1 This material must be reviewed prior to attending your General Orientation class. Please ask any related questions at your General Orientation class. Welcome to the 2014 Catholic Health System Online Orientation Component

2 Leonardo Sette ‐ Camara, Esq Compliance & Privacy Officer

3 To prevent, find and correct violations of CHS standards, governmental laws, regulations and rules To promote honest, ethical behavior in the day-to-day operations To understand the ethical, professional, and legal obligations associates have and our role in meeting those obligations

4 As healthcare professionals and providers, we are dedicated to caring for and improving the health and well being of the people we serve in the community Compliance means “doing the right thing”

5 Attain compliance by: Embracing our Mission and Values Adherence to Policies and Procedures Found in Compliance 360 Maintaining high standards of business and ethical conduct Delivering high quality patient care

6 Standards of Conduct & Ethical Conduct Deal openly and honestly with others Maintain high standards of conduct in accordance to the CHS Mission, directives of the Catholic Church, and applicable federal, state and local laws and regulations Conflict of Interest We have a responsibility to act on the best interests of Catholic Health. We need to avoid situations that lead to actual or perceived conflicts of interest Documentation and Billing Must be accurate and complete

7 Associate Compliance Guidebook Provides information on the Standards of Conduct and is available on CHS website. An observation of failure to follow Standards of Conduct, Policies or Procedures, or observation of an error requires reporting. Associates can face disciplinary action and even termination for failure to report such events.

8 All associates are expected to follow standards for Legal and Regulatory Compliance Business Ethics Conflict of Interest Appropriate Use of Resources Confidentiality Professional Conduct Responsibility And follow the Code of Ethics

9 Enhance the Patient Experience Have a questioning attitude Pay attention to details Follow the rules Be accountable for your actions Providing high quality services and upholding patient rights supports the Compliance Program.

10 Compliance policies and procedures are available on Compliance 360 (or in an on-site reference manual) and apply to all CHS associates. Additional compliance policies are also applicable to: Home Care Clinical Laboratory Physician Practices Nursing Facilities Coding and Billing Home Health Agency PACE Program

11 It is fraudulent to either document services that were not performed or to submit claims for services without appropriately documenting those services Missing clinical notes (dates, signatures, orders, care or service rendered) or test results Incomplete or illegible documents Improper billing and coding can be interpreted as fraud or abuse and lead to a false claim with the government resulting in penalties Reimbursement can only be sought for services or items that have been provided and appropriately documented. If it’s not documented, it’s not done.

12 It is a crime to knowingly make a false record, file, or submit a false claim with the government for payment. A false claim can include billing for service that: Was not provided or documented Was not ordered by a physician Was of substandard quality Improperly coded or billed It is also unlawful to improperly retain overpayments. Allows for Qui Tam Relator – notification to government with protection (Whistleblower provision)

13 Government Sanctions Individuals or entities can be excluded from participation in Medicare and Medicaid programs. CHS must not submit any claims to Medicare and/or Medicaid in which a sanctioned individual or entity provided care or services. If an associate/provider is sanctioned, he/she must provide notification immediately to the Compliance Officer.

14 If working on behalf of CHS, do your actions or activities result in personal gain or advantage, potential adverse effect for CHS or the potential to interfere with professional judgment, objectivity or ethical responsibilities? Potential Conflicts of Interest Relationships include financial relationship for yourself or your immediate family member or secondary employment Consultant Speakers’ Bureau Advisory Panel Administrative positions with Pharm or DME Third Party Payor Other entities doing business with CHS All potential Conflicts of Interest must be reported.

15 Associates may NOT accept any cash gifts or cash equivalent gifts (gift cards) from any person or business conducting or seeking to conduct business with CHS Prior to receiving work-related Gifts Social or entertainment events Free meals Associates must consult with their supervisor. See CHS Policy for further information.

16 Ensures that limited English proficiency or hearing impaired persons utilizing CHS services are able to understand and communicate with CHS associates and physicians Provided FREE of charge to the patient Mandatory service by law Documentation is vital to compliance Language Assistance Program Policy is found in Compliance 360

17 HEALTH INSURANCE PORTABILITY ACCOUTABILITY ACT and HITECH Health/Information Technology for Economic and Clinical Health Act Privacy and Security Policies are found in Compliance 360

18 Individually identifiable health information Also known as Protected Health Information (PHI) Transmitted or maintained in any form or medium

19 Names Full face photos Medical Record Number Health Plan Number Account Numbers Certificate/License Numbers Vehicle Identifiers and web addresses Biometric Identifiers Geographic subdivisions smaller than a state All elements of dates related to birth date, admission, discharge, or date of death, ages over 89 Telephone and fax numbers Social Security Number Any other unique identifying data

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21 Be aware of surroundings Be conscious of who is in the immediate area when discussing sensitive patient information or at your computer terminal (lower your voice) Secure area when not attended Close out of computer screens containing PHI before leaving the area Close medical records/chart when not in use Do not allow other associates to utilize your ID and password Report theft or loss of computer devices immediately Correct Disposal of PHI (shred bin)

22 Telephones Be careful with phone call pertaining to patient information Fax Machines and Scanners Pick up faxed or printed PHI immediately Use fax cover sheet, verify # and receipt Scan PHI only to CHS accounts Make sure to encrypt if being sent outside CHS Careful forwarding and replying Mail Double check name/address and material prior to sending

23 Curiosity can be a normal human trait … However accessing health information on yourself, family members, friends, co-workers, persons of public interest or any others that you are not involved in the care of or Disclosing PHI inappropriately Are … VIOLATIONS of HIPAA Individuals do NOT have the right to look up their own health records. Your computer use can be monitored.

24 Fraud and Abuse Fraud Defined: An intentional deception or misrepresentation that could result in some unauthorized benefit to a person or Catholic Health Abuse Defined: Practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary cost, or in reimbursement of services that are not medically necessary or that fail to meet professionally recognized standards for health care

25 Documentation issues Improper billing and coding Offering or receiving kickbacks, bribes, or rebates The service has not been rendered by the identified provider, to the identified person, or on the identified date

26 Lack of integrity Ethical incidents Theft or misuse of services Improper political activity Breech of corporate confidentiality Improper use of proprietary information Environmental health and safety issues Dishonest communication (spoken or documents) Improper business arrangements Failure to follow Record Retention policy Receipt of incentives for patient referrals The Associate Guidebook or your supervisor can provide additional info.

27 Immediate supervisor or appropriate department Higher level manager Compliance Officer Nancy Sheehan, Esq Also available 24/7 Compliance Line Confidential and Anonymous (if desired)

28 Behavior issues Human Resource policy violations Union contract matters … Should be reported to Human Resources Policies on Compliance 360 include: Corrective Action Fair Treatment Review

29 Protects associates from adverse action when they do the right thing and report a genuine concern Reckless or intentional false accusations by CHS associates are prohibited Reporting the possible violation does not protect the constituent from the consequences of their own violation or misconduct Associates have a duty to report HIPAA/Compliance concerns

30 Upholding CHS Mission and Values Adhering to Code of Conduct, Policies and Procedures and the Law Completing education and employment requirements Constant monitoring for concerns Duty to report concerns and support non-retaliation During an investigation Be truthful Preserve documentation or records relevant to ongoing investigations

31 For associate and CHS managers/supervisors/administrators Fines and Prison sentences Corrective action - Includes termination of employment for violations or failure to report concerns For Catholic Health System Exclusion from government funded insurance programs (Medicare/Medicaid) Fines

32 Putting words into action … “We judge ourselves based on our intentions … Others judge us based on our actions.” Adhere to the CHS code of conduct, policies and procedures, and other standards

33 Duty to report Compliance/HIPAA concerns as soon as aware of situation Do the right thing … Apply ethical decision making If uncertain … Always Seek Knowledge (A.S.K.) Use Associate Booklet on CHS website as a reference

34 Compliance/HIPAA Privacy Officer Leonardo Sette – Camara CHS HIPAA Hotline Compliance Hotline (available 24/7) All reports are confidential.

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36 Risk Management is the systematic review of events that present a potential for harm and could result in loss for the system.

37 Review Identification Review Occurrence Reports Review Patient/Visitor Complaints Participate in Root Cause Analysis Review concerns expressed by CHS staff

38 Loss Prevention Educational programs through CHS University Department specific in-services

39 Claims Management Investigating and reporting occurrences and claims made to insurance carriers Assist with discovery requests for lawsuits Process Summons, Complaints and Subpoenas ** NOTIFY RISK MANAGEMENT IMMEDIATELY UPON RECEIPT OF A WORK RELATED SUMMONS OR SUBPOENA

40 Claims Management - Continued Within CHS, a process server is to be directed to Administration of the facility in order to serve a Summons or Subpoena. (HIM may accept subpoenas for hospital records.) *** INDIVIDUAL DEPARTMENTS SHOULD NOT ACCEPT, EVEN IF IT IS FOR SOMEONE IN THE DEPARTMENT.

41 Risk Financing Obtaining and maintaining appropriate insurance coverage: HPL (Healthcare Professional Liability) GL (General Liability) D&O (Directors and Officers) Property and Casualty Auto Crime Fiduciary (Finance)

42 An occurrence is an event that was unplanned, unexpected and unrelated to the natural course of a patient’s disease process or routine care and treatment.

43 Patient harm/potential harm like falls, medication errors Visitor injury Patient related equipment “failure” Security issues like elopement, crime, altercations Lost or damaged property

44 Enhance the quality of patient care Assist in providing a safe environment Quick notice of potential liability

45 Any associate or physician who discovers, witnesses or to whom an occurrence is reported, is responsible for documenting the event immediately by means of the Occurrence Report. Anyone who requires assistance should contact the department manager. DO NOT MAKE COPIES OF AN OCCURRENCE REPORT.

46 The completed Occurrence Report is to be forwarded to the Department Manager who will investigate the occurrence and forward to Quality & Patient Safety Department who will forward to Risk Management.

47 Patient and visitor safety are assessed from both clinical and environmental perspectives Notify Quality & Patient Safety of patient occurrences Notify Security of visitor or property occurrences Risk Management will be notified and will participate in evaluation of occurrence Risk Management will report occurrences to insurance carrier in cases of potential liability Risk Management will manage claim as indicated

48 Date (MM/DD/YY) and time (military) State facts, be clear and concise Your own observations If event described to writer, use quotes or “according to …” Do not place blame in the record DO NOT REFER TO OCCURRENCE REPORT IN THE MEDICAL RECORD

49 EMTALA is the Emergency Medical Treatment and Active Labor Act (aka COBRA) EMTALA provides a guideline for safely and appropriately transferring patients in accordance with Federal regulations.

50 The law provides for a medical screening exam (MSE) to all individuals seeking emergency services on hospital property. Hospital property includes the driveway, parking lot, lobby, waiting rooms and areas within 250 yards of the facility. If an emergency medical condition is found, it will be stabilized within the hospital’s ability to do so, prior to the patient’s transfer or discharge. If a patient does not have an emergency medical condition, EMTALA does not apply. *** IMPORTANT: NEVER SUGGEST THAT A PATIENT GO ELSEWHERE FOR TREATMENT

51 Fair and Accurate Credit Transactions Act of 2003 or “RED Flag Rules” Hospitals that maintain covered accounts must develop and implement written policies and procedures to identify, detect, prevent, and mitigate identity theft.

52 Alerts, notifications, warnings Presentation of suspicious information Suspicious activity Notice from patient, law enforcement, etc. ** Patient Access, Health Information, Finance, I.T. departments primarily involved.

53 You can help reduce opportunities for Identity Theft by keeping PHI confidential and out of public view. If you believe someone is presenting suspicious documents or acting in a suspicious manner, notify your supervisor who will notify Risk Management.

54 Carol Ahrens, RN, BSN Director, Risk Management Joanne Ricotta, RN, BSN Risk Management Coordinator Linda McGavin Risk Management Technical Assistant Amy Maurer Legal Services Administrative Assistant

55 Violence can have a negative effect on an organization as reflected by: Low morale Increased job stress Increased worker turnover Reduced trust of management or co-workers

56 Contact with violent people or those with history of violence Contact with those under the influence of drugs and/or alcohol Contact with people having psychotic diagnoses Contact while transporting patients Contact with people perceiving a long wait for service Working alone

57 Watch for signals of impending violence: Verbally expressed anger and frustration Body Language such as threatening gestures Signs of drug or alcohol use Presence of weapons

58 Assess current demeanor when you enter a room or begin to relate to a patient or visitor Be vigilant throughout the encounter Don’t isolate yourself with a potentially violent person Keep an open path for exiting

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60 NIOSH (National Institute for Occupational Safety and Health) defines workplace violence as violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty.

61 Threats: Expressions of intent to cause harm, including verbal threats, threatening body language, and written threats. Physical Assaults: Attacks ranging from slapping and beating to rape, homicide, and use of weapons such as firearms, bombs, or knives. Muggings: Aggravated assaults, usually conducted by surprise and with intent to rob.

62 Workplace violence in hospitals usually results from patients and occasionally from family members who feel frustrated, vulnerable, and out of control.

63 Violence takes place During times of high activity such as meal time or visiting hours or patient transportation When service is denied When a patient is involuntarily admitted When limits are set regarding eating, drinking, tobacco use or alcohol use

64 Hospital personnel having direct contact with patients and families are at increase risk.

65 An elderly patient verbally abused a nurse and pulled her hair when she prevented him from leaving the hospital to go home in the middle of the night. An agitated psychotic patient attacked a nurse, broke her arm, and scratched and bruised her. A disturbed family member whose father had died in surgery walked into the E.D. and fired a handgun, killing a nurse and an EMT and wounding a physician.

66 Anywhere in the hospital, but it is most frequent in the following areas: Emergency Departments Any Critical Care area Waiting Rooms Geriatric Units

67 Violence can have a negative effect on an organization as reflected by: Low morale Increased job stress Increased worker turnover Reduced trust of management or co-workers

68 Contact with violent people or those with history of violence Contact with those under the influence of drugs and/or alcohol Contact with people having psychotic diagnoses Contact while transporting patients Contact with people perceiving a long wait for service Working alone

69 Watch for signals of impending violence: Verbally expressed anger and frustration Body Language such as threatening gestures Signs of drug or alcohol use Presence of weapons

70 Assess current demeanor when you enter a room or begin to relate to a patient or visitor Be vigilant throughout the encounter Don’t isolate yourself with a potentially violent person Keep an open path for exiting

71 Present a calm, caring attitude Don’t match the threats Avoid giving commands Acknowledge a person’s feelings Avoid behavior that may be interpreted as aggressive

72 Remove yourself from the situation Call Security or 911 for HELP if needed Report any potential or actual violent incidents to your department manager

73 No universal strategy exists to prevent violence All hospital workers should be alert and cautious when interacting with patients and visitors Staff need to be aware of polices and procedures relating to violence prevention

74 Obesity: Understanding, Awareness, and Sensitivity Catholic Health Orientation 2013

75 Consequences of Obesity Psychological and Social Well-Being Negative Self-Image Discrimination Can be difficult to maintain personal hygiene Depression Turnstiles, cars, and sitting may be too small Diminished sexual activity

76 Social Discrimination Studies show society has a low respect for morbidly obese May have limited number of friends May experience social rejection Have poor quality in relationships

77 Weight Bias in Healthcare What assumptions do I make based only on weight regarding a person’s character, intelligence, professional success, health status, or lifestyle behaviors Could my assumptions impact my ability to care for these patients? Do I only look at their weight problem, and not other health related issues?

78 Challenge the Bias Lead by example: influence peers and others to demonstrate patient sensitivity, become a good role model. Don’t tolerate behind-the-back whispers, jokes, even in private. If no one questions obesity bias, what will ever stop it?

79 Strategies for Healthcare Consider that patients may have had negative experiences with other healthcare professionals regarding their weight; approach patients with sensitivity. Recognize that many patients have tried to lose weight repeatedly. Acknowledge the difficulty of lifestyle changes.

80 Our Role We need to care for both physical and emotional needs. Support and encouragement are so important. Compassion and empathy must be conveyed. Communication and listening skills are essential. Smile, look at the person, do not ignore a patient because of their obesity.

81 Catholic Health Systems Employee Breastfeeding Support

Overview

83 Support of Breastfeeding is a Priority Reduced Risk for Infants with Exclusive Breastfeeding 1, 2 Obesity Ear Infections Respiratory Infections Asthma Gastrointestinal Infections Atopic Dermatitis Type 1 & Type 2 Diabetes Leukemia Sudden Infant Death Syndrome Necrotizing Enterocolitis

84 Public Health Case Breastfeeding is the standard for infant feeding and protects infants and children from many significant infectious and chronic diseases. $13 billion of direct pediatric health-care costs and more than 900 lives would be saved annually if 90% of women were able to breastfeed exclusively for six months as recommended. 2 Women who breastfeed have a reduced risk of breast and ovarian cancer, type 2 diabetes, postpartum depression, and cardiovascular disease. 3-5

85 Work Remains a Barrier to Breastfeeding 6-10 Full-time employment decreases breastfeeding duration by an average of more than eight weeks. Mothers are most likely to wean their infants within the first month after returning to work. Only 10% of full-time working women exclusively breastfeed for six months. Catholic Health is a leader in supporting breastfeeding moms in the workplace.

86 If a mother chooses to breastfeed, she needs to pump breast milk during the workday in order to maintain her milk supply. Missing even one needed pumping session can lead to decreased milk production and other undesirable consequences.

87 Women Need Worksite Lactation Support 11 Breaks for lactation are similar to other work breaks for attending to physical needs: Time to eat/drink, restroom breaks, accommodation for health needs (e.g., diabetes) When mother and child are separated for more than a few hours, the woman must express milk. Missing even one needed pumping session can have undesirable consequences: Discomfort – Leaking – Inflammation Infection – Decreased Milk Production Breastfeeding Cessation

88 How to Support Breastfeeding Employees In general, women need 30 minutes (15 to 20 minutes for milk expression, plus time to get to and from a private space and to wash hands and equipment) approximately every 2 to 3 hours to express breast milk or to breastfeed. Needs may vary from woman to woman and over the course of the breastfeeding period.

89 Business Case 11 Lactation programs are cost-effective, showing a $3 return for every $1 invested. By supporting lactation at work, employers can reduce turnover, lower recruitment and training costs, cut rates of absenteeism, boost morale and productivity, and reduce health-care costs. Lactation accommodation is not one-size-fits-all. Flexible programs can be designed to meet the needs of both the employer and employee.

90 Breastfeeding = Increased Productivity 11 Breastfeeding reduces illness of the baby = fewer absences of parent employees = immediate return on investment. Breastfeeding support in the workplace helps families meet their breastfeeding and childrearing goals = higher job satisfaction, increased loyalty, increased ability to focus on job responsibilities, higher return to work postpartum, and lower turnover = immediate return on investment. Breastfeeding prevents chronic disease in women who breastfeed and contributes to a healthier future workforce through reduction of obesity and chronic disease = long- term payoff that keeps on giving.

91 Fair Labor Standards Act Section 7 of the Fair Labor Standards Act was amended effective March 2010:  Employers are required to provide “reasonable break time for an employee to express breast milk for her nursing child for 1 year after the child’s birth each time such employee has need to express the milk.”  Employers are also required to provide “a place, other than a bathroom, that is shielded from view and free from intrusion from coworkers and the public, that may be used by an employee to express breast milk.” Legal Basis

92 Common Concerns of Breastfeeding Mothers 11 Modesty Time and social constraints Lack of support Making enough milk for their babies

93 Resources What resources are available for managers? Catholic Health Policy on Lactation (Compliance 360) Identify location within your department for your associate – talk with your manager about a room for your use Direct associates with specific breastfeeding/personal advice regarding lactation can call What resources are available for employees? Baby Café at Sisters Mercy and Sisters Hospital Lactation Department Educational materials, professional support.

94 References (1-6) 1.Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D, Trikalinos T, Lau J. (Tufts- New England Medical Center Evidence-based Practice Center). Breastfeeding and maternal and infant health outcomes in developed countries. Evidence Report/Technology Assessment No Rockville, MD: Agency for Healthcare Research and Quality; 2007 Apr. AHRQ Publication No. 07-E007. Contract Nu pp. Available from: 2.American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the in the United States: A pediatric cost analysis. Pediatrics. 2010;125(5): e Schwarz EB, Ray RM, Stuebe AM, Allison MA, Ness RB, Freiberg MS, Cauley JA. Duration of lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol. 2009;113(5): Gunderson EP, Jacobs DR, Chiang V, et al. Duration of lactation and incidence of the metabolic syndrome in women of reproductive age according to gestational diabetes mellitus status: A 20-year prospective study in CARDIA—The Coronary Artery Risk Development in Young Adults Study. Diabetes. 2010;59(2): Fein B, Roe B. The effect of work status on initiation and duration of breast- feeding. American Journal Public Health. 1998:88(7):

95 References (7-12) 7. Cardenas R, Major D. Combining employment and breastfeeding: Utilizing a work-family conflict framework to understand obstacles and solutions. J Bus Psychol. 2005; 20(1): Galtry J. Lactation and the labor market: Breastfeeding, labor market changes, and public policy in the United States. Health Care Women Int. 1997;18(5): Texas Department of State Health Services. WIC Infant Feeding Practices Survey, United States Breastfeeding Committee. Workplace Accommodations to Support and Protect Breastfeeding. Washington, DC: United States Breastfeeding Committee; Available from: USBC.pdf USBC.pdf 11.Department of Health and Human Services (U.S.). The Business Case for Breastfeeding. Steps for Creating a Breastfeeding Friendly Worksite: Bottom Line Benefits [Kit]. US Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau HRSA Inventory Code: MCH Available from: US Department of Labor. Break Time for Nursing Mothers. [Online] Available from:

96 Social Media Policy Review Social Media is defined as user generated content that is shared over the internet via technologies that promote engagement, sharing and collaboration. It includes, but is not limited to social networking sites such as Facebook, LinkedIn, Flickr and Twitter, personal websites, news forums and chat rooms. Catholic Health recognizes social media as an avenue for self-expression. Associates must remember that they are personally responsible for the content they contribute and should use social media responsibly. Catholic Health’s human resources policies – including its equal employment opportunity and sexual harassment/non-harassment policies – and its policies on patient confidentiality/HIPAA, apply to associates’ on line conduct.

97 Social Media Policy Review, cont. 1. Follow Catholic Health values, Code of Conduct and policies in all social media usage. Know and follow the Catholic Health code of conduct, which is available online at and the Catholic Health Conduct Principles and Corrective Action Policy. Behavior related to social media must comply with all Catholic Health policies, including any Confidentiality Agreements, HIPAA policies and rules of practice, discrimination and harassment policies, computer use policies and any other policies that govern the content or manner of your social media usage. 2. Carefully consider what you post. You are personally responsible for the content you publish on blogs, wikis or any other form of user-generated media. Be mindful that what you publish may be public for along time. If you're about to publish something that makes you even a little uncomfortable, reconsider whether the publication is a good idea and whether it violates any Catholic Health rules. If you are unsure or have questions, discuss it with your manager or Human Resources prior to posting the information. Ultimately, you have sole responsibility for what you post and publish in any form of online social media. If your social media activity shows that you have exercised poor judgment in such activities, or if your activities in social media violate any Catholic Health policies, Catholic Health take legal or disciplinary action against you.

98 Social Media Policy Review, cont. 3. Representation of Catholic Health on any social media site is subject to approval. Anyone creating a presence on any social media outlet for the purpose of representing an entity of Catholic Health should first gain approval from the Communications and Marketing Department. This will ensure that the organization as a whole is aware of all official communication efforts of its facilities, departments, and associates. No Catholic Health associate or stakeholder should create any presence (user or group), or post material to any website as a representative of any Catholic Health entity without authorization. 4. Affiliation with Catholic Health must be disclosed. Every website, “fan page” or other online destination that is controlled by Catholic Health must make that fact known to users and must be authorized according to internal protocols

99 Social Media Policy Review, cont. 5. Identify your opinions as your own and not those of Catholic Health. Associates must use appropriate disclaimers when using social media. If you choose to identify yourself as affiliated with Catholic Health, or if you identify your role at Catholic Health, you should write in the first person. You must make it clear that you are speaking for yourself and not on behalf of Catholic Health. Use a disclaimer such as “The postings on this site are my own and don't necessarily represent Catholic Health’s positions, strategies or opinions." 6. Do not disclose private, confidential or proprietary information. Do not provide confidential information regarding Catholic Health, our business, patients, associates or affiliates. Know and follow the Catholic Health privacy policy. 7. Abide by federal and state laws. Do not violate federal and state laws, including discrimination, harassment, bullying, copyright, fair use and financial disclosure laws.

100 Social Media Policy Review, cont. 8. Be respectful. Associates must not use any form of social media to harass, bully, coerce, intimidate or retaliate against other Catholic Health associates or anyone affiliated with Catholic Health. Associates must not post anything that is false, obscene, defamatory, libelous, threatening or abusive whether in word, images or audio, about Catholic Health or anyone affiliated with the organization including other associates. Lastly, speak respectfully about our current, former and potential customers, partners, associates, and competitors. 9. Be professional. If you choose to identify yourself as a Catholic Health associate or affiliated person, ensure that your profile and related content is consistent with how Catholic Health requires you to represent yourself when interacting with colleagues and clients. If you have joined Catholic Health recently, be sure to update your social profiles to reflect our code of conduct guidelines.

101 Social Media Policy Review, cont. 10. Do not engage in solicitation. Do not advertise for a third party on Catholic Health’s social media pages or when referencing Catholic Health. See also Catholic Health’s Solicitation policy, HR 106, which applies to activity in relation to social media. 11. Associates may not use any Catholic Health social media site to gain access to contact lists or names to be used for any purpose that would violate federal or state laws or any Catholic Health policy. 12. Do not post photographs taken on Catholic Health property without the consent of the individuals in the photos or if the information in the photos is confidential, patient information, proprietary, offensive as outlined in Catholic Health’s Media Policy, CHS CM Do not post malignant materials. Do not post materials that contain software viruses, worms, disabling code, or any other computer code, files or programs designed to interrupt, destroy or limit the functionality of any computer software or hardware or telecommunications equipment.

102 Social Media Policy Review, cont. 14. Think twice before “connecting.” Carefully consider whether connecting to other Catholic Health associates, customers, donors, medical staff, volunteers, board members, independent contractors, affiliates, vendors, business partners, or competitors via social media is appropriate for your level, position, and responsibilities. Not everyone wants to be your “friend,” and it may be awkward to refuse to “friend” or to “unfriend” a co- worker, customer or business associate or to learn overly personal information about such people (or for them to learn overly personal information about you). To the extent that you do connect via social media with people affiliated with Catholic Health, consider using available privacy filters or settings to block any inappropriate, unprofessional, or overly personal information about you from such people. Associates in supervisory or managerial roles should be especially mindful of appropriate boundaries. 15. Use of Catholic Health address. Associates should not use their CH addresses to register for social media unless use of social media on behalf of Catholic Health is required by or directly related to the associate’s job. Associates may reference their Catholic Health employment and contact information on professional networking sites, such as LinkedIn. Access to social media is prohibited for non-exempt associates during work time unless job related.

103 Social Media Policy Review, cont. Catholic Health reserves the right to host or sponsor internal or external social media sites for its own business purposes. Unauthorized access to or editing of any Catholic Health sponsored social media site is strictly prohibited. By posting content on any Catholic Health social media site, you grant to Catholic Health the right to reproduce, distribute, or publish such content and the right to create derivative works from your content, edit or modify such content and use such content for any Catholic Health purpose. Associates have no right to privacy with respect to any information sent, received, created, accessed, obtained, viewed, stored or otherwise found at any time on Catholic Health’s computer network or using Catholic Health’s electronic equipment. Conduct that violates other policies would also be prohibited through social media. Associates are encouraged to report known or suspected violations of any policy to their supervisor or Human Resources. Human Resources will investigate a claim in the same fashion as if the associate made a complaint directly to HR. See also Discrimination and Harassment policy, HR 016. Associates who violate this policy will be subject to corrective action, up to an including termination of employment. See also HR 011, Conduct Principles and Corrective Action. Catholic Health may monitor any social media activity of individuals covered by this policy if there is reason to believe that a policy or legal violation has occurred as well as in connection with Human Resource investigations. Catholic Health reserves the right to edit or remove posts that violate this policy.

104 The Uninsured Expected Payment and Healthcare Assistance Policy

105 Policy The policy divided is into three distinct sections that grant different rights to patients based on the following Catholic Health ministries: Acute Care Continuing Care Home Healthcare

106 Acute Care All uninsured patients of Catholic Health receiving treatment at one of the Catholic Health’s acute care facilities who are residents of New York State, a contiguous State or the state of Ohio, excluding the following services: - Non-Medically Necessary Elective Services (e.g. cosmetic surgery), - Long term level of care services (Sub-Acute or Skilled Nursing), - Physician services other than Catholic Health primary care physician services, and - Medical equipment and supplies

107 Continuing Care Continuing Care: All residents of Catholic Health receiving treatment at one of the Catholic Health’s Long Term Care facilities (Hospital and Non Hospital Based) that are subject to insurance co-payments or deductibles and Adult Home residents may be eligible for charity care.

108 Home Healthcare Home Healthcare: All patients that receive services within the Catholic Health Home Care division (Certified Agencies, Licensed Agencies, and Infusion Pharmacy) may be eligible for Charity Care.

109 Acute Care Section Policy and Procedures All patients registered as uninsured (i.e., those without insurance, also often referred to as self pay) will automatically be enrolled in the Healthcare Assistance Program. An optional application form will be offered at time of registration, but failure to complete the application will not exclude enrollment. As such, uninsured patients presenting for care at a Catholic Healthcare acute care facility need do nothing to apply for healthcare assistance.