The House of The Good Shepherd

Code of Conduct

To download a copy of our Code of Conduct, click here.


Our Compliance Program Plan covers the compliance issues, laws and regulations and guidelines that are relevant to a provider of senior services including Senior Living Communities that may provide a wide range of healthcare services. This includes but is not limited to DHHS, Medicare and Medicaid regulatory issues, guidelines from the Office of Inspector General, Internal Revenue Service and the Office of Civil Rights of the Department of Health and Human Services, Occupational Safety and Health Administration as well as other regulatory and business issues.

The term Associate defines the various individuals who are associated with The House of the Good Shepherd. All individuals, including employees, vendors, contractors, volunteers, directors and officers are members of our team in providing care and services to our residents.

The scope of the program includes:

Policies and procedures that guide our organization in appropriate business practice and promote compliance with laws and governmental regulations;

Recommendations and resources for training programs that are mandatory for Associates to ensure understanding of the Code of Conduct;

Distribution of a copy of the Code of Conduct to all Associates and with a written acknowledgment of its receipt by the Associate;

Structures that include appropriate disciplinary monitoring and review of potential fraud and abuse issues conducted to identify need for corrective action as well as additional training;

Mechanisms established to provide Associates with a means to report potential noncompliance issues or other areas of concern without fear of retribution;

A process for corrective action that includes appropriate disciplinary measures, to address any issues of noncompliance;

Guidelines that have been developed for prevention of, and when required, response to identified compliance issues. This includes an annual review of the Compliance Program and modifications to the Program as appropriate;

Designation of a Compliance Officer and other appropriate bodies such as a Compliance Committee charged with the responsibility for developing, operating and monitoring the Compliance Program within the organization.

Any questions regarding the policies in this Code of Conduct or references should be directed to your immediate supervisor, the Compliance Liaison or member of the Compliance Committee or the Compliance Officer.

We are a CCRC that provides a continuum of care including independent, assisted living/comprehensive personal care and skilled nursing environments. This Code of Conduct applies to every person at every level of the organization. This includes employees, board of directors, volunteers, independent contractors, subcontractors and vendors who may provide or are involved with healthcare or billing. The term Resident refers to individuals who receive the various types of healthcare, and other services that we provide.

The House of the Good Shepherd is a Continuing Care Retirement Community licensed under the New Jersey Department of Health and Senior Services for:

Skilled Nursing
Assisted Living
Comprehensive Personal Care
Independent Living

The CODE OF CONDUCT is supported by the policies and procedures.

Structure and Organization

Friends Services for the Aging, along with Brethren, Mennonite and Quaker organizations involved in providing services to the elderly, have established a collaborative Compliance Program known as the Peace Church Compliance Program (PCCP).

The Board of Directors of The House of the Good Shepherd and Friends Services for the Aging have jointly established the following structure, reporting relationships and responsibilities to oversee the administration of the PCCP and to ensure that all potential issues or violations identified by any Associate are investigated and addressed.

Compliance & Privacy Officer (Compliance Officer)

The FSA Senior Director of Compliance, Karla Dreisbach, CHC serves as our Compliance & Privacy Officer. She has the responsibility to assist the Compliance Liaison, the CEO and the Board of Directors in designing, establishing and overseeing efforts in establishing, maintaining and monitoring compliance within the organization.

The Compliance Officer works with the Executive Director and the Compliance Liaison and has periodic reporting responsibility to the Board of Directors. The Compliance Officer is also accountable to the Executive Director of Friends Services for the Aging. The Compliance Officer is responsible for the oversight of the PCCP including continued coordination with the Compliance Liaison for the development, implementation, training, monitoring and enforcement activities within the organization. The Compliance Officer is assisted by Compliance Specialists in providing services to The House of the Good Shepherd.


The Executive Director carries the overall responsibility for creating a culture that values and emphasizes compliance and integrity and ensures privacy.

Judie McFarland, RNC has been appointed as the Compliance Liaison. She is responsible for coordinating compliance activities in conjunction with the Compliance Officer. These activities include quarterly audits, responses to hotline and overseeing the organization’s Compliance Committee. As a function of this role, the Compliance Liaison also functions as the Privacy Officer.

The Organization’s Compliance Committee is comprised of members of the management team. The Compliance Liaison is the chair for this committee. The committee meets on a quarterly basis.


Dear House of the Good Shepherd Associate:

Quality care of our resident/client population has always been our commitment at The House of the Good Shepherd (HOTGS). In an effort to maintain and improve the quality of the services we provide, we have implemented the Compliance and Privacy Program.

This handbook will explain the Compliance and Privacy Program to you so that you can apply the guidelines in your daily duties at The House of the Good Shepherd. If you have any questions, comments or concerns regarding these guidelines you should contact your immediate supervisor. You may also contact the Senior Director of Compliance at 215-646-0720 or use the confidential Peace

Church Compliance Line of 1-800-211-2713.

Thank you for continuing to work in a manner that achieves the goals of our organization.

The House of the Good Shepherd Board of Directors and Executive Director


Code of Conduct


The Code of Conduct is the foundation of the Compliance Program. The Code of Conduct is a guide to appropriate workplace behavior; it will help you make the right decisions if you are not sure how to respond to a situation. This Code of Conduct applies to everyone including all staff, management, board of directors, volunteers, contractors and vendors. Our staff must comply with both the spirit and the letter of all federal, state and local laws and regulations that apply to the healthcare and other services that the organization provides, as well as, all laws that apply to our business dealings. Violations of these laws and regulations can result in severe penalties for us and the individuals we do work with including financial penalties, exclusion from participation in government programs and in some cases imprisonment.

As an Associate, we share a commitment to legal, ethical and professional conduct in everything that we do. We support these commitments in our work each day, whether we care for residents, order supplies, prepare meals, keep records, take physician orders, pay invoices or make decisions about the future of our organization.

The success of The House of the Good Shepherd as a provider of healthcare and other services depends on you, your personal and professional integrity, your responsibility to act in good faith and your obligation to do the right things for the right reasons.

The Compliance Program provides principles, standards, training and tools to guide you in meeting your legal, ethical and professional responsibilities. As an Associate, you are responsible for supporting the Compliance Program in every aspect of workplace behavior. Your performance review and continued working relationship includes understanding and adhering to the compliance plan as it applies to your job responsibilities and all your interactions with The House of the Good Shepherd.

This handbook describes our Code of Conduct. It supplements the Employee Handbook and the specific Policies and Procedures that apply to departmental job responsibilities. As a business partner or contracted partner it provides guidelines and expectations for our continued relationship. The Code of Conduct discusses the importance of:

Care Excellence – providing quality, compassionate, respectful and clinically appropriate care.

Professional Excellence – maintaining ethical standards of healthcare and business practices.

Regulatory Excellence – complying with federal and state laws, regulations and guidelines that govern healthcare, housing services and other services we provide.

A Shared Responsibility

Because we are in the business of caring for and providing services for others, it is critical that each of us adheres to appropriate standards of behavior. As individuals and as an organization we are responsible to many different groups. We must act ethically and responsibly in our relations with:

Residents and their families;
Colleagues and coworkers;
Volunteers and affiliated colleagues;
Healthcare payors, including the federal and state governments;
Regulators, surveyors and monitoring agencies;
Physicians, Nurse Practitioners, Physician Assistants;
Vendors and suppliers;
Business associates; and
The Communities we serve.

Any compromise in our standards could harm our residents, our coworkers and our organization. Like every organization that provides healthcare, we do business under very strict regulations and close governmental oversight. Fraud and abuse are serious issues. Sometimes even an innocent mistake can have significant consequences that could result in substantial penalties to THE HOUSE OF THE GOOD SHEPHERD.

All Associates are required to complete training on the Code of Conduct and the Compliance Program as a condition of employment and business relationship and you must follow the Code of Conduct to remain employed. The Code of Conduct sets forth mandatory standards. There is no justification for departing from the Code of Conduct no matter what the situation may be. Every Associate is responsible for ensuring that they comply with the Code of Conduct and all policies and procedures. Any Associate who violates any of these standards and/or policies and procedures is subject to discipline up to and including termination of employment.

A Personal Obligation

As we are each responsible for following the Code of Conduct in our daily work, we are also responsible for enforcing it. This means that you have a duty to report any problems you observe or perceive, regardless of your role.

As an Associate, you must help ensure that you are doing everything practical to comply with applicable laws. If you observe or suspect a situation that you believe may be unethical, illegal, unprofessional or wrong, or you have a clinical, ethical or financial concern, you must report it. Your are expected to satisfy this duty by complying with the Three-Step Reporting Process and New Jersey required reporting obligations.


Compliance/Grievance Reporting Process

A specific communication process is in place for reporting compliance and/or grievance issues.

  1. Talk to your department head. He or she is most familiar with the laws, regulations and policies that relate to your work.
  2. If you are not able to talk to your department head, seek out another member of the management team.
  3. If, for whatever reason, neither of the above options is acceptable, you may speak with:

Hollie Driscoll, our Compliance Officer, at extension 5734; and/or

Deborah Beards, Executive Director, at extension 5720

Both of their offices are located in the first floor administrative wing.

If none of the above steps resolves your questions or concerns, or if you prefer, you may call the toll free Compliance Line at 800-211-2713 for assistance. All calls are confidential and you may call ANONYMOUSLY if you choose.

You can submit a report in good faith to the Compliance Line without fear of reprisal, retaliation, or punishment for your actions. Anyone, including a supervisor, who retaliates against a staff member for contacting the Compliance Line or reporting compliance issues in another manner, will be disciplined.

The Compliance Line is staffed by an outside agency and is available 24 hours, 7 days a week. Each call is investigated and kept confidential to the highest degree possible.

Rev. 10/11

Care Excellence

Our most important job is providing quality care to our residents. This means offering compassionate support to our residents and working toward the best possible outcomes while following all applicable rules and regulations.

Resident Rights

Residents receiving healthcare and other services have clearly defined rights. To honor these, we must:

  • Make no distinction in the admission, transfer or discharge of a resident, or in the care we provide on the basis of race, gender, age, religion, national origin, disability, color, marital status, veteran status, medical condition, sexual orientation or other protected class status, insurance or financial status;
  • Treat all residents in a manner that preserves their dignity, autonomy, self-esteem and civil rights;
  • Protect every resident from physical, emotional, verbal or sexual abuse or neglect;
  • Protect all aspects of resident privacy and confidentiality;
  • Respect client’s personal property and money and protect it from loss, theft, improper use and damage;
  • Respect the right of residents and their legal representatives to be informed of and participate in decision about their care and treatment;
  • Respect the right of residents and/or their legal representatives to access their medical records as required by the Health Information Portability and Accountability Act (HIPAA);
  • Recognize that residents have the right to consent or refuse care and the right to be informed of the medical consequences of such refusal;
  • Protect residents’ rights to be free from physical and chemical restraints; and
  • Respect the residents’ right to self-determination and autonomy.

Abuse and Neglect

We will not tolerate any type of resident abuse or neglect – physical, emotional, verbal or sexual. Residents must be protected from abuse by Associates, family members, legal guardians, friends or any other person. This standard applies to all residents at all times. The state of New Jersey defines abuse as the following:

Abuse – the infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual, including a care taker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. This presumes that instance of abuse of all residents, even those in a coma, cause physical harm, or pain or mental anguish. The term includes the following:

  • Verbal Abuse - Any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to clients or their families, or within their hearing distance, regardless of age, ability to comprehend or disability;
  • Sexual Abuse – includes sexual harassment, sexual coercion or sexual assault;
  • Physical Abuse – Includes hitting, slapping, pinching, kicking. The term also includes controlling behavior through corporal punishment or deprivation
  • Mental Abuse – include humiliation, harassment, threats of punishment or deprivation;
  • Involuntary Seclusion – Includes separation of a resident from other residents from his or her room or confinement to his or her room against the resident’s will or the will of the resident’s legal representative;
  • Neglect – The deprivation by a caretaker of goods or service which are necessary to maintain physical or mental health.

Any Associate who abuses or neglects a resident is subject to termination. In addition, legal or criminal action may be taken. Abuse and neglect must be reported immediately to your supervisor or other member of management under the mandatory reporting requirements in the state of New Jersey. DO NOT call the Compliance Line for issues of abuse or neglect.

Report them immediately!

Resident Confidentiality

Every Associate must treat all resident information, including any documents or records that contain client-identifying information, medical records and charts as confidential. Associates must use and disclose medical, financial or personal information only in a manner consistent with the HIPAA Privacy policies and procedures and state and federal law.

Resident Property

Associates must respect residents’ personal property and protect it from loss, theft, damage or misuse. Associates who have access to property or funds must maintain accurate records and accounts.

Providing Quality of Care

As a Continuing Care Retirement Community (CCRC), our primary commitment is to provide the care, services and products necessary to help each resident reach or maintain his or her highest possible level of physical, mental and psychosocial well-being. The House of the Good Shepherd has policies and procedures and provides training and education to help each Associate strive to achieve this goal. You will learn about policies and procedures specific to your job responsibilities as part of your employment orientation and training.

Our care standards include:

  • Accurately assessing the individual needs of each resident and developing interdisciplinary care plans that meet those assessed needs;
  • Reviewing goals and plans of care to ensure that the residents’ ongoing needs are being met;
  • Providing only medically necessary, physician prescribed services and products that meet the residents’ clinical needs;
  • Confirming that services and products (including medications) are within accepted standards of practice for the resident’s clinical condition;
  • Ensuring that services and products are reasonable in terms of frequency, amount and duration;
  • Measuring clinical outcomes and resident satisfaction to confirm that quality of care goals are met;
  • Providing accurate and timely clinical and financial documentation and record-keeping;
  • Ensuring that residents’ care is given only by properly licensed and credentialed providers with appropriate background, experience and expertise;
  • Reviewing resident care policies and procedures and clinical protocols to ensure that they meet current standards of practice; and
  • Monitoring and improving clinical outcomes through a Quality Improvement Committee with established benchmarks.

Medical Services

We are committed to providing comprehensive, medically necessary services for our residents. The Medical Director provides oversight to physicians and other medical services as defined by state and federal regulations. The Medical Director is compensated at a fair market value for the services he or she provides. The Medical Director oversees the care and treatment policies and is actively involved in the Quality Improvement Committee.

Professional Excellence

The professional, responsible and ethical behavior of every Associate reflects on the reputation of our organization and the services we provide. Whether you work directly with residents or in other areas that support resident services you are expected to maintain our standards of honesty, integrity and professional excellence, everyday.

Hiring and Employment Practices

The House of the Good Shepherd is committed to fair employment practices. When hiring and evaluating, we:

  • Comply with federal, state and local Equal Employment Opportunity laws, hiring the best qualified individuals regardless of race, color, age, religion, national origin, gender identity, sexual orientation or disability. All promotions, transfers evaluations, compensation and disciplinary actions also follow this policy.
  • Conduct employment screenings to protect the integrity of our workforce and welfare of our residents and Associates.
  • Require all who need licenses or certifications to maintain their credentials in compliance with state and federal laws; documentation of licenses or certifications must be provided.

Employee Screening

The House of the Good Shepherd is prohibited by federal or state law from employing, or retaining, or contracting with anyone who is excluded from any federal or state funded programs. Screening procedures have been implemented and are conducted prior to hire and a minimum of annually thereafter, to identify such individuals. These standards also apply to temporary healthcare workers. These policies and procedures are intended to ensure that we do not contract with, employ or bill for services ordered, rendered or supervised by anyone:

  • Confirmed with a positive drug test;
  • Convicted of a violent crime, including assault, abuse or rape;
  • Convicted of a criminal offense related to healthcare, including fraud, neglect or abuse of clients;
  • Convicted of a felony in the preceding seven years;
  • Convicted of an offense considered exclusionary by state statutes regulation or standard;
  • Excluded from or ineligible to participate in federal healthcare programs;
  • Disbarred or excluded by a duly authorized licensing agency; or

As long as you are employed or affiliated with The House of the Good Shepherd, you must immediately report to your supervisor if you are convicted of an offense that would preclude employment in a healthcare facility; if action has been taken against your license or certification; or if you are excluded from participation in a federal or state healthcare program. Any Associate who is alleged to have committed a serious criminal act will be suspended or, if convicted of a felony, terminated.

Employee Relations

To maintain an ethical, comfortable work environment, staff must:

  • Refrain from any form of sexual harassment or violence in the workplace;
  • Treat all colleagues and coworkers with equal respect, regardless of their national origin, race, color, religion, sexual orientation, age, gender identity or disability;
  • Protect the privacy of other Associates by keeping personal information confidential and allowing only authorized individuals access to the information; and
  • Not supervise or be supervised by an individual with whom they have a close personal relationship.

Workplace Violence

Every employee has the right to work in a safe environment. Violence, abuse or aggressive behavior will not be tolerated.

Workplace Safety

Maintaining a safe workplace is critical to the well-being of our residents, visitors and coworkers. That is why policies and procedures have been developed that describes the organization’s safety requirements. Every Associate should become familiar with safety regulations and emergency plans regarding fire and disaster in their work area.

In addition to organizational policies, we must abide by all environmental laws and regulations. You are expected to follow organizational safety guidelines and to take personal responsibility for helping to maintain a secure work environment. If you notice a safety hazard, you must take action to correct it if you can, or report it to your supervisor immediately.

Drug and Alcohol Abuse

We are committed to maintaining a workforce dedicated and capable of providing quality resident services and performing other applicable duties. To that end, Associates are prohibited from consuming any substance that impairs their ability to provide quality services or otherwise perform their employment.

Associates may never use, sell or bring on company property, alcohol, illegal drugs and/or narcotics or report to work under the influence of alcohol, illegal drugs and/or narcotics. For an Associate who appears to have work performance problems related to drug or alcohol use, a drug and alcohol screening will be conducted and appropriate action will be taken if necessary.

Illegal, improper or unauthorized use of any controlled substance that is intended for a resident is prohibited. If an Associate becomes aware of any improper diversion of drugs or medical supplies, the Associate must immediately report the incident to his or her department supervisor, the Compliance Liaison, the Compliance Officer or the Compliance Line.

The House of the Good Shepherd occasionally sanctions events which include alcohol and employees are expected to act responsibly.

Organizational Relations

Professional excellence in organizational relations includes:

  • Maintaining company privacy and keeping proprietary information confidential;
  • Avoiding outside activities or interests that conflict with responsibilities to The House of the Good Shepherd and reporting such activity or interest prior to and during employment;
  • Allowing only designated management staff to report to the public or media; and
  • Requiring that The House of the Good Shepherd comply with the licensing and certification laws that apply to its’ business.

Proprietary Information

In the performance of their duties, Associates may have access to, receive or entrusted with confidential and/or proprietary information, that is owned by The House of the Good Shepherd and that is not presently available to the public. This type of information should never be shared with anyone outside the organization without authorization from a member of the executive team.

Examples of proprietary information that should not be shared include:

  • Resident and Associate data and information;
  • Details about clinical programs, procedures and protocols;
  • Policies, procedures and forms;
  • Training materials;
  • Current or future charges or fees or other competitive terms and conditions;
  • Current or possible negotiations or bids with payers or other clients;
  • Compensation and benefits information for staff;
  • Stocks or any kind of financial information; and/or
  • Market information, marketing plans or strategic plans.

Business Courtesies and Gifts

Associates may not accept any tip or gratuity from residents; neither may they receive gifts from nor give gifts to residents; nor may they borrow money from nor lend money to residents; nor may they engage with residents in the purchase or sale of any item. Associates may not accept any gift from a resident under a will or trust instrument except in those cases where the Associate and resident are related by blood or marriage.

Associates may not serve as a resident’s executor, trustee, administrator, or guardian or provide financial services or act under a power of attorney for a resident except in those cases where the Associate and resident are related by blood or marriage or has a previous relationship with the resident prior to them moving in.

Under no circumstances will an Associate solicit business courtesies, entertainment or gifts that depart from the Business Courtesies and Gifts policy.

Conflict of Interest

A conflict of interest exists any time your loyalty to the organization is, or even appears to be, compromised by a personal interest. There are many types of conflict of interest and these guidelines cannot anticipate them all, however the following provide some examples:

  • Financial involvement with vendors or others that would cause you to put their financial interests ahead of ours;
  • An immediate family member who works for a vendor or contractor doing business with the organization and who is in a position to influence your decisions affecting the work of the organization;
  • Participating in transactions that put your personal interests ahead of The House of the Good Shepherd or cause loss or embarrassment to the organization;
  • Taking a job outside of The House of the Good Shepherd that overlaps with your normal working hours at or interferes with your job performance; or
  • Working for The House of the Good Shepherd and another vendor that provides goods or services at the same time.

All Associates must ensure that they remain free from actual or perceived conflicts of interest.

Use of Property

Property – everything from office supplies and computers to company vehicles – represents a significant expense and should only be used for legitimate business purposes. Everyone must make sure that they:

  • Only use property for the organization’s business, not personal use;
  • Exercise good judgment and care when using supplies, equipment, vehicles and other property; and
  • Respect copyright and intellectual property laws; or
  • Never copy or download software without permission from IT.

Computers and the Internet

Associates are expected to use computers, email and internet systems appropriately and according to the established policy and procedure. Associates are not permitted to use the internet for improper or unlawful activity or download or play games on organization computers.

Internet use can be tracked and how Associates use their time on the Internet will be monitored.

Vendor Relationships

We take responsibility for being a good client and dealing with vendors honestly and ethically. We are committed to fair competition among prospective vendors and contractors for our business. Arrangements between The House of the Good Shepherd and its vendors must always be approved by management. Certain business arrangements must be detailed in writing, approved by management and the Compliance Officer or designee. Agreements with contractors and vendors who receive resident information, with the exception of care providers, will require a Business Associate Agreement with the organization as defined by Health Insurance Portability and Accountability Act/HITECH. Contractors and vendors who provide resident care, reimbursement or other services to resident beneficiaries of federal and/ or state healthcare programs are subject to the Code of Conduct and must:

  • Maintain defined standards for the products and services they provide to The House of the Good Shepherd and the residents;
  • Comply with all policies and procedures as well as the laws and regulations that apply to their business or profession;
  • Maintain all applicable licenses and certification and provide evidence of current workers compensation and liability insurance as applicable; and
  • Require that their Associates comply with the Code of Conduct and the Compliance Program and related training as appropriate.

Marketing and Advertising

We use marketing and advertising activities to educate the public, increase awareness of our services and recruit new Associates. These materials and announcements, whether verbal, printed or electronic will present only truthful, informative, non-deceptive information.

We abide by the HIPAA/HITECH privacy rules in our marketing practices and provide individuals instructions on how to opt out of future communications.

Regulatory Excellence

Because we are in healthcare, we must follow the many federal, state and local laws that govern our business. Keeping up with the most current rules and regulations is a big job – and an important one. We are all responsible for learning and staying current with the federal, state and local laws, rules and regulations, as well as the policies and procedures that apply to our job responsibilities.

Billing and Business Practices

We are committed to operating with honesty and integrity. Therefore, all Associates must ensure that all statements, submissions and other communications with residents, prospective residents, the government, suppliers and other third parties are truthful, accurate and complete.

We are committed to ethical, honest billing practices and expect every Associate to be vigilant in maintaining these standards at all times. We will not tolerate any deliberately false or inaccurate billing. Any Associate who knowingly submits a false claim, or provides information that may contribute to submitting a false claim such as falsified clinical documentation, to any payer – public or private – is subject to termination. In addition, legal or criminal action may be taken.

Prohibited practices include, but are not limited to:

  • Billing for services or items that were not provided or costs that were not incurred;
  • Duplicate billing - billing for item or services more than once;
  • Billing for items or services that were not medically necessary;
  • Assigning an inaccurate code or resident status to increase reimbursement;
  • Providing false or misleading information about a resident’s condition or eligibility;
  • Failing to identify and refund credit balances;
  • Submitting bills without supporting documentation;
  • Soliciting, offering, receiving or paying a kickback, bribe, rebate or any other remuneration in exchange for referrals; and/or
  • Unlawfully inducing business associates.

If you observe or suspect that false claims are being submitted or have knowledge of a prohibited practice, you must immediately report the situation to a supervisor, the Compliance Liaison, the Compliance Officer or the Compliance Hotline.

Referrals and Kickbacks

Associates and related entities often have close associations with local healthcare providers and other referral sources. To demonstrate ethical business practices, we must make sure that all relationships with these professionals are open, honest and legal.

Resident referrals are accepted based solely on the clinical needs and our ability to provide the services required by the resident and our ability to provide the identified services. The House of the Good Shepherd never solicits, accepts offers or gives kickbacks of any kind.

A “kickback” is an item or service of value including cash, goods, supplies, gifts, “freebie” or bribes that is received in exchange for a business decision such as a resident referral. Accepting kickbacks is not only against policies and procedures but also against the law. To assure adherence to ethical standards in our business relationships, Associates must:

  • Verify all business arrangements with physicians or other healthcare providers or vendors in a written document; and
  • Comply with all state and federal regulations when arranging referrals to physician-owned businesses or other healthcare providers.

Associates cannot request, accept, offer or give any item or service that is intended to influence – or even appears to influence – a healthcare service paid for any private or commercial healthcare payer or federal or state healthcare program, including Medicare and Medicaid, or other providers.

Copyright Laws

Print and electronic materials are protected by copyright laws. Associates are expected to respect these laws and not reproduce electronic print or print material without the permission from the writer or publisher.

Financial Practices and Controls

Ensuring that financial and operating information is current and accurate is an important means of protecting assets. All Associates must make sure that all information provided by bookkeepers, accountants, reimbursement staff, internal and external auditors and compliance staff are accurate and complete. We must also comply with federal and state regulations when maintaining accounting records and financial statements and cooperate fully with internal and external audits.

Fair Dealing

All Associates must deal fairly with residents, suppliers, competitors and other Associates. No Associate, manager or director shall take unfair advantage of anyone through manipulation, concealment, abuse of privileged information, misrepresentation of material facts, or any other unfair dealing practice.

Protection and Proper Use of Assets

All Associates must protect the assets of the organization and ensure their authorized and efficient use. Theft, carelessness and waste have a direct impact on the organization’s viability. All assets must be used solely for legitimate business purposes.

Document Creation, Use and Maintenance

Every Associate is responsible for the integrity and accuracy of documents, records, and e-mails including, but not limited to, client medical records, billing records, and financial records. No information in any record or document may ever be falsified or altered.

Associates must not disclose internally or externally, either directly or indirectly, confidential information except on a need to know basis and in the performance of their duties. Associates must never disclose confidential information externally unless expressly directed to do so by legal counsel. Upon termination of employment an Associate must promptly return all confidential information to the organization.

Examples of confidential business information includes potential or threatened litigation, litigation strategy, purchases or sales of substantial assets, business plans, marketing strategies, organizational plans, financial management, training materials, fee schedules, department performance metrics and administrative policies.

Licensure and Certification

We are committed to ensuring that only qualified professionals provide care and services to residents. Practitioners and other professionals treating residents must abide by all applicable licensing, credentialing and certification requirements. In addition, every effort is made to validate licenses and certification through the appropriate state or federal agency and screening of all employees through the OIG and GSA data bases.

Voluntary Disclosure

It is the policy of The House of the Good Shepherd to voluntarily report fraudulent conduct it uncovers that affects any federal or state healthcare program.

Government Investigations

We are committed to cooperating with reasonable requests from any governmental inquiry, audits or investigations. Associates are encouraged to cooperate with such requests, conscious of the fact that Associate(s) have/has the following rights:

  • Associate has the right to speak or decline to speak, as all such conversation is voluntary;
  • Associate has the right to speak to an attorney before deciding to be interviewed; and
  • Associate can insist that an attorney be present if he/she agrees to be interviewed.

In complying with policy you must not:

  • Lie or make false or misleading statements to any government investigator or inspector;
  • Destroy or alter any records or documents in anticipation of a request from the government or the court;
  • Attempt to persuade another team member or any person to give false or misleading information to a government investigator or inspector; or
  • Be uncooperative with a government investigation.

If you receive a subpoena or other written request for information from the government or a court, contact your supervisor, the Compliance Liaison or the Compliance Officer before responding.

Disciplinary Action

Disciplinary action will be taken against any Associate who fails to act in accordance with this Code of Conduct,the Compliance Program, supporting policies and procedures and applicable federal and state laws. Disciplinary action may be warranted in relation to violators of the Compliance Program and to those who fail to detect violations or who fail to respond appropriately to a violation, whatever their role in the organization. Disciplinary action will utilize standard disciplinary processes or termination of business relationships and agreements. The Compliance Officer, in conjunction with the Chief Executive Officer, is empowered to initiate the disciplinary action through the immediate supervisor and to monitor appropriate implementation of the disciplinary process.

Compliance Questions

The laws applicable to our operations are numerous and complicated. When an Associate is not sure whether a particular activity or practice violates the law or the Compliance Program, the Associate should not “guess” as to the correct answer. Instead, the Associate should immediately seek guidance from his or her department supervisor or the Compliance Liaison. Associates will not be penalized for asking compliance-related questions. Indeed, we are intent on maintaining a culture in which every Associate is comfortable asking the questions necessary to ensure that he or she understands the duties imposed on him or her by this Code of Conduct, the Compliance Program and other applicable federal and state laws.


The Compliance Program is critical for The House of the Good Shepherd’s continued success. You are crucial to ensuring the integrity of this organization. The Code of Conduct and the Compliance Program set standards for the legal, professional and ethical conduct of our business. Some key points to remember are:

  • The House of the Good Shepherd and all its Associates are committed to personal and organizational integrity, to act in good faith, and to be accountable for our actions.
  • The Code of Conduct and the Compliance Program prepare us to deal with the growing complexity of ethical, professional and legal requirements of delivering healthcare and the CCRC environment.
  • The Compliance Program is an ongoing initiative designed to foster a supportive work environment, provide standards for clinical and business conduct, and offer education and training opportunities for Associates.

The success of The House of the Good Shepherd’s Compliance Program depends on our commitment to act with integrity, both personally and as an organization. As an Associate, your duty is to ensure that the organization is doing everything practical to comply with applicable laws. You are expected to satisfy this duty by performing your responsibilities in accordance with professional standards, the regulations and the policies and procedures.

To download a copy of our Code of Conduct, click here.

October, 2010


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