP if needed
Report any potential or actual violent incidents to your department manager
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No universal strategy exists to prevent violence
All hospital workers should be alert and cautious when interacting with patients and visitors
Staff need to be aware of polices and procedures relating to violence prevention
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Obesity: Understanding, Awareness, and Sensitivity
Catholic HealthOrientation
2013
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Consequences of ObesityPsychological and Social Well-Being
Negative Self-ImageDiscriminationCan be difficult to maintain personal hygieneDepressionTurnstiles, cars, and sitting may be too smallDiminished sexual activity
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Social Discrimination
Studies show society has a low respect for morbidly obeseMay have limited number of friendsMay experience social rejectionHave poor quality in relationships
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Weight Bias in Healthcare
What assumptions do I make based only on weight regarding a person’s character, intelligence, professional success, health status, or lifestyle behaviorsCould my assumptions impact my ability to care for these patients?Do I only look at their weight problem, and not other health related issues?
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Challenge the Bias
Lead by example: influence peers and others to demonstrate patient sensitivity, become a good role model.Don’t tolerate behind-the-back whispers, jokes, even in private.If no one questions obesity bias, what will ever stop it?
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Strategies for Healthcare
Consider that patients may have had negative experiences with other healthcare professionals regarding their weight; approach patients with sensitivity.Recognize that many patients have tried to lose weight repeatedly.Acknowledge the difficulty of lifestyle changes.
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Our RoleWe need to care for both physical and emotional needs.Support and encouragement are so important.Compassion and empathy must be conveyed.Communication and listening skills are essential.Smile, look at the person, do not ignore a patient because of their obesity.
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Catholic Health SystemsEmployee Breastfeeding Support
Catholic Health SystemsEmployee Breastfeeding Support
Overview
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Support of Breastfeeding is a Priority
Reduced Risk for Infants with Exclusive Breastfeeding 1,
2
ObesityEar InfectionsRespiratory InfectionsAsthmaGastrointestinal InfectionsAtopic DermatitisType 1 & Type 2 DiabetesLeukemiaSudden Infant Death SyndromeNecrotizing Enterocolitis
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Public Health Case
Breastfeeding is the standard for infant feeding and protects infants and children from many significant infectious and chronic diseases. $13 billion of direct pediatric health-care costs and more than 900 lives would be saved annually if 90% of women were able to breastfeed exclusively for six months as recommended.2
Women who breastfeed have a reduced risk of breast and ovarian cancer, type 2 diabetes, postpartum depression, and cardiovascular disease.3-5
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Work Remains a Barrier to Breastfeeding6-10
Full-time employment decreases breastfeeding duration by an average of more than eight weeks.Mothers are most likely to wean their infants within the first month after returning to work.Only 10% of full-time working women exclusively breastfeed for six months.Catholic Health is a leader in supporting breastfeeding moms in the workplace.
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If a mother chooses to breastfeed, she needs to pump breast milk during the workday in order to maintain her milk supply.
Missing even one needed pumping session can lead to decreased milk production and other undesirable consequences.
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Women Need Worksite Lactation Support11
Breaks for lactation are similar to other work breaks for attending to physical needs:
Time to eat/drink, restroom breaks, accommodation for health needs (e.g., diabetes)
When mother and child are separated for more than a few hours, the woman must express milk. Missing even one needed pumping session can have undesirable consequences:
Discomfort – Leaking – Inflammation Infection – Decreased Milk ProductionBreastfeeding Cessation
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How to Support Breastfeeding Employees
In general, women need 30 minutes (15 to 20 minutes for milk expression, plus time to get to and from a private space and to wash hands and equipment) approximately every 2 to 3 hours to express breast milk or to breastfeed.Needs may vary from woman to woman and over the course of the breastfeeding period.
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Business Case11
Lactation programs are cost-effective, showing a $3 return for every $1 invested. By supporting lactation at work, employers can reduce turnover, lower recruitment and training costs, cut rates of absenteeism, boost morale and productivity, and reduce health-care costs. Lactation accommodation is not one-size-fits-all. Flexible programs can be designed to meet the needs of both the employer and employee.
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Breastfeeding = Increased Productivity11
Breastfeeding reduces illness of the baby = fewer absences of parent employees = immediate return on investment.Breastfeeding support in the workplace helps families meet their breastfeeding and childrearing goals = higher job satisfaction, increased loyalty, increased ability to focus on job responsibilities, higher return to work postpartum, and lower turnover = immediate return on investment.Breastfeeding prevents chronic disease in women who breastfeed and contributes to a healthier future workforce through reduction of obesity and chronic disease = long-term payoff that keeps on giving.
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Fair Labor Standards ActSection 7 of the Fair Labor Standards Act was amended effective March 2010:
Employers are required to provide “reasonable break time for an employee to express breast milk for her nursing child for 1year after the child’s birth each time such employee has need to express the milk.”
Employers are also required to provide “a place, other than a bathroom, that is shielded from view and free from intrusion from coworkers and the public, that may be used by an employee to express breast milk.”
Legal Basis
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Common Concerns of Breastfeeding Mothers 11
ModestyTime and social constraintsLack of supportMaking enough milk for their babies
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ResourcesWhat resources are available for managers?
Catholic Health Policy on Lactation (Compliance 360)Identify location within your department for your associate – talk with your manager about a room for your useDirect associates with specific breastfeeding/personal advice regarding lactation can call 862-1939
What resources are available for employees?Baby Café at SistersMercy and Sisters Hospital Lactation DepartmentEducational materials, professional support.
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References (1-6)
1. Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D, Trikalinos T, Lau J. (Tufts-New England Medical Center Evidence-based Practice Center). Breastfeeding and maternal and infant health outcomes in developed countries. Evidence Report/Technology Assessment No. 153. Rockville, MD: Agency for Healthcare Research and Quality; 2007 Apr. AHRQ Publication No. 07-E007. Contract Nu. 290-02-0022. 415 pp. Available from: http://www.ahrq.gov/Clinic/tp/brfouttp.htm
2. American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-41.
3. Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the in the United States: A pediatric cost analysis. Pediatrics. 2010;125(5): e1048-56.
4. Schwarz EB, Ray RM, Stuebe AM, Allison MA, Ness RB, Freiberg MS, Cauley JA. Duration of lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol. 2009;113(5):974-82.
5. Gunderson EP, Jacobs DR, Chiang V, et al. Duration of lactation and incidence of the metabolic syndrome in women of reproductive age according to gestational diabetes mellitus status: A 20-year prospective study in CARDIA—The Coronary Artery Risk Development in Young Adults Study. Diabetes. 2010;59(2):495-504.
6. Fein B, Roe B. The effect of work status on initiation and duration of breast-feeding. American Journal Public Health. 1998:88(7): 1042-46.
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References (7-12)
7. Cardenas R, Major D. Combining employment and breastfeeding: Utilizing a work-family conflict framework to understand obstacles and solutions. J Bus Psychol. 2005; 20(1): 31-51.
8. Galtry J. Lactation and the labor market: Breastfeeding, labor market changes, and public policy in the United States. Health Care Women Int. 1997;18(5): 467-80.
9. Texas Department of State Health Services. WIC Infant Feeding Practices Survey, 2009.
10. United States Breastfeeding Committee. Workplace Accommodations to Support and Protect Breastfeeding. Washington, DC: United States Breastfeeding Committee; 2010. Available from: http://www.usbreastfeeding.org/Portals/0/Publications/Workplace-Background-2010-USBC.pdf
11. Department of Health and Human Services (U.S.). The Business Case for Breastfeeding. Steps for Creating a Breastfeeding Friendly Worksite: Bottom Line Benefits [Kit]. US Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau. 2008. HRSA Inventory Code: MCH00254. Available from: http://www.womenshealth.gov/breastfeeding/programs/business-case/index.cfm
12. US Department of Labor. Break Time for Nursing Mothers. [Online]. 2010. Available from: http://www.dol.gov/whd/nursingmothers
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Social Media Policy ReviewSocial Media is defined as user generated content that is shared over the internet via technologies that promote engagement, sharing and collaboration. It includes, but is not limited to social networking sites such as Facebook, LinkedIn, Flickr and Twitter, personal websites, news forums and chat rooms. Catholic Health recognizes social media as an avenue for self-expression. Associates must remember that they are personally responsible for the content they contribute and should use social media responsibly. Catholic Health’s human resources policies – including its equal employment opportunity and sexual harassment/non-harassment policies – and its policies on patient confidentiality/HIPAA, apply to associates’ on line conduct.
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Social Media Policy Review, cont.1. Follow Catholic Health values, Code of Conduct and policies in all social media usage.
Know and follow the Catholic Health code of conduct, which is available online at http://www.chsbuffalo.org/AboutUs/Policies/Standards and the Catholic Health Conduct Principles and Corrective Action Policy. Behavior related to social media must comply with all Catholic Health policies, including any Confidentiality Agreements, HIPAA policies and rules of practice, discrimination and harassment policies, computer use policies and any other policies that govern the content or manner of your social media usage.
2. Carefully consider what you post. You are personally responsible for the content you publish on blogs, wikis or
any other form of user-generated media. Be mindful that what you publish may be public for along time. If you're about to publish something that makes you even a little uncomfortable, reconsider whether the publication is a good idea and whether it violates any Catholic Health rules. If you are unsure or have questions, discuss it with your manager or Human Resources prior to posting the information. Ultimately, you have sole responsibility for what you post and publish in any form of online social media. If your social media activity shows that you have exercised poor judgment in such activities, or if your activities in social media violate any Catholic Health policies, Catholic Health take legal or disciplinary action against you.
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Social Media Policy Review, cont.
3. Representation of Catholic Health on any social media site is subject to approval.
Anyone creating a presence on any social media outlet for the purpose of representing an entity of Catholic Health should first gain approval from the Communications and Marketing Department. This will ensure that the organization as a whole is aware of all official communication efforts of its facilities, departments, and associates. No Catholic Health associate or stakeholder should create any presence (user or group), or post material to any website as a representative of any Catholic Health entity without authorization. 4. Affiliation with Catholic Health must be disclosed. Every website, “fan page” or other online destination that is controlled by Catholic Health must make that fact known to users and must be authorized according to internal protocols
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Social Media Policy Review, cont.5. Identify your opinions as your own and not those of Catholic Health.
Associates must use appropriate disclaimers when using social media. If you choose to identify yourself as affiliated with Catholic Health, or if you identify your role at Catholic Health, you should write in the first person. You must make it clear that you are speaking for yourself and not on behalf of Catholic Health. Use a disclaimer such as “The postings on this site are my own and don't necessarily represent Catholic Health’s positions, strategies or opinions." 6. Do not disclose private, confidential or proprietary information.
Do not provide confidential information regarding Catholic Health, our business, patients, associates or affiliates. Know and follow the Catholic Health privacy policy. 7. Abide by federal and state laws.
Do not violate federal and state laws, including discrimination, harassment, bullying, copyright, fair use and financial disclosure laws.
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Social Media Policy Review, cont.
8. Be respectful. Associates must not use any form of social media to harass, bully, coerce, intimidate or retaliate against other Catholic Health associates or anyone affiliated with Catholic Health. Associates must not post anything that is false, obscene, defamatory, libelous, threatening or abusive whether in word, images or audio, about Catholic Health or anyone affiliated with the organization including other associates. Lastly, speak respectfully about our current, former and potential customers, partners, associates, and competitors. 9. Be professional. If you choose to identify yourself as a Catholic Health associate or affiliated person, ensure that your profile and related content is consistent with how Catholic Health requires you to represent yourself when interacting with colleagues and clients. If you have joined Catholic Health recently, be sure to update your social profiles to reflect our code of conduct guidelines.
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Social Media Policy Review, cont.10. Do not engage in solicitation.
Do not advertise for a third party on Catholic Health’s social media pages or when referencing Catholic Health. See also Catholic Health’s Solicitation policy, HR 106, which applies to activity in relation to social media. 11. Associates may not use any Catholic Health social media site to gain access to contact lists or names to be used for any purpose that would violate federal or state laws or any Catholic Health policy. 12. Do not post photographs taken on Catholic Health property without the consent of the individuals in the photos or if the information in the photos is confidential, patient information, proprietary, offensive as outlined in Catholic Health’s Media Policy, CHS CM 001. 13. Do not post malignant materials.
Do not post materials that contain software viruses, worms, disabling code, or any other computer code, files or programs designed to interrupt, destroy or limit the functionality of any computer software or hardware or telecommunications equipment.
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Social Media Policy Review, cont.14. Think twice before “connecting.”
Carefully consider whether connecting to other Catholic Health associates, customers, donors, medical staff, volunteers, board members, independent contractors, affiliates, vendors, business partners, or competitors via social media is appropriate for your level, position, and responsibilities. Not everyone wants to be your “friend,” and it may be awkward to refuse to “friend” or to “unfriend” a co-worker, customer or business associate or to learn overly personal information about such people (or for them to learn overly personal information about you). To the extent that you do connect via social media with people affiliated with Catholic Health, consider using available privacy filters or settings to block any inappropriate, unprofessional, or overly personal information about you from such people. Associates in supervisory or managerial roles should be especially mindful of appropriate boundaries. 15. Use of Catholic Health e-mail address.
Associates should not use their CH e-mail addresses to register for social media unless use of social media on behalf of Catholic Health is required by or directly related to the associate’s job. Associates may reference their Catholic Health employment and contact information on professional networking sites, such as LinkedIn.
Access to social media is prohibited for non-exempt associates during work time unless job related.
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Social Media Policy Review, cont.Catholic Health reserves the right to host or sponsor internal or external social media sites for its own business purposes. Unauthorized access to or editing of any Catholic Health sponsored social media site is strictly prohibited.
By posting content on any Catholic Health social media site, you grant to Catholic Health the right to reproduce, distribute, or publish such content and the right to create derivative works from your content, edit or modify such content and use such content for any Catholic Health purpose.
Associates have no right to privacy with respect to any information sent, received, created, accessed, obtained, viewed, stored or otherwise found at any time on Catholic Health’s computer network or using Catholic Health’s electronic equipment. Conduct that violates other policies would also be prohibited through social media. Associates are encouraged to report known or suspected violations of any policy to their supervisor or Human Resources. Human Resources will investigate a claim in the same fashion as if the associate made a complaint directly to HR. See also Discrimination and Harassment policy, HR 016. Associates who violate this policy will be subject to corrective action, up to an including termination of employment. See also HR 011, Conduct Principles and Corrective Action. Catholic Health may monitor any social media activity of individuals covered by this policy if there is reason to believe that a policy or legal violation has occurred as well as in connection with Human Resource investigations. Catholic Health reserves the right to edit or remove posts that violate this policy.
The Uninsured Expected Payment and Healthcare
Assistance Policy
Policy
The policy divided is into three distinctThe policy divided is into three distinctsections that grant different rights to patientssections that grant different rights to patientsbased on the following Catholic Healthbased on the following Catholic Healthministries:ministries:
Acute CareAcute Care Continuing CareContinuing Care Home HealthcareHome Healthcare
Acute Care
All uninsured patients of Catholic Health receivingAll uninsured patients of Catholic Health receivingtreatment at one of the Catholic Health’s acute caretreatment at one of the Catholic Health’s acute carefacilities who are residents of New York State, a contiguousfacilities who are residents of New York State, a contiguousState or the state of Ohio, excluding the following services:State or the state of Ohio, excluding the following services: - Non-Medically Necessary Elective Services (e.g. - Non-Medically Necessary Elective Services (e.g.
cosmetic surgery),cosmetic surgery), - Long term level of care services (Sub-Acute or Skilled - Long term level of care services (Sub-Acute or Skilled
Nursing),Nursing), - Physician services other than Catholic Health primary - Physician services other than Catholic Health primary
care physician services, andcare physician services, and - Medical equipment and supplies- Medical equipment and supplies
Continuing CareContinuing Care
Continuing Care:Continuing Care:
All residents of Catholic Health receiving treatmentAll residents of Catholic Health receiving treatment
at one of the Catholic Health’s Long Term Careat one of the Catholic Health’s Long Term Care
facilities (Hospital and Non Hospital Based) thatfacilities (Hospital and Non Hospital Based) that
are subject to insurance co-payments orare subject to insurance co-payments or
deductibles and Adult Home residents may deductibles and Adult Home residents may
be eligible for charity care.be eligible for charity care.
Home HealthcareHome Healthcare
Home Healthcare:Home Healthcare:
All patients that receive services within theAll patients that receive services within the
Catholic Health Home Care divisionCatholic Health Home Care division
(Certified Agencies, Licensed Agencies, and (Certified Agencies, Licensed Agencies, and
Infusion Pharmacy) may be eligible for Infusion Pharmacy) may be eligible for
Charity Care.Charity Care.
Acute Care Section Policy and Procedures
All patients registered as uninsured (i.e., thoseAll patients registered as uninsured (i.e., thosewithout insurance, also often referred to as self without insurance, also often referred to as self pay) will pay) will automatically be enrolledautomatically be enrolled in the in the Healthcare Assistance Program. An optional Healthcare Assistance Program. An optional application form will be offered at time of application form will be offered at time of registration, but failure to complete the application registration, but failure to complete the application will not exclude enrollment. As such, uninsured will not exclude enrollment. As such, uninsured patients presenting for care at a Catholic patients presenting for care at a Catholic Healthcare acute care facility Healthcare acute care facility need do nothingneed do nothingto applyto apply for healthcare assistance. for healthcare assistance.