Corporate Compliance Policy
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MORAVIAN MANOR
300 West Lemon Street
Lititz, PA 17543
MANUAL:
SECTION:
Corporate Compliance
Introduction
SUBJECT:
Corporate Compliance Policy
Approved by: Corporate Compliance Officer: ______________________________________
______________________________________________________________________________
DISTRIBUTION: Executive Office; Board of Trustees
POLICY:
Date of Origin: November 1998
Date of Last Edit: August 24, 2006
A. General Principles
1. It is the policy of Moravian Manors, Inc., (hereinafter referred to as “Facility”) to comply
with all applicable federal, state, and local laws and regulations, both civil and criminal.
2. No employee has any authority to act contrary to the provision of the law or to authorize,
direct, or condone violations offered by any other employee.
3. Any employee or agent of this Facility who has knowledge of facts concerning the
Facility’s activities that he or she believes might violate the law has an obligation,
promptly after learning such facts, to report the matter to his or her immediate superiors
or to the institution’s corporate compliance officer.
4. Moravian Manor’s Standards of Conduct are established as printed in “Our Guiding Light
to Corporate Compliance.”
5. This Facility will take steps to communicate effectively its standards and procedures to
all employees and agents by requiring participation in training programs and by
disseminating publications that explain in a practical manner what is required.
6. This Facility will take steps to achieve compliance with its standards by utilizing
monitoring and auditing systems reasonably designed to detect criminal or otherwise
inappropriate conduct by its employees and agents and by having in place and publicizing
a reporting system whereby employees and other agents can report criminal or otherwise
inappropriate conduct by others within the organization without fear of retribution.
7. This Compliance Policy will be consistently enforced through appropriate disciplinary
mechanisms, including, as appropriate, discipline of individuals responsible for the
failure to detect an offense and those individuals who actually committed or conducted an
offense. The form of discipline that will be appropriate will be case-specific.
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8. After an offense has been detected, the Facility will take all reasonable steps to respond
appropriately to the offense and to prevent further similar offenses – including any
necessary modifications to its program to prevent and detect violations of law.
B. Commitments
Facility is a tax-exempt organization that is organized for the promotion of the health of the
individuals who reside in this Facility’s service area. In order to further its tax-exempt
purposes, this Facility, its Board, officers, employees, and agents hereby express the
following commitments:
1. To the community, this Facility is committed to the promotion of health and to using the
Facility’s best efforts to satisfy the medical needs of the community while operating in a
fiscally responsible manner.
2. To the Facility’s employees, this Facility will implement and maintain employment
practices and programs that comply with all applicable Federal and state laws.
3. To the Facility’s residents, this Facility is committed to providing an appropriate quality
of care, consistent with available facilities and resources, which is responsive to patient
needs and complies with government laws and resources that govern the operation of a
tax-exempt facility.
4. To the Facility’s healthcare practitioners, this facility is committed to providing resident
care in a manner consistent with the highest standards of professionalism.
5. To third-party payers, both private and public, this Facility is committed to submitting
bills for inpatient and outpatient services in a timely and accurate fashion and reporting
all reimbursable costs to the Medicare and Medicaid program and to any other third party
in a legally appropriate manner.
6. To the Facility’s suppliers, this Facility stresses a sense of responsibility that enables it to
be a good customer. When this Facility determines that it is in its best interest to utilize a
competitive bidding process, this Facility is committed to a fair and equitable bidding
process. The Facility is committee to paying no more than fair market value for services
and supplies it obtains from other parties and to compliance with the Conflict of Interest
Policy which has been adopted by the Board of Trustees.
7. To all who do business with this Facility, the Facility shall conduct its business in a
manner that is consistent with the Facility’s tax-exempt status and all other applicable
laws and regulations.
C. Federal and State Tax-Exempt Status
1. This Facility is a not-for-profit entity that is exempt from federal taxation pursuant to
Section 501(c)(3) of the Internal Revenue Code. That tax-exempt status could be
jeopardized if any of the tax-exempt benefits enjoyed by this Facility inure to the benefit
of certain private individuals. All employees, consultants, and agents who contract with
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this Facility must do so in a manner that is consistent with this Facility’s federal taxexempt status.
2. This Facility is exempt from federal taxation, in part, because it advances a charitable
purpose, relieves the government of some of its burden, has an absence of private profit
motive, and provides benevolent care and community service. Violations by employees,
consultants, or agents of any law or regulation governing the Medicare and Medicaid
program, the anti-referral provisions of any state or federal law will not be tolerated. In
addition to the loss of federal tax exemption, violations of these laws might subject this
Facility and the employee involved to criminal prosecution and significant civil penalties.
Directors are to monitor whether employees in their departments receive adequate
education of how these laws and regulations affect the employee’s duties and make each
employee aware of this policy and his or her duty to report any suspected violations.
3. Political contributions and activities might also jeopardize this Facility’s federal taxexempt status. No funds or assets, including the work time of any employee, will be
contributed, loaned, or made available directly or indirectly to any political party or to the
campaign of any candidate for federal, state, or local office. Any involvement and
participation in a political campaign by employees must be on an individual basis, on
their own time, and at their own expense. Further, when an employee speaks on public
issues, it must be made clear that comments or statements made are those of the
individual and not of this Facility.
4. This Facility is also exempt from certain state and local taxes, including but not limited to
state income tax, state sales tax, and local real estate taxes. All employees must make a
good faith effort not to jeopardize the Facility’s exemption from state and local taxation.
D. Compliance Officer
1. A Corporate Compliance Officer is designated by the President/CEO. Each employee
has a duty to report any suspected violations of any of these Standards to the Compliance
Officer. When the Compliance Officer is made aware of a potential violation of these
Standards, the Compliance Officer will contact this Facility’s President/CEO and, when
necessary, the Compliance Officer is authorized to secure the opinions of outside legal
counsel, outside consultants, and other experts in compliance issues. Any investigation
of a suspected violation of these standards shall be done by the Compliance Officer under
the direction of the Facility’s outside legal counsel in a manner which protects the
confidentiality of the reporter of any such violation to the greatest extent possible.
2. The Compliance Officer shall also review and, when the Compliance Officer determines
that it is reasonable to do so, disseminate to appropriate parties the monthly program
exclusion listing by the Inspector General’s Office and of the Department of Health and
Human Services that are published in the Federal Register from time to time. The
Director of Administrative Services will also regularly review and disseminate the new
statutes, regulations, pronouncements, or directives of the federal or state government,
the government’s fiscal intermediary, any third-party payers, or any trade association or
trade publication that might affect these Standards.
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3. The Compliance Officer shall also monitor this Facility’s continued compliance with the
terms and conditions set forth in any settlement agreement that might be executed by this
Facility with the federal or state government.
E. Duty to report violations of these standards
It is the duty of each employee to report promptly any suspected violation of these Standards
to the Compliance Officer. The Compliance Officer’s office is located at Moravian Manor,
300 West Lemon Street, Lititz, PA 17543. The Compliance Officer’s telephone number is
(717) 626-0214, Extension 6125. Alternatively, suspected violations of these Standards may
be reported to the President/CEO or the Moravian Manor Corporate Compliance Hotline
(625-6004). Retaliation by any supervisor against an employee, professional staff member,
or contractor for reporting compliance issues will not be permitted.
F. Conclusion
These do not constitute an express or implied employment contract but rather are intended to
communicate certain current policies. The Board or management of this Facility reserves the
right to change, modify, or waive all provisions herein. If any employee has a question
concerning a particular provision contained herein, or concerning any practice not addressed
in this document, he or she should confer with the Compliance Officer or the President/CEO.
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