COMMITMENT TO COMPLIANCE
Genacross Lutheran Services is committed to operating in a legal and ethical manner. In order to ensure its operation in accordance with the mission of Genacross and in compliance with applicable laws, Genacross has developed an Organizational Integrity Program (OIP). The OIP applies to all directors, officers, employees, contractors, vendors, suppliers, and agents of Genacross — essentially, every individual involved in providing services for or on behalf of Genacross.
Genacross strives to foster a culture of compliance within its organization, such that all employees, agents, and other individuals or entities working with Genacross will “live” compliance when carrying out their responsibilities on behalf of Genacross. Genacross recognizes that compliance is a cooperative effort and that it cannot meet its high standards without the support and assistance of the employees, individuals, and other entities with whom Genacross works. Genacross expects each of these parties to contribute to its compliance culture by recognizing and doing “the right thing.” In addition, Genacross expects each of these parties to honor its commitment to the delivery of quality health care consistent with applicable state and federal health and safety standards.
The primary components of Genacross’s OIP are as follows:
- Values and OIP Policies. This manual sets forth Genacross’s values, which emphasize the mission, shared common values, and ethics that guide its actions. The manual also includes OIP policies and procedures designed to ensure Genacross’s compliance with laws governing specific areas of its operations.
- Oversight. Genacross has appointed a Vice President for Organizational Integrity to develop, operate, and monitor its OIP and report directly to the President/CEO and Board Audit Committee.
- Education and Training. Genacross employees receive education regarding the OIP and the laws relative to their job responsibilities. Familiarity with the OIP and applicable policies and procedures is part of every employee’s job responsibilities.
- Communication & Reporting. An important goal of the OIP is that all employees feel comfortable reporting to Genacross any inappropriate activity. In fact, all employees have an obligation to report violations, suspected violations, questionable conduct, or questionable practices in accordance with the reporting mechanisms established by the OIP. Retaliation against any employee for reporting is strictly prohibited.
Because Genacross believes that organizational integrity is a cooperative effort, it has adopted a chain of command approach with respect to reporting and response. That is, all employees are expected to report suspected violations to their immediate supervisor. Assuming that the issue is within the supervisor’s area of expertise, the supervisor will determine the appropriate response. If a supervisor needs assistance, the supervisor can report the potential violation “up the chain” to his supervisor for additional input. Further reports up the chain may be necessary in the event of significant OIP issues.
Genacross recognizes that situations may arise where an employee does not feel comfortable reporting to his supervisor, or an employee may be concerned that his supervisor will not address the issue. Because Genacross does not wish for these concerns to deter employees from reporting legitimate compliance concerns, it has also developed mechanisms for reporting anonymously and/or directly to the Vice President for Organizational Integrity.
- Monitoring. Genacross coordinates audits and reviews to monitor compliance and identify risk areas.
- Discipline. Genacross has developed policies to exclude any individuals or entities from employment or contracting with Genacross that are excluded from participating in government health care programs. Additionally, employees or contractors who violate the OIP are subject to disciplinary action, including potential termination of the relationship.
- Investigation. The Vice President for Organizational Integrity may consult with others who specialize in the area of complaint to investigate, identify problems, and implement corrective action.
STATEMENT OF VALUES
Genacross is a faith-based ministry and as such, recognizes and celebrates the inherent goodness of all ministry partners who strive to live out our shared mission with integrity. This Statement of Values reflects not only Genacross’s commitment to act in a legal and ethical manner but also the mission, shared common values, and ethics of Genacross. This Statement of Values is aspirational, and Genacross recognizes that, even though Genacross and its ministry partners may strive to adhere to the Statement of Values, it may not be followed in every circumstance due to extenuating uncontrollable influences.
The following Statement of Values applies to Genacross’s employees and, where appropriate, Genacross’s independent contractors, volunteers, and vendors. Genacross will judge whether to continue its relationships with such persons and entities based on their compliance with these principles.
Any questions regarding violations, suspected violations, or a conflict of interest to this Statement of Values or any other part of the OIP should be promptly directed to an employee’s supervisor. Supervisors may seek additional guidance from their own supervisors or the Vice President for Organizational Integrity if necessary.
Inspired by the Christian faith, we embrace individuals and families with compassionate care and services throughout life’s journey.
Faithfulness to Christ
As part of the Church, we perform our work in response to Jesus Christ and as an extension of His ministry.
Genacross welcomes and affords just, equitable, and respectful treatment to all residents, clients, and employees, regardless of religious persuasion. However, all Genacross activities shall be conducted in a manner compatible with Christian values and beliefs. These are often expressed by the Golden Rule, “Do unto others as you would have them do unto you,” or the Hippocratic dictum, “Do good and do no harm.” Genacross follows the model of sacrificial love for all people borne witness to the life, death, and resurrection of Jesus Christ. We shall strive to provide a work environment that promotes communication, positive collegial support, and mutual respect of abilities and talents.
Equality and Justice
We recognize the equality of all persons in our offering of services and the opportunity for services, advocating justice and seeking to develop and balance all resources at our disposal to serve vulnerable persons with more intense needs.
Genacross shall accord just, equitable, and respectful treatment to residents, clients, and families in our care. We shall treat colleagues with professionalism, respect, and dignity. We shall not discriminate against, nor harass, nor grant a discriminatory advantage to residents, clients, families, or colleagues on the basis of race, color, creed, sex, national origin, marital status, political or religious beliefs, physical or mental conditions, family, social, or cultural background, or sexual orientation.
Wholeness of Life
We recognize and value the life and inherent worth of each person, helping individuals experience dignity and the fullest level of their physical, mental, emotional, spiritual, and vocational ability.
Genacross will give primary consideration for the welfare, happiness, and comfort of our residents and clients. This consideration will serve as a basis for all decisions, including the protection of confidentiality, privacy rights, and self-determination. We are committed to kindness, consideration, and diplomacy in our dealings. Furthermore, action that may jeopardize the quality of life or dignity of Genacross residents or clients will not be tolerated.
We value and demonstrate honesty, fairness, and trustworthiness in all of our relationships.
We shall not use professional relationships with residents, clients, or their families for private advantage or gain. We shall not engage in any relationship with a resident, client, or family member other than the professional relationship determined by the services Genacross offers.
Information obtained in the course of providing treatment or services shall be kept confidential, and disclosure shall be made in accordance with law. In addition, Genacross shall not knowingly submit fraudulent or inaccurate information to any third party.
Genacross is committed to serving loyally and will publicly lift up its mission and values. Genacross encourages adherence to the Golden Rule and will refrain from destructive criticism and gossip. This implies cooperation and support of co-workers, supervisors, and all other departments and ministries.
Quality of Service
We seek to deliver services of the highest quality by demonstrating competence, continuous improvement, innovation, and creativity.
Genacross shall promote and maintain quality assurance in its operations. In order to ensure the highest quality services, our quality activities will include treatment programs, personnel matters, professional growth and development, and finance. In addition, we shall actively seek personal and professional activities that will enable each person to perform successfully their responsibilities with skill and creativity.
We shall assess the effectiveness of current programs, status of goals and objectives, progress of long-range planning, and external and internal changes that may affect the mission of Genacross.
Stewardship of Resources
We exercise faithful stewardship of our financial resources and physical assets, and we are responsible and accountable for their proper deployment in the work of our ministry.
Genacross shall manage its resources in an efficient and effective manner. We shall be positive stewards of these resources. No one shall take any action that may jeopardize the licensure, certification, or financial stability of any ministry or of Genacross as a whole.
Generally Accepted Accounting Principles (GAAP) shall be used in designing financial systems and documentation requirements. Financial reporting shall be timely and reflect the true nature of business transactions, assets, liabilities, and net assets.
PRINCIPLES CONSISTENT WITH THE STATEMENT OF VALUES
Examples of behaviors consistent with the Genacross Statement of Values include, but are not limited to:
Legal Compliance. Genacross employees will refrain from any illegal conduct and shall comply with all Genacross policies and procedures governing the workplace. All employees must comply with licensure and certification, nondiscrimination, and fraud and abuse laws applicable to Genacross. When an employee is uncertain of the meaning or application of a statute, regulation, policy, or the legality of a certain practice or activity, he or she shall seek guidance from his or her immediate supervisor. If necessary, supervisors may seek additional guidance from their supervisors, the Executive Director (if applicable), or the Vice President for Organizational Integrity.
Honest Communication. Genacross requires candor and honesty from individuals in the performance of their responsibilities and in communication with our attorneys and auditors. No individual shall make false or misleading statements to any resident, person, or entity doing business with Genacross about residents, persons, or entities doing business or competing with Genacross, or about the products or services of Genacross or its competitors.
Honest and Professional Documentation of Records. All records maintained by Genacross, including resident records, billing records, and accounting records, should honestly and accurately reflect the information that they contain. Medical and business record entries should be appropriately made as soon as possible after an encounter occurs or as required by policy or law. Employees shall not destroy or alter Genacross records in anticipation of, or in response to, a request for documents by any applicable government agency or from any court, or from any party in conjunction with a lawsuit.
Gifts from Residents. Employees are prohibited from soliciting tips, personal gratuities or gifts from residents and from accepting monetary tips or gratuities. If a resident or another individual wishes to present a monetary gift, he/she should be referred to the appropriate administrative office. The Family & Youth ministry allows resident-to-staff gift giving within the parameters of the resident’s individual habilitation plan (IHP). The Genacross Housing ministry allows the Resident Council-sponsored exchange of gifts of a nominal amount.
Other Gifts. Individuals are prohibited from accepting any gifts from people or companies that do business with Genacross without their supervisor’s written permission. Gifts influencing decision-making of Genacross will not be approved by supervisors. Additionally, individuals will not solicit gifts from people or companies that do business with Genacross.
Confidentiality of Resident Information. All Genacross employees have an obligation to maintain the confidentiality of resident information of Genacross’s nursing ministry residents in accordance with all applicable laws and regulations. Employees shall refrain from revealing any personal or confidential information concerning any of Genacross’s residents or clients, unless supported by legitimate business or care purposes. In general, employees shall not disclose confidential medical or personal information pertaining to Genacross’s nursing ministry residents without the express written consent of the resident or appropriate legal representative and in accordance with applicable laws and Genacross policies and procedures. If questions arise regarding an obligation to maintain the confidentiality of information or the appropriateness of releasing information, employees should seek guidance from their supervisor or the HIPAA Privacy Officer.
Confidentiality of Genacross Information. Genacross’s confidential business information, such as business strategies, payment and reimbursement information, negotiations, quality assurance materials, and trade secrets, should be protected and shared only with individuals having a need to know such information in order to perform their job responsibilities. Salary, benefit, and other personal information relating to employees shall be treated as confidential. Personnel files, payroll information, disciplinary matters, and similar information shall be maintained in a manner designed to ensure confidentiality in accordance with applicable laws. Employees will exercise caution to prevent the release or sharing of information beyond those persons or outside entities that may need such information to fulfill their job function or duties under the law.
Business Relationships. Individuals will engage in business transactions and relationships at arm’s length. Those employees involved in contract negotiations are encouraged to seek competitive bids from more than one vendor. Individuals will not seek to gain advantage through the improper use of payments, business courtesies or other inducements.
Professional Conduct. Individuals are expected to conduct themselves so as to avoid actual impropriety and/or the appearance of impropriety in making decisions relative to their relationship, duties, and responsibilities in the organization. Employees may not use their positions at Genacross to profit personally or to assist others in profiting in any way at the expense of Genacross or the residents, clients, and tenants under our care, or their families.
VIOLATIONS OF THE STATEMENT OF VALUES
Employees and other persons shall promptly report all violations or suspected violations of this Statement of Values or any other part of the OIP by other employees to their supervisors.
Reporting Suspected Violations and Inquiries
Genacross believes that a compliance program functions best when all employees assist in promoting compliance within their own area of expertise. To take advantage of the different competencies and knowledge within its organization, Genacross has adopted a chain of command approach to compliance reporting and inquiries regarding potential issues.
All employees are required to report violations, suspected violations, questionable conduct, or questionable practices of which they become aware to their immediate supervisors. If the employee’s immediate supervisor does not have the necessary knowledge to respond to a report or inquiry, the supervisor may, in turn, move the issue another rung up the chain by reporting to his supervisor. Reports and inquiries are to be moved further up the chain of command and all the way to the Vice President for Organizational Integrity, as necessary, until the individual with the appropriate expertise is reached and can respond to the report. Further reports up the chain may also be necessary in the event of significant OIP issues. Supervisors will provide their Vice Presidents a copy of all compliance reports received by the supervisor.
Genacross believes that the majority of OIP issues may be appropriately handled through the chain of command approach. However, in the event an employee’s supervisor is implicated in the potential wrongdoing, or if an employee is concerned that the supervisor will not respond to a report, Genacross has established alternate procedures for reporting. First, the employee may choose to “skip” a level and make the report to the next supervisor in the chain of command. Alternately, the employee may report directly to the Vice President for Organizational Integrity in writing at 2021 N. McCord Road, Toledo, OH 43412, or by filing a report through Genacross’s toll-free fraud and abuse hotline at 866-392-8058.
A NOTE ABOUT ANONYMOUS REPORTS:
Genacross is committed to fostering a compliance culture where all employees feel comfortable and are proactive in reporting potential violations directly to their supervisors. However, because Genacross does not wish for inappropriate activity to go unreported for any reason, employees are always free to report potential violations to the Vice President for Organizational Integrity anonymously.
Employees should keep in mind the following when considering an anonymous report:
- It is an essential element of every employee’s job to report potential compliance violations directly to their immediate supervisor;
- Employees may be subject to disciplinary action for failure to report wrongdoing; and
- Genacross strictly prohibits any retaliation or discrimination against employees for reporting potential compliance violations.
Please note that there may be additional reporting obligations for certain compliance violations under the laws governing the operation of nursing facilities. Employees are also required to comply with these reporting obligations, which are addressed in other policies and procedures of Genacross. For example, employees must report resident abuse to the Administrator in accordance with Genacross’s abuse policies and procedures.
The following guidelines shall apply to all reports made pursuant to this OIP:
- No Retaliation. Genacross prohibits any retaliatory action against an employee for making any verbal or written compliance communication in good faith to his or her supervisor, the OIP hotline, an anonymous drop box, the Vice President for Organizational Integrity, or to any government agency.
- Discipline. There will be discipline or other consequences for failure to report timely and thoroughly. Prompt and complete disclosure may be considered a mitigating factor in determining an employee’s discipline or sanction if they are the wrongdoer. The discipline or sanction shall not be increased because an employee reported his or her own violation or misconduct.
- Interference with Reporting. No employee shall attempt to prevent any person from making a compliance report. If an employee does try to prevent a person from making a report, then that employee shall be subject to disciplinary action, which may include termination.
ENFORCEMENT & DISCIPLINE
- Consistent Enforcement. The standards established in this OIP and the Statement of Values shall be consistently enforced through disciplinary proceedings and sanctions. These shall include, but are not limited to, informal reprimands, formal reprimands, demotion, suspension, and termination. In determining the appropriate discipline for any violation of the OIP and the Statement of Values, Genacross shall treat all employees equally, without taking into account a particular employee’s title, position, or function within Genacross.
- Discipline for Compliance Violations. Any employee who engages in a violation of standards established in the OIP, the Statement of Values, or any other laws or regulations, shall be subject to disciplinary action, up to and including termination in accordance with Genacross’s disciplinary policy located in its Employee Manual. Genacross shall accord no weight to an employee’s claim that any improper conduct was undertaken for the benefit of Genacross. Any such conduct is not for the benefit of Genacross and is expressly prohibited.
When appropriate, discipline shall be enforced against employees for failing to detect or report wrongdoing. This means that employees must understand that they have an affirmative duty to report wrongdoing.
- Misconduct by Agents & Contractors. Genacross will investigate reports of misconduct by its agents and contractors. If misconduct is found, then appropriate actions will be taken, including, if necessary, termination of the independent contractor agreement.