VOLUNTEER OR IENTATION & RE-ORIENTATION

2016

My signature on this form acknowledges that I have received, understand & agree to adhere to all policies and procedures outlined within, including HIPAA and the Mount Sinai Code of

Conduct.

__________________________________________ ________________

Name Date

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WELCOME

We welcome you as a volunteer at Mount Sinai Medical Center. You are now part of our proud tradition. Throughout the years volunteers have donated thousands of hours to Mount Sinai Medical Center. They befriend the lonely, the bereaved, and comforted the helpless. They have done clerical work, manned desks, served coffee and snacks to patients and pushed wheelchairs and book carts. Now, you have made the same time-honored commitment to helping others. The board of trustees and the administration of Mount Sinai Medical Center wish to thank you for your consideration. We feel certain that in return you will find fulfillment and new friends as you join hands with other loyal members of our Mount Sinai volunteers.

THE BENEFITS OF BECOMING A VOLUNTEER

We are pleased that you have chosen to become a volunteer at Mount Sinai Medical Center. Volunteers have been a traditional part of Mount Sinai’s history since its early years. These volunteers have chosen to devote their time and expertise to helping patients and assisting staff members. As a volunteer, you are a member of the Mount Sinai family, and entitled to the following benefits.

o Vouchered meals for volunteers who work a minimum of 4 hours aday

o Free parkingo Free seasonal and H1N1 fluvaccinationso Free annual tuberculosis testingo Pharmacy discounto Training and on-going in-serviceo Recognition and awards for services renderedo Credit Union membership

Aside from these benefits, when you or a member of your family is a patient or in need of medical services,notify the Volunteer Services Office so that we may keep in touch or be of assistance to you. However, the most important benefit is intangible. It is the personal satisfaction volunteers receive from their work withpatients, families and staff and the warm bond of friendship that is formed among the volunteers andpersonnel.

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GENERAL INFORMATION

More than seventy areas of the medical center receive supplementary assistance from the volunteers. The goal of both the staff and the volunteers is to provide the patient with quality care and comfort. Our volunteers range in age from 14-year-old teenagers to 90+ year-old retired men and women who bring to their assignments experience, skills and their desire to help others. The manager of Volunteer Services tries to match the volunteer to the job so that the greatest degree of mutual satisfaction is achieved.

Mount Sinai’s Board of Trustees and the Administration express their appreciation of your service through an annual awards ceremony. In order to document the hours you work and receive full credit for them, it is your responsibility to sign in.

PLEASE REMEMBER:

TO TURN OFF YOUR CELL PHONE OR PUT ON SILENT. DO NOT USE CELL PHONES WHILE IN PUBLIC AREAS . USE OF EARPHONES IS NOT PERMITTED WHILE ON DUTY.

As a volunteer, you must agree to the following:

Assignment: Devote at least four hours one day a week for a minimum of 75 hours.

Verification of hours, including letter of recommendation, is given for75 hours and above ONLY.

Identification Badge: You must bring a photo ID to secure an identification badge.

Background Check: All volunteers must agree to a criminal background check.

Orientation & Re-Orientation: As a new volunteer of Mount Sinai Medical Center, you are requiredto read and sign an orientation package designed to acquaint you with our medical center, policies,benefits and safety regulations. Orientation will also be reviewed during your interview.

You will be given a re-orientation package annually to keep you up to date regarding any newprocedures, policies, regulations and changes in the medical center. These changes will also beposted in the volunteer office.

Tuberculosis Test: For the protection of our patients, staff and volunteers, it is a requirement that all

volunteers receive an annual tuberculosis test. If you haven’t had a tuberculosis test within the pastsix months, you will be required to take the test.

Permission: Volunteers between the ages of 14 and 17 must submit parental permission.

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Communications: Problems concerning your assignment, vacations or absences or situations which youobserve that may involve staff are to be reported to the manager of Volunteer Services.

Sign-in-Procedure: It is mandatory that you sign in upon arrival and sign out before leaving so that yourpresence may be verified as well as documented at any time during your tour of duty. There will be noletters for school without this documentation.

Violation of the guidelines of any specific service is grounds for transfer from the area. It is also theprerogative of the Manager of Volunteer Services to transfer a volunteer no longer able to carry outthe prescribed duties of a specific area. Weekend and evening volunteers, please keep theVolunteer Office up to date with your hours. Make sure your sign-in sheets are submitted to thevolunteer office by the end of each month.

Parking: Volunteers will be assigned parking in the employee parking lots.

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GUIDELINES FOR VOLUNTEERS

Confidentiality: Certain relationships are, by law, confidential, and information about them may not be disclosed. Among these are the patient and doctor/medical facility. It is not just immoral and unethical to disclose information concerning patients, but it is also illegal. Any breach of a patient's inviolate right to privacy is cause for dismissal.

The medical center keeps confidential information on patients, employees and volunteers. This includes names, addresses, insurance, wages and salaries, employment history, diagnoses and other tests.

Access to this information is on a “need to know” basis/ Anyone who has access to confidential information of any nature is expected to maintain the confidentiality of that information.

PLEASE NOTE THE LIST OF “PUBLICITY CODES” BELOW AND THEIR MEANING. THESE CODES WILL APPEAR NEXT TO THE PATIENT’S NAME ON THE PATIENT CENSUS AS WELL AS OTHER REPORTS YOU MAY ENCOUNTER.

@ FAMILY ONLY INFECTIOUS DISEASES ^ NO CALLS/NO VISITORS + NO FLOWERS % NO CLERGY & NO PHONE CALLS $ NO VISITORS ! RELEASE NO INFORMATION (if asked about a patient with this publicity code, simply

say that we have “no information” regarding a patient with that name.)

Tips & Gifts: Soliciting tips or gifts for services to patients/visitors is not permitted. Volunteers may not solicit patients or visitors for any cause, private employment arrangements or distribute any literature to them on behalf of any cause or organization at any time. Tips and gifts offered by patients/visitors to volunteers should be courteously declined. a patient or visitor wants to contribute merchandise or monies to Mount Sinai, direct him/her to the Foundation.

Dress Code: When reporting for duty you are expected to be clean, neat with well groomed hair and nails. Excessive use of perfume, cosmetics and jewelry is to be avoided. Clothing is to be clean, odor-free, wrinkle free and professional.

Uniform: PROFESSIONAL ATTIRE - NO JEANS, SHORTS, SHORT SKIRTS OR OPEN-TOE SHOES

I.D. Badge: Identification badges must be worn visible and at shoulder height at all times. Emblem: Sewn on left sleeve of uniform. Women: Pink volunteer uniform must be worn over white top and white slacks or skirt. Men: White volunteer uniform worn with dark colored pants. Teens: Girls – red pinafore over white top and long white pants or skirt (below knee).

Boys – red vest over white top (tucked in) and dark pants. Cologne & Please avoid highly scented perfume or cologne. Jewelry: Minimal amount of jewelry -follow the rule: two is too many.

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Leave of Absence: Volunteers who are absent for a period of more than six weeks are subject to reassignment by the manager of Volunteer Services.

No Solicitation: Solicitation is prohibited by the rules of the medical center without prior written approval of medical center administration.

Don’t: 1. give a patient anything to eat or drink unless authorized by a nurse or physician;2. discuss anything about a patient with anyone;3. push a patient in a gurney or a patient with an I.V. drip;4. assist a patient in or out of a bed, wheelchair or automobile.5. accept tips or gifts for services.

Media Policy: All stories for the media must be submitted to and coordinated by the Public Relations Department of the medical center. No volunteer or member of a volunteer's family should independently arrange for media coverage. Suggestions for feature stories or other items must be submitted to the Volunteer Services Department for approval. Once accepted, the concept or setting of appointments will be handled by the Public Relations Department.

Auxiliary Membership: Volunteers are encouraged to become members of the Mount Sinai Medical Center Auxiliary. For more information, volunteers may contact the Auxiliary president or a member of the Auxiliary Board.

Performance Improvement: Our mission is to provide quality service to our patients. If you see something that you think needs improvement, you should notify your manager or department head or call the Performance Improvement Department at extension 5-7951.

Infection Control:

Wash your hands before and after contact with patients. Clean clothes and good personal hygiene are important in controlling infection. Observe written precautions posted in Isolation rooms, using gloves and/or mask if necessary. Do not come to work if you have been exposed to any communicable disease as colds or flu.

WHEELCHAIR SAFETY TIPS

Before using a wheelchair, check to make sure it is completely operational. If not, return the wheelchair to the volunteer office and notify staff.

Whenever a person is getting in or out of a wheelchair, LOCK BOTH WHEELS and FOLD FOOTREST UP.

NEVER LEAVE A PERSON IN A WHEELCHAIR UNATTENDED, not even for a moment.

If you must turn your attention away from your patient, place your hand on their shoulder while you look away.

Entering or leaving elevators, going over any threshold, or going down a ramp – go backwards.

Volunteers may push a patient in a wheelchair, however only an employee may assist them in and out of the wheelchair.

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NO SMOKING

Mount Sinai Medical Center is a smoke-free environment. Smoking is not allowed in any interior area of any building on any campus or any exterior location, such as parking lots or walkways.

SAFETY AND SECURITY

We want Mount Sinai Medical Center to be a safe place for volunteers, employees, patients and visitors.

Watch for untidy, unsafe or unsanitary conditions or activities anywhere in the hospital andnotify the department head in charge of the area.

Remind patients/visitors of the no smoking rules. Walk, do not run. Do not play tricks or engage in "horseplay." Use correct body mechanics for lifting. Use all safety equipment provided for your job. Observe Mount Sinai's 10 mile per hour speed limit, all traffic signs and lights. Use crosswalks when crossing streets. In case of an emergency, dial 123 (no other numbers are necessary).

Vehicle Parking Permits

The Security Department will issue you a vehicle parking permit to be hung on your rearview mirror. This permit will enable Security Officers to notify volunteers of flat tires, head lights left on or vehicles sustaining damage.

Help Security Officers by reporting:

Unknown persons in non-public areas without I.D. badges. Unauthorized persons in any area. Suspicious persons or activities. Loss of personal, hospital or patient property. Vandalism. Dangerous conditions.

Our Security Officers will help by:

Patrolling and maintaining security. Investigating incidents or losses. Controlling traffic and enforcing traffic regulations. Assisting with control of disturbances. Assisting or helping you call for assistance if your car won't start. Escorting you to your car if you work an evening or night shift.

If an emergency situation occurs and you need immediate assistance from Security, call ext. 52305, briefly state the situation and give your location. Help will be dispatched promptly. If possible, stay on the line and give further information.

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On-duty Accident Reports:

If an accident occurs while on duty, report the accident to your immediate supervisor and to the manager of Volunteer Services. An Injury Report Form will be filled out and you will be sent to the Emergency Department for treatment, if necessary.

A security officer may respond to your supervisor's call when an accident occurs.

Fire Alarms:

The fire alarm will only sound/strobe on the floor of activation, the floor above and the floor below within the same building. So, if the alarm is activated on 2 Main, you will hear the alarm and see the strobes on 1 Main and 3 Main; however, keep in mind you will NOT hear/see the alarm on 2 Greenspan or 2 Blum. If there is smoke or fire on 2 Main, the alarm will activate on 1, 2 & 3, to begin with, but IF the smoke/fire travels through the hall to another building additional smoke and heat detectors will activate causing the alarm to also “spread”/

When the alarm is activated in the buildings listed below, the following automatic message will play. “Attention please, there has been an emergency alarm activated in this area, remain calm and stand by for instructions from staff/”

De Hirsch Meyer Warner Blum Greene Greenspan Radiology Emergency Department Gumenick/Ambulatory Cardiac Research Center

All other buildings (listed below) will hear the following automated message. “BEEP, BEEP, BEEP0May I have your attention please? May I have your attention please? There has been a fire emergency reported in the building, please evacuate the building by the nearest exit. Do not use the elevators. BEEP, BEEP, BEEP/” Once the alarm has been cleared, you will hear the following automatic message three times. “CODE RED-ALL CLEAR/”

Simon Medical Office Building Ascher Lowenstein MRI/Wien Center Energy Building Pearlman Research Facility Childcare Center Security Administration

When you hear an alarm in your area, activate R.A.C.E. (see below); prepare to assist for a vertical evacuation. Use fire extinguishers only for small, controllable fires - see instructions below (P.A.S.S).

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Stay in your own area and do not use telephones for routine calls. Assist as needed anddirected by supervisor within the area with any fire preparation (closing doors, preparing forevacuation, etc).

DO NOT USE ELEVATORS.

It is very important for volunteers to know and understand RACE and PASS as inspectors/regulators may ask you what you would do in case of a fire. Your response would be “We practice RACE and if we must use an extinguisher, we use the acronym PASS/”

R-A-C-ER - Rescue

A - Alarm

C - Confine

E – Extinguish

- help staff remove patients. - activate alarm - report fire.

- close doors to isolate smoke.

- assist in putting out fire when appropriate.

P – A – S – S P - PULL: A - AIM: S - SQUEEZE: S - SWEEP:

Aim at the base of the fire Aim at thebase of the fire Squeeze the handle Sweep side to side.

Fire prevention and prompt action in case of fire are important.

Know the location of alarm boxes and fire extinguishers in your area.

Know where the exits and stairs are located.

PLEASE REMEMBER WHEN YOU HAVE COMPLETED YOUR ASSIGNMENT(And will not be returning) TO:

Notify the volunteer office. Return your ID badge and parking permit to the Security Office.• Return your uniform to the volunteer office.

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OUR MISSION

To provide quality health care to our diverse community enhanced through teaching, research, charity care and financial responsibility.

VISION

To be a highly respected regional referral center providing quality health care, teaching and research.

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Operation Excellence: Total Customer Satisfaction

Standards of Performance

PERSONAL APPEARANCE

1. Wear name badge, photo up, at shoulder height.2. Wear jewelry in accordance with hospital dress code policy (two is too many).3. Dress professionally in clean, neatly pressed clothes or uniform, as outlined in the dress code

policy.4. Do not eat or drink within the sight of visitors/patients; carry food/drink items in covered

containers.5. Do not chew gum at any time.

ENVIRONMENT

1. Return equipment and/or supplies to their proper place; regulatorystandards require hallways to be kept clear.

2. Clean up spills and/or soiled areas whenever possible, otherwise notify housekeeping.3. Pick up and dispose of litter when you see it in the hallways and/or on the grounds.

COMMUNICATION

1. Wear a smile on your face and in your voice; offer a greeting to everyone.2. Develop and maintain a "can do" attitude.3. Be courteous to everyone at all times.4. Ask "is there anything else I can do for you before I leave" at the end of each encounter.5. Listen carefully to what customers say; do not interrupt.6. Listen attentively; keep eye contact and ask clarifying questions during all verbal complaints.

Be sure to apologize for any inconvenience. Thank the individual(s) for bringing the issue toyour attention. Take immediate action.

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TELEPHONE ETIQUETTE

1. Know how to operate telephone system. 2. Answer calls within three rings. 3. Answer all calls with a greeting (Good Morning, Good Afternoon) identify your department and your name and ask “How may I help you?”

4. Use "please" and "thank you" all the time. 5. Ask permission before putting a caller on hold and upon returning to the line, thank the

caller for holding. 6. Acknowledge callers on hold at least every 30 seconds. 7. Ask the caller for permission to be placed on speaker phone; do not answer your phone

using the speaker. 8. Return all calls and messages as per departmental standards and no later than the end of the

business day. 9. Do not drink or eat while using the telephone. 10. Brief the colleagues who will be covering phones for you so that they are prepared for any

calls that you may expect, and take detailed messages. 11. When transferring a phone call, make sure that the person you are transferring to is

available and inform them who is calling and the reason for the call. 12. Do not make or receive personal calls in public areas. This includes cell phones.

HALLWAY ETIQUETTE

1. Offer to assist anyone who appears lost or puzzled. 2. Escort lost visitors to their destination or find someone who can. 3. Avoid conversations regarding hospital or patient business in all public areas, including the

shuttle bus. 4. Avoid inappropriate personal conversations in the presence of patients and/or visitors. 5. Speak in low voice tones at all times. 6. Address conflicts behind closed doors.

ELEVATOR ETIQUETTE

1. Allow visitors to enter the elevator first. 2. Smile & speak to fellow riders; the elevator is an opportunity to make a favorable

impression. 3. Face patients in wheelchairs toward the elevator door. 4. Hold elevators doors open and allow visitors/patients to enter/exit before you. 5. Utilize patient service elevators for patient transport. 6. Pause briefly before boarding the elevator and hold the door open or press the "open door"

button; wait for passengers to exit prior to boarding. 7. Do not discuss hospital or patient issues on the elevator.

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CONFIDENTIALITY

1. Information about patients is confidential and should not to be discussed with anyone other than the patient's direct caregivers.

2. Hospital business/issues are confidential and should not be discussed. 3. Information regarding patients and their conditions may be released only in accordance with

hospital policy. 4. Always knock before entering a room, even if the door is open. Upon leaving the room, ask

the patient if he/she would like the door open or closed.

RESPONDING TO CUSTOMERS

1. Greet colleagues, visitors, and patients immediately upon entering your work area. 2. Keep wait time to a minimum. Each department will develop & abide by standards that

reflect reasonable timeframes. 3. Whenever a patient/visitor must wait, explain the reason for the delay and update the

patient/visitor every 15 minutes. 4. When outpatients are finished with their procedure, walk them back to the lobby or to the

exit of the department; offer directions to their next destination or escort them, if necessary.

ALL VOLUNTEERS

1. Address each patient by Mr., Mrs., Ms., or by his/her preferred name; make eye contact at every encounter. Do not call patients, Honey, Sweetie, Mami, Papi, etc.

2. Introduce yourself by name and position to each patient and family member. 3. Do not shift responsibility/ Refrain from using phrases such as, (I don't know0, we're really

busy0, we're working short//, not my fault0, I can't believe they///” 4. If possible, speak in the patient’s native or preferred language/ 5. Identify and communicate patient's preferences to other caregivers.

Respect patients' privacy.

FAMILY

1. Respond as if the patient is a member of your family. 2. Offer support to families, understanding their fear and anxiety.

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REMEMBER THE SINAI WAY

S SMILE – be positive and show that you care.

I INTRODUCE –state your name and role.

N NARRATE – explain what you are doing and what is next.

A ANSWER – answer all questions.

I IMPACT – “I am here for you.”

NAMES TO REMEMBER:

PRESIDENT/CHIEF EXECUTIVE OFFICER: STEVE SONENREICH SENIOR VICE PRESIDENT OPERATIONS: ANGEL PALLIN SENIOR VICE PRESIDENT NETWORK DEVELOPMENT: CHARLENE WELKER EXECUTIVE/SR. VICE PRESIDENT OF FINANCES: ALEX MENDEZ SENIOR VICE PRESIDENT/CHIEF NURSING OFFICER: KAREN MOYER PRIVACY OFFICER: JOSE CAMPS

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HIPAA

(HEALTH INSURANCE PORTABILITY and ACCOUNTABILITY ACT)

What is HIPAA?

Health insurance portability and accountability act of 1996 – Federal Law

What does it cover?

Privacy and security of patient information Protects patients’ privacy and confidentiality of protected health information. Privacy and security rules punish individuals or organizations that fail to keep patient

information confidential – Federal law

Who enforces HIPAA?

Office of Civil Rights (OCR) in the Department of Health and Human Services (HHS) enforces HIPAA regulations.

What are the penalties for non-compliance?

Civil and criminal penalties Maximum of 10 years in jail and a $250,000 fine for serious offenses Wrongful disclosure can include fines and jail time Gaining access to health information under false pretenses can result in 5 years in jail and

$100,000 fine Disciplinary action per hospital policy

What is our commitment?

We are committed to protecting patient privacy and confidentiality To build trust Communicate with or about patients. Involving patient health information should be private

and limited to those who need to know for treatment, payment and health care operations

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What is confidential information?

Individually identifiable health information includes = written, spoken, electronic:

Name Address Employee Relatives’ names Date of birth Telephone and fax number E-mail address Social security number Medical record number Member or account number Certificate number Voiceprint Fingerprints Photos Codes Any other characteristics, such as occupation, which may identify the individual

Notice of Privacy Practices:

Privacy Notice – explains how patients’ protected health information is used for treatment, payment and health care operations.

Given to patients on first visit to the facility (both inpatients and outpatients) Lists patients rights Lists hospital responsibilities

What are the patient’s rights?

May request restrictions on use and disclosure Obtain a copy of the Privacy Notice Inspect and copy their medical record Request an amendment to medical record Obtain a list of who has received their record Ask to have mail sent to another address Opt out of directory listing

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What are our responsibilities?

Keep patient information confidential Provide patients with Notice of Privacy Practices – on web, posted, in person Abide by terms of notice Obtain patient acknowledgement of receiving notice Use minimum necessary when using and disclosing patient information (except for

treatment purposes) Are there other responsibilities?

Provide patients with a means of submitting complaints regarding privacy Notify patient if we cannot agree to a restriction request Accommodate reasonable requests for contacting patient at other address

What are the HIPAA policies and procedures?

Designate a Privacy Officer – JOSE CAMPS, EXT. 52722 Privacy Notice Minimum necessary-based on need to know Audit trail for tracking disclosures Patient access to medical record Request amendments to medical record Confidentiality and release of patient information Verification of identity and authority of persons requesting patient information Authorization for release of information

How can we protect patient’s privacy?

Don’t leave patient records lying around Don’t discuss patients in public areas (elevators, bus, cafeteria, hallways) Don’t leave information about patient’s health on an answering machine Don’t access information inappropriately Don’t share passwords Close curtains Log off computer when finished Dispose of patient information in locked containers for shredding Keep passwords secret Use minimum necessary information. Place computer screens so that they cannot be viewed by public Ask for identification, verify authority Refer privacy complaints to the Privacy Officer, JOSE CAMPS

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HIPAA SECURITY RULE By now, you know about the HIPAA Privacy Rule – federal standards that protect our fundamental right to privacy and confidentiality. The Department of Health and Human Services (HHS) issued a second set of federal standards to protect health information in electronic form. It’s called the HIPAA Security Rule. We also have a third set of federal standards – The health Information Technology for Economic and Clinical Health Act, or the HITECH Act. HITECH expands the HIPAA privacy and security protections and includes:

Additional patient rights

New requirements for business associates

Breach notification requirements

New marketing provisions

Stiffer penalties for noncompliance

SECURITY BASICS Let’s look at who and what is protected by the Security Rule, so you’re not opening the door to breaches in privacy or security.

The Security Rule protects:

Confidentiality of electronic PHI, or also called EPHI (Electronic Patient Health

Information)

Integrity of EPHI – Meaning once EPHI is created, it can’t be tampered with

Availability of EPHI, so it can only be accessed by people with the authority to do so

whenever it’s needed/

Like the Privacy Rule, health information is protected when it contains personal information that connects the patient to the information, such as;

Patient’s name and address

Social security number

Billing information

Physician’s notes

Any information that can identify the patient

Important procedures that must be followed when working with medical center computers:

1- Never share your password with anyone 2- Never share EPHI with anyone 3- Never leave the computer unattended 4- Always logoff the computer when you are finished

If you have any questions relating to the Privacy and Security rule or you have concerns, contact the Privacy Officer at 305-674-2722.

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COMPLIANCE HOTLINE

CODE OF CONDUCT

The Code of Conduct demonstrates how Mount Sinai conducts business in a proper manner, following state, federal and accreditation standards, as well as Medical Center policy. We are expected to behave honestly, ethically, and in compliance with applicable laws, which is why it is important for all of us to take time to review and become familiar with the Code of Conduct as well as Medical Center policies and procedures.

The Medical Center requires that all officers, trustees, employees, volunteers, physicians, allied health professionals, contractors, subcontractors, agents and other persons who provide patient care items or services or who perform billing or coding functions report any suspected violations of Federal healthcare program requirements or of Mount Sinai’s own policies and procedures to an appropriate representative of the Medical Center.

ETHICS AND COMPLIANCE COMMITTEE

The Ethics and Compliance Program is supported and monitored by the Ethics and Compliance Committee. The Ethics and Compliance Committee is chaired by the Chief Compliance Officer and involves all operational areas of the Medical Center.

What is the Compliance Hotline? The Compliance Hotline is a simple way for Mount Sinai employees, volunteers and associates to confidentially report activities that may involve ethical violations or unlawful conduct at the Medical Center. The Compliance Hotline is managed and operated by an independent firm hired by Mount Sinai to ensure effective communication, integrity and confidential reporting. The Compliance Hotline is available toll-free, 24 hours a day, in both the English and Spanish languages. A trained operator takes each call, gathers the needed information, and ensures that the report is immediately sent to the Mount Sinai’s Ethics and Compliance Department for investigation and appropriate action.

Who May Utilize the Compliance Hotline? The Compliance Hotline is available for use by any employee, volunteer or associate of the Medical Center. Everyone has an individual responsibility for reporting any activity that appears to violate applicable laws, rules, regulations, accreditation standards, Medical Center policy and this Code of Conduct.

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MOUNT SINAIMEDICAL CENTERTANDARDS OF CONDUCT

What should be reported to the Hotline? Users may call the Compliance Hotline to report suspected violations of the Code of Conduct, policies and regulations related to:

• Fraud and Abuse • Conflicts of Interest • Confidentiality, Privacy and Security of Health Information • Suspected instances of Identity Theft or Fraud • Environmental Health and Safety • Billing and Coding Integrity • Patient Rights/Patient Neglect and Abuse • Safeguarding Property and Medical Center Assets • Record Keeping Problems • Business and Professional Ethics • Ineligible Persons or Entities • Research

Reporting Compliance Concerns There are several options for an employee, volunteer or associate to report a compliance concern. As a first step, an employee, volunteer or associate has the choice to report any concerns to a supervisor, or to the Chief Compliance Officer at (305) 674-2916. Any person who feels uncomfortable reporting via these means is able to call the confidential Compliance Hotline.

Investigation of Hotline Reports Calls to the Compliance Hotline are answered by an independent, third-party communications specialist. This specialist documents the information received and generates a written report that is transmitted to the Chief Compliance Officer for investigation. In addition, the caller is given a case number for their use to provide additional information or to inquire about the status of the report. Every report received from the Confidential Hotline is investigated, and the results of the investigation are provided to the caller via the Hotline. Depending on the outcome of the investigation, appropriate action(s) may be taken to correct or to prevent any improper behavior revealed by the report. Results of the investigations are shared with the Ethics and Compliance Committee and senior leadership of the Medical Center.

Non-Retaliation The Medical Center is committed to investigating all reported concerns promptly and confidentially to the extent possible. There will be no retaliatory or disciplinary action taken against an employee or volunteer for making a good-faith report to the Confidential Hotline.

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CONFIDENTIALITY, PRIVACY AND SECURITY

Confidential information includes, but is not limited to:

• Medical records (“hard copy” or electronic)-• Individually Identifiable Patient Information including. Names- Address- Dates (birth,

death, admission, discharge, etc.); Phone (Including Fax); Financial Account, Medical Record, Health Plan Beneficiary Numbers; • Social Security Numbers; • License Numbers-• Full face photographic images or comparable mages; • Any other unique identifying number or characteristic-• Personnel & Payroll records- and • Minutes of meetings at which confidential information is discussed.

For questions regarding privacy & confidentiality, contact the Privacy Officer at 305-674-2776. Please dispose of confidential information in the special, locked consoles or shredders in your department, and follow your departmental records retention policies for electronic files and records. All employees and volunteers whose duties bring them into contact with electronically stored patient information are expected to observe all security rules regarding safeguarding confidential patient information in electronic form. Portable electronic storage devices which are authorized to contain patient records and other confidential information must be secure at all times. For additional information, please contact the Information Security Officer at 305-674-2947.

Patient Information As employees, volunteers and associates of the Medical Center, we are privileged to have access to information that is personal and private. Our patients trust us to keep their information confidential. This means we should share records or patient information with authorized persons only. These are people who are involved in the care of the patient and those who have a legal right to know/ It’s our duty to be sure that we use personal information only for the purpose for which it is provided/ Please be sure that all of your conversations which concern patients’ care are held in a place that protects patient privacy and confidentiality. Be careful not to leave private information where it may be seen or taken by people who do not have a right to it. When sharing confidential health information, with those with a right to know the information, please be sure to share only the minimum information necessary for the purpose. Any requests for information concerning our patients should be directed to the Health Information Management Department where the requests can be processed in keeping with legal and policy requirements.

Medical Center Information Medical Center information should not be discussed or shared with the news media. Please refer all calls to the Public Relations Department at 305-674-2600. Requests for information about an employee should be directed to the Human Resources Department, including requests for employment references and personal information. If you have any questions or concerns about privacy, security and/or confidentiality, or if you are aware of any improper release of confidential information, please tell your supervisor or manager. You are encouraged to contact the Department of Ethics and Compliance.

You may also report any violations of Mount Sinai policy to the anonymous Compliance Hotline.

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Identity Theft It is Mount Sinai policy to comply with the federal and state laws requiring us to respond appropriately when facts suggest that an individual is presenting false identity or other information for the purpose of obtaining services at Mount Sinai Medical Center. Employees and volunteers are to report any indications of possible identity theft or similar fraud to their department manager and/or director.

Quality Patient Care Mount Sinai promotes health care quality, patient safety, and cost efficiency through focused initiatives/ Furthering Mount Sinai’s mission provides an opportunity for all employees and volunteers to make a positive difference in the community. The Medical Center quality assessment and improvement processes are integrated into overall policies and operations. The results of the evaluations are reviewed by the Quality and Patient Safety Committee and the Medical Staff Quality Performance Committee.

Here are a few things we can do to improve the service we provide to our patients: • Report medication or treatment errors according to Medical Center policy/ • Keep information about a patient private/ • Be polite to patients and loved ones. • Maintain a safe patient care environment/ • Report problems with medical equipment to Clinical Engineering/ • Inform patients about their role in patient Safety/

Patient Rights The Medical Center believes that recognizing and respecting patient rights is an important aspect of care that encourages patients to become more involved and informed in their care. Recognizing and respecting patient rights directly affects the provision of care. Care, treatment and services should be provided in a way that respects and fosters the patient’s dignity, autonomy, positive self-regard, civil rights and involvement in his or her care. Further the Medical Center believes that care, treatment, and services should also be carefully planned and provided with regard to the patient’s personal values, beliefs, and preferences.

Care at Mount Sinai Medical Center includes addressing processes and activities as they relate to patient rights by:

• Informing patients of their rights and responsibilities/ • Helping patients understand and exercise their rights. • Respecting patients’ values, beliefs, and preferences/ • Informing patients of their responsibilities regarding their care, treatment, and services/ Some of the ways we meet standards of care related to patient rights include: • Respecting patients’ right to receive visitors they designate including, but not limited to a spouse, a domestic partner (including a same sex domestic partner), another family member, or a friend, subject to reasonable or clinically necessary restrictions. • Honoring the patient’s right to give or withhold informed consent/ • Informing patients about advance directives/ • Complying with end of life decisions made by patients and surrogates/ • Complying with decisions made by patients and families about organ donation. • Respecting the patient’s right to receive information in a manner he or she understands/

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• Respecting the patient’s rights during research, investigation and clinical trials/ • Providing a process to have complaints reviewed by the Medical Center.

Patient Safety Hotline The Medical Center recognizes that Patient Safety is a priority for the organization and strives for continued improvement in the quality of care it provides to patients. While the Medical Center believes policies and procedures and compliance with state, federal and Joint Commission standards establishes a foundation for a strong patient safety program it believes that feedback from stakeholders can only improve the program. As a consequence, the organization has established a Patient Safety Hotline so that patients, family members, physicians, nurses and all employees are encouraged to express any safety concerns. Callers may remain anonymous. The telephone number is toll free and managed by a third party. The number is 888-234-2959.

Fraud and Abuse Mount Sinai is committed to full compliance with all federal, state and local health care program requirements/ “Fraud” involves the making of a false statement in order to receive some benefit to which one is not entitled/ “Abuse” includes practices which directly or indirectly result in unnecessary costs to a government health care program. Examples of fraud and abuse include: • Billing for services or supplies which were not provided or furnished-• Altering claims forms or receipts in order to receive higher payments; • Duplicate billing to the government health care program and the patient or another insurer; and • Offering, paying, soliciting, or receiving bribes, kickbacks or rebates, directly or

indirectly, to induce referrals of patients or the purchase of goods or services paid for by government health care programs. Mount Sinai expects that all individuals associated with the Medical Center will avoid fraudulent or abusive practices and promptly report these practices when they occur. All providers and suppliers participating in federal and state healthcare programs are required to follow specific requirements to combat fraud and abuse. Fraud and abuse may be prosecuted under state and federal law and can result in restitution, fines, and, in some cases, jail time. Such cases can also result in exclusion of individuals or institutions from participation in government health care programs.

Fraud and abuse guidelines state that we must: • Provide only services that are documented as being medically necessary, when required

by applicable regulations. • Document accurately and completely the services that we provide/ • Perform complete, accurate and consistent coding of medical records in accordance

with regulatory requirements and guidelines. • Report all costs according to generally accepted accounting practices and according to

Medical Center policy. • Maintain internal accounting controls/ • Maintain accurate billing to government payers, commercial insurance payers, and patients, as

well as conform to pertinent Federal and state laws and regulations. All of these measures improve our level of service, while helping to assure that we remain on firm legal and ethical grounds. For additional guidance or information regarding fraud and abuse, you are encouraged to consult Mount Sinai’s written policies on these topics, or to contact the Department of Ethics and Compliance.

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Ineligible Persons/Entities Mount Sinai will not contract with, employ, or bill for services rendered directly or indirectly by a person or organization which has been excluded from, or is ineligible to participate in, government healthcare programs as indicated on the Department of Health and Human Services List of Excluded Individuals/ Entities or the General Services Administration’s List of Parties Excluded from Federal Programs, or has been convicted of a crime related to the provision of healthcare items or services. Employees, volunteers, contractors, vendors and individuals holding clinical privileges at Mount Sinai must report if they become excluded or otherwise ineligible for participation in a government healthcare program, or if they have been convicted of a crime involving the provision of healthcare items or services.

Human Research Mount Sinai complies with all federal, state and local regulations regarding human subjects’ research, investigations and clinical trials involving our physicians or professional staff. Mount Sinai strives to protect all individuals involved in research and to assure that their safety, welfare and rights are respected/ All human subjects’ research to be conducted wholly or, in part, at Mount Sinai Medical Center must be submitted to the Mount Sinai Medical Center Institutional Review Board for review. This requirement is waived for non-employed physicians whose research project is conducted entirely within their office recruiting their own private practice patients.

Mount Sinai works to ensure that patients or third party payers are not billed for the cost of research-related tests, procedures, and supplies which are paid for by a study sponsor or which are otherwise not appropriate to be charged to the patient or the patient’s insurance or government health care programs. For assistance with billing issues related to research, please contact the office of Research Administration at 305-674-2790.

Record keeping Mount Sinai maintains many types of records. These include medical records, documents, and information that are received via electronic methods, including e-mail. State and federal regulations impose specific requirements for keeping and destroying specific types of records. Because departments maintain various types of records, we should take time to become familiar with the departmental policies that apply to the documents we use, manage and create every day. There are a number of rules that commonly apply to everyone. Please keep the following in mind:

• Do not falsify facts or make false record entries. • Do not remove any Medical Center files or documents from the premises/ • Keep records confidential/ • Maintain and destroy records according to record the applicable retention policy/ • Give records only to those people who are authorized by policy and regulatory requirements to

have access.

Safeguarding medical center and patient property All employees, volunteers and associates are expected to use Medical Center property and resources responsibly and only for an appropriate purpose. In addition, employees are expected to use facilities and equipment correctly to avoid injury. Medical Center property may not be used for non-Medical Center purposes without written permission. Medical Center time, facilities, or equipment may not be used for unapproved purposes. Ask your supervisor if you have any questions about proper use of Medical Center property and resources.

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Workplace health and safety The Medical Center strives to maintain a working environment which is free from hazards or unsafe conditions. All of us must follow safety standards and regulations and take extra care to:

• Dispose of medical waste, environmentally sensitive and other hazardous material correctly. • Use personal protective equipment to protect you and others from exposure to dangerous

substances. • Prepare and react timely to internal and external disasters, such as fires and

hurricanes. • Be familiar with Mount Sinai’s Emergency Preparedness Plan/ Please report all

incidents and accidents involving people, equipment and property to Risk Management at 305-674-2555.

Political activity and lobbying Mount Sinai advocates for legislative issues that affect the Medical Center. However, Mount Sinai is a not-for-profit Medical Center and does not contribute funds to support political parties, individuals running for office, or for the advancement of controversial political issues. Medical Center employees, volunteers and associates are free to support political campaigns or issues outside of their duties at Mount Sinai. However, employees and volunteers are expected to ensure that private political activities are not carried on in such a way as to suggest an endorsement by the Medical Center.

Tobacco-free environment It is the policy of the Medical Center to educate staff and the public at large about the hazards of smoking and tobacco use and to provide smoking cessation assistance. As a health care provider and as an employer the Medical Center is committed to providing patients, visitors, staff and volunteers with an environment that promotes healthy behaviors. For this reason, Mount Sinai Medical Center campuses are Tobacco Free. As of July 1, 2010, all individuals on the Medical Center property are prohibited from using any tobacco products while on any campus.

Gifts It is inappropriate for us to give or receive, directly or indirectly, any gifts (including cash, services, favors, or other things of value) that may improperly influence, or appear to influence, business relationships. Some small perishable items may be allowed, however, you must notify your supervisor if you are offered a gift of any kind. Never request or accept gifts from a patient in exchange for services. If someone offers you cash, do not take it. If they insist, notify your supervisor or manager. The giving of gifts to, or receiving gifts from, individuals or businesses who are doing business with (or who are seeking to do business with) the Medical Center, or who may represent a possible source of referrals for patients or other business may be contrary to law. Please check with your Supervisor or the Department of Ethics and Compliance with any questions about such gifts.

Conflicts of interest Employees, volunteers and associates of the Medical Center sometimes have personal or financial interests which make it inappropriate for those persons to be involved in certain activities and transactions of the Medical Center. These situations are called “conflicts of interest/” Here are two examples of what may be considered a conflict of interest:

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• A situation in which an employee or associate (or a member of that employee, volunteer or associate’s family) has a financial interest in a company that does business with Mount Sinai. • A situation in which a Mount Sinai employee, volunteer or associate also works part-

time for a Mount Sinai vendor, competitor or supplier. It is extremely important that any employee, volunteer or associate of the Medical Center promptly disclose any conflict of interest to a supervisor, even if the conflict is just a possibility.

Relationships with vendors and competitors Information that is used by the Medical Center is private. This includes business strategies, costs, finances, and other economic matters. Business information about the Medical Center may not be discussed with anyone outside our organization.

Only Administration may enter into contracts with another business entity.

Dealing honestly with customers, vendors and consultants Respect for our patients, guests and business associates requires that we only make statements that we know are honest and accurate. We also prepare written documents in a timely manner and keep all business information, records and reports complete and truthful. Likewise, it is important that we abide by trademark and copyright laws and licensing requirements. We support ethical business behavior by properly representing ourselves to the public. In order to effectively control both internal and external printed materials, all proposed printed material to be used by any Medical Center department with any outside audience must be presented to the Director of Marketing at 305-674-2388 for consultation and approval prior to production.

Respect and dignity in the workplace It is the policy of the Medical Center to maintain a work environment free from all forms of unlawful harassment/ Comments or conduct relating to a person’s race, ethnic background, gender, religion, age, handicap, or sexual orientation, which fail to respect the dignity and feelings of the individual are unacceptable. Employees, patients, volunteers and visitors are to be treated with dignity, respect, and courtesy.

Sexual harassment is a violation of the law and will not be tolerated or condoned. This behavior is defined as unwanted sexual advances, requests for sexual favors and all other verbal or physical conduct of a sexual nature, especially where it:

• Becomes a term or condition of employment/ • Is used to make decisions affecting someone’s job. • Creates an intimidating, hostile, or offensive work environment/ Sexual harassment

also includes comments, jokes, suggestions, sexually oriented statements or other remarks or actions that are offensive.

The Medical Center will do everything possible to prevent discrimination and harassment of any kind. All of us have the right to work in an environment of mutual respect and professionalism. Please report any activities involving discrimination or harassment to your supervisor, manager, the Human Resources department at 305-674-2500, or the Compliance Hotline.

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Disruptive behavior Disruptive behavior affects morale or staff turnover and can be harmful to patient care. Behavior such as intimidation, verbal or physical abuse, sexual misconduct, or the creation of a hostile or offensive work environment will not be tolerated. Individuals working at all levels of the Medical Center, including management, clinical and administrative staff, licensed independent practitioners, and governing body members are expected to conduct themselves in a professional manner so that the workplace is free from behaviors that could have a negative impact on patient safety.

Solicitation and distribution It is our purpose to provide undivided attention to our responsibility of caring for patients. Solicitation includes, but is not limited to, handing out, dispensing, selling, or requesting another person to take, acknowledge or buy materials, literature, substances, goods or items. Employees and volunteers may not solicit patients or visitors for any cause or private employment arrangements. It is the policy of Mount Sinai to prohibit any solicitation of an employee, volunteer, patient, or the patient’s relatives and/or friends/ Personal items or notices from any source other than Administration may not be posted on Medical Center bulletin boards. Items that promote any organization or commercial, political ideology, religious, or other cause, or a certain message or slogan that may disturb patients or otherwise interfere with patient care services may not be displayed.

Drug-free workplace The Medical Center is committed to a drug free work place. It is our policy to foster an environment of zero tolerance for the unlawful manufacture, distribution, dispensing, possession, or use of alcohol, controlled substances or illegal drugs in the work place.

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Dear Volunteers:

Mount Sinai Medical Center has always taken great pride in their volunteer services. Your efforts addso much to our accomplishments throughout the years.

Some of you will give economic support; some give time; and others will provide the tender loving careand loyalty that make our medical center so vital to the Miami Beach community.

We need and appreciate each of you with your very special talents.

Volunteers are the best medicine!

Sincerely,

Edie Shapiro, ManagerVolunteer Services Dept.

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