Code of Conduct
The Easterseals Hawaii Code of Conduct is built around the organization’s commitment to the highest possible standards of ethical business conduct.
The Code reflects Easterseals Hawaii’s, its affiliates’, and subsidiaries’ collective commitment and responsibility to provide the best service, practice ethical business behavior, meet rigorous professional standards, comply with laws, regulations, and policies that governs their work, and uphold each organization’s reputation. It also reflects its commitment and recognition that everything it does is in connection with its values – Courage, Integrity, Innovation, Collaboration, Passion and Excellence.
Please read the Code — bear in mind, it applies to every individual affiliated with Easterseals Hawaii, its affiliates’, and subsidiaries’ communities, as well as operations and activities which might occur on the premises and other locations.
If you have a question or concern about the Code, we want to hear from you. Contact the Office of Risk Management or the Compliance HelpLine at 1-833-44-PROTECT or [email protected]
Effective February 22, 2018
Our Code of Conduct (the “Code”) reflects our collective commitment and responsibility to provide the best service, practice ethical business behavior, meet rigorous professional standards, comply with laws, regulations, and policies that govern our work, and to uphold our organization’s reputation. It also provides the mechanisms for asking questions and reporting concerns or suspected violations without fear of retaliation.
The Standards described in our Code below, along with our Mission Statement, Purpose and Values serve as guidance in promoting ethical, honest and lawful decisions and actions for us as members of the ESH Community.
This Code and its related policies may not address every possible situation you may encounter, so it is up to you to use sound judgment and seek help whenever you need it. Talk to your Supervisor, or contact People and Performance, Quality or the Office of Risk Management (ORM) if you have any questions. In the event that more than one policy applies to any situation, all such policies will be applied to the fullest extent possible. If there is a conflict or gap in the individual policy provisions, the provisions of the policy that is most consistent with the Values of ESH and compliance with the law will be applied.
The Code may be modified as the organization continues to grow, and the norms of client care and business practices change. The current Code is available on the ESH Intranet (Confluence).
Easterseals Hawaii provides exceptional, individualized, family-centered services to empower people with disabilities or special needs to achieve their goals and live independent, fulfilling lives.
To change the way the world defines and views disability by making profound, positive differences in people’s lives every day.
ESH values Courage, Integrity, Innovation, Collaboration, Passion and Excellence.
The ESH Code of Conduct applies to every individual affiliated with Easterseals Hawaii and all of its Affiliates and Subsidiaries (“ESH”) including employees, practitioners, volunteers, interns, students, researchers and board members. It also embraces consultants and vendors when they are contracted to do business for ESH and those who claim an affiliation or association with ESH.
The Code of Conduct applies to all work, operations and activities of ESH, including clinical service delivery, which might occur both on-premises and other locations.
As members of the ESH Community, we are each responsible for upholding these high standards in our work and professional relationships.
Duty to Report
You have an important role in assisting us to comply with laws, regulations, and policies. If you have a question, or concern or suspect a violation, it is your individual responsibility to ask about it or report it to the appropriate person. You can also contact the ESH Compliance HelpLine at 1-833-44-PROTECT.
ESH takes all reports made to the Compliance HelpLine very seriously. Questions will be answered and all reports will be promptly investigated and appropriate corrective action will be taken, if warranted by the investigation.
Additional Responsibilities of Managers and Supervisors
Managers and Supervisors have the additional responsibility of shaping a values-based culture within ESH. You are also responsible for:
- Staying current with regulatory changes, and complying with them,
- Ensuring alignment with ESH Strategy, Objectives, Operational Plans and Approved Frameworks,
- Identifying and reporting opportunities for improving operations through greater efficiency, quality, security and compliance and for promoting meaningful customer impact,
- Ensuring your department obtains necessary licenses, permits, approvals and authorizations before action is taken,
- Assisting your department in determining the appropriate person to notify when they have clinical, quality, compliance, privacy, operational or other questions, and
- Ensuring your staff completes all required training at the start of employment and subsequent mandatory annual and other periodic training.
Confidentiality and Anonymity
You can report concerns or suspected violations giving your name and contact information. ESH takes confidentiality very seriously and will maintain, to the full extent of the law, confidentiality of the individual making the report. If an investigation is initiated, information will be shared only on a need-to-know basis. However, you may choose to report anonymously. Please note that in such cases we will not be able to inform you of the results of investigation.
ESH maintains a Non-Retaliation Policy that prohibits any member from retaliating against a community member who has reported a concern or suspected violation in good faith. Retaliation is subject to discipline, up to and including termination from employment and/or suspension of privileges.
We expect our actions to demonstrate our care for our clients, their families and the community as a whole.
We will strive to uphold the below five standards while we fulfill our role at ESH.
Standard 1 – Quality of Care and Safety
We expect our actions to demonstrate our care for our clients, their families, and the community as a whole. ESH is committed to providing high quality care in a manner that fully complies with all applicable laws, regulations, policies and standards of care.
Dignity and Respect
We deliver services with dignity and respect for each person, including the client’s family members. We are equitable in our decisions and mindful of their impact on other groups and people.
We are committed to providing and maintaining a safe, drug-free and healthy working environment for our clients, practitioners, employees and members of the ESH Community.
Access to Quality Care
We acknowledge that the quality of services provided to our clients is of the utmost importance to us and we will continue to make efforts to enhance the same. We will embody respect, caring, fair-mindedness and thoughtfulness in our actions towards all those we serve, the community and ESH. We will ensure that our interactions with clients, providers, vendors, and other stakeholders continue to maintain professional boundaries so that quality of care and risk management at ESH is not compromised.
We will respect the right of the individuals we serve to make informed decisions and seek their participation in all aspects of treatment. Similarly, we will also respect their right to refuse services and be informed of the consequences of such action.
Standard 2 – Privacy and Confidentiality
Privacy and confidentiality is vital to us. We will protect the privacy of our clients, employees and other stakeholders’ information, whether written, oral, electronic or image-based, and permit only such disclosures as allowed by applicable law.
Protected Health Information (PHI)
Our clients and families have trusted us with their sensitive information. We will respect the client’s right to privacy and confidentiality. We will safeguard their PHI and request, use, share or disclose only the minimum necessary and on a need-to-know basis.
Protected Health Information (PHI) includes any individually identifiable information that relates to past, present, or future medical behavioral conditions, treatment or payment that may identify a patient of client. It can be found in client records or financial and operational systems.
There are several federal and state laws governing the privacy and security of PHI including the Health Insurance Portability and Accountability Act (HIPAA) and Security Rules.
We possess personal information such as addresses, salaries, benefits and payments of our clients’ families, employees, practitioners, volunteers, interns, students, researchers, board members, donors, consultants and vendors. We should access this information only for the fulfillment of our job requirements.
We will protect their privacy and permit disclosures only as mandated by legal obligations.
We do not reveal confidential information related to ESH’s business strategies, objectives and plans, financial transactions and data, software, intellectual property and research data unless it is for a legitimate business reason and to an authorized person.
We are responsible for ensuring the security of information entrusted to us. We will abide by our security policies and controls to ensure confidentiality. We will access data and facilities using our own log-in credentials, passwords and identification badges.
ESH respects the rights of its employees and other community members to use blogs and other social media tools as a form of self-expression and communication.
However, we will use all forms of social media appropriately and respectfully and ensure that there is no negative impact on our clients and their families, or on our employees, donors, partners and affiliates (even our competitors) or other community members, or on the business or reputation of ESH.
Media and Public Relations Policy
ESH community members may not speak to, or provide written comments to, the media on behalf of ESH without formal approval and media training. Requests for comment or opinion should be directed to the Communications Department.
Standard 3 – Personal Conduct and Business Ethics
Gifts and Gratuities
Community members of ESH should discourage the acceptance of gifts from clients and business associates. In rare instances, community members may accept gifts which are of nominal value, perishable and are to be shared with office staff, e.g., cakes, brownies, chocolates, flowers, fruits, etc. Gifts of a personal nature are not permitted such as perfume and clothing.
Under no circumstances will any member accept cash or cash equivalent as gifts, e.g., gift cards, dining vouchers, tickets to sports, golfing or other entertainments, stocks, bonds, etc.
Gifts and Business Courtesies from Vendors
Community members of ESH are discouraged from offering gifts to or receiving gifts from vendors even if such gifts are occasional and of nominal value and perishable. In rare instances, gifts such as cakes, chocolates, flowers, etc. which are to be shared with office staff might be accepted.
Under no circumstances, might any community member offer or receive a gift when the intent is to generate business or influence an ESH decision.
Conflict of Interest
ESH community members are expected to act at all times in the best interest of the organization, its clients and their families. Employees, volunteers, staff should avoid engaging in outside activities that might compromise or negatively impact their job performance.
A conflict of interest occurs if outside activities or personal interests influence, or appear to influence, the ability to make objective decisions on behalf of ESH. Employees, practitioners, volunteers, interns, students, researchers and board members should disclose any situation where there is an actual conflict, or a potential conflict, to the Compliance and Risk Officer.
We will refrain from personal fundraising (other than fundraising on behalf of ESH) in the workplace.
Discrimination, Diversity and Inclusion
We respect diversity within our workplace and promote inclusion. We practice fair and equal treatment of employees, practitioners, volunteers, interns, students, researchers and board members. Vendors and consultants are expected to abide by our standards.
You are expected to report abuse, violence, harassment or intimidation of any kind that you witness or experience in the workplace.
We will be good stewards of the resources entrusted to our care. We will be respectful of ESH’s property, equipment, supplies and assets and will use them judiciously within the scope of our job responsibilities and to further the mission of the organization.
Duty of Regard
We will ensure that only personnel authorized by policy and agreement bind or commit ESH (including the witnessing of documents) to obligations which align with the mission and vision of the organization.
We will not bring personal property into the workplace that is offensive to others.
We will not use ESH electronic mail or other property to convey or communicate inappropriate material.
We will strive to ensure that all promotions and marketing of our services are in accordance with the values of our organization and the Easterseals national brand guidelines while being respectful and sensitive to the needs of our clients and their families and our other stakeholders.
Standard 4 – Compliance with Laws and Regulations
ESH is a not-for-profit organization in the business of delivering health care services and as such is highly regulated. It behooves each of us to ensure that our professional conduct is in accordance with applicable laws, regulations and policies, especially those relating to the handling of client referrals and placement, billing and payment practices, clinical and payor relationships, vendor contracts, lobbying, environmental health and safety, employment practices, etc.
These laws and regulations are complex; hence, ESH provides regular training and policies. It is your responsibility to ensure that you complete the training required and refer to policies when the need arises.
Fraud, Waste and Abuse Laws
There are several laws and regulations that apply to the provision of health care services. Some of them describe “fraud, waste and abuse” in detail such as the False Claims Act, the Anti-kickback statute and the Physician Self-referral Law (also called the Stark Law). ESH strives to comply with all applicable laws.
Employees should not knowingly submit bills/claims that they believe to be inaccurate or improperly coded. Nor should they ignore the knowledge that a claim is false. All bills/claims should be well-supported by internal documentation.
Moreover, we should only employ individuals, and hire contractors, who have not been excluded from participation in federal and state health care programs.
We are committed to using the funds, time and other resources of the organization in a judicious manner without leading to waste and in accordance with achieving the organization’s mission.
We will endeavor together to provide and maintain a safe, drug-free and healthy working environment for our clients and their families, employees and other community members. We will operate and maintain equipment, facilities and processes in a safe manner.
Cooperation with Government Investigations
We will respectfully cooperate with all government auditors and investigators.
You should immediately bring any requests for information, which may include audit requests, search warrants, subpoenas, civil investigative demands, and similar to the attention of your Supervisor or to Quality or the Office of Risk Management (ORM).
Tax Exempt Designation
ESH enjoys the designation of a tax-exempt organization under Section 501 (c) (3) of the Internal Revenue Code operated for charitable purposes. To ensure that ESH does not lose its tax-exempt designation, community members should ensure they contract to only pay fair market value for goods and services, not engage in activities for the benefit of private interests nor engage in substantial political or legislative, i.e., lobbying activities.
In situations where ESH community members participate in political affairs, it is required that they make clear that they are acting as private citizens and not on behalf of ESH. If the community member chooses to contribute to a political campaign, it should be as an individual and not as an ESH representative.
Standard 5 – Financial Reporting
Accuracy and Completeness
We will make every effort to ensure accuracy, completeness and timeliness in our accounts, financial reports, tax returns, expense reimbursements, time sheets and other documents including those submitted to government agencies and other stakeholders. All entries should reflect the precise nature of the activities and transactions of the business and be free from error.
Audits and Monitoring
We will commit to annual audits by an independent agency to ensure the financial integrity of our records and accurate filings with government agencies.
We will monitor and analyze our financial and other information to ensure the appropriate use of monies for the achievement of organizational goals.