Code of Conduct

Our Commitment to Integrity

Our Code of Conduct (Code) is our pledge to serve those who depend on Majestic Home Health ’s services. It is our promise to honor this commitment with integrity through quality care, service excellence, responsible stewardship, and respectful teamwork. The Code lays out the ethical and legal standards that help us live up to our values and do what is right.

How to Use Our Code

Our Code is designed to be a resource for when you need information about our policies, procedures or standards, or when you are dealing with a difficult ethics or compliance situation.

It is impossible to anticipate every question or situation that may arise, so in addition to the Code, Majestic Home Health also has other resources that can help. These additional resources are referenced throughout the Code and listed at the end. Remember – Majestic Home Health puts its faith in you to use good judgment and if you need help, to always ask before you act.

Compliance Mandate

Compliance with the Code is a non-negotiable and a condition of employment at and doing business with Majestic Home Health.

Who Must Follow Our Code?

Everyone who works for Majestic Home Health , or on its behalf, must follow our Code. It applies to all of Majestic Home Health ’s owners, officers, Care Team Members, and others acting on behalf of Majestic Home Health such as vendors, contractors, medical directors, attending physicians, and healthcare professionals providing services to our patients.

Care Team member Responsibilities

Doing Whatever It Takes, and Then Some is shared responsibility among all Majestic Home Health Care Team Members. To meet this commitment

Take responsibility for your own actions. Always act with integrity. Be professional, respectful, and ethical when acting on behalf of Majestic Home Health.

Know the standards, policies and procedures and apply them. This includes the guidance in the Code, policies and applicable laws, and professional standards. Live by both the letter and the spirit of these standards every day.

Never feel forced to violate our principles. If you ever feel such pressure or have any questions, consult with your supervisor or another Majestic Home Health resource.

Be familiar with the law and ask questions.

You do not have to be a legal expert, but you should be aware of the basic laws and regulations that affect your specific job and level of responsibility. Ask questions, if needed.

Making the Right Choice

Complete all required training in a timely way. Keep up-to-date on current standards and guidance, and ask questions about anything you do not understand.

Be an involved member of Majestic Home Health. Be quick to offer suggestions on how to improve processes, and on making policies and procedures easier to understand.

Cooperate with audits and investigations. Be honest and truthful when responding to questions from auditors and investigators. Never destroy or alter records during, or in anticipation of, an audit or investigation.

Report concerns of possible misconduct. If you know or suspect a violation of law, regulations, procedure, or policy has occurred, or if you are concerned about the ethics or compliance implications of a situation, talk to your supervisor or another Majestic Home Health resource. Never assume that management already knows or does not care about an issue. Always speak up if you have concerns.

Additional Responsibilities of leadership – lead by example

Supervisors and managers have additional responsibilities:

• Be instructive. Distribute the Code to new Care Team Members and others as required by Majestic Home Health ’s policy. Ensure that they understand the standards outlined in the Code and our policies and procedures.
• Be proactive. Ensure that Care Team Members are properly trained and understand their responsibilities. Be clear that you expect them to always comply with the law, the Code, and other applicable standards.
• Be receptive. Maintain an open-door policy. Make it known that you are open and available to address questions or concerns about ethics or compliance-related issues.
• Do not ask others to do what is prohibited. Never ask, pressure, or expect a Care Team Member or others to violate laws, regulations, the Code, or Majestic Home Health policies and procedures

Examples of General Workplace Issues

• Harassment Discrimination
• Suspected use of alcohol or illegal drugs in the workplace, including misuse of prescription drugs Personal problems between you and another Care Team Member
• Wage, hour, and schedule issues

Examples of Compliance and Ethics Issues

• Inaccurate coding or billing Retaliation for reporting a concern or cooperating in an investigation False or inaccurate claims submitted to Medicare, Medicaid, or other payors
• Suspected violation of law, regulations, the Code, policies, standards, or procedures
• Do not retaliate or tolerate it from others. Anyone who makes a good faith report of a suspected violation of law, policy or procedure must not suffer retaliation, including cooperating with an audit or investigation.

Raising Questions and Concerns

If you see or suspect any violations of law, regulation, the Code, or other Majestic Home Health standards, or if you have a question about what to do, promptly talk to your supervisor or another available Majestic Home Health resource (see Majestic Home Health Resources list on Page 37). When all Care Team Members fulfill this requirement to raise concerns in a timely way, we demonstrate our commitment to moral, ethical, and legal conduct.

Our Non-Retaliation Policy

Retaliation undermines our values and can hinder our ability to deliver excellent service to those in our care. Majestic Home Health is committed to protecting you from retaliation if you report concerns in good faith or cooperate with an investigation or audit.

If you experience conduct you feel is retaliation for reporting or assisting in the investigation of a good faith report, promptly notify the Office of Corporate Compliance & Ethics so it can be addressed.

Investigations and Confidentiality

All information shared with any resource or reporting channel will be treated confidentially to the extent allowed by law and shared only on a need-to-know basis (e.g., with the investigator) to address the issue. Investigations. When an investigation is necessary, it will be conducted by the Office of Compliance & Ethics, the Human Resources department, or other appropriate internal or external resources. Some types of misconduct must be reported by law to external agencies.

Your responsibility. Cooperate fully with any investigation or audit. Be forthcoming and truthful when talking with an investigator or auditor. Never alter or destroy records in anticipation of, or response to, an investigation or audit.

Sometimes the Legal Counsel will issue a “hold” on internal documents.

Additionally, records that are related, yet not part of the hold, must also be preserved until the conclusion of the query and per the record retention policy.

Accountability and Corrective Action

Violation of the laws, regulations, the Code, and other standards can cause legal and financial liability for Majestic Home Health and you. It also may result in harm to our patients, and reputation. Consequently, you must report any actual or suspected ethics or compliance concern that comes to your attention. Anyone found responsible for such misconduct will be disciplined according to the nature of the violation, up to and including, termination of employment and, in some cases, be subject to legal penalties and prosecution.

Waivers and Exceptions

Majestic Home Health periodically reviews the Code and recommends changes for approval by its Executive Compliance Committee. In very rare situations, Majestic Home Health may determine it is appropriate to waive a provision of the Code. All such waivers must be granted only by the Corporate Compliance Committee or Corporate Compliance & Privacy Officer and documented.

Our Commitment

We provide our patients with the excellent care and services necessary to experience the highest physical, mental, and psychosocial well-being they individually can achieve. Our teamwork and dedication to this principle create the highest quality of care.

What to Know

Excellent quality care has many components, including a focused effort to:

• Provide quality services to all persons who require them without regard to race, color, national origin, sex, gender identity, sexual orientation, age, or disability;
• Treat all patients, and their families with respect and dignity at all times;
• Provide appropriate and qualified staffing;
• Protect patient privacy and maintain appropriate records;
• Ensure appropriate care tailored to meet the patients’ clinical needs;
• Educate patients, and/or their families concerning the care provided, and involve them in all details or aspects of their care; and
• Ensure patient safety.

What to Do

Know the standards. Read and thoroughly understand the policies, procedures and standards that relate to your role or level of caregiving.

Complete related training. Seek help from your supervisor to understand anything that is not clear.

Be vigilant. Recognize and report those practices and situations that could be improved to prevent lapses in care quality or patient safety.

Speak up. Immediately report issues related to quality care or patient safety that could be or have been jeopardized. Bring your concerns to the attention of your supervisor or another Majestic Home Health resource. This is so critical that it is a condition of continuing employment.

One of our patients has a history of falls. She often gets up and wanders during the night. I worry that she will fall and hurt herself. How can I help her?

This is a safety concern and should be reported to the Clinical Director so the interdisciplinary team can implement appropriate interventions and update the care plan for this patient.

One of my patients often refuses care. Do I have to document this?

It is just as important for Care Team Members to document when a patient refuses care as it is when they provide care. Care Team Members should take credit for all their efforts by documenting alternatives or accommodations offered when a patient refuses care, as well as notify their supervisor of refusals so that the care plan can be updated if necessary.

Elder Justice Act

Everyone who works on behalf of Majestic Home Health is required by law to report any reasonable suspicion of a crime committed against any person who is a patient of, or is receiving care from Majestic Home Health . The report must be made to specific law enforcement agencies and to the applicable state survey agency. Timing is critical. Make the report within 2 hours of forming a reasonable suspicion that a crime has occurred if there is a serious bodily injury. Report within 24 hours of forming a reasonable suspicion if there is no serious bodily injury.

What to Do

Treat patients with dignity and respect. A patient with behavior issues or a Care Team Member with an unusually busy shift are no reasons to treat a patient poorly. You must treat all patients as you would want your own beloved family member to be treated all of the time.

Communicate appropriately. Speak with patients in a way they can understand. Encourage questions and seek help when you encounter language or other communication barriers.

Invite involvement. Help patients understand their rights and get them involved in determining appropriate aspects of their care.

Protect patients. Ensure that patients are protected to the extent possible. Prevent and refrain from physical, mental, sexual, or verbal abuse as well as neglect, misappropriation (theft), and exploitation. These may come from not only fellow Care Team Members, but also from other patients, volunteers, agency staff, family members, visitors, legal guardians, friends, or any other persons.

Speak Up. If you become aware of or suspect abuse, misappropriation (theft), or exploitation related to a patient, you must report it immediately to your supervisor or another supervisor in your chain of command.

Where to Report Abuse and Neglect

Per federal regulations, a facility must ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source of misappropriation of patient property, are reported to the State Survey Agency and other officials such as Adult Protective Services, when applicable.

Reporting must occur no later than 2 hours after the allegation is made.

I work with a nurse who is rough sometimes, and can be rude to the patients. I am not the only one that feels this way, but everyone is afraid to say something. What should I do?

If one of our Care Team Members is not treating our patients with excellence, you MUST report it. Anyone who is aware and does NOT protect a patient by reporting, is complicit in the behavior and will be disciplined accordingly. Under no circumstances will Majestic Home Health tolerate retaliation against any Care Team Member who reports potential abuse, neglect, mistreatment or misappropriation in good faith.

I am a nurse, and I occasionally visit patients in a skilled nursing building. I love my job, but I sometimes forget to knock on the door to a patient’s room and ask permission to enter. I’m always polite, and no one ever complains when I go into their room. I think it’s a silly rule that I first have to knock and ask permission to enter. Is it OK for me to enter a patient’s room without doing this?

No. Requiring Care Team members to knock on doors and ask permission to enter is not a “silly rule” – it is a federal regulation. All patients have rights guaranteed to them under federal and state laws and regulations. Each patient has the right to be treated with respect and dignity and that includes respecting their privacy. All Care Team Members are responsible for the preservation of patients’ rights.

Safeguarding the Privacy of our Patients

During the course of their care, we gather a great deal of personal information about our patients. It is our duty and legal obligation to safeguard this Protected Health Information (PHI) to prevent inappropriate access, use, and disclosure. We are committed to following all laws, rules, and regulations related to patient privacy, so we only access and use PHI needed to do our jobs or when required by law or regulation. We can only disclose PHI with proper authorization.

What to Know 

Majestic Home Health has developed policies and procedures to help you ensure that all PHI is safeguarded.PHI includes information such as:

• Demographics (e.g., names, birthdates, phone numbers, email address, geographic identifiers, gender)
• Medical record number  Social Security Number  Insurance ID number
• Diagnoses
• Medical Test Results  Medications
• Payment Information

What it Means

Protected Health Information includes medical, financial, and personal information that can be used to identify an individual. This includes all such information exchanged verbally or maintained in written or electronic form. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 and its related regulations guide us in how we may use and share this information appropriately.

What to Do

Uphold patient privacy. Follow our policies and procedures. Do not access, use, discuss, or share PHI except when necessary for treatment, payment, or healthcare operations. Ensure you have authorizations for any disclosures. Access only the PHI you need. For example, if you only need a patient’s insurance ID number to complete a task, do not access the entire medical record.

Limit communication with others about PHI. Avoid conversations or electronic communication with Care Team Members about PHI, unless they have work-related “need to know.” Do not talk to anyone outside Majestic Home Health about PHI unless they are authorized to know.

Avoid mentioning PHI on social media. Never post information or photographs that could be linked to a patient on social media, social networking sites, or blogs without their authorization.

Keep passwords and security codes confidential. Never share your passwords and security codes and never allow another person to use your computer while you are logged in.

I am a CNA, and yesterday I ran into Mrs. Miller while I was out shopping. Mrs. Miller regularly visits one of our patients and they are friends from church. During our chat, Mrs. Miller said she had just returned from a trip and wondered how her friend, Mr. Jones, is doing. Mr. Jones is regularly one of the patients I care for, but I did not tell her much, only that he was still a patient and his condition has not changed recently. Did I tell her too much?

Probably not. Although Mrs. Miller is not a member of Mr. Jones’ family and probably not involved in his care, it is acceptable to acknowledge to anyone who asks about him that he is a patient as long as Mr. Jones has not requested that his information not be shared. A better response would have been to thank her about her concern for our patient, but politely inform her that you are not allowed to give out information about patients without their authorization

I’m a nurse and during a patient’s visit I received a phone call regarding another one of our patients. It was a brief phone call but I answered a few questions about their condition and care. My patient and their family overhead the entire conversation. Is this a privacy violation?

If the information shared on the phone was regarding the patient and their care, this is not acceptable. You should excuse yourself to answer the phone before discussing PHI around people that need to know . This would be a violation of our privacy policies.

Gifts, Entertainment, and Business Courtesies

We avoid real or perceived conflicts related to gifts, entertainment, or business courtesies. Further, we will never offer or accept such courtesies if the intent is to influence objective business decision-making or in exchange for any referrals to Majestic Home Health.

What to Know

Patients and their Families. Those in your care may offer you gifts, gratuities or tips as an expression of gratitude. Accepting such a courtesy may give the impression that you are providing special care to, or somehow favoring, a particular patient. Also, it may be perceived that you are inducing the individual to stay longer in our care or causing them to accept medically unnecessary services. Please see next page for details on what you may or may not accept

Outside Care Partners. Business courtesies can cause conflicts when they involve current and potential Care Partners and other individuals or entities outside of Majestic Home Health .

Giving or accepting these courtesies can be seen as an attempt to improperly influence the relationship. When outside entities offer you materials, funding, or other resources for educational purposes, you must obtain approval from the Corporate Compliance and Privacy Office or Legal and Risk Services department before accepting.

Government Representatives. When government personnel or contractors are involved, strict guidelines prohibit any type of gratuity or payment for their meals, travel, or lodging expenses. They must pay their fair share whenever participating in joint work with Majestic Home Health (e.g., they buy their own meal if a meeting runs into lunchtime).

Government workers know these regulations and should automatically decline any courtesy that is improper for them to accept. If you give anything of value to a government official, it could be a legal violation even if there is no intent to influence the official’s action or decision. This means you cannot entertain an official, or engage in other activities favorable to influencing them, without first obtaining authorization from Majestic Home Health ’s Legal and Risk Services or Office of Corporate Compliance & Ethics department (see also section entitled “Political Participation”).

What to Do

Never solicit or accept gifts and courtesies from those in our care or their families.

However, incidental gifts (e.g., perishables such as food) that can be shared with other Care Team Members may be accepted at the discretion of facility management.

Never solicit items of value. You cannot request any tangible or intangible item of value, even a favor, from any person or entity outside of Majestic Home Health (e.g., vendors).

Do not give or accept cash or cash equivalents. This includes tips, gratuities, and gift cards, including those for particular stores or food establishments.

You may offer or accept some courtesies involving Care Partners. Modest gifts of perishables or consumables, as well as gifts, entertainment, and other business courtesies of nominal value ($50 or less), may be accepted if they are given no more than three times per year and shared with other Care Team Members, if practical. This includes meals paid for by vendors/Care Partners.

Uphold the policies. Comply with policies of the recipient’s organization and our own when offering any business courtesy. When courtesies involve government workers, follow our policies. You must also uphold any state or local regulations that pertain to business courtesies. It is important to get authorization from Majestic Home Health ’s Legal and Risk Services or Compliance departments before entertaining a public official or engaging in unauthorized lobbying efforts. (See section, “Political Participation”). Refuse inappropriate courtesies. This may be uncomfortable for you or offensive to the giver, but when a courtesy is improper, you must politely decline it.

Ask for guidance when you are unsure. Consult with your supervisor or another Majestic Home Health resource such as the Legal and Risk Services or Corporate Compliance & Ethics department.

Diversity, Non-Discrimination, and Harrassment-Free Workplace 

Majestic Home Health brings together a workforce with various skills, perspectives, experiences, and other personality characteristics. This diversity of talent creates strong teams that consistently deliver the best quality care. We respect Care Team Members, job applicants, and Care Partners, judging them only on their qualifications, skills and achievements.

What to Know

Each of us is responsible for respecting, accepting, and valuing individual differences among fellow Care Team Members, and for treating them in the way they deserve to be treated.

Unlawful harassment, discrimination, and other unwelcome conduct is prohibited based on race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, age, disability, genetic information, veteran status, or any other characteristic protected under federal, state, or local laws.

Disruptive behavior that creates an intimidating or hostile workplace is not permitted.

What it Means

Unlawful harassment includes, but is not limited to:

• Slurs or epithets;
• Verbal or non-verbal threats; Derogatory comments in verbal, written or electronic form;
• Verbal or physical conduct of a sexual nature that creates an intimidating, hostile, or offensive working environment.

What to Do

Act with respect. Treat others professionally and with respect at all times. Be aware of how others perceive your conduct. Comments, jokes, emails, texts, pictures, and other materials that seem appropriate to you may be offensive to others in the workplace.

Avoid inappropriate bias. Do not discriminate against others based on any characteristic protected by law or Majestic Home Health policy.

Support diversity. Be inclusive of others and help them feel like a valued member of the team.

I told a joke at work about my own ethnicity. No one listening was from the same ethnic group. Everyone laughed after I told the joke, but later HR told me someone complained. I did not mean to offend anyone, so how could this happen?

You never know who might be offended by a joke, even if all listeners seemed to enjoy it and they do not appear to share the characteristic in the joke. You may think it is funny, but someone in the audience may have had a friend or family member of that ethnicity, or maybe they simply do not like derogatory comments about any culture. Also remember, your intent does not matter – just how it is perceived.

Personal Privacy

Some of us have access to the personal information of our Care Team Members, Care Partners, and others outside of Majestic Home Health . Personal confidential information can be used to commit identity theft and to harm individuals. We are dedicated to protecting this information, accessing, using, and disclosing it only when necessary to do our jobs.

What to Know

We protect the privacy of our Care Team Members and Care Partners’ personal confidential information with the same level of diligence with which we protect that of our patients.

Only a few Care Team Members will need to access, use, or share personal information for work purposes. However, if you should accidentally encounter such information in the workplace, you must know what to do to protect it.

What to Do

Understand the types of protected personal information. Many types of personal information are protected by law and our policies, such as personally identifiable information (PII) including Social Security Numbers, bank accounts, and credit card numbers.

Protect the personal confidential information of others. This includes current and former Care Team Members, job applicants, physicians, contractors, and other Care Partners. Ensure this information is secured with limited access and transmitted electronically according to our policies and procedures.

Do not share personal information outside Majestic Home Health. The only exception is if your job involves handling the personal information of Care Team Members such as Human Resources, Accounts Payable, Benefits staff, or certain Care Partners who need access. Seek advice from Legal and Risk Services department if a regulatory body, law enforcement, or anyone else requests Care Team Member information.

Access or discuss personal confidential information only with a legitimate business purpose. Business conversations involving this information must be conducted in a place where they cannot be overheard. Laptops should be used securely to avoid exposing the information.

Destroy personal information that is no longer needed. Follow our record retention policies when such information is no longer required for business purposes.

Promptly report loss or unintentional disclosure. Bring the issue to your manager or another Majestic Home Health resource. Do this promptly because time is critical to addressing the problem.

What it Means

Personally Identifiable information is any data that could potentially be used to identify a particular person. PII includes many types of data, such as name, driver’s license number, financial accounts, email addresses, physical addresses, phone numbers, birth date, and even photos.

Many types of PII are similar to PHI (e.g., address, birthdate), but PHI is the term used in a healthcare context, and includes medical information.

We provide a safe and healthy work environment for Care Team Members, Care Partners and visitors to our facilities. Each of us is responsible for acting in a way that protects the health and safety of our Care Team Members, our Patients and patients, and others in the workplace. We also have a responsibility to protect and preserve the natural environment.

What to Know

In the course of Majestic Home Health ’s operations, hazardous and infectious materials and waste are often used or generated. Majestic Home Health is responsible for the proper handling and disposal of these materials to protect the environment.

Majestic Home Health has a zero-tolerance policy against threats or acts of physical violence. This includes abusive or aggressive behavior intended to threaten or intimidate another person in our workplace or at any off- site work-related activity. Do not tolerate physical violence or threats of harm. No firearms or weapons will be allowed on Majestic Home Health property at any time, except for those carried by law enforcement officers.

What to Do

Uphold the standards. Follow all Majestic Home Health health and safety standards, including those related to handling, storage, and usage of hazardous materials, other pollutants, and waste. Ensure Majestic Home Health complies with its permits, as required. These allow Majestic Home Health to safely discharge hazardous materials into the air, sewage systems, water pollution control facilities, or onto land.

Engage qualified disposal services. Hire only reputable, licensed services to transport and dispose of hazardous materials, pollutants, and infectious wastes.

Do not conceal improper dumping. No one at Majestic Home Health may conceal improper discharge or disposal of hazardous materials, pollutants, or infectious wastes.

Accurately maintain all records. Permits, approvals, records, and controls must be maintained as required by environmental laws and regulations until such documents are destroyed with permission of the Legal and Risk Services department, or in accordance with our record retention policy.

Manage physical safety. Uphold security standards by following entry and ID protocols, such as badging in without allowing others to “tailgate” through. Ensure safety by keeping work areas, hallways, and patient rooms free from obstacles, unsecured wires, and other potential hazards.

Promptly report any concerns. Notify your supervisor or another Majestic Home Health resource about any unsafe equipment, violence, or other situation that could threaten human health or safety or damage the outside environment.

Keep the workplace safe and healthy. Every Care Team Member plays a part in maintaining a safe and healthy workplace by preventing, watching for, and reporting unsafe practices or work conditions.

I noticed as I was leaving a skilled nursing facility visiting a patient, that the back door wasn’t latching securely. I was going to fill out a maintenance request form on my next shift. Should I wait?

No. You should NEVER wait to report a potential safety risk for one of our patients. Any delay at all in reporting a faulty latch on a door could place a patient at extreme risk for harm resulting from an elopement. Always assess any maintenance concern to determine if there is a potential risk of harm to a patient.

Drug and Alcohol Use

 Majestic Home Health ’s committed to providing a safe environment and the highest level of service, while minimizing the risk of accidents and injuries. This can only be achieved by Care Team Members who come to work free from the influence of alcohol and illegal or misused drugs.

What to Know

All Care Team Members must be free from the influence of alcohol, illegal drugs, and misuse of prescription drugs while on facility property or while performing job duties on behalf of Majestic Home Health

Distributing or possessing alcohol, illegal drugs, or legal controlled substances that are improperly obtained at work or while on duty is prohibited.

Off-the-job manufacturing distribution, dispensing, or possession of illegal or unauthorized substances is not permitted. Off-the-job substance use is prohibited if it affects work performance, (e.g., absenteeism, tardiness, or poor job performance).

What to Do

 Never come to work impaired by substances. You cannot perform your work duties properly and safely under the influence of alcohol, illegal drugs, or legal controlled substances that are improperly obtained or misused.

Report any use or presence of prohibited substances at work. This can prevent accidents and injuries before they happen.

Fulfill your extra responsibilities if controlled substances are part of your job. Ensure they are securely stored and accounted for according to policy. Immediately report any missing or diverted drugs.

Report drug convictions. If you are convicted of a drug violation, you must notify your supervisor immediately.

I went to see a patient at an Assisted Living and I notice that they have had an increase in PRN medication use, but the patient denies receiving the medication. Maybe the patient is forgetting. I don’t want to get anyone in trouble. What should I do?

You should tell your supervisor without question. Drug diversion by a Care Team Member is a dangerous problem. You must always protect our patients who may be at risk from an impaired nurse or may be in pain because they are not receiving their medication. In addition to potentially harming a patient, by not reporting a drug diversion, you are preventing a Care Team Member from getting the help they may need. There are resources to help a Care Team Member with a problem.

Billing for services

We will comply with all payor rules and prepare accurate, properly coded billing statements that reflect only medically necessary and billable services provided and documented in the medical record.

What to Know

The False Claims Act prohibits us from knowingly submitting false claims to or withholding money due to Federal healthcare programs. Many states also have false claims laws. Our policies prohibit us from knowingly sending inaccurate or false claims to any of our payors.

An innocent misunderstanding, careless mistake, or error related to billing has potentially serious consequences. It could lead to allegations of fraudulent billing practices, which could expose Majestic Home Health and its Care Team Members to legal liability.

What to Do

Properly document care and treatment information. Patient records must be accurate, timely, and complete. Follow proper coding procedures. Assign codes accurately based on the information in the medical record.

Create accurate bills. Only bill for items and services provided based on the care documented in the medical record. Review bills thoroughly prior to submitting a claim. Follow Majestic Home Health ’s policies and procedures for checking claims against supporting documentation to ensure any errors identified are corrected prior to billing.

What it Means

False claims could include:

• A service or item that was not provided, not medically necessary, or billed more than once.
• A non-covered service billed as a covered service.
• Services billed separately that are covered in the room rate.
• Inadequate or substandard care.
• Use of inaccurate coding (“upcoding”), patient status to increase reimbursement.
• Failing to promptly identify and refund overpayments.
• Submitting bills that are not supported by clinical documentation.
• Knowingly means the actual knowledge or acting in reckless disregard or in deliberate ignorance of the truth or falsity of the information.
• Promptly research and resolve potential overpayments (e.g., credit balances). If a claim appears to have been overpaid, promptly review the account to determine if a payor or individual has overpaid the amount due and, if so, refund any overpayments as soon as practical. Any refund must be made within timeframes set by federal and state laws.
• Raise any billing concerns. If you become aware of or suspect any inaccuracy or other issue in the coding and billing process, including overpayments, immediately raise the issue to your supervisor or another Majestic Home Health resource.

The physician for one of our Medicare Part A patients is out of town, so I have not been able to get his signature on the Physician Recertification that is due. We are supposed to submit our Medicare bills today. Can I submit the bill and get him to sign the Recertification later when he returns?

No. A valid Physician Certification/Recertification for Medicare services is a condition of payment under federal regulations. Consequently, we cannot submit a Medicare Part A claim without a required Recertification if one is due. When the physician returns, you should complete a Delayed Recertification that includes an explanation of why it is late. (“Physician was out of town when Recertification was due”), then have the physician sign and date it. You may then bill the claim.

I am not involved in the billing process, so how does this billing standard apply to me?

Billers rely on YOU. As you are not directly involved in billing, it is up to you to ensure regulatory compliance and ethical practices in the billing process by providing accurate, timely, and complete documentation of the services you provide.

Conflicts of Interest

To best serve those in our care, we set aside our own interests when they conflict with those of our organization, or our patients. We will not divide our loyalties or use our position for our own benefit or for that of our families and friends.

What to Know

A conflict can occur in many personal and business situations.

Corporate opportunity. If you learn about a business opportunity due to your job that would benefit Majestic Home Health , you must receive approval before you or a family member may pursue it.

Outside employment or other services. Any outside employment, consultant relationship or service (e.g., membership on a community board) should be discussed with your supervisor in advance to make sure any potential conflicts are addressed.

Personal investments. You must not have substantial investment in one of Majestic Home Health ’s customers, suppliers, or competitors, unless the investment complies with Majestic Home Health ’s Conflicts of Interest policy. “Substantial” generally means that your investment is big enough to potentially influence your    decision-making to benefit your investment at the expense of Majestic Home Health.

Personal relationships. Avoid having a family member or intimate relationship with another Care Team Member within your management chain or if you have influence over the person’s salary or career path. If you are in such a relationship with a subordinate or supervisor, or with a current or potential business partner, you must disclose it to your supervisor or higher-level manager.

What it Means

A conflict of interest may occur when you have a competing personal interest that divides your loyalties and interferes with your ability to make objective decisions for Majestic Home Health . A personal interest exists when you, your friend, or a member of your family stands to gain as a result of your decision. Failure to use good judgment to avoid these situations can undermine the trust others place in Majestic Home Health , damaging its reputation and our ability to serve those in our care.

What to Do

Examine your loyalties. Consider only the best interests of Majestic Home Health and its patients when making business decisions.

Be aware. Recognize and avoid activities and relationships that are, or may appear to be, conflicts of interest.

Choose Care Partners wisely. If you select Care Partners or vendors, choose them based only on their merit. If a friend, family member, or company they own seems like a potential Majestic Home Health , Care Partner, excuse yourself from the selection process and disclose the relationship to your supervisor. Speak up. Disclose any actual, potential, or perceived conflict of interest to your supervisor or another Majestic Home Health resource.

My sister owns a company that provides excellent attendant care. Can I pass her name along to the Care Team Members who select these services for our company?

Yes. Majestic Home Health is always looking for excellent Care Partners and vendors, and your sister may fit the criteria. It is OK to pass her name along, but you cannot be involved in the selection process. Also, if you are a Majestic Home Health leader, recognize that a suggestion from you may be perceived as a mandate to those who engage these services. Be careful not to send this message by making it clear you understand she must compete for business.

Sue is the manager of the team. Crystal and Tom are both on the team but Sue is very good friends with Tom has noticed, Crystal has been getting better assignments. Tom wants to know if he should tell someone. Is this a conflict of interest or just unfair?

It could be both. If Sue and Crystal are such good friends that it appears the relationship clouds Sue’s objective business decisions related to Crystal, this could be a conflict of interest. This situation needs to be disclosed and addressed. Because this also feels unfair to Tom and likely other Care Team Members, even if this is not deemed to be a conflict after investigation, Sue will be informed of the perception of unfairness she has created. She will be required to work with the Human Resources department to address it.

What to Do

Examine your loyalties. Consider only the best interests of Majestic Home Health and its patients when making business decisions.

Be aware. Recognize and avoid activities and relationships that are, or may appear to be, conflicts of interest.

Choose Care Partners wisely. If you select Care Partners or vendors, choose them based only on their merit. If a friend, family member, or company they own seems like a potential Majestic Home Health , Care Partner, excuse yourself from the selection process and disclose the relationship to your supervisor.

Speak up. Disclose any actual, potential, or perceived conflict of interest to your supervisor or another Majestic Home Health resource.

My sister owns a company that provides excellent attendant care. Can I pass her name along to the Care Team Members who select these services for our company?

Yes. Majestic Home Health is always looking for excellent Care Partners and vendors, and your sister may fit the criteria. It is OK to pass her name along, but you cannot be involved in the selection process. Also, if you are a Majestic Home Health leader, recognize that a suggestion from you may be perceived as a mandate to those who engage these services. Be careful not to send this message by making it clear you understand she must compete for business.

Sue is the manager of the team. Crystal and Tom are both on the team but Sue is very good friends with Tom has noticed, Crystal has been getting better assignments. Tom wants to know if he should tell someone. Is this a conflict of interest or just unfair?

It could be both. If Sue and Crystal are such good friends that it appears the relationship clouds Sue’s objective business decisions related to Crystal, this could be a conflict of interest. This situation needs to be disclosed and addressed. Because this also feels unfair to Tom and likely other Care Team Members, even if this is not deemed to be a conflict after investigation, Sue will be informed of the perception of unfairness she has created. She will be required to work with the Human Resources department to address it.

Protecting our resources

 We use organizational resources wisely and for appropriate purposes. Each of us is personally responsible for protecting Majestic Home Health resources to prevent loss or damage. Examples of our assets include finances, facilities, equipment, medical supplies, information systems, intellectual property, and confidential Information.

What to Know

Majestic Home Health resources are both tangible (e.g., things you can touch) and intangible (e.g., ideas and information). They must be used primarily for Majestic Home Health business.

Personal use of our resources is prohibited, except in limited situations. Personal use must not negatively affect productivity or the work environment.

Majestic Home Health has the rights to monitor usage of its equipment, network, and systems. Automated software may be used to monitor material created, stored, sent, or received on its computer networks. No one should expect privacy related to his or her internet or email usage.

What to Do

Properly use and disclose confidential business information. Access and share it only for legitimate business purposes. Protect intellectual property and confidential information by disclosing it only to authorized parties.

Follow our information security policies. Safeguard information in both paper and electronic formats. Never share passwords or disclose information in public forums.

Documents containing sensitive data, including information concerning Patients or patients, should be handled carefully during work hours and must be properly secured when not in use. Access and maintain confidential information only on Majestic Home Health information systems. Never store or access confidential information on a personal computer or other media. All computers and other devices including storage media (e.g., USB devices) that will be used to store or access confidential information should be obtained from or authorized by Majestic Home Health ’s Information Technology department.

Protect others’ confidential business information. Care Partners’ pricing, agreements, and other sensitive business date must be safeguarded as securely as our own. Also protect and do not misuse the intellectual property of others, such as purchased software.

Be vigilant. If you observe individuals whom you do not recognize using terminals in your area, report this to your supervisor immediately.

Report misuse, loss, and disclosure. Promptly speak up to your supervisor, Executive Director or the Corporate Compliance & Privacy Officer if you believe confidential information has been mishandled, stolen or lost.

Protect others’ confidential business information. Care Partners’ pricing, agreements, and other sensitive business data must be safeguarded as securely as our own. Also protect and do not misuse the intellectual property of others, such as purchased software.

What it Means

 Confidential Majestic Home Health Information and Intellectual Property

Confidential Information is related to Majestic Home Health business that is proprietary, has not been published or disclosed publicly, or is otherwise restricted from being widely communicated.

Once type of confidential information is Intellectual Property, which is an idea, design, or other concept owned by Majestic Home Health . Sensitive date like this is often marked “confidential,” but not always. You must be able to identify confidential material by its nature.

Examples of confidential information include: Majestic Home Health methods, processes, techniques, computer software, equipment, service marks, copyrights, research data, clinical data, marketing and sales information, personnel data, patient lists, financial data, plans, and all other undisclosed know-how and trade secrets.

Creating and Managing our Business Records

Patients, our Care Team Members, government officials, and Care Partners rely on the accuracy and completeness of our disclosures and business records. Every Care Team Member is responsible to maintain truthful and complete records of all types, including patient records, work records, financial records, and all other organizational documents in a way that is consistent with our policies and procedures.

What to Know

Majestic Home Health is required by law to retain certain types of medical and business records, usually for a specified period of time. Failure to do so may result in fines, penalties, and legal liability.

All Majestic Home Health records should be retained and destroyed in accordance with the schedules outlined in applicable policies. Legal liability could result if a document is destroyed before its scheduled destruction date.

Established accounting practices and procedures must be followed to assure the complete and accurate recording of all transactions.

All records should be retained and destroyed in accordance with the schedules outlined in applicable policies. Legal liability could result if a document is destroyed before its scheduled destruction date.

Established accounting practices and procedures must be followed to assure the complete and accurate recording of all transactions.

What it Means

The term “business records” covers a wide variety of documents in healthcare, including expense reports, medical records, treatment plans, billing claims, purchase agreements, benefit claims, Care Team Member records, financial statements, marketing plans, invoice payments, controlled substance records, cleaning logs, and much more. You likely work with more than one type of record at Majestic Home Health and play an important role in ensuring their accuracy and completeness.

What to Do

Create accurate, professional, and complete business records. Write your business communications carefully and clearly, whether on paper or electronically. Poorly written documents and communications may create misunderstandings.

Know your responsibilities related to records. Be familiar with the record-keeping procedures that apply to your job. You are accountable for the accuracy and truthfulness of the records you create and sign.

Comply with records retention and destruction schedules. Make sure you know the schedules for your department, division, region, or facility. Destroy records only according to our records retention policy, and never in response to, or in anticipation of, an investigation or audit. If you think that documents should be saved beyond the prescribed retention period, consult your supervisor or Majestic Home Health ’s Legal and Risk Services department.

Comply with legal holds. A “legal hold” informs Care Team Members when information must be preserved for potential litigation or investigation. Information that is under a legal hold cannot be destroyed per the normal schedule until the hold is lifted by the Legal and Risk Services department.

Properly destroy protected information not needed for a task. “Incidental” or minor documents containing protected data that may be created or obtained in the everyday course of business must be destroyed appropriately when it is no longer needed or not required to be retained.

Watch for potential fraud. Be alert for any false statements, omissions, incomplete or misleading information, or any other inaccuracy in our records. Speak up to your supervisor if you have any concerns.

Antitrust, Fair Competition, and Trade Practices

We are committed to avoid practices that limit free and open competition. We never seek to gain competitive advantages through unethical or illegal means, but rather through excellent care and services.

What to Know

Anti-competitive or antitrust laws make illegal any formal or informal agreement or understanding in any format that restricts competition, whether expressed or implied.

Such laws are designed to preserve and promote fair and honest competition. The greatest danger for violations lies in interactions with competitors.

No Care Team Members should participate in any behavior that may be viewed as restricting competition.

Although Majestic Home Health is a privately held company without publicly traded stock, we are prohibited from engaging in insider trading of public company securities.

What to Do

Use good judgment when talking with competitors. Avoid discussions about competitively sensitive information or limiting competition. If such a conversation occurs, leave the meeting immediately and report the matter to our Legal and Risk Services department.

Protect competitive information of third parties. Never share competitively sensitive information of Care Partners or other third parties with their competitors.

Ask if you are unsure. If you have questions or are uncertain about how antitrust laws may apply to a certain activity, contact your supervisor or another Majestic Home Health resource.

What it Means

Antitrust laws are complex. The rules vary based on the situation, but typical activities that may be considered antitrust violations that should be avoided or reported, include discussing the following with competitors:

• Future Majestic Home Health business plans,
• Current Majestic Home Health prices or reimbursement levels,
• How business is conducted with suppliers or customers.

My neighbor works at a long-term care facility in town that is a friendly competitor of Majestic Home Health . We started talking at a local event and she mentioned the struggle her facility was having with increasing costs of supplies. I told her how Majestic Home Health was negotiating a new nationwide contract with a supplier that will reduce our prices and result in a huge revenue increase for the supplier. Did I do anything wrong?

Yes. You should not talk with competitors about the circumstances under which Majestic Home Health conducts business with suppliers, other third-party partners, or customers. This potential antitrust matter should be reported to our Legal and Risk Services department.

Business Relationships with Third Parties

Our Care Partners, suppliers, vendors, and competitors play an important part in the success of our business. Third party partners provide Majestic Home Health with critical services and goods that further our mission. Competitors motivate us to find new and better ways to deliver quality care and serve others. We value these third parties and treat them fairly, honestly, and ethically.

What to Do

Treat our Care Partners the way you want to be treated. Conduct these relationships with mutual respect, honesty, fairness, and without discrimination.

Obtain competitive information from appropriate sources only. Find this information in publications, websites, industry feeds, and other public sources.

Honor others’ confidentiality obligations.

Respect the duty of others to keep confidential the competitive information they must protect.

Keep non-public business information of third parties confidential. This includes price lists, strategies, and agreements.

Select care partners based only on their merits.

Do not be influenced by their personal relationships or your own biases.

Be careful in accepting competitive information from third parties. Know their sources and be sure the information is not protected by non-disclosure or confidentiality agreements or trade secret laws.

What to Know

We embrace objectivity in selecting our Care Partners, focusing on qualifications and diversity in the selection process. We gather competitive intelligence legally and ethically – never through fraud, misrepresentation, or deception.

What it Means

Business Partners or Care Partners refers to outside organizations or companies that do substantial amounts of work with us to fulfill a key need in our operations (e.g., contracted pharmacy provider).

Vendors typically provide services. Suppliers provide products and materials. The term “Care Partners” is often used to include all three types of third parties.

Communicating with the public Majestic Home Health must speak with one voice when communicating to the public about disclosures, announcements, or other information. This helps us deliver messages that are objective, transparent, and consistent. We communicate professionally and honestly with the public according to the highest standards of integrity. Our social media posts and internet communications reflect good judgment and personal responsibility.

What to Know

Only authorized persons are permitted to speak on behalf of Majestic Home Health. Our marketing and public-facing materials must be truthful and accurate.

Our social media policy is designed to protect the Majestic Home Health and its Care Team Members rather than to restrict protected speech and the flow of useful and appropriate information. It should not be interpreted to restrict a Care Team Member’s constitutional or statutory rights.

What to Do

Refer requests from the media. Refer all requests for information from any news media representative to the CEO‘s Office or Majestic Home Health ‘s Marketing Department.

Ensure a consistent voice in our marketing messages. All advertising or marketing materials related to Majestic Home Health must be accurate, ethical, and non-offensive. Ask for assistance from the Legal and Risk Services department to review and approve any such materials before using.

Pre-approve outside speaking or writing engagements. Seek approval before making public speeches, writing articles for professional journals, or other public communications, if you are identified with Majestic Home Health.

Access social media only for business purposes. Care Team Members may not access social media sites from Majestic Home Health -issued equipment or systems at any time unless the sites are being used to perform their job duties and have been approved by their supervisor.

Use good judgement on social media. Exercise personal responsibility to avoid postings that may negatively impact Majestic Home Health ’s business and reputation.

Speak on your own behalf in all postings. If you identify yourself as a Majestic Home Health Team Member, or discuss matters related to the Majestic Home Health or the healthcare industry on a social media site, include a clear disclaimer stating that your opinions are yours alone and do not represent the official views of Majestic Home Health.

I was chatting with a Care Team Member last night on a social media site, and we started discussing a patient. We never mentioned his real name, but we did talk about his age and medical condition and our opinion that he is very cranky. Was this OK to do?

Not exactly. Chatting about a patient in a respectful manner without identifying him would be OK. In this case, combining his age and diagnosis may be enough to discover his identity, which is not OK. However, what is definitely against our standards is your comment about his attitude. This could reflect negatively on Majestic Home Health , especially if your connection to Majestic Home Health was clear and you did not state that your were expressing your own opinions.

Heathcare Laws and regulations

Majestic Home Health operates in a highly regulated industry governed by laws and regulations that can be lengthy and complicated. We understand that compliance with these rules is critical to Majestic Home Health ’s success.

We are committed to uphold all the legal standards that apply to our jobs and to the organizations’ business.

What to Know

Majestic Home Health participates in the Medicare and Medicaid programs, which are both governed by extensive laws and regulations that require our compliance.

The Federal False Claims Act prohibits knowingly submitting a false claim to the government for payment. As required by the Deficit Reduction Act of 2005 (DRA), Majestic Home Health strives to prevent, detect, and eliminate fraud, waste, and abuse in all government-funded programs from which Majestic Home Health receives payments.

As part of our commitment to integrity, we must maintain open, honest, and legal relationships with current or potential referral sources. The two applicable federal laws related to our relationships with referral sources are the Federal Anti-Kickback Statute (AKS) and the Physician Self-Referral Law or “Stark Law.” May states have similar laws.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) guides us in how to use, share, and protect the personal, protected health information of our patients. We uphold this law by accessing, using, or disclosing patient protected health information in oral, written, or electronic form only when we have a legitimate business reason to do so or when authorizations or the law require it. (See section on Safeguarding the Privacy of our patients.

Convictions, Exclusions, and Sanctions

You must inform your supervisor, another supervisor in your chain of command, or the Compliance department if you are convicted of a felony, are informed that you are under investigation, or advised that you are no longer eligible to participate in any federal or state program or contract such as Medicare or Medicaid.

What to Do

Uphold federal and state healthcare program requirements. This includes Medicare and Medicaid laws and regulations, federal and state guidelines, provider agreements, and accreditation standards.

Comply with the False Claims Act.

Report concerns regarding actual or potential false claims such as billing for services no provided, not supported by documentation, or not billed in accordance with regulations or payor guidelines.

Comply with the AKS and Stark laws.

Avoid offering or accepting improper inducements. Never offer to pay, accept, or give anything of value to anyone for Patient or patient referrals. Also, do not request or accept payments or anything of value from vendors or suppliers to influence decisions regarding purchase of goods or services used for Patient or patient care that is reimbursable by a federal healthcare program.

Follow Majestic Home Health policies and procedures regarding contracts. Obtain all required approvals before signing any contracts, and only sign contracts that have been reviewed and approved by the Legal and Risk Services department.

Speak up if you have questions or concerns. Take questions and concerns about the laws to Majestic Home Health ‘s Legal and Risk Services or the Compliance & Ethics department. Always consult with them before entering into a relationship with someone that could influence referrals.

Our medical director has approached me and asked for a raise in the hourly rate for his services. He said that he is also the medical director for another facility in the area that pays him a lot more. Can I give him the raise he is requesting?

Maybe. If you believe the facility’s medical director deserves to be considered for a raise, you should contact the Legal and Risk Services department to discuss. Majestic Home Health has a specific process that must be followed for all new medical director contracts as well as modifications to existing contracts. As part of that process, the proposed compensation terms are reviewed and prepared to ensure that they are at a “fair market” rate and are “commercially reasonable.” Consequently, you should never make promises to a physician about his or her compensation or a prospective medical director agreement. In this instance, if it is determined that a raise is appropriate, a new contract with the revised terms must be approved per Majestic Home Health ’s policies and procedures, then signed and executed before any payment changes may be made.

Licensure

We ensure all applicable Care Team Members (Employed and Contracted) are properly licensed and follow the laws and regulations governing their respective professions.

What to Know

Care Team Members who deliver care must have up-to-date licenses or certifications necessary for their respective professions. If a Care Team Member or a contractor provides services or treatments with an inactive license or certification (e.g., expired), there may be serious consequences for the Care Team Member, Care Partner or Majestic Home Health.

What to Do

Maintain active licensure and adherence to professional standards. All Care Team Members and others acting on behalf of Majestic Home Health must maintain an active license, certification, or other credentials for the state(s) in which they work, and follow applicable state professional acts and codes of ethics at all times.

Notify your supervisor of any concerns. If any issues arise such as expiration, probation, revocation, or any investigation that may lead to an action related to your professional license, inform your supervisor immediately to ensure that proper actions are taken.

We ensure all applicable Care Team Members (Employed and Contracted) are properly licensed and follow the laws and regulations governing their respective professions.

Supervisors play a role. Supervisors and managers are expected to be aware of these standards and promote compliance with the rules. Speak up if you are unsure. Questions or issues related to licensure or professional practice acts or codes should be referred to your supervisor or another Majestic Home Health resource.

I worked almost two weeks after my nursing license expired before I realized it, and then renewed my license online with the state board. Are there any consequences to Majestic Home Health for the gap in my licensure?

Maybe. In some states, if you are a few days late renewing your license, you may renew it and pay a small penalty with no other consequences (e.g., effective date of renewal is still the date it expired.) In other states, if you are even a day late renewing your licenses, you are considered unlicensed for the day. Consequently, Care Team Members must inform their supervisor immediately if they realize their license has expired before it is renewed or when any action has been (or may be) taken related to their license (e.g., suspension, probation, investigation initiated that may result in an action affecting licensure.) Your supervisor will then contact the Compliance department so it may analyze the situation and ensure all necessary actions are taken.

Regulated Pharmaceuticals

We are conscientious and vigilant in carrying out our obligations to handle and dispense prescription drugs and controlled substances at Majestic Home Health facilities in accordance with all applicable laws, regulations, and Majestic Home Health procedures.

What to Know

Laws covering prescription drugs and controlled substances support the integrity of our national drug distribution system and protect consumers by assuring that these drugs are safe, properly labeled, and administered to the correct patients. These laws prohibit diversion of any prescription drug or controlled substance in any amount for any reason to an unauthorized individual or entity. Violation of any law or Majestic Home Health policy involving prescription drugs, controlled substances, or other pharmaceuticals may result in disciplinary action, up to and including termination of employment.

Supporting our communities

Majestic Home Health strives to be a responsible citizen in the communities where it operates. While we each are encouraged to be active in our community by supporting events and causes, we avoid pressuring others to support or contribute to our favorite charities.

What to Know

Majestic Home Health encourages Care Team Members to become actively involved in their communities. Majestic Home Health provides support to various educational, cultural, and civic endeavors. Such support may involve gifts of time, scholarships, sponsoring activities, and serving on community or university boards.

Care Partners may request contributions from Majestic Home Health for charitable causes. These must be through the Majestic Home Health process, like all other contributions.

Use good judgment when getting involved. Carefully consider your participation in community activities so it does not conflict with your responsibilities to Majestic Home Health . If a business partner asks you for a contribution from your own funds, make sure it will not give the appearance of a conflict of interest.

Make sure your charitable causes are clearly your own. Ensure that your personal support of charitable causes is not viewed as that of Majestic Home Health ’s.

I do volunteer work with a local non-profit group that asked me if Majestic Home Health would donate its old furniture for their office. They do good work in the community that benefits the elderly. Would Majestic Home Health donate the furniture?

Maybe. It must first be made clear that Majestic Home Health will not seek or accept any improper advantage from making the donation. Then it must align with Majestic Home Health ’s charitable giving policies. To make sure these issues are addressed, corporate donation requests must be referred to the Majestic Home Health Legal Department.

Political Activities

Majestic Home Health supports and encourages the voluntary participation of Care Team Members in the political process, as they desire. This is one of every American’s most basic rights

Lobbying

Lobbying is the process of where interest groups or lobbyists attempt to influence public policy through contacts with public officials. At times, Majestic Home Health may ask certain managers to contact members of government and other officials, in full compliance with applicable lobbying laws, to advocate for our position on issues. Majestic Home Health may periodically engage lobbyists or lobbying firms to help promote its interests, according to established internal controls to assure that all activities are legal.

No Care Team Member should ever engage in lobbying, or engaging anyone else to act as a lobbyist, without prior authorization from the Chief Executive Officer.

What to Know

Federal and state laws limit the nature and extent of individual and organizational political participation. Care Team Members may make personal political contributions or communicate their personal beliefs to elected officials, as long as it cannot be viewed as coming from Majestic Home Health.

Federal law prohibits reimbursement of individuals for their personal political contributions.

Organizational political activities differ from those that are personal. Majestic Home Health may occasionally speak out on issues of importance.

What to Do

Use your own time and resources. Your political activities must not interfere with your responsibilities at Majestic Home Health. Majestic Home Health resources such as copiers, phones, computers, and offices must never be used for your political activities.

Speak and act on your own behalf. Ensure that your personal political views and activities are not viewed as those of Majestic Home Health . Unless specifically authorized to represent Majestic Home Health , clearly label any personal communication with legislators as your own.

Refer inquiries about Majestic Home Health ‘s political position. If you are contacted by legislators or regulators regarding Majestic Home Health ’s position on public issues, you should refer them to your supervisor or the Chief Operating Officer.

Elections are coming up, and in order to vote, I need to go to the polling place during work hours. Is this allowable?

Yes. Care Team Members are expected to schedule their voting time so as not to interfere with work time, but in instances where work schedules may interfere with your ability to vote either before or after work, you will be given reasonable time off to vote in accordance with state law. You must give your supervisor notice of your need for leave for this purpose prior to election day.

A political candidate that I support has added elder care issues to his political platform. He wants to hold a rally in town and is looking for someone to donate the location. Would Majestic Home Health be willing to host this in one of their buildings?

No. Majestic Home Health encourages its patients to exercise their right to participate in the election process and encourages elected officials and candidates to visit our facilities to meet with them.

However, Majestic Home Health believes it would be improper to host a rally for a candidate seeking election or reelection or allow them to solicit donations from patients, their families, or Care Team Members.

Our compliance and ethics program

Majestic Home Health is committed to conducting its business ethically and with integrity. This includes preventing and detecting fraud and abuse and complying with all state and federal laws that apply to our jobs and our business to deliver quality care to our patients. Majestic Home Health designed and implemented a Compliance and Ethics Program (Program) to promote and support ethical and legal conduct and a culture of integrity through accountability to a system of compliance and ethics standards.

What to Know

The Program includes the following elements:

• Risk assessment to identify compliance, ethics, and reputational risks and evaluate the strength of related internal controls;
• Oversight by a Chief Compliance Officer supported by a Compliance department and a Compliance Advisory Board comprised of senior leaders;
• Written standards of conduct, policies, and procedures;
• Education and training programs for all affected persons;
• Open lines of communication including reporting mechanisms, such as Lighthouse;  Risk Assessment, auditing and monitoring to identify and reduce problems;
• Prompt investigation and response; and
• Enforecment of appropriate corrective action.

What to Do

Comply with Majestic Home Health ’s standards, rules, and requirements. Uphold our Code, complete all required training on a timely basis, cooperate with investigations and audits, speak to your supervisor with ethics or compliance questions or concerns, and never retaliate.

Report potential or actual misconduct. Majestic Home Health provides many resources to help you with your concerns.

Avoid consequences of non-reporting. Failure to report known or suspected wrongdoing may itself result in disciplinary action against those who failed to report the incident.

Resources 

Your supervisor can answer your questions and help you decide the best course of action in most situations – or connect you to other resources that can.

For a human resources or general workplace issue that you are unable to resolve with your supervisor, contact your human resources manager, division human resources director, or the corporate Human Resources Department.

For suspected violations of Majestic Home Health ’s network or computer systems, call the Customer Support Center.

If you have a question or concern about an actual or suspected HIPPA Privacy issue, please contact Majestic Home Health ’s Corporate Compliance & Privacy Officer at 317-759-8523 or at compliance@majesticcare.com.

CORPORATE COMPLIANCE & ETHICS DEPARTMENT

Questions or concerns also may be reported directly to the Office of Corporate Compliance & Ethics in one of the following ways:

• Contact the Confidential Hotline System:
• Call the toll-free hotline (without caller-ID) at 1-833-460-0008  Use the internet: https://report.syntrio.com/majesticcare.com
• Lighthouse is available 24/7/365 and managed by a third-party vendor.
• If you choose to submit an anonymous report to Lighthouse, a six-digit case number will be provided so you may later submit more information related to your original report. This also allows the Office of Corporate Compliance & Ethics to communicate with you (e.g., as questions) and still protect your anonymity. No one at Majestic Home Health has access to your case number. You may also submit a report including your name but request anonymity. If you do so, you anonymity will be protected up to the limits of the law.

Translation services are available for both written and verbal reports.