Caring for Our Patients
Each of us at Hackensack Meridian Health is focused on the protection and care of our patients, and we use the Patient Bill of Rights to guide our behavior toward patients and their families.
Our number one priority is to provide high quality and safe health care services to all of our patients. The provision of health care services to patients must comply with all federal and state laws, regulations, guidelines and policies. While these laws and regulations may vary depending on the type of service (hospital, nursing home, home health agency, etc.), certain standards of clinical excellence apply to all patient care services to insure we provide safe treatment to all our patients.
Patient Rights
The Patient Bill of Rights is provided in the information packets that patients requiring hospital, home care, or nursing home services receive, as well as being available online on our websites. Patient rights practices and policies are emphasized in team member orientation and periodic educational sessions. Hackensack Meridian holds public forums to discuss advance directives and other topics related to patient rights and health information. Patient safety is connected to our efforts to protect the patient at all times.
Medical Care
Hackensack Meridian bases each patient’s plan of care on the assessed needs of the individual patient. We protect the integrity of clinical decision-making, regardless of how Hackensack Meridian compensates its team members, clinical staff, and licensed independent practitioners. Hackensack Meridian makes no distinction in admission or treatment based on race, color, age, religion, national origin, sex, disability, handicap, sexual orientation, gender identity or expression, diagnosis, or any other protected category. Similarly, a patient’s ability to pay or source of payment will not be a consideration. We monitor quality indicators to verify our ongoing efforts are always focused on positive care outcomes.
Patients are entitled to receive understandable explanations from their physicians about their medical condition, recommended treatment, expected results, and risks involved and reasonable medical alternatives. Patients are further required to give informed, written consent prior to the start of specified, non-emergency medical procedures or treatments, and have the right to refuse medication and treatment after possible consequences have been explained clearly to them, unless otherwise required by law.
Personal Needs
Patients are entitled to be treated with courtesy, consideration, and respect for their dignity and individuality, to have freedom from physical and mental abuse, and to have physical privacy during medical treatment and personal hygiene functions unless they need assistance.
Patient Freedom of Choice
We respect patients’ freedom to make informed decisions about their health care. We inform patients of all appropriate alternatives and their benefits and risks, as well as post-discharge provider care options. If Hackensack Meridian is affiliated with a health care facility where needed care could be provided, we disclose the nature of such affiliation.
Safe Discharges and Transfers
We will not transfer or discharge any patient except in accordance with a safe discharge plan. Hackensack Meridian complies with the requirements under the Emergency Medical Treatment and Labor Act (commonly referred to as “EMTALA”), which governs emergency medical treatment and transfers to another facility once a patient’s condition has been stabilized. Emergency patients are transferred to another facility only after they have been stabilized and only if they request such a transfer or the clinical services they need are not available at Hackensack Meridian.
Medical Records
We are responsible for accurate and timely documentation of services provided to individuals in our care. We ensure that medical records meet the requirements of medical staff bylaws, accreditation standards and relevant laws and regulations.
Patients are entitled to have prompt access to the information in their medical record as provided for in the Health Insurance Portability and Accountability Act (referred to as “HIPAA”). Other access to the medical record is limited to authorized individuals with a need to access the record as defined in Hackensack Meridian Health policy. Patients may obtain, upon request, an electronic copy of their medical record, if their health record is maintained in electronic form.
Ethical Research
Hackensack Meridian is committed to protecting the rights of people who participate in our medical research. Consistent with federal and state laws and regulations, Hackensack Meridian operates an Institutional Review Board (“IRB”), which assures that patients asked to participate in biomedical and behavioral research are provided with sufficient information about clinical research. Information must include the benefits, burdens, and risks of the proposed study, which will enable them to make informed judgments about participation. Refusal to participate or withdrawal from a study will not compromise the quality of care. Physicians, nurses, and other persons associated with Hackensack Meridian may not use Hackensack Meridian facilities, volunteers, staff, or equipment to conduct research without prior written approval of Hackensack Meridian’s Health and its IRB. Hackensack Meridian’s IRB monitors all research activity to ensure relevant policies are followed, including research protocols, privacy, and reporting. As in all financial record keeping, our policy is to submit only true, accurate, and complete costs related to research grants.
Patient Information Security and Confidentiality
Hackensack Meridian Health (HMH) is dedicated to protecting the privacy of our patients by preserving the confidentiality and security of individually identifiable health information, whether or not such information is maintained electronically, in writing, is spoken or in any other medium. Any actual or perceived violation of patient privacy, patient confidentiality or security should be reported to the Director of Privacy.
In accordance with our appropriate access and privacy policies and procedures, which reflect HIPAA requirements and are available on the Hackensack Meridian website, no person of Hackensack Meridian Health has a right to any patient information other than that necessary to perform his or her job.
- HMH will use and disclose individually identifiable health information for purposes of treatment, payment, or health care operations in accordance with Federal and State law.
- HMH will provide and have available our Notice of Privacy Practices, which includes descriptions of individual rights with respect to protected health information (such as the right to inspect, copy, amend, or correct their health records) and the anticipated uses and disclosures of this information that may be made without the patient’s written authorization.
- HMH team members and physicians will only view a patient’s personal health information on a need to know basis. Whenever using, disclosing, or requesting protected health information, we will use reasonable efforts to limit the amount of individually identifiable information we use, disclose, or request to the minimum necessary to accomplish the purpose for which the use, disclosure or request is made.
- Before sharing any individually identifiable health information with a non-HMH entity or individual, HMH will first verify that such entity or individual is a properly authorized business associate of HMH unless otherwise permitted by law.
- To the extent possible, HMH will ensure that our business associates provide us with satisfactory assurance that they will safeguard and keep confidential, our patient’s individually identifiable health information.
- When providing information to a directory (such as a patient directory maintained in a hospital) or to the next of kin or other person involved in the care of the patient, reasonable efforts will be made for the patient to be given notice and the opportunity to decline prior to the information being disclosed.
- By law, HMH treats designated patient information, such as mental health notes, substance abuse and HIV/AIDS, with the strictest of confidence and will not release or disclose such information without the patient’s prior written consent or by valid court order or as otherwise permitted by law.
- Respecting the privacy rights of HMH patients applies equally when outside a HMH facility or when in a private social setting.
- HMH IT Security has implemented security mechanisms to protect patient information when transmitting electronically.
Coding and Billing
Hackensack Meridian Health will comply with all federal and state laws, regulations, guidelines, and policies relating to coding and billing practices. While such coding and billing requirements are complicated, Hackensack Meridian has dedicated team members with expertise in such matters. Coding and billing shall be accurate and claims are submitted only for services that are actually rendered and medically necessary. Any cost reports filed must accurately reflect costs incurred for furnishing health care services. Hackensack Meridian has developed detailed policies and procedures relating to coding and billing practices, which are contained in the Patient Accounting Department Policies and Procedures. If you have responsibilities in coding and billing, you have been provided with special training in these policies and procedures.
All third party agencies who perform billing, claims processing, collection, coding or other related tasks will acknowledge their acceptance and agreement to conduct business in accordance with Hackensack Meridian Health’s Compliance Program, as outlined in this Code and the guidelines, furnished by the federal government for Third-Party Medical Billing Companies.
Accounting
We maintain accurate and complete financial records. These records serve as the basis for managing the business; for measuring and fulfilling Hackensack Meridian Health’s obligations to patients, team members, vendors, contractors and others; and for compliance with tax and financial reporting requirements. All financial information must be treated confidentially and may be disclosed only to those needing the information for work purposes. Hackensack Meridian has a system of internal controls to insure the organization’s ability to record, process, summarize, and report financial data accurately.
Document Retention and Disposal
Hackensack Meridian Health’s team members generate and receive a substantial volume of documents. Medical and business documents and records are retained in accordance with the law and our record retention policy, which includes comprehensive retention schedules and is available online on the Hackensack Meridian Health’s Intranet. Medical and business documents include paper documents such as letters and memos, computer-based information such as e-mail or computer files on disk or tape, and any other medium that contains information about the organization or its business activities. It is important to retain and shred/destroy records only according to our policy. Hackensack Meridian Health’s record retention policy ensures that records are: a) retained as required, b) stored methodically and economically, c) secured for confidentiality, and d) destroyed when required.
Regulatory Issues
Hackensack Meridian Health provides various health care services in different settings that meet appropriate federal, state and local licenses, permits and accreditations. Hackensack Meridian Health’ is subject to numerous laws, rules and regulations, including access to treatment, consent to treatment, medical record keeping, confidentiality, patient’s rights, terminal care decision-making, medical staff membership and clinical privileges, and Medicare and Medicaid regulations.
Hackensack Meridian Health is also subject to federal and state labor laws, discrimination laws, consumer protection laws, and general and professional liability laws. Each person of Hackensack Meridian Health should be familiar with the legal and regulatory requirements applicable to his or her role. When in doubt, consult your team leader, the Chief Compliance Officer, or other leaders outlined in this Code.
Additional legal and regulatory requirements can be found on Hackensack Meridian Health’s Policy Manual.
Three areas in which we must be particularly observant are:
Antitrust
Antitrust laws are designed to promote fair competition in the marketplace. All Hackensack Meridian Health activities must comply with applicable antitrust and similar laws. Examples of conduct prohibited by these laws include: (1) sharing strategic, marketing information or pricing of Hackensack Meridian Health services with a competing health care system or provider; (2) agreeing with other providers not to do business with a payor or supplier; (3) disclosing terms of vendor contracts to a competing health care system or provider. Individuals are expected to seek advice from Hackensack Meridian Health’s Office of Legal Services when concerned that a business decision involves the risk of a violation of antitrust laws or when a competitor suggests that Hackensack Meridian Health participate in a questionable activity.
Tax-Exempt Status
Hackensack Meridian Health and many of its affiliates are organized as not-for-profit corporations, and are exempt from state and federal taxation as charitable institutions. As not-for-profit entities, Hackensack Meridian Health and these affiliates have a legal and ethical obligation to only engage in activities to further charitable purposes, and to use resources in a manner, which furthers the public good, not the private or personal interest of any individual. Consequently, Hackensack Meridian Health `and these affiliates will only enter into compensation arrangements for services, which reflect fair market value, will avoid other payment or compensation arrangements, which may be construed as creating private benefit, will accurately report payments to appropriate taxing authorities, and will file all tax and information returns in a manner consistent with applicable laws.
Additionally, laws governing tax-exempt organizations prohibit certain lobbying and political activity by Hackensack Meridian Health. Therefore, Hackensack Meridian Health does not make campaign contributions or endorse political candidates. Hackensack Meridian Health resources are not used to support or oppose political candidates. Individuals may personally participate in and contribute their own funds to political organizations or campaigns, provided it is clear that they are not acting as an agent or on behalf of Hackensack Meridian Health.
Environment
It is Hackensack Meridian Health’s policy to comply with all environmental laws and regulations relating to its business, and to operate Hackensack Meridian Health’s business in a manner that protects the environment and conserves natural resources. All hazardous and biohazardous wastes (including medical waste) must be handled, stored, and disposed of in accordance with applicable laws, regulations, and Hackensack Meridian Health’s policies. All Hackensack Meridian Health team members should immediately alert supervisors to any situation regarding the discharge of hazardous substance, improper disposal of a hazardous substance, improper disposal of medical waste, or any situation, which may be potentially damaging to the environment.
Detecting and Preventing Fraud and Abuse
Health care compliance programs have been established in part to prevent, detect, and correct fraud and abuse in patient services billing.
Fraud means intentionally misrepresenting facts, knowing that the deception could result in some unauthorized benefit – usually payment from a health care program such as Medicare, Medicaid or a private insurer.
Abuse involves actions that are inconsistent with accepted sound medical, business, or fiscal practices. Abuse directly or indirectly results in unnecessary costs or improper payments.
Audit Services’ function is to review key activities to insure they are effective, with internal controls in place to prevent fraud or abuse, and to support management, staff, and the Board of Trustees in identifying and controlling risk to the Network and its assets.
Payments and Gifts to or from Referral Sources
Federal laws impose substantial criminal and/or civil penalties on entities and individuals who solicit or accept anything of value from a referral source (physician, nursing home, home health agency, durable medical equipment company, laboratory, or any other party that can submit claims for items or services to a governmental health program) in exchange for the purchase, lease, or referral of services or items, which could be paid for by the Medicare or Medicaid programs. These laws are designed to detect and punish fraud and abuse in the delivery of and payment for health care services. Any offers of payment (in cash or in kind) or gifts to a referral source or the acceptance of payment or gifts by a team member or agent of Hackensack Meridian from a referral source are prohibited.
Given these federal laws, and similar state laws prohibiting payments for referrals, the following guidelines apply to any arrangement with a referral source:
- Before entering into any arrangement or agreement with a physician or other referral source, the terms must be in writing and be approved by Hackensack Meridian Health’s Office of Legal Services. Examples of such arrangements include leasing of space or equipment, recruiting personnel, obtaining loans, consulting or other professional services, purchasing supplies or equipment, etc.
- Do not accept free goods or services, discounts, rebates, or allowances from vendors without prior approval of Purchasing, which will evaluate whether such activities are permitted under applicable laws and regulations. When appropriate, Materials Management will consult with the Office of Legal Services. Hackensack Meridian Health‘s affiliated companies not utilizing the Materials Management services should have their supervisor review any activities pertinent to this provision for compliance. Any rebates from vendors must be accurately reflected in the provider’s cost report.
- Consult the Office of Legal Services if you have any questions about what is proper or improper conduct in this area.
Conflicts of Interest
A conflict of interest may occur if a Hackensack Meridian Health team members’ outside activities, personal financial interests, or other personal interests influence or appear to influence his or her ability to make objective decisions in the course of the team member’s job responsibilities. Hackensack Meridian Health has adopted a conflict of interest policy to ensure that all decisions made by Hackensack Meridian are made solely to promote the best interests of Hackensack Meridian Health without regard to the benefit to an individual (or that individual’s family) involved in the decision-making process. Information obtained because of your relationship with Hackensack Meridian Health must never be used for personal benefit or profit. This policy applies to trustees, officers, team members, vendors, contractors, volunteers, medical staff members and residents.
All individuals are expected to conduct their activities to avoid actual conflicts of interest or even the appearance of impropriety. Even the appearance of a conflict between personal gain and the interest of Hackensack Meridian erodes the trust and confidence upon which Hackensack Meridian Health’s reputation rests. Personal interests should never conflict with, or appear to conflict with, the interests of Hackensack Meridian Health.
A conflict may exist if an individual, or a member of his/her family:
- Has an ownership or investment interest in any firm or vendor doing business (or seeking to do business) with Hackensack Meridian Health.
- Receives compensation from a person, firm, or vendor, which does business (or seeks to do business) or competes with Hackensack Meridian Health.
- Has an ownership interest or holds a fiduciary position (director, trustee, or officer) in any business that competes with Hackensack Meridian Health.
Use common sense when evaluating a particular situation. If you have questions or doubts, ask a leader in the Compliance department or the Chief Compliance Officer. They will determine whether the situation involves an actual conflict of interest or appearance of impropriety. The failure to disclose an actual or perceived conflict of interest may result in disciplinary action, up to and including termination.
Gifts and Business Courtesies from Non-Referral Sources
NOTE: This section does not apply to payments, gifts, or business courtesies from referral sources. See Payments and Gifts to or from Referral Sources for Hackensack Meridian’s policy on those situations.
The acceptance of gifts or business courtesies must never compromise the best interests of Hackensack Meridian. Even the appearance of impropriety is to be avoided. The following guidelines should be used when deciding whether to accept a gift or business courtesy from a non-referral source:
- Cash gifts or gift cards are strictly prohibited from any source outside the Hackensack Meridian Health (patient, vendor, contractor, etc.)
- Team members shall not solicit gifts or business courtesies of any kind from patients and their families, visitors, vendors, suppliers, contractors or other persons.
- Team members may accept gifts (but never cash or gift certificates) of a nominal value from patients and their families or visitors as a show of their appreciation. If a patient and/or their family or visitor would like to make a monetary gift or donation, he/she should be referred to the appropriate Hackensack Meridian Health foundation using cards available for this purpose.
- Gifts or business courtesies (including services, meals or entertainment), regardless of their value, should never be accepted if they will or will even appear to affect or influence decision-making by the person receiving the gift or business courtesy. Hackensack Meridian Health has not attempted to define acceptable gifts by reference to a dollar amount. Depending on the situation, a gift or a business courtesy with even a value of $25.00 can be problematic.
- If you have any doubt or concern about a specific gift or business courtesy, see our Corporate Compliance department.
- Do not offer or give anything of value with the expectation of influencing the judgment or decision-making process of any purchaser, supplier, customer, or government official.
- Visits sponsored by prospective or current vendors to inspect equipment or services for possible Hackensack Meridian use or to attend training events should be approved by the appropriate Hackensack Meridian administrator in advance, as per policy
- Holiday gifts sent to your department or unit that are not otherwise prohibited by this policy (usually perishable items or flowers) should be shared with all members of the department.
- Acceptance of any gift should be reported to your supervisor and where appropriate, noted as part of the annual Conflict of Interest Disclosure.
Human Resources
Hackensack Meridian Health extends equal employment opportunities and freedom from discrimination and harassment to all individuals regardless of sex, race, age, religious beliefs, marital status, citizenship status, sexual orientation, national origin, disability, and any other protected category. In determining suitability for employment, promotions, transfers, demotions, and wages, Hackensack Meridian Health’s decisions are based on merit. Hackensack Meridian Health Human Resources policies outline the disciplinary consequences for violations of the standards expected of all team members.
Hackensack Meridian Health expects team members to treat co-workers, patients, vendors, contractors, and visitors with respect and courtesy. Hackensack Meridian Health will not tolerate discrimination or harassment including but not limited to unwelcome sexual advances or other verbal, non-verbal, or physical conduct of a sexual nature.
Team member involvement with drugs and alcohol can adversely affect job performance and team member morale, jeopardize patient and team member safety, and undermine the public’s confidence and Hackensack Meridian Health’s reputation. It is therefore the intent of Hackensack Meridian Health to establish and maintain a safe workplace and a healthy and efficient workforce free from the effects of drug and alcohol abuse. Violations will result in appropriate disciplinary action, up to and including termination, in accordance with Hackensack Meridian Health policies and procedures regarding Substance Abuse and Fitness for Duty. For additional guidance, team members should refer to the appropriate Human Resource policies available online.
If you have concerns regarding possible violations of these policies, you should contact your immediate or departmental team leader, Human Resources representative, a leader in the Compliance department, or the Chief Compliance Officer. General questions relating to Human Resources policies or issues should be directed to your designated Human Resources representative.
Environment of Safety
All Hackensack Meridian Health facilities comply with government regulations and rules, Hackensack Meridian Health policies, and required facility practices to promote the protection of workplace health and safety for our patients, team members, vendors, contractors, and visitors. Team members, students, health care practitioners, vendors, and contractors are screened prior to access to our facilities to determine if they have been convicted of any crimes, which might compromise the environment of safety Hackensack Meridian Health is committed to maintaining. Hackensack Meridian Health has established a ONELink system available on the Hackensack Meridian Health Intranet that provides all team members the ability to identify and quickly report for correction any situation, which presents a potential hazard to our patients, visitors, team members, vendors or contractors.
Electronic Media
Software Copyright Infringement
Hackensack Meridian Health licenses the use of computer software from a variety of outside vendors. Unauthorized copying of software programs could expose you and Hackensack Meridian Health to litigation and result in damage claims from software vendors. Never copy copyrighted software for personal or business use if such reproduction is not permitted by written license agreement.
Communication System
All communications systems, including but not limited to electronic mail, Intranet, Internet or social media access, telephones, text messages and voice mail are the property of Hackensack Meridian Health and are to be used primarily for business purposes in accordance with electronic communications policies and standards. Users of computer and telephonic systems should presume no expectation of privacy in anything they create, store, send, or receive on the computer and telephonic systems, and Hackensack Meridian Health reserves the right to monitor and/or access communications usage and content consistent with Hackensack Meridian Health policies and procedures. Violation of these standards may result in removal from the Hackensack Meridian Health network and other disciplinary action up to and including termination. You are NOT permitted to share or divulge your username and/or password with another person.
Social Media
Posting information on a social media site should not include any confidential or specific information on, patients, residents, co-workers or projects you are working on. Posting of any confidential patient or business information is against Hackensack Meridian’s privacy and security policies and may result in disciplinary action, up to and including termination.
Copyrights
Hackensack Meridian Health team members, vendors, and contractors may only use copyrighted materials as allowed by the organization’s policy on such matters. Hackensack Meridian Health team members, vendors, and contractors may not use the name, logo or other service marks of Hackensack Meridian Health or any of its subsidiaries or affiliates without the authorization of the Chief Marketing Officer or designee.
