Doing the right thing together.

Code of Conduct

Corporate Compliance

Genesis Health System exists to provide compassionate, quality health services to all those in need.

ContentsIntroduction ...................................................................................2Genesis Health System Values ......................................................3Confidential Business Information ................................................3Conduct in Genesis Facilities or While Acting on Behalf of Genesis ..........................................................4Conflicts of Interest .......................................................................4Gifts and Entertainment ................................................................5Books and Records ........................................................................6Coding and Billing Compliance/Fraud and Abuse .......................7Anti-Kickback/Self-Referral Laws ..................................................9Antitrust Laws and Fair Competition. ...........................................9Environmental/Occupational Safety and Health ...........................10Intellectual Property ......................................................................10Nonprofit/Tax-Exempt Status. ......................................................11Government Contracting ..............................................................11Research Activities. .......................................................................12Government Investigations ...........................................................12Reporting Code of Conduct Violations. ........................................13Conclusion .....................................................................................14

INTRODUCTION This Code of Conduct (“Code”) describes the commitment of Genesis Health System (“Genesis”) to the highest ethical standards of honesty and integrity. This Code applies to all Genesis employees, Board members, volunteers, hospital-based physicians and contractors who provide patient care or who perform billing or coding services on behalf of Genesis. This Code applies to the conduct of physicians (referred to as the “Medical Staff”) and allied health practitioners when practicing in a Genesis hospital or Genesis affiliate or when conducting business on behalf of Genesis. This Code is not intended to govern the private practice of physicians and allied health practitioners.

The Code is the foundation of the Genesis Corporate Compliance Program and is supplemented by other policies including some referenced in this Code. If you have concerns about business ethics, compliance with the Code of Conduct, the Compliance Program, applicable laws and regulations, or Genesis policies and procedures, it is your duty to report your concerns to your manager, the Chief Compliance & Enterprise Risk Officer (“Chief Compliance Officer”) or the Compliance Hotline.

It is also very important that you report any suspected or actual violations of this Code. No concern is too small or unimportant to bring to the attention of your manager. If you are not comfortable reporting concerns to your manager, you can contact the confidential Compliance Hotline (866-956-3270). Failure to comply with the Code of Conduct will result in corrective action for noncompliance, including but not limited to, educational counseling, employment suspension, and/or termination.

When you receive the Code you will be required to state in writing that you have received, read, understand and will abide by the Code.

While this Code is not a contract for employment, it is a way for you to acknowledge that you know, understand, and will follow the rules based on Genesis policies and procedures, Federal, State and Local laws and the Code.

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GENESIS HEALTH SYSTEM VALUES Our Mission: Genesis Health System exists to provide compassionate, quality health services to all those in need.

Our Vision: Genesis Health System will be the health care provider of choice in our Iowa-Illinois region. We strive to advance health status by offering a full spectrum of high quality health services and technology.

Our Values: Genesis Health System realizes and is committed to the mission and vision through:

Safety - We practice safety behaviors and error prevention techniques to ensure the safety of our patients, visitors and co- workers.

Integrity - We are honest, open in our communications, and consistent in doing what we say we will do.

Compassion - We provide a caring response to the physical, emotional and spiritual needs of all.

Accountability - We accept individual and collective responsibility for everything we do.

Respect - We recognize the dignity and worth of the individual, acknowledging the diversity of needs, experiences and talents of each person.

Excellence - We strive to achieve the best in everything we do.

CONFIDENTIAL BUSINESS INFORMATIONHealth care is very competitive. It is critical that you do not disclose confidential Genesis business information to unauthorized persons.

In the course of your duties, you may learn trade secrets, proprietary information, commercially sensitive information and financial information about Genesis.

Never share confidential business information with friends, family members, Genesis competitors, suppliers, contractors, or anyone else who does not have a need to know the information. If you are not sure if you should share information related to Genesis, either within or outside the organization, ask your manager.

Examples of confidential business information include:

• Genesis earnings estimates

• Expansion or reduction of Genesis’ operations

• Increase or decrease in Genesis’ business

• Client or vendor lists

• Merger or acquisition proposals involving Genesis

• Pricing and costs

• Borrowings by Genesis Health System

• Reimbursement rates or methods

• Lawsuits involving Genesis

• Internal audit reviews and summaries

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CONDUCT IN GENESIS OR WHILE ACTING ON BEHALF OF GENESISGenesis is committed to complying with federal and state laws that prohibit substance abuse, discrimination and harassment in the workplace.• To provide an efficient and productive

work environment to perform your duties safely, competently, efficiently and in a way that protects Genesis patients and the interests of Genesis and its employees.

• You are expected to conduct yourself in a way that reflects personal honesty and integrity, reflects positively on Genesis, and meets Genesis’ obligation to provide quality care to patients.

• If you are an employee, you must comply with all applicable federal and state employment laws, including those relating to discrimination based on age, race, religion, gender, sexual orientation or disability, and those relating to compensation and overtime pay.

• It is a violation of law and Genesis policy to use illegal drugs or alcohol while you are on duty. If you use illegal drugs or alcohol while on duty you may be penalized up to and including termination of employment with Genesis, your contract, or Medical Staff privileges in accordance with Medical Staff Bylaws and Medical Staff Rules and Regulations.

• Sexual harassment is not permitted including sexual advances, request for sexual favors, or any sexually offensive verbal, visual or physical conduct.

Employees should refer to the Genesis Employee Handbook and Genesis Values for more information about what is considered acceptable and unacceptable behavior.

CONFLICTS OF INTERESTYou must not engage in any activity that conflicts with Genesis’ interests.

For Example:• If you deal with contractors, suppliers,

vendors or competitors you must not take advantage of your position at Genesis for any sort of personal gain.

• If you have an interest in a company (for example, a company owned by your family), you may not do business with that company on behalf of Genesis unless you first receive approval from the Chief Compliance Officer and the Vice President of Finance/CFO.

• You may not do business with a relative on behalf of Genesis unless you have first notified and received approval from the Chief Compliance Officer and the Vice President of Finance/CFO.

• See Conflicts of Interest policy for more information.

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GIFTS AND ENTERTAINMENTAcceptance of gifts or entertainment from persons or companies that do, or want to do, business with Genesis can often cause an actual or perceived Conflict of Interest. Conflicts or the appearance of a conflict can be very damaging to our reputation and the trust among Genesis, its customers and the community.

For Example:• Do not accept any gift that is cash or

cash-like (such as gift certificates). Any person or group that would like to make a gift that is cash or cash-like should be referred to the Genesis Foundation.

• If you are a Genesis employee, do not accept gifts or favors from Genesis’ patients. With prior approval of your manager, you may accept:

• A small gift of minimal value (for example, a hat, t-shirt, coffee mug or vendor promotional item) as long as it will not influence how you do your job.

• Reasonable business entertainment (for example, a dinner for the purpose of discussing Genesis business with someone who does business with Genesis).

• Items that are given by a vendor or a patient as long as these items are infrequent, of minimal value, consumed or enjoyed by staff at work, and will not cause any real or perceived Conflict of Interest (for example, food during the holiday season or provided by a vendor during a training session, flowers, or pizza provided by a patient’s family).

EMPLOYMENT OF RELATIVESRelatives may not work in a direct reporting relationship, except in rare cases whereit is deemed to be in the best interest of Genesis. (See Employment of Relatives policy)

OUTSIDE EMPLOYMENT AND OTHER ACTIVITIES• Employees must not engage in activities

during scheduled working hours that are not related to Genesis business.

• Employees, contractors, and members of the Medical Staff must not use Genesis equipment, supplies or information, including but not limited to client lists, financial reports, business or strategic plans, vendor lists, fee schedules or reimbursement rates, or marketing information, in connection with any non- Genesis activities.

• Employees can work at another job (self- employment or employment by others) outside of their work for Genesis as long as it does not adversely affect their job performance or create a Conflict of Interest. (See Conflict of Interest policy).

• Genesis employees who are independent contractors or have an employment relationship with a Vendor cannot operate in the capacity as an employee/ agent of that vendor at any Genesis facility.

• Board Members, Executive Management, Department Directors/Management or employees with purchasing authority must disclose to the Chairman of the Board if they become a director or officer of (or accept a position of responsibility), with any other company that may cause a Conflict of Interest.

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EXCLUSION FROM MEDICARE OR MEDICAID PROGRAMSGenesis may not conduct business with or employ any individual or organization that has been excluded from participation in the Medicare or Medicaid programs. (See Background Screening/Excluded Individuals policy)

• Genesis will routinely monitor government-sponsored websites that list individuals and organizations that have been designated as “excluded providers.”

• All employees have an obligation to immediately report when they become aware they have been excluded from any government programs.

BOOKS AND RECORDSMAINTAIN ACCURATE RECORDS• Books and records include but are

not limited to patient charts, medical records, clinical logs, clinical reports, financial reports, accounting records, research reports, expense reports, time sheets and any other documents that might reflect Genesis’ business.

• Record all entries in Genesis’ books and records accurately and in a timely manner.

• Any late entries that are recorded should be noted as such and include the date and time the entry is made. Any late entries must be recorded in such a way as not to mislead potential readers regarding when and how the entry was made.

• Do not engage in any “off the books” transactions that are not accurately reflected in Genesis’ books and records.

• See Document Management Retention and Destruction policy for more information.

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CODING AND BILLING COMPLIANCE/FRAUD AND ABUSEGenesis is committed to following all federal, state and third-party payor requirements that govern billing, coding, documenting and submitting claims for payment and cost reports. These laws are intended to prevent health care fraud and false claims.

Coders must be licensed or credentialed. Coding must be accurate, properly reflect the services provided, and consistent with applicable coding rules and standards.

Cost reports must be accurate and properly reflect the statistics, charges and costs for services provided. All bills, claims and requests for reimbursement, and all documentation supporting those claims or requests must be complete and accurate and must reflect reasonable and necessary services ordered by an appropriately licensed medical professional.

It is a violation of the federal Civil False Claims Act to knowingly submit, or cause to be submitted, false or fraudulent claims to the government.

The following are examples of illegal activities:• Billing for supplies or services not

delivered or billing more than once for the same service.

• Misrepresenting services provided.

• Falsely certifying that services were medically necessary.

• Collecting or attempting to collect amounts that exceed the co-payment and deductible from a Medicare or Medicaid beneficiary who has assigned benefits.

• Asking for, offering or receiving a kickback, bribe, or rebate or any other form of payment, in exchange for patient referrals.

• Offering valuable items or services to Medicare or Medicaid beneficiaries to attract their business.

• Providing financial incentives to limit services to Medicare patients.

If you discover inaccurate coding or an inaccurate claim, immediately notify management or the Chief Compliance Officer, even if the bill or claim has already been submitted for reimbursement.

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RELATIONSHIP WITH PATIENTS PATIENT RIGHTS: Patients must receive quality care that is delivered in a considerate, respectful and cost- effective manner. Patients have the right to:• Have or make advance directives.

• Know the names and roles of all physicians, nurses and other hospital staff members caring for them.

• Have an opportunity to talk with their physician and other direct caregivers about their diagnosis, treatment, and the prognosis of their illness or injury and any follow-up care they may require.

• Consent or decline to take part in proposed research studies or human experimentation affecting care and treatment.

• Privacy and confidentiality about their care, diagnosis and medical records.

• Receive upon request an explanation of billed services and available payment methods.

• Impartial access to all health care services without regard to race, color, creed, national origin, sex, lifestyle, social status, age, disability, ability to pay, source of payment, or existence of an advance directive.

• See Genesis Patient Rights and Responsibilities/Non-Discrimination policy for more information.

EMERGENCY MEDICAL TREATMENT AND LABOR ACT (EMTALA)• Any individual who comes to a Genesis

dedicated emergency department or who is on Genesis property and who requests examination or treatment (or needs examination or treatment based on observation of the individual’s appearance or behavior) shall be given an appropriate medical screening examination and stabilizing treatment.

• If the person is found to have an emergency medical condition, Genesis will provide either necessary stabilizing treatment or an appropriate transfer to another medical facility where stabilization can occur.

• See EMTALA policy for more information.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA)• HIPAA protects the right to privacy and

confidentiality of a patient’s diagnosis and medical information as well as billing and payment information.

• Do not use or disclose patient-specific information unless it is permitted or required by law, or unless the patient has authorized such disclosure. Do not access any patient information other than that necessary to perform your duties.

• You must adhere to the HIPAA rules at all times. If you have any questions about how you may access, use, or disclose patient information you should contact the Genesis Privacy Officer at 563-421- 7262.

• See Permitted Uses and Disclosures of PHI for Treatment, Payment and Health Care Operations policy for more information.

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ANTI KICKBACK/SELF REFERRAL LAWSPHYSICIAN RELATIONSHIPS Do not enter into financial relationships with physicians on behalf of Genesis that could violate state or federal laws such as the Anti-Kickback Statue or the physician self-referral law (the Stark Law).

For example, it is a violation of federal law and Genesis policy to:• Provide free or significantly discounted

billing, nursing or other staff services.

• Pay more than fair market value for goods or services.

• Provide or agree to provide any direct or indirect compensation to a physician or a physician’s immediate family member in exchange for patient referrals.

If you have any questions about the laws listed in this section or any other rules affecting financial relationships with physicians, contact the Vice President of Legal Affairs.

ANTITRUST LAWS AND FAIR COMPETITIONAntitrust laws are designed to promote fair competition in the marketplace. At Genesis, we believe that a healthy competitive marketplace is good for patients and employees. Antitrust laws are designed to encourage fair trade and competition in the marketplace. We will not behave in a way that is anti-competitive or violates these laws. Consult with the Vice President of Legal Affairs when considering business decisions that could raise antitrust issues.

Examples of conduct prohibited by these laws include:• Sharing strategic, marketing information

or pricing of Genesis services with a competing health care system or provider.

• Agreeing with other providers not to do business with a payor or supplier.

• Disclosing terms of supplier contracts to a competing health care system or provider.

ENVIRONMENTAL/ OCCUPATIONAL SAFETY AND HEALTHGenesis is committed to responsible, safe disposal of waste products.

• Follow all applicable laws, regulations and Genesis policies to help Genesis maintain a workplace free from health and safety hazards.

• If you are involved in or see an accident that 1) injures (or may have injured) a patient, employee or visitor, or 2) damages property, you must report it to management immediately and complete an unusual occurrence form.

• If you have a question or suspect a violation of an environmental or occupational safety and health law, immediately report the situation to the Chief Compliance Officer.

INTELLECTUAL PROPERTYGenesis licenses the use of computer software from a variety of outside vendors. Unauthorized copying of software programs can expose you and Genesis to litigation and result in damage claims from software vendors.

• You may only use material copyrighted by Genesis, or Genesis trademarks, patents and other “intellectual property” for authorized Genesis business.

• You may not use Genesis computers, internet access or other software or equipment to download music, software, movies or anything else that might violate copyright or trademark laws.

• When you use copyrighted materials, trademarks or other protected intellectual property rights, make sure that you are doing so legally.

• If you have a question about intellectual property laws, please refer the question to the Vice President of Legal Affairs.

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NONPROFIT/TAX-EXEMPT STATUSGenesis is a nonprofit organization and exempt from state and federal taxes as a charitable institution. As a nonprofit entity:

• The resources of Genesis will be used only in furtherance of charitable purposes and in a manner that furthers the public good rather than the private or personal interests of any individual.

• All Genesis business transactions must be in the best interest of Genesis and negotiated independently for “fair market value”.

• Genesis may not participate directly or indirectly in political activities and Genesis employees may not use work time to campaign on behalf of or in opposition to a candidate.

GOVERNMENT CONTRACTINGGenesis will obey all laws and regulations concerning the bidding, pricing, negotiation and performance of government contracts.

• All information submitted to the government on behalf of Genesis must be truthful, complete and accurate.

• Any statements or claims to the government on behalf of Genesis that you know not to be true violates the law and Genesis policy. This is true whether the statement or claim was verbal or written, including bids, proposals, and requests for payment or reimbursement.

• You must strictly obey the terms contained in any government contract, including price terms.

Examples of information you and Genesis are not authorized to have include:• Confidential governmental information

concerning bidding, the selection process for a particular contract or a competitor’s bid on a particular contract.

• If you suspect that there has been an improper payment to Genesis in connection with a government contract, promptly report it to management who will report it to the Chief Compliance Officer.

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RESEARCH ACTIVITIESEmployees, contractors and the Medical Staff engaged in research activities must comply with federal, state laws, regulations and guidelines.

• Genesis engages in a variety of biomedical and clinical research activities, some of which are funded by the federal government.

• Genesis employees and researchers participating in research activities at any Genesis facility must comply with all applicable policies of the Genesis Research Department and the policies, procedures and directives of the Genesis Institutional Review Board.

GOVERNMENT INVESTIGATIONSIt is Genesis’ policy to cooperate with reasonable requests from any governmental agency concerning operations. The fact that a law enforcement agent requests information from the organization, an employee or physician does not mean that a law has been broken. If an attorney or a representative of any government agency contacts you as part of an investigation of Genesis:

• Immediately contact the Genesis Chief Compliance Officer at 563-421- 8325 during business hours or the Administrator-On-Call during evening and weekend hours.

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REPORTING CODE OF CONDUCT VIOLATIONSIf you think a Genesis business practice or relationship is or could be illegal or improper, or the practice affects the safety of services and quality of patient care, it is your responsibility to report this information. Start with your supervisor; he or she will be able to find the policies and procedures in place to guide your conduct.

If you are not comfortable talking with your supervisor about a potentially illegal or improper business practice, contact the Chief Compliance Officer or any member of the Compliance Department at 563-421-8326 or email Compliance@genesishealth.com.• You may also call the confidential

Corporate Compliance Hotline at 866-956-3270. Your call will remain anonymous. All reports to the hotline must contain enough information for the Chief Compliance Officer to investigate the concerns raised.

If you are not comfortable talking with your supervisor about a practice or process that is or could affect the safety of patient services or the quality of patient care:

• You may call the Safety Hotline at 563-421-SAFE (7233) to report potential hazards or dangerous situations that could result in patient harm.

• Your call is confidential and may be anonymous.

Genesis policies prohibit any retaliation or retribution against an individual who reports a potential or suspected violation in good faith. Reporting “in good faith” means individuals will report instances when they believe there has been a violation or when there is the potential or likelihood that a violation will occur. It also means that individuals will not make frivolous or false reports, nor will they use the various compliance reporting mechanisms for retaliation against another individual or Genesis.

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CONCLUSIONThis Code explains how Genesis expects you to conduct yourself on the job, while working at any Genesis facility, or on behalf of Genesis. However, the Code cannot address every ethics or compliance situation that you may face. When you need further guidance and cannot find it in this Code, ask someone in management or the Chief Compliance Officer. You should also talk to management or the Chief Compliance Officer if you ever feel that you are being pressured to act inappropriately, whether by an employee, a physician, a supplier, a competitor, or a patient. If management does not resolve your concerns satisfactorily, contact the Chief Compliance Officer directly. In addition, if you have any questions about a law or the legality of a particular action, you should contact the Chief Compliance Officer.

You must bring up any concern, no matter how small if you think the concern raises issues under this Code. You will not be penalized in any way for reporting concerns in good faith.

Compliance Hotline866-956-3270

Safety Hotline563-421-SAFE (7233)

Genesis Health System will not exclude, deny benefits, or otherwise discriminate against any person on the grounds of race, color, creed, national origin, sex, life-

style, social status, age, disability, ability to pay, source of payment, or existence of an advance directive in admission to, participation in, or receipt

of the services and benefits of any of its programs and activities.

Interpreter services, auxiliary aids and communication tools are available in our patient care areas at no cost to patients and families with limited English skills

or hearing and sensory impairments.

Compliance Hotline 866-956-3270

Safety Hotline 563-421-SAFE (7233)

GHS Audit and Compliance Committee members can be reached at GHSBoardofDirectors@genesishealth.com Gregory J. BushRoger J. HillDavid C. LarsonWilliam R. StormWilliam M. Tank, Jr.G. Chris WahligC. Dana Waterman III

Revised April 2020 | Last Reviewed January 2019