CODE OF CONDUCT: A GUIDE FOR EVERY STATCARE URGENT CARE EMPLOYEE

PROGRAM OVERVIEW

Purpose of the Code of Conduct

Statcare established this Code of Conduct so that employees will know and understand expectations of behavior. This Code of Conduct serves as a framework within which all employees are expected to operate. Responsibility for lawful and ethical behavior is a personal responsibility, and every employee will be held accountable for his or her conduct.

The Code of Conduct is intended to be comprehensive and easily understood. It is not meant to answer every question that might arise in your daily activities; however, it does provide guidelines, direction, and resources to tap into to respond to matters and circumstances in the course of your Statcare duties. No set of guidelines, including our own, can ever substitute for the sound judgment, common sense, and personal integrity required to meet the challenges of your job.

Employee Responsibilities

Statcare employees are expected to treat compliance with ethical standards as a critical element of their responsibilities.

Every Statcare employee is required to:

• Read and abide by this Code of Conduct

• Be familiar with, understand, and observe the basic legal and regulatory requirements that are relevant to his or her duties

• Ensure the confidentiality of patient and related information

• Adhere to the highest ethical standards when acting on behalf of Statcare.

• Respect the cultural values and religious beliefs of patients and family members, co-workers, staff members, and visitors

• Prevent and/or refrain from discrimination or harassment of any kind, including racial, ethnic, or sexual harassment
• Refrain from conflicts of interest and/or using a position for personal gain
• Report possible or actual violations of law or ethical standards

Compliance Questions

Integrity, common sense, and sound judgment are your best guides in determining if your personal actions meet the expected standards for ethical and lawful behavior. However, if you find yourself in a situation where you are unsure, ask yourself these questions:

• Is my action consistent with office practices and legal or regulatory requirements?

• Could my action give the appearance (to others) of impropriety or wrongdoing?

• Will the action bring discredit to any employees or, to Statcare, if disclosed fully to the public?

• Can I defend my action to my supervisor, other employees and to the general public?
• Does my action meet my personal code of behavior?

Leadership Responsibility for Compliance Communication

Management and supervisory employees are responsible for communicating the requirements of the Corporate Compliance Program and this Code of Conduct to those who report to them by emphasizing its importance; taking appropriate measures to detect and correct any violations and prevent a recurrence, and imposing consistent and appropriate discipline, if warranted. Leadership personnel is expected to create and maintain an open environment where employees are encouraged and comfortable raising compliance concerns or asking questions. Adherence to the Code of Conduct and support of the Corporate Compliance Program are components of the employee evaluation process for all employees and management staff.

Organizational Ethics and Quality of Care

Patient Care and Patient Rights

We recognize our ethical and moral obligation to the patients and community we serve. We treat all patients with respect and dignity and provide a single standard level of care that is both necessary and appropriate and in accordance with federal, state, and city laws and regulations, as well as Clinic policy. We make no distinction in the admission, transfer, or discharge of patients or in the care we provide based on race, color, religion, national origin, ethnicity, age, sexual orientation, disability, marital status, veteran’s status, or source of payment.

Patients’ Bill of Rights, which all employees are required to honor. is posted conspicuously in public areas throughout the office, includes the rights of patients to make decisions about their medical care. We will ensure that a qualified practitioner evaluates every patient before initiating a treatment plan, as well as ensure that all services are performed by appropriately credentialed and properly trained individuals.

We respect the rights of patients to be involved in all aspects of their care and obtain informed consent for treatment. As applicable, each patient or patient designee is provided with a clear explanation of care including, but not limited to, diagnosis, treatment plan, right to refuse or accept care, care decision dilemmas, and an explanation of the risks and benefits associated with available treatment options. Patients or their designee have the opportunity for the resolution of complaints. Thorough and complete records of patient information will be maintained.

Confidentiality / Clinic Information

We are committed to maintaining the confidentiality of all proprietary information according to existing laws and standards.

Patient Confidentiality and Privacy

We carefully avoid any unwarranted invasion or disclosure of patient’s privacy. We collect information about the patient’s medical condition, history, medication, and family illnesses to provide the best possible care. We realize the sensitive nature of this information and are committed to maintaining its confidentiality.

• All patients are provided with the written Notice of Privacy Practices.

• Access to Protected Health Information (PHI) is limited to those permitted by law and Clinic policy.

• Use only legitimate means to collect the information and, whenever practical, obtain it directly from the individual concerned.

• Maintaining computer passwords and access codes in a responsible and confidential manner.

• Report violations of confidentiality breaches to your supervisor or management team.

• Ensure that patient information is not discussed in any public area.

Any employee who engages in an unauthorized or unlawful disclosure of information in violation of the privacy rights of our patients is subject to disciplinary action, up to and including termination.

Additionally, employees must not make inappropriate modifications to any information or destroy or disclose any information except as authorized. Documents containing sensitive data, including patient and Protected Health Information should be properly secured at the end of the business day.

Statcare staff is expected to take reasonable precautions to ensure the physical security of confidential information and facilities.

Information Owned by Others

Employees who are in a position to receive an outside party’s confidential information (oral, visual, or written) must do so in accordance with company policy or specific agreement with the outside party. Personal software should not be copied for any work done for Statcare, placed or utilized in any Statcare-owned computer system, or generally brought onto Statcare premises.

Employee Privacy

Statcare respects the privacy and dignity of all staff. Statcare collects and retains employee personal information that is required for the effective operation of Statcare or that is required by law. Statcare has implemented policies and procedures that protect and limit access to employee personal information and comply with applicable laws that govern employee privacy. Employees are prohibited from accessing or otherwise using employees’ records or information unless authorized to do so for legitimate business purposes.

Conducting Clinic Business

We will conduct our business in accordance with all laws and regulations and act in a manner that is in the best interest of our institutions and those whom we serve.

Oversight of Clinic/Patient Assets

Managers are responsible for establishing appropriate internal controls within their areas(s) of purview to safeguard Statcare assets, ensure the accuracy of financial records and reports, and maintain accurate reporting of all transactions. The integrity of Statcare’s financial records is critical to effective company operations and is a key factor in maintaining the confidence and trust of our employees and patients, and other stakeholders.

Accuracy, Retention, and Disposal of Documents and Records

Each Statcare employee is responsible for the integrity and accuracy of our business documents and records in order to comply with regulatory and legal requirements, as well as to ensure that records are available to defend our business practices and actions. No one may alter or falsify information on any record or document.

Medical and business records must be fully and accurately completed and maintained, consistent with proper business practices. Statcare takes necessary measures, including the assessment of new hardware and software, to ensure the accuracy and functionality of all appropriate computerized and automated information systems. Employees must comply with Statcare’s record retention policies.

Trade Practices/Antitrust Issues

We are required to comply with all antitrust laws, which are designed to preserve and foster fair and honest competition within the free enterprise system. These laws could be violated by discussing Statcare business with a competitor, such as how our patient charges are established, disclosing the terms of supplier relationships, or agreeing with a competitor to refuse to deal with a supplier. Our competitors are other health systems and facilities in geographic markets where we operate. In general, avoid discussing sensitive topics with competitors or suppliers.

Physician Relationships

Any business arrangements with a physician or a physician group must be structured to ensure compliance with legal requirements. Such arrangements must be in writing and approved by the management team.

Referrals

Statcare does not pay for referrals. We accept referrals and admissions based solely on patients’ clinical needs and our ability to render the needed services. No employee or any other individual acting on behalf of Statcare is permitted to solicit or receive anything of value, directly or indirectly, in exchange for the referral of patients. Statcare is committed to ensuring that physicians make appropriate referrals in accordance with applicable federal Stark laws and relevant state laws. Statcare does not offer or receive inducements or create situations in which Statcare appears to be offering or receiving an improper inducement.

Third Party Payer Relationships

Billing, Coding and Reimbursement

Statcare is committed to full compliance with all laws and regulations relating to billing, coding, and reimbursement. This commitment applies to the government programs of Medicare and Medicaid, as well as those of other third-party payers. We will ensure that all billings to governmental and third-party payers are true and accurately reflect services only for medically necessary services and other necessary data provided to our patients. Employees are prohibited from knowingly presenting or causing to be presented claims for payment or approval, which are false, fictitious, or fraudulent. Statcare operates oversight systems to verify that claims are submitted only for services actually provided, and services are billed as provided. Appropriate training is provided to employees involved in the billing, coding, and claim submission process.

Any subcontractors engaged to perform billing or coding services are expected to have the necessary skills, quality control processes, systems, and appropriate procedures to ensure all billings for government and commercial insurance programs are complete and accurate.

If mistakes or errors occur, they are reported to a manager promptly and corrected in a timely and appropriate manner. If improper payment occurs, we will notify the payer promptly and process refunds in a timely manner. Strict compliance with all relevant Medicare and Medicaid laws and regulations is required by all employees.

Statcare does not routinely waive patients’ deductibles or copayments or otherwise provide for financial benefits to patients.

Restrictions for Government Personnel

Employees may not provide or pay for meals, refreshments, travel, or lodging expenses for government employees; offer any type of gratuity under any circumstances; or entertain a public official without authorization from the Legal Department.

Government Inquiries and Investigations

It is the policy of Statcare to cooperate with and properly respond to all governmental inquiries and investigations. Any employee approached by any federal or state law enforcement or regulatory agency (i.e. Medicare, Medicaid) official seeking information about any aspect of the clinic shall immediately notify their supervisor who in turn must notify the management team. It is Statcare’s policy to ensure that government agencies are provided promptly with all necessary and appropriate information

Personal Use of Statcare Resources

Statcare’s assets, which include employees’ time, materials, supplies, equipment and information, are to be used and maintained primarily for business-related purposes. You may not use these resources in a manner that could be harmful or embarrassing to Statcare. Any use of Statcare resources for personal financial gain unrelated to Statcare is prohibited.

Copyright

Statcare employees are prohibited from reproducing any copyrighted materials without the express permission of the copyright holder unless appropriately licensed from the copyright holder. All staff is required to adhere to laws and policies relating to intellectual property, including patents, trademarks, and copyrights.

Electronic Media

All communications systems, electronic mail, Internet access, or voice mails are the property of Statcare and are to be primarily used for business purposes. Limited responsible personal use of communications systems is permitted; however, Statcare reserves the right to monitor the use of its electronic media resources and to take appropriate disciplinary measures in cases of misuse. Patient or confidential information should not be sent through the Internet or Intranet until such time that its confidentiality can be ensured. Employees may not use communication systems to send harassing, threatening, or obscene messages, send copyrighted documents that are not authorized for reproduction, conduct a job search or open misaddressed mail.

Workplace Conduct and Practices

General

As an organization, Statcare recognizes that our employees, physicians, and volunteers, who serve our company, are our greatest assets. Statcare is committed to providing an employment setting that treats all staff with fairness, dignity, and respect, and affords them an opportunity to grow, to develop professionally, and to work in a team environment.

It is Statcare’s policy to:

• Provide equal opportunity for employment and advancement on the basis of ability and aptitude

• Protect the health and safety of employees

• Compensate employees fairly and equitably

• Train employees adequately relative to their job responsibilities

Employees are encouraged to develop their individual skills and understanding of their job.

Equal Employment Opportunity and Diversity

Statcare is committed to providing an equal opportunity work environment. We will comply with all laws, regulations, and policies related to nondiscrimination and fair employment practices in all of our personnel actions. Such actions include hiring, placement, transfers, promotions, training, compensation, evaluations, leaves of absence, recruiting, corrective action, and discipline and staff reductions. We make reasonable accommodations to the known physical and mental limitations of otherwise qualified staff with disabilities. Retaliation against individuals for raising claims of discrimination or harassment is prohibited.

Employment/Screening

Statcare verifies the credentials and qualifications of all individuals applying for employment and hires only qualified individuals with appropriate expertise, licensure, and experience.

We will not hire or contract with any individual or entity who is excluded, suspended, debarred, or otherwise ineligible to participate in the federal healthcare programs (Medicare, Medicaid)) or has been convicted of a criminal offense related to the provision of healthcare items or services and has not been reinstated in the federal healthcare programs after a period of exclusion, suspension, debarment or ineligibility.

Harassment/Workplace Violence

All Statcare staff have the right to work in an environment free of harassment. Statcare will not tolerate harassment by anyone based on the diverse characteristics or cultural backgrounds of those who work at Statcare. Degrading or humiliating jokes, slurs, intimidation or other harassing conduct is not acceptable. Any form of sexual harassment is strictly prohibited. This prohibition includes unwelcome sexual advances or requests for sexual favors in conjunction with employment decisions, as well as other verbal or physical conduct that creates a hostile work environment.

Statcare does not tolerate workplace violence, which includes threatening, aggressive, or abusive behavior. Moreover, as part of our commitment to a safe workplace, staff are prohibited from possessing firearms, other weapons, or other dangerous instruments and materials on the premises of Statcare.

Immigration

Federal law prohibits Statcare from hiring individuals who are not legally authorized to work in this country.

Hiring of Former Government Employees

Former government employees who, upon termination of their government service, seek employment with Statcare must obtain clearance from the management team to preclude any potential conflict of interest.

Employee Loyalty and Conflicts of Interest

Conflict of Interest

In the course of conducting Statcare business, we are expected to put Statcare’s interests ahead of any outside business, commercial or personal interest. Employees should avoid situations in which conflict of interest, or the appearance of a conflict, could arise. A conflict of interest may also exist if the demands of your outside activities influence or appear to influence your ability to make objective decisions in the course of your job responsibilities.

All employees are required to complete a conflict of interest questionnaire upon hire and certain categories of staff are required to file an annual disclosure statement. Because it is impossible to describe every potential conflict of interest scenario, Statcare relies on your commitment to exercise sound judgment to seek advice when appropriate, and to adhere to the highest ethical standards in the conduct of your professional and personal interactions. Anyone who believes he or she has a conflict of interest or the appearance of a conflict of interest shall immediately report it to his or her supervisor, department manager, or the Corporate Compliance Officer. For additional guidance as to Statcare’s policy on these types of issues, the Conflict of Interest policy should be consulted.

Outside or Dual Employment

Employees’ primary employment obligation is to Statcare. Any activities, such as a second job or personal business, must not conflict with obligations to Statcare. Employees with secondary employment that may be perceived as a conflict of interest with their Statcare position must make such a disclosure to their supervisor.

Gifts and Entertainment/Business Courtesies

Gifts and entertainment represent an area of potential conflict in situations where a competitive, regulatory, supervisory, or adversarial relationship could exist. Giving or accepting gifts and entertainment can sometimes be construed as an attempt to unduly influence a relationship.

It is Statcare’s policy that no personal gifts may be offered or received under circumstances in which the gift might possibly influence the exercise of proper business judgment, regardless of whether this was or was not the intent of the donor or recipient. Accordingly, one should not provide or accept gifts of more than nominal value. Gifts of money (including gift certificates) are never acceptable. Solicitation of personal gifts or entertainment is never permissible.

Acceptance of a perishable or consumable gift (e.g., fruit baskets, cookies, flowers) of nominal value given to a department or group by a vendor during the holiday season or by a patient as a token of appreciation is permissible; however, such gifts should be shared with other staff.

There may be times when employees may wish to accept from a current or potential business associate an invitation to attend a social event, participate in training and educational opportunities or receive information about new products or services. Employees should seek reimbursement from the company for associated expenses in accordance with company policy. Questions related to gifts and entertainment and business courtesies should be referred to the Compliance Officer.

Political Activities and Contributions

Statcare funds or resources are not to be used to contribute to political campaigns or for gifts or payments to any political party or any of their affiliated organizations. Statcare resources include employees’ work time, telephones, or computers.

Employees are permitted to participate in the political process at their own time and own expense, but may not do so on behalf of Statcare. Further, employees are not permitted to use his or her position at Statcare to further the political activity of any person or group.

Senior management is responsible for developing Statcare’s position on relevant legislative and regulatory issues. If you are contacted by legislators or regulators regarding Statcare’s position on public issues, you should refer them to the Compliance Officer. No employee may engage in lobbying or hire an outside lobbyist or consultant without authorization from the management team.

Promotion of Products

It is a violation of Statcare policy for employees to endorse commercial products using Statcare’s name without the prior approval of Statcare. Payment for endorsement is not permitted. Vendors are not permitted to market their products on Statcare premises without prior approval.

Health and Workplace Safety

Environmental Health and Safety

Statcare is committed to providing and maintaining a healthy, safe and secure environment for all patients, staff and visitors. We comply with applicable laws and regulations relating to the environment, including those relating to the handling, storage, use and disposal of pollutants, hazardous materials and infectious wastes that may be used or generated in the course of Company operations. Statcare is dedicated to promoting the occupational health and safety of its staff. It is Statcare’s policy to provide and require the use of appropriate protective equipment and measures, and insist that all work be performed in a safe and responsible manner. All staff is required to become familiar with emergency and safety plans.

Employees must immediately report workplace injuries or unsafe conditions in accordance with company-specific policy and procedure. No employee will be subjected to retaliation or reprisal for being injured on the job or for reporting a workplace injury or unsafe situation.

Substance Abuse and Impairment

Statcare is committed to an alcohol and drug-free work environment. All staff is expected to report for work free of the influence of alcohol and illegal substances.

Working under the influence of any illegal drug or alcohol, using, possessing, or distributing illegal drugs while at work or on Statcare premises may result in immediate termination. Statcare may use drug testing as a means of enforcing this policy.

Prescription Drugs

Statcare is legally responsible for the proper distribution and handling of regulated pharmaceutical products, including prescription drugs, controlled substances, hypodermic needles, and drug samples. All employees must be vigilant in complying with all applicable laws, regulations, and Company procedures, maintaining the highest professional standards in safeguarding pharmaceuticals of all kinds and preventing unauthorized access to them. If you become aware of the diversion of drugs from Statcare, it should be reported immediately to your supervisor or to the Corporate Compliance Officer.

Business and Community Conduct

Marketing and Advertising

Our marketing material reflects only those services available in accordance with our licensure and accreditation. We will present only truthful and non-deceptive information in these materials. The Marketing team is responsible for reviewing and evaluating all material that is distributed to the community to ensure that the information being provided is accurate.

Relationships with Suppliers, Vendors, and Subcontractors

Statcare manages its relationships with suppliers, vendors, and subcontractors in a fair and reasonable manner, consistent with all applicable laws, good business practices, and in accordance with Statcare policies and procedures. Selection of suppliers, vendors, and subcontractors will be made on the basis of objective criteria, including quality, service, price, delivery, technical excellence, adherence to schedules, and supply of goods and services. Purchasing decisions will be made on vendors’ ability to meet Statcare’s needs and not on personal relationships, friendship, favors, gratuities, or contributions. Suppliers, vendors, and subcontractors will be expected to abide by this Code of Conduct.

Corporate Compliance Program

Corporate Compliance Program Structure and Your Responsibility

The Corporate Compliance Program is intended to demonstrate in the clearest possible terms the absolute commitment of Statcare to the highest standards of integrity, ethics, and compliance. The Corporate Compliance Officer, appointed by the President of Statcare, has responsibility for the implementation of the Corporate Compliance Program.

Obligation to Report

Every employee has a responsibility and is required to report any activity by any colleague, physician, contractor, or vendor that appears to violate applicable laws, rules, regulations, or this Code of Conduct, through the appropriate chain of command. Failure to make an appropriate report may result in disciplinary action. Reporting enables the potential problem to be investigated promptly and addressed in a timely and appropriate manner.

What to Report

Report concerns about any legal, ethical, quality, behavioral or practical issue or any activity that you think may be a problem. Pay particular attention to issues related to federal healthcare programs (i.e. Medicare, Medicaid). Reasonable belief that a violation is possible is sufficient to initiate a report. To help you determine whether an issue should be reported, consider the following questions:

• Does the matter comply with pertinent Company policies and procedures?

• Is the action legal? Is it ethical?

• How would the action appear if it were disclosed to the public?

Resources for Reporting Violations

Reports of suspected or actual violations can be made in person, by telephone or in writing. Employee reports should first be made, if possible, to the employee’s supervisor.

Reporting Concerns – Non-Retaliation

Retaliation against any employee who seeks advice, raises a concern, or reports an ethical or compliance issue in good faith will not be tolerated. An employee who deliberately makes a false accusation with the purpose of harming or retaliating against another employee will be subject to disciplinary action.

Internal Investigations

Statcare is committed to investigating all reported concerns promptly and confidentially to the extent possible. The Corporate Compliance Officer will coordinate any findings and take prompt and appropriate corrective action(s). We expect all employees to cooperate with investigation efforts.

Corrective Action

Where an internal investigation substantiates a reported violation, appropriate corrective measures will be taken, including, but not limited to, notifying the appropriate governmental agency, instituting appropriate disciplinary action, and implementing systemic changes to prevent a similar violation from recurring in the future. Corrective action plans will be shared with all appropriate parties.

Consequences of Noncompliance

Failure to comply with applicable laws and regulations, or with the requirements of this Code of Conduct or Statcare’s policies and procedures, or to report violations or suspected violations, could pose significant risks to Statcare, our employees, as well as to the patients we serve. Examples of consequences to Statcare and/or employees for noncompliance include exclusion from participation in federal healthcare programs, such as Medicare; criminal and/or civil fines, and penalties.

Disciplinary Action

Disciplinary action, up to and including termination, may be taken for:

• Violating this Code of Conduct

• Failing to report a violation of the Code of Conduct or cooperate in an investigation

• Retaliating against an individual for reporting a violation or possible violation of the Code of Conduct

• Deliberately making a false report of a violation of the Code of Conduct

Principles of fairness will apply, including, when appropriate, a review of a disciplinary decision.

Internal Monitoring and Auditing

Statcare is committed to an ongoing assessment process. Monitoring and audit activities are conducted under the auspices of the Corporate Compliance Officer. The audits will be designed to address Statcare’s compliance with laws, regulations, and policies governing, among other things, coding, reimbursement, documentation, medical necessity, and other areas that may be deemed as high-risk areas.

Additional Resources

While this Code of Conduct provides overall general guidance, there are additional guiding resources with respect to our Corporate Compliance Program available

to Statcare employees. They include Statcare-wide, company-wide policies and procedures, the Employee Handbook, as well as consultation with individuals within your chain of command, beginning with your immediate supervisor. Additional resources include periodic informational newsletters and other similar advisory memoranda.

Acknowledgement

Upon initial employment, all staff is required to sign an Employee Acknowledgement form confirming that they have received this Code of Conduct and that they will read, understand and commit to abide by its provisions.

FOR MORE INFORMATION

For more information on the Corporate Compliance Program, call the Corporate Compliance Officer at (917) 924-4347 Ext: COM. Specific institutional policies and procedures can be found in Corporate Compliance, Administration, and Human Resources manuals. Additionally, in-service training programs are scheduled throughout the year.