Code of

EXCELLENCE& Code of

CONDUCT

HEALTHCARE

Anderson HealthcareCode of Excellence

And Code of Conduct

Purpose

Anderson Healthcare is committed to providing quality healthcare services in thecommunities we serve. In order to provide these quality healthcare services, Anderson Healthcaremust have high standards of professional, ethical, legal and conscientious business practices. Topromote ethical and lawful conduct throughout our organization, Anderson Healthcareimplemented a system-wide Compliance Program. As the foundation of the ComplianceProgram, to ensure our commitment to maintaining excellence, respect and integrity in all aspectsof our professional and business conduct and our operations, we have prepared this Code ofExcellence and Code of Conduct.

The Code of Excellence and the Code of Conduct (referred to as Standards) apply to allemployees, Medical Staff, Allied Health Staff, Board of Trustees, volunteers, students, contractors,consultants, suppliers and vendors (coworkers) of Anderson Healthcare. The Codes identify thestandards that everyone within our organization must understand and follow and is intended tobe a resource for resolving questions about appropriate conduct in the work place. In additionto outlining expectations for daily interactions and conduct, the Codes also assist each of us inour obligation to comply with federal and state laws, as well as Anderson policies. While theseCodes are great resources, they cannot replace each person’s sense of fairness, judgment, honestyand integrity. Thus, if you encounter a situation that is not addressed in the Code of Excellenceor Code of Conduct, but which just does not feel right, it is important to discuss the situationwith your supervisor or our Compliance Officer.

Some of the standards addressed in this Code of Excellence or the Code of Conduct maynot apply to the services you perform at Anderson; however, everyone needs to be aware of allexpectations contained in these Codes so that we understand the responsibilities of all who workat Anderson Healthcare. The importance of each individual’s involvement and participation inthe Compliance Program cannot be overemphasized. Each person within our organization isessential to the success of our Compliance Program and needs to be fully committed tocompliance with these Codes.

Thank you for your contributions and commitment to our organization’s compliance efforts.

Keith Page, President/CEO

Mission

To exceed expectations by providing personal, convenient, quality healthcare.

VisionOur community turns to Anderson Healthcare first for all healthcare needs.

Values: Pillars of Excellence

Service: Provide excellence in patient centered and compassionate services, making Anderson Healthcare the provider of choice for the community.

People: Attract, develop, support and retain skilled, service-oriented and culturally diverse team members committed to Anderson Healthcare’s Mission.

Quality: Demonstrate excellence in clinical outcomes and patient safety by providing quality care through continuous improvement.

Growth: Expand services and develop affiliations and partnerships, as a community hospital, to meet the healthcare needs of Anderson Healthcare’s service area.

Finance: Strengthen the financial performance of Anderson Healthcare, throughexceptional stewardship to support investment in people, technology, facilities andservices.

Mission, Vision and Values

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Mission, Vision And Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Code Of Excellence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Honesty and Integrity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Attitude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Accountability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Commitment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Professionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Drug Free Workplace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Confidentiality and Privacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Use of Computer and Communication Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Telephone Etiquette . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Elevator Etiquette . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Call Lights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Dress Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Code Of Conduct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Employment Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Fraud and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Billing for Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Relationships with Our Physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Kickbacks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Gifts, Gratuities and Entertainment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Conflict of Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20Intellectual Property . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Emergency Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Patient Care Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22Patient Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23Charity Care and Discounts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23Excluded and Sanctioned Individuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24Antitrust . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24Tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25Politics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25Reporting Information Related to Finances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26Compliance with Code of Excellence and Code of Conduct . . . . . . . . . . . . . . . . . . .27Code of Excellence and Code of Conduct Reporting . . . . . . . . . . . . . . . . . . . . . . . .28Code of Excellence and Code of Conduct Acknowledgement Form . . . . . . . . . . . .29

TABLE OF CONTENTS

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Code of

EXCELLENCE

CODE OF EXCELLENCE

To demonstrate my commitment to this principle:I WILL… n Be truthful in all my actions and will not knowingly

mislead others or act dishonestly.

n Maintain accurate, timely and complete records ofpatient care and business activities.

n Make patient care decisions focusing on patients' needsand best interests of the patient.

n Commit to the highest standards of business ethics andintegrity.

n Avoid any activity or scheme that would take advantageof anyone for their money, property or services.

n Not destroy or alter the organization’s documents. n Obtain the approval of my director, in advance, if I am

requesting to use Anderson Healthcare equipment,supplies, materials or services for personal or non-workrelated purposes.

n Obtain approval from my direct supervisor in advance ofany plan to use company time for an activity that bringspayment to me.

To demonstrate my commitment to this principle:I WILL… n Demonstrate a respectful and caring attitude by treating

others as I wish to be treated.

n Convey a positive attitude and refrain from rudenessand negativity by using such statements as:

“It’s not my job” instead say: “I’ll find someone who canhelp you”

“I didn’t do it” instead say: “I’ll make this right”

“We are short staffed” instead say: “I’ll do whatever ittakes”

n Acknowledge people immediately even if I need to stopwhat I am doing.

n Greet people with a smile or hello, make eye contactand introduce myself.

n Use the person’s name whenever possible.

n Anticipate people’s needs and not wait to be asked. n Keep my personal or professional stressors away from

my patients and coworkers.

n Bring work-related concerns to my supervisor fordiscussion.

n Be mindful of my body language because it speakslouder than words.

n Be positive in all my discussions about AndersonHealthcare.

Honesty and IntegrityHonesty and Integrity are themost important qualities for

our interactions andrelationships with our patients

and coworkers.

AttitudeWe will never get a second

chance to make a firstimpression.

Therefore every interaction isan important one.

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AccountabilityAccountability means taking pridein what I do and the responsibilityfor the outcomes of my efforts. Ibelieve that my work is areflection of myself.

CommitmentTeamwork – one for all – all forone. My coworker is every fellowemployee, volunteer or student,medical staff, allied health staff,vendor and contractor ofAnderson Healthcare.

CommunicationThe goal of communication ismutual understanding.

CODE OF EXCELLENCE

To demonstrate my commitment to this principle:I WILL… n Fulfill the responsibilities of my job.

n Avoid blaming and instead focus on addressing issues.

n Be accountable for maintaining required licenses,certifications and mandatory professional education.

To demonstrate my commitment to this principle:I WILL… n Be loyal to Anderson Healthcare.

n Support my organization and the work of fellowcoworkers.

n Commit to encouraging, valuing and supportingdiversity.

n Follow through on my commitments.

n Be willing to accept additional responsibility.

n Function with the understanding that cooperation isexpected in the workplace.

To demonstrate my commitment to this principle:I WILL… n Follow the AIDET principles: Acknowledgement Introduction Duration Explanation Thanks

n Encourage patients and significant others to askquestions and respond to their concerns in a timelymanner.

n Get someone who can help if a patient or coworkermakes a request that I am unable to fulfill.

n Avoid creating rumors or engaging in hostile,condemning or demeaning communications.

n Take responsibility to obtain and read hospitalcommunications as directed by my manager.

n Use easy-to-understand and appropriate languagewhen giving patient information.

n Avoid providing false or misleading statements to anypatient or any other person.

n Remember that face to face communication can bebetter than email.

n Leave the appropriate e-mail or voicemail when I plan tobe away for an extended period of time (e.g. vacation). 6

CODE OF EXCELLENCE

To demonstrate my commitment to this principle:I WILL… n Understand that patients’ family and significant others

are as important as the patient.

n Keep patients, significant others and coworkersinformed.

n Escort or obtain the assistance of a coworker orvolunteer for visitors who need directions.

To demonstrate my commitment to this principle:I WILL… n Treat coworkers as teammates who deserve my respect.

n Be courteous in both verbal and nonverbalcommunications.

n Treat every coworker as a professional and recognizeour different areas of expertise.

n Respect the privacy of my fellow coworkers.

n Avoid chastising or embarrassing coworkers.

n Relate to all patients and coworkers equally, regardlessof age, gender, gender orientation, disability, race,ethnicity, creed, religion or national origin.

n Consider another’s priority in addition to my own.

n Extend professional courtesy to everyone, set asidedifferences when working with others, address issueswith the involved party and enlist the assistance of asupervisor if necessary.

n Welcome new coworkers and be supportive by offeringhelp and setting an example of the level of cooperationexpected in our workplace.

ServiceIt is important that we supportAnderson Healthcare’s values,

mission and vision. Ourprimary goal is to exceed our

patients’ and coworkers’expectations. I recognize ourpatients have a choice wherethey receive their healthcare.

ProfessionalismA commitment to a

professional and caringenvironment is very

important.

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SafetySafety is everyone’s job. Wemanage and operate our businessin a manner that respects ourenvironment and conservesnatural resources. We strive to useour resources appropriately andefficiently and dispose of all wastein accordance with applicablelaws. It is essential to report allknown or suspected safetyconcerns and immediately notifythe supervisor of any situationinvolving improper disposal ofhazardous waste or any othersituation that may be damaging tothe environment.

CODE OF EXCELLENCE

To demonstrate my commitment to this principle:I WILL… n Utilize Personal Protective Equipment (PPE) as

appropriate.

n Be aware of Safety Data Sheets (SDS) as it relates to mydepartment.

n Not falsify, tamper with, render inaccurate, or fail toinstall, a required monitoring device.

n Follow the basics of good body mechanics to protectmyself, my coworker and my patients.

n Use the safe patient handling equipment.

n Return equipment and supplies to the appropriateplace.

n Utilize security services when the need arises.

n Intervene if I recognize an unsafe situation.

n Use equipment, supplies, material and services only asauthorized.

n Notify my supervisor of any workplace injury or anysituation creating a danger of workplace injury so thatimmediate corrective measures can be taken.

n Question individuals without an ID badge, asappropriate

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Drug Free WorkplaceAnderson Healthcare is a drug-free workplace. AndersonHealthcare is committed tomaintaining a safe, healthful andefficient environment for theorganization, its employees,coworkers and visitors.Employees are to remain free ofimpairment related to substanceabuse. The illegal possession orsale of any drug or alcohol on theorganizations’ property or any ofits related services is prohibited. Inaddition, the Drug-FreeWorkplace Act of 1988 requiresan organization’s services whoreceive federal grants to certify itwill provide a drug-freeworkplace.

CODE OF EXCELLENCE

I UNDERSTAND… n Unless service of alcoholic beverages at official

Anderson Healthcare functions is authorized, it isprohibited to use alcohol at Anderson Healthcarefunctions.

n The use of controlled substances or alcoholic beveragesby employees or coworkers; or employees or coworkersworking under the influence of these chemicals, isinconsistent with the behavior expected of employeesand coworkers.

n This type of behavior subjects employees, coworkersand visitors to unacceptable safety risks, andundermines Anderson Healthcare’s ability to operateeffectively and efficiently.

n All employees and coworkers must remain free fromimpairment due to the use of drugs and alcohol whileon the job and from use, possession, manufacture, orsale of any drug or alcohol on Anderson Healthcareproperty.

n The unauthorized use of alcoholic beverages in theworkplace or the unlawful use, possession,concealment, transportation, promotion, sale ordistribution of controlled substances on the job, onAnderson Healthcare Property or while engaged inAnderson Healthcare business off the property is strictlyprohibited and will subject the employee to disciplinaryaction.

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CODE OF EXCELLENCE

To demonstrate my commitment to this principle:I WILL… n Discuss company business only in private areas.

n Maintain patients’ privacy and confidentiality and willnot discuss patient information in any public place suchas an elevator, open hallway or cafeteria.

n Access patient information only as it pertains to my workand job duties.

n Share patient information only with those who have aneed to know for patient care reasons and as otherwisepermitted by the organization’s HIPAA privacy policies.

n Keep unauthorized persons out of patient care areas.

n Apply all privacy and security safeguards to protectedhealth information as required by the organization’sHIPAA privacy and security compliance policies.

n Respect patients’ privacy and modesty by knockingbefore entering a room.

n Explain to the patient closing the curtain for privacy.

n Ask visitors and family to leave the room during patientcare interactions unless the patient indicates otherwise.

n Avoid using any social media in any form to discusspatients or any other confidential information.

n Understand personal and medical staff information isconfidential and is not shared beyond those individualswith a need to know to fulfill their job functions andconsistent with applicable law and our policies.

If questions arise regarding an obligation to maintain theconfidentiality of information, or whether releasingspecific information is appropriate, Anderson Healthcarecoworkers should seek guidance from their departmenthead, manager, supervisor, administrative director orPrivacy Officer.

Confidentiality and Privacy

Anderson Healthcarecoworkers have access to a

broad variety of confidential,sensitive and proprietary

information. If thisinformation is released

inappropriately, it could causeharm to patients, Anderson

Healthcare’s business partnersand Anderson Healthcare itselfand may violate federal and

state law. Everyone is obligatedto actively safeguard

confidential, sensitive andproprietary information toprevent the unauthorized

disclosure of such information.

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Use of Computer andCommunicationSystems Patient, personal, and financialinformation is housed in ourelectronic record applications.Accessing only what is appropriateand preventing all other access isvital to the protection ofAnderson, coworkers and ourpatients. All communications,electronic mail, intranet, internetaccess, voice mail or paper recordsare the property of AndersonHealthcare and should be used forbusiness purposes only.

CODE OF EXCELLENCE

To demonstrate my commitment to this principle:I WILL… n Obtain proper authorization before using our

organization’s computing resources from theInformation Technology department.

n Use the organization’s computing resources forpurposes only for which I am authorized.

n Keep my access privileges confidential (Username andpasswords).

n Electronically transmit or distribute material onlyconsistent with the organization’s policies andguidelines.

n Respect the privacy of other users. More specifically,avoid reading, deleting, copying, or modifying anotheruser's data, information, files, e-mail or programs("electronic files") without the other user's expressedpermission.

n Refrain from introducing any program or data intendedto disrupt normal operations (e.g., a computer "virus"or "worm") into Anderson Healthcare’s computersystems.

n Refrain from circumventing or attempting to circumventnormal log-on procedures, or security procedures.

n Refrain from using our computer resources forrecreational game playing, or streaming video or audio.

n Refrain from opening e-mails from unknown/suspicioussources.

n Use email for business purposes only.

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CODE OF EXCELLENCE

To demonstrate my commitment to this principle:I WILL… n Make a good impression by answering on the first ring

whenever possible and remember that the tone sets thestage.

n Avoid eating, drinking or chewing gum while speakingon the telephone.

n Answer all calls with a greeting identifying yourdepartment and yourself. For example: “Good morning,third medical, this is Susie”.

n Use the speakerphone only when necessary. If aspeakerphone must be used, ask for permission andinform the caller of who else is present in the listeningarea.

n Avoid transferring a call blindly. Notify the receivingparty of the call, and provide the caller with thetelephone number in case the call is lost. If the call isanswered in voicemail, let the caller know and ask if theywould like to leave a message or call back at a latertime.

n Obtain the caller’s permission before placing him/her onhold and thank the caller for holding when returning tothe call.

n Leave the appropriate voice message, if planning to beaway for an extended period (e.g., vacation).

n Return calls promptly.

To demonstrate my commitment to this principle:I WILL…

n Use the elevator as an opportunity to make a favorableimpression by smiling and politely speaking to fellowpassengers.

n Pause briefly before attempting to board an elevator soas to not block the way for anyone wishing to exit.

n Allow enough space in the elevator for people withdisabilities and other passengers.

n Give patients and visitors priority use of the elevator.

n Keep in mind that many staff, patients and visitors ridethe elevator; avoid discussing any patient information orany other inappropriate topics.

Telephone EtiquetteAnswering telephones correctly

and politely is everyone’sresponsibility.

Elevator EtiquetteGood elevator mannerscontribute to customersatisfaction and smooth

transportation.

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Call LightsThe No Pass Zones empower anyemployee who sees a call light to

respond, even if it is not theemployee’s department. The No

Pass Zone ensures the patient thatthe entire team is working

together to meet their needs.

Dress CodeThe professional appearance ofAnderson Healthcare staff isimportant. Our patients’,coworkers’ and customers’

opinion and perception of thequality of patient care is related towhether or not someone presentsa professional appearance. When

all employees present aconsistently professional

appearance, it translates directly toincreased customer satisfaction.

MeetingsMeetings are needed in order toreceive and provide information,share ideas and resolve issues. For

meetings to be effective, it isimportant to give our undivided

attention to all participants.

CODE OF EXCELLENCE

To demonstrate my commitment to this principle:I WILL… n Answer call lights in a way that demonstrates the care,

courtesy and respect our patients deserve.

n See the call light

n Take time to drop in and introduce myself (AIDET)

n Find out what the patient needs.

n Pass the need on if I can’t fulfill the request.

To demonstrate my commitment to this principle:I WILL… n Adhere to the dress code.

n Wear my ID badge, placing it above the waist, facingout, and not attach ornamentation directly to thebadge.

To demonstrate my commitment to this principle:I WILL… n Show respect to others by either silencing electronic

devices, placing them on vibrate mode, removingmyself from the meeting to transact calls, or quietlyidentifying that I am in a meeting.

n Always make every effort to be on time and berespectful of other’s time during meetings.

n Avoid sideline discussions during meetings.

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Code of

CONDUCT

Employment PracticesAnderson is committed to fair andequal employment opportunitiesand to treating everyone withrespect and courtesy. AndersonHealthcare recruits, hires, trains

and promotes individuals withoutregard to race, color, creed,

religion, age, disability, gender,national origin, citizenship, orveteran status. All personnel

actions including those relating tocompensation, benefits, transfers,layoffs, organization-sponsoredtraining and tuition assistanceprograms are administered

without regard to race, color,creed, religion, age, disability,

gender, national origin,citizenship or veteran status.

Fraud and AbuseFRAUD is the intentional

deception or lack of truthfulnessby a person with knowledge thatthis lack of truthfulness couldresult in some illegal benefit tohim or herself or some other

person. ABUSE is inconsistent orunsound business, financial ormedical practices that result inunnecessary cost, being paid forservices that are not medically

necessary or don’t meetprofessionally recognized standards

for health care. A consistentadherence to honesty and integrity

guides all that we do.

CODE OF CONDUCT

I understand this means... n There is no harassment or discrimination in the

workplace and we expect the same from all ourcoworkers and patients, and any visitor to AndersonHealthcare.

n Anderson Healthcare will not tolerate any harassing,intimidating or disruptive conduct that interferes withwork performance or creates an intimidating, hostile oroffensive work environment.

n Any allegation of harassment or discrimination will bepromptly investigated in accordance with applicablehuman resources policies.

n Compensation and promotion of employees are doneaccording to our policies and procedures.

n Equitable benefits are provided to all eligibleemployees.

n That reasonable accommodation is made to the knownphysical and mental limitations of otherwise qualifiedindividuals with disabilities.

To demonstrate my commitment to this principle:I WILL… n Avoid making or receiving direct, indirect or disguised

payments in exchange for the referral of patients.

n Avoid submitting false, fraudulent or misleading claimsto any government entity or third party payor.

n Avoid making a false description in order to gain orretain participation in a program or to obtain a paymentfor any service.

n Avoid falsely certifying that a service was medicallynecessary.

n Avoid making any false or misleading statements aboutthe products or services of Anderson Healthcare orabout Anderson Healthcare’s competitors.

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CODE OF CONDUCT

I understand that... n We charge patients for clinical services provided

consistent with applicable laws and policies.

n We assign codes that we believe in good faithaccurately reflect the services provided and aresupported by documentation in the medical record.

n We do not bill for any items and services not renderedor not medically necessary and do not falsify a diagnosisor a type or level of service to obtain payment.

n We do not submit a claim piecemeal or in a fragmentedfashion to maximize reimbursement for tests andprocedures that are required to be billed together (i.e.,unbundling).

n We have controls in place to prevent unbundling,upcoding and duplicate billing for the same services.

n We respond to billing inquiries in a timely manner, andwe resolve inaccuracies for claims previously submitted.

n We make every effort to work with our employees whoperform our billing and coding process so that theyhave the appropriate skills to perform these functionsaccurately.

n Any subcontractors engaged to perform services forAnderson Healthcare are expected to comply withapplicable laws and follow the same high standards ofcoding and billing.

n We do not knowingly submit claims for payment thatare false or inaccurate.

n If we identify a refund due to a payor, we make refundsas required by law.

Billing for ServicesFederal law prohibits

healthcare providers fromknowingly submitting false orfraudulent claims for payment

to Federal healthcareprograms. State laws containsimilar prohibitions. Examplesof false claims include claims

for services not rendered,claims that characterize theservice differently from theservice actually provided orclaims that do not comply

with applicable laws. AndersonHealthcare implementedpolicies and procedures to

facilitate accurate coding andbilling for services provided to

our patients. All claimssubmitted to any payor mustbe accurate and cost reportsmust be prepared consistentwith applicable laws. Codingis our method to identify andclassify diseases and procedures

and is based on the careprovided and the

documentation in the medicalrecord. Coding and billing

must be timely, accurate andcomplete. Knowingly

presenting or causing to bepresented claims to any payorwhich are false or fraudulent is

prohibited.

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Relationships with Our Physicians

Relationships with physicians aresubject to the Federal Stark Lawwhich prohibits a physician fromreferring a patient to an entity fordesignated health services, whichinclude, among others, hospitalservices, payable by Medicare ifthe physician has a “financialrelationship” with the entity.

“Financial relationship” includes acompensation arrangement or aninvestment interest. The Stark

Law disallows Medicare paymentsfor services provided pursuant to

prohibited referrals. Allarrangements with physiciansmust be structured to assure

compliance with the Stark Lawand other applicable laws. Anyproposed arrangement with

physicians which may implicatethe Stark Law shall be evaluatedand approved by the ComplianceOfficer, in consultation with the

legal counsel.

CODE OF CONDUCT

I understand that... n No payments can be made to a physician/physician

group without a current and signed agreement in place.

n Agreements with physicians must be put in writing andapproved in advance by Administration.

n Compensation to physicians for services must beconsistent with fair market value and not take intoaccount the volume or value of referrals to AndersonHealthcare.

n There is no “private understanding” to referrals ofbusiness.

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CODE OF CONDUCT

I understand that... n We accept patient referrals/admissions solely based on

the patient's clinical needs and our ability to render theneeded services.

n We will not pay or offer to pay anyone - employees,physicians or other persons - for referrals of patients.

n No employee or other person acting on behalf ofAnderson Healthcare is permitted to enter into anyagreements with referral sources that are linked directly,or indirectly, to the referral of patients.

n No employee or any other person acting on behalf ofAnderson Healthcare is permitted to solicit or receiveanything of value, directly, or indirectly, in exchange forthe referral of patients.

n Our physicians and other health care providers makepatient referrals solely based on the patient's clinicalneeds and the abilities of the referred provider torender such services.

n We do not waive insurance co-payments or otherwiseprovide financial benefits to patients in return foradmission.

n Under certain circumstances, Anderson Healthcare mayprovide for appropriate financial arrangements (such asallowing monthly payments over time) to patients basedpurely on their financial need.

n We inform patients of their options as to home health,hospice, durable medical equipment, home infusion,and other ancillary health care services and to allowpatients to choose when selecting any services that thepatient may require.

KickbacksThe Federal Antikickback Lawapplies to relationships withphysicians and other referral

sources and prohibits direct orindirect remuneration in

exchange for the referrals ofpatients. Anderson Healthcareaccepts patients based on their

health care needs and ourability to provide the neededservices. No payments or

other remuneration shall begiven to anyone in exchange

for patient referrals.

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Gifts, Gratuities andEntertainment

The giving of gifts can have thegoal to influence, or be consideredby an independent person to beseen as having the potential toinfluence, us in our conduct ofour duties or responsibilities at

Anderson Healthcare.

CODE OF CONDUCT

I understand this means... n It is permissible to keep individual gifts that have a value

not greater than $15 per item, as long as the total valueof $75.00 is not exceeded for gifts in any one year fromany one individual or organization. I will talk to my directsupervisor if I do not know the value of a gift.

n Seeking clarification from a supervisor is necessary ifthere is a question whether a gift is acceptable.

n To the extent possible, gifts received should be sharedwith my coworkers.

n Any gift of cash or cash equivalents (e.g. Visa Gift Card)is never permissible to accept from a patient, a familymember, a business partner or any company with whomwe do business.

n Gifts may be accepted if they are consumable orperishable, and cannot have a value of more than $15per person.

n No money, services or other things of value may beoffered to influence the judgment or decision-makingprocess of any purchaser, supplier, customer,government official or other person involved in any typeof business with Anderson Healthcare.

n My Department Director or the Compliance Officerneeds to be notified if I have been offered excessiveentertainment, gifts or other favors by a company doingor seeking to do business with Anderson Healthcare, orby a competitor of Anderson Healthcare.

n Business transactions with vendors, contractors andother third parties may not involve improper incentivesin exchange for influence or assistance in a transaction.(For example: offers of gifts or favors, requests for giftsor favors, bribes, tips, etc.)

n It is not permissible to give gifts of greater than $15 invalue or to use gifts as inducements to patients.

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CODE OF CONDUCT

To demonstrate my commitment to this principle:I WILL… n Identify any other jobs I have outside Anderson

Healthcare to my director/administrative director, if theother position affects the performance of my duties forAnderson Healthcare.

n Inform my director/administrative director beforeaccepting outside employment while employed byAnderson Healthcare.

n Obtain the approval of my director/administrativedirector before engaging in consulting or other outsideactivities.

n Identify financial investments that appear to impact orcould impact the objective and efficient performance ofmy work at Anderson Healthcare to mydirector/administrative director.

n Identify if I or members of my family receive personalbenefits as a result of my position at AndersonHealthcare to my director/administrative director.

n Disclose personal relationships and business activitieswith contractors (those we do business with) that mightbe seen as influencing the performance of my duties.

n Maintain a current Conflict of Interest document andprovide any updates to the Compliance Officer.

n Not provide consulting or other similar services to anycompany doing or seeking to do business withAnderson Healthcare if providing this service wouldimpair my ability to perform my duties at AndersonHealthcare.

n Not use “insider” information (a fact not known to thepublic) for any business activity conducted by or onbehalf of Anderson Healthcare.

Conflict of InterestA conflict of interest can exist

when financial or otherpersonal considerations

directly or indirectly affect orappear to affect personal

judgement when carrying outduties or providing safe,

quality care and treatment toour patients. Products andservices must be bought and

sold based solely on their valueand merit.

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Intellectual PropertyFederal and State laws protectintellectual property which

includes copyrights, trademarks,patents and trade secrets.

Copyright laws provide protectionwhen an original work of

authorship such as a book or anarticle, a computer software

program or a recorded program isfixed in a tangible medium ofexpression. Trademark laws

protect consumers from confusionabout the source and quality of

goods or services. Patent laws givean inventor exclusive rights tomake, use and sell the patented

invention. Trademarked,registered, patented or privately-owned information is exclusive to

the company who owns thatinformation.

Emergency TreatmentAs an organization we follow the

federal EMTALA regulationsregarding the care and treatmentof patients seen in our EmergencyRoom and Urgent Care centers.Transfers to other facilities areonly done when in compliance

with state and federal regulations.

CODE OF CONDUCT

To demonstrate my commitment to this principle:I WILL… n Not obtain or share confidential business information

from competitors (this includes customer lists, price lists,contracts or other information).

n Avoid communicating confidential information.

n Maintain Anderson Healthcare’s intellectual propertyrights, including any patents, trademarks, copyrightsand software; these are carefully maintained andmanaged to preserve and protect their value.

n Avoid acquiring confidential or privately ownedinformation belonging to another person or business ina wrongful way.

n Avoid using any publication, document, computerprogram, information or product in violation of a thirdparty’s interest in that product.

n Avoid making copies of documents or computerprograms in violation of applicable copyright laws orlicensing agreements, either for my own use or the useof Anderson Healthcare.

I understand... n We provide a medical screening examination and

stabilizing treatment to all who come to us foremergency treatment to determine whether anemergency medical condition exists.

n We provide a medical screening examination andstabilizing treatment to all who are in labor.

n We provide this treatment regardless of the person’sability to pay or if they lack insurance.

n We transfer patients with emergency conditions to otherfacilities only at the patient’s request or if we do nothave the capacity or capability to meet their needs andthe appropriate care level is available at another facility.

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CODE OF CONDUCT

Employees, and at times coworkers, have the most direct linkto our patients and our operations and are in the bestposition to identify potential problems. Therefore, AndersonHealthcare relies on its employees and coworkers to providefeedback to make improvements to patient care services. Inany circumstance where an employee or coworker has aconcern about patient safety or quality of patient care, theemployee or coworker is obligated to promptly raise theissue with their supervisor, or Compliance Officer, so that theissue can be properly evaluated and addressed.

To demonstrate my commitment to this principle:I WILL… n Treat all patients with dignity and respect.

n Provide care that is safe and appropriate.

n Provide assurance and preserve patient dignity duringprocedures.

n Not engage in conduct that endangers a patient.

n Bring any patient care or safety concerns to theattention of my supervisor.

n Timely report any malfunction of medical equipment orany injury to a patient caused by any medical device.

Patient CareStandards

Anderson Healthcare iscommitted to providing highquality, safe, compassionateand cost effective health careservices. Patient care related

standards may be contained invarious policies of Anderson

Healthcare and are dictated bynumerous legal standards, such

as Medicare hospitalconditions of participation,

hospital licensingrequirements, The Joint

Commission Standards andmany others. Every employeeand coworker shall understand

and follow the laws,professional standards and

Anderson policies andprocedures related to patient

care and shall strive to provide exceptional patient

care at all times.

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Patient RightsHealth care services provided by

Anderson Healthcare are available toall patients and Anderson Healthcare

does not discriminate, exclude ortreat people differently because ofage, gender, gender orientation,

gender identity and/or expression,disability, race, color, creed, religion,national origin, citizenship, veteranstatus, military status, unfavorabledischarge from military, disability,genetic information and testing orother lawfully protected status. Wedo not discriminate against any

person or group as we care for andtreat our patients. We offer free aids

and services to individuals withdisabilities to communicate

effectively with us and provide freelanguage services to individualswhose primary language is not

English. We respect cultural heritageof every person. Each of our patientsis given a statement of patient rightswhich explain that each patient has,

among other rights, the right tomake informed decisions abouthealth care services, the right torefuse treatment and the right to

confidentiality of medicalinformation.

Charity Care andDiscounts

Financial assistance is available toour patients in the form of financialneeds discounts and charity care.

CODE OF CONDUCT

To demonstrate my commitment to this principle:I WILL… n Be familiar with and understand patient rights.

n Ensure that care provided to our patients is consistentwith and supports patient rights.

n Be sensitive and respectful of each patient’s culturalpreferences and needs.

I understand… n Financial assistance is provided in a manner that

addresses the patient’s individual situation and complieswith applicable eligibility criteria as defined in ourfinancial assistance policies.

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CODE OF CONDUCT

I will... n Avoid completing orders from a not-on-staff practitioner

until their licensure, OIG exclusions database andMedicaid participation status is verified, if this pertainsto my job duties.

n Avoid employing or contracting with any individual untilthe OIG, Medicaid and GSA exclusion databases arechecked, if this pertains to my job duties.

n Avoid contracting/working with a vendor until the Officeof Inspector General LEIE, GSA SAM excluded vendordatabases are checked, if this pertains to my job duties.

To demonstrate my commitment to this principle:I WILL… n Avoid participating in any agreements to fix prices, bid

rigging, collusion (including price sharing) withcompetitors.

n Avoid discussing prices with competitors, includingprices charged for the services offered by AndersonHealthcare and the prices paid by Anderson Healthcarefor goods and services.

n Avoid participating in boycotts, certain exclusivedealing and price discrimination agreements.

n Avoid participating in bribery, theft of trade secrets,deception, intimidation and similar unfair practices.

n Not provide past, current or expected price lists,financial terms of managed care contracts or similarinformation to competitors or accept such informationfrom a competitor of Anderson Healthcare.

n Not discuss with, provide to or accept from,competitor’s strategic plans, budgets, wages, marginsand other confidential information.

n Seek advice from Anderson Healthcare’s ComplianceOfficer when confronted with business decisionsinvolving a risk of violation of the antitrust laws.

Excluded andSanctioned IndividualsWe cannot accept orders from

unlicensed, excluded orsuspended (from taking care ofMedicare of Medicaid Patient)

physicians or allied healthpractitioner. State licensuremust be checked for anyphysician or allied health

practitioner new to AndersonHealthcare. Any new provider,

employee or vendor is alsoverified against state and theOIG Exclusions List to assure

we may work with thatindividual before therelationship begins.

AntitrustAntitrust laws are laws that wemust follow and are designed

to create a level playing field inthe marketplace (where

Anderson Healthcare doesbusiness), promote faircompetition and protect

consumers from unfair tradepractices.

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TaxAs a tax-exempt entity, AndersonHealthcare is required to act incompliance with applicable tax

exempt laws, to engage inactivities that support the

organization’s charitable purposesand to ensure that resources are

used to further the interests of theorganization, rather than the

private or personal interests of anyindividual.

PoliticsThe Anderson Healthcare

organization is not allowed to useour funds or resources to

contribute to or participate inpolitical campaigns, or to give

gifts or a payment to any politicalparty or political organizationunless consistent with state and

federal law.

CODE OF CONDUCT

I understand... n Payments for services must be consistent with fair

market value.

n All business of the organization shall be conducted in amanner designed solely to advance the interests ofAnderson Healthcare.

n Any travel and entertainment expenses must bereasonable, consistent with the organization’s policiesand appropriately incurred for the benefit of theorganization.

I understand... n I cannot contribute money, property, or services at

Anderson Healthcare’s expense to any politicalcandidate, party, organization, committee or individualin violation of any applicable law.

n As a private citizen I may participate and be involved inthe political process.

n I may be asked to make my own contact with membersof the government, such as writing letters to present ourposition specific to certain issues.

n When making these communications on the behalf ofAnderson Healthcare, approval and direction would beprovided by the Chief Executive Officer after he hasconsulted with Administrative Council.

n We as an organization may address issues affectingAnderson Healthcare and our senior leaders woulddevelop our position on legislative and regulatorymatters.

n If I am contacted by legislators, the press, regulators orother parties as a representative of AndersonHealthcare that relate to our position on pubic issues, Iwill refer them to our Communications Director.

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CODE OF CONDUCT

To demonstrate my commitment to this principle:I WILL… n Clock in and out in a way that shows my actual hours

worked.

n Provide financial reports, accounting records, expenseaccounts, expense reports and other documents thataccurately reflect facts and the true nature of thetransaction.

n Understand that improper or fraudulent accounting,documentation or financial reporting is not inaccordance with Anderson Healthcare policy and maybe in violation of applicable laws.

ReportingInformation Related

to FinancesFinancial reporting involveseveryone in the organization

and includes accuratereflection of time worked,

expense reports, departmentaland organization financereports and accounting

records.

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CODE OF CONDUCT

Compliance with Codeof Excellence and Code

of Conduct

I understand this means...This Code of Excellence and Code of Conduct providesgeneral guidance regarding appropriate conduct, behaviorand appearance. All actions taken by or on behalf ofAnderson Healthcare must be consistent with the Code ofExcellence and applicable laws. The legal requirementsoutlined are designed to provide guidance with respect tocompliance with applicable laws. However, it is important tounderstand that these descriptions do not fully address allapplicable legal requirements and that compliance with allapplicable laws is expected, even if those laws are notspecifically described in these Codes. Anderson Healthcarehas developed a set of compliance and other policies thatexpand on and more fully address many principles coveredin the Codes and it is important to be familiar with and followthose policies. For more specific information and guidance,please refer to the following documents:

Employee HandbookPatients’ Rights and ResponsibilitiesOrganizational and Departmental Policies and Procedures

If any questions arise with respect to compliance with theCode of Excellence, Code of Conduct or any law, suchquestions should be directed to the Compliance Officer.Failure to abide by the Code of Excellence and Code ofConduct may lead to a disciplinary action, ranging fromverbal warning to immediate termination. The Code ofExcellence and Code of Conduct do not provide anyadditional employment or contract rights to employees orother persons.

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CODE OF EXCELLENCE

There will be no retribution for asking questions or raisingconcerns about the Codes or for reporting possibleimproper conduct. Employees who report complianceconcerns in good faith will not suffer adverse employmentconsequences or be discriminated against as a result ofmaking a report. If you are unsure whether the Code ofExcellence and Code of Conduct has not been followed, youcan discuss the situation with your director and then decideif it should be reported. All reports will have a response – theresponse can include education, process changes orappropriate discipline. Reports and reporter’s identity arekept confidential and anonymity is maintained, if possible.

I will... n Avoid retaliation against any person who reports

unethical behavior or violation of the Code ofExcellence or Code of Conduct or laws in good faith.

n Understand there are several ways to report:

Anderson Hospital:Confidential voice mail Hotline: Ext. 5362 Intranet – Home page – Patient Safety and Compliance HotlineCommunity Hospital of Staunton:Hotline Number: 888-644-5762Website: www.MyComplianceReport.com

Discuss with my Supervisor, Manager, Director orAdministrative Director

Discuss with Administrative Director of HumanResources or Compliance Officer by e-mail,voicemail or in person

Code of Excellenceand Code of Conduct

ReportingWe have the responsibility toreport any activity that webelieve violates the Code of

Excellence or Code ofConduct. This includes

activities that involve unethicalbehavior, or violate our

policies or applicable laws. Aviolation of the Codes must bereported. No coworker may

discourage or prohibit anothercoworker from reporting a

violation or potential violationof these Codes or applicable

laws.

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Code of Excellence andCode of Conduct

AcknowledgementForm

This is to certify that I havereceived, read and understand theCode of Excellence and Code ofConduct. After reviewing the

Code of Excellence and Code ofConduct, I have asked my

director, manager or supervisor, Administrative Director ofHuman Resources or the

Compliance Officer to clarify anyareas in which I needed additionalguidance. I acknowledge that I amfully aware that compliance withthe Codes is a condition of my

employment.

CODE OF CONDUCT

I further pledge and acknowledge the following: 1. That it is my duty to know and understand the ethical

standards, legal standards and company policiesapplicable to performing my daily tasks.

2. I pledge to act in compliance with the Code ofExcellence and Code of Conduct and any compliancepolicies applicable to my responsibilities.

3. I pledge to be in full compliance with all applicablelaws, federal health care program requirements and withAnderson policies and procedures.

4. I will report any conduct that I believe constitutes aviolation of the Code of Excellence or Code of Conductas outlined in the Codes.

5. I will seek advice from my Director, Manager, Supervisor,Administrative Director of Human Resources, or theCompliance Officer concerning appropriate actions thatI may need to take in order to comply with the Code ofExcellence or the Code of Conduct.

6. I understand that failure to comply with the Code ofExcellence or Code of Conduct may subject me todisciplinary action.

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HEALTHCARE

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