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rehabilitation institute inc rehabilitation institute of chicago compliance program handbook may 2012

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table of contents 01 introduction 03 purpose of compliance handbook 04 compliance program 06 code of conduct 18 administration of ric s compliance plan 20 education and training related to the compliance program 21 reporting and investigation of compliance issues 24 contact with and investigations by government agents and investigators 24 conclusion 25 appendix a employee attestation form 26 appendix b employee guide for responding to governmental agents and investigators

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introduction we are a group of people committed to a common purpose to maximize the recovery or ability of our patients by providing them access to the highest quality of medical care that is infused with the latest scientific knowledge regardless of what job we have at ric our duty is to actively support this purpose and by doing so to secure ric s future and reputation ric s continued success depends on the behaviors and contributions of every employee what we do and how we do it matters integrity and consistent ethical and legal behavior is the fundamental core of ric integrity can be thought of as doing the right thing with every decision we face every time integrity and ethical conduct are expected from each of us under every circumstance moreover anyone associated with ric deserves to be treated with respect consideration courtesy and dignity ric s compliance program is organized to help us achieve these behavioral expectations and guide us when issues arise the word compliance itself means adhering to a set standard this handbook summarizes ric s code of conduct the corporate compliance program and associated policies and procedures please carefully review and familiarize yourself with these materials and consider them as practical tools intended to help you make appropriate decisions when you find yourself in a difficult situation demonstrating through your behavior that you hold the highest of ethical standards is essential in fact doing so is a condition of your employment at ric ric employees give life to the ric mission you are the most important asset we have and your ethical conduct is vitally important to the future of ric if you ever have concerns about the integrity ethical or legal behavior of another employee or any part of the institute it is critical that you raise them ­ and we encourage you to use this handbook as a guide thank you for your commitment and for helping us to continue to strengthen ric s culture of integrity 01 sincerely joanne c smith md president and chief executive officer m jude reyes chairman of the board

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02 compliance hotline 800.273.8452

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purpose of compliance handbook this compliance program handbook handbook has been designed to help you the employees of ric as well as the members of the board of directors other agents outside vendors contractors and any other individuals or entities providing goods or services to or on behalf of ric understand your responsibility to act in a legal professional and ethical manner although the term employee is used in this handbook it is meant to apply to any of the preceding individuals or entities this handbook has been adopted by ric s board of directors it is a reaffirmation of ric s existing policies and practices to comply with the laws and ethical directives throughout our system of care this handbook sets forth the standards that form the basis of the program and should be viewed as a tool to guide you in making the right decision or seeking out an appropriate colleague to assist you as you conduct your daily activities 03 there are times when the specific issue may not be addressed by this handbook or a colleague is not available and you will have to make the decision yourself under those circumstances consider the following ·is the action legal ·does my action give the appearance of impropriety ·will my action bring discredit to me or ric when disclosed ·will my family and friends and coworkers be embarrassed by my action when disclosed · can i defend my action to my supervisor other employees and to the general public ·does my action conform to the spirit of this handbook if you can answer each of those questions then what action you should probably take becomes apparent.

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04 compliance program overview the purpose and objectives of the program are to · establish and communicate the standards of conduct expected of all employees · define the duties and responsibilities of the compliance officer as well as the compliance committee · establish the responsibilities of ric and its various departments programs etc · ensure regular training and education to ric employees to learn about the program compliance with specific laws rules and regulations in their areas and other topics that will assist in ensuring an effective program · establish a system of monitoring and oversight in order to assure adherence to applicable laws rules and regulations as well as ric policies and procedures · establish and communicate processes for employees to report any concerns related to wrongdoing or compliance with the program · develop an annual work plan to prioritize reviews audits training and education related to the program the goal is to integrate the program into all of our daily work activities this program includes the code of conduct which is incorporated into this handbook each employee who was employed when the program was adopted was given a copy of the handbook and new employees will be given a copy of the handbook during their initial orientation ric agents outside vendors contractors and any other individuals or entities providing goods or services to or on behalf of ric will be provided with the program and/or code of conduct on a case by case basis the handbook is accessible at all times in the corporate compliance office and online through ric connect ric s program will update correct and add information as required due to changing laws rules regulations or policies while ric will generally attempt to communicate material changes to the program prior to or concurrent with implementation of that change ric reserves the right to change the program without notice to its employees as necessary your duties as an mployee as an employee of ric you have a responsibility to understand and comply with this handbook new employees will be required to acknowledge in writing the receipt of the handbook and your commitment to the program including reading the handbook · during your annual performance review you will be required to demonstrate that you are aware of the existence of the program and its requirements · if you are a supervisor you will be responsible for monitoring and enforcing the handbook within your specific areas of responsibility · you must perform your job responsibilities in accordance with the program ric recognizes that it is unrealistic to expect each of you to know every law rule or regulation that applies to every aspect of your job this handbook is just one resource available to employees · you may also receive additional information during your initial employee orientation and additional compliance training sessions for the system of care or for your particular area or department you are responsible for attending any training that you are invited to as well as reading all of the materials that you are provided ·

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if you become aware of any act that is contrary to the program you are responsible for immediately giving that information to the compliance officer if for any reason you feel uncomfortable reporting such a situation to this individual or feel your issue was not adequately resolved you may speak with any member of the office of general counsel or report through the anonymous compliance hotline at 1-800-273-8452 as an employee you have the responsibility to cooperate and participate as requested in person or by record review in any and all audits investigations and reports performed as part of the program these responsibilities outlined above are a condition for continued employment with ric decisions regarding hiring promotion performance review and compensation will take into consideration whether you have complied with your responsibilities under the program also employees may be subject to discipline in accordance with ric s human resources staff handbook and policies for failing to perform these duties discipline includes but is not limited to reprimand suspension or discharge the following are examples of conduct that may result in disciplinary action · failure to perform any obligation required relating to compliance with the program or applicable laws rules or regulations · failure to report suspected violations of the program or applicable laws to an appropriate person · knowingly filing false reports of suspected violations with the purpose of harming or retaliating against a colleague · knowingly accessing or disclosing personal health information of a patient or employee in an inappropriate manner · attempting to retaliate against another employee who reported a suspected violation · failure on the part of a supervisory or managerial employee to implement and maintain policies and procedures reasonably necessary to ensure compliance with the terms of the program or applicable laws or regulations 05

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06 code of conduct overview the code of conduct forms the basis of the program at ric the code of conduct addresses six primary areas of responsibility relating to the performance of your activities i compliance with laws applying to ric s business ii business ethics such as honesty and integrity iii confidentiality of patient information ric business information and personnel information iv conflicts of interest rules pertaining to external interests v business conduct relating to gifts gratuities inducements or bribes vi standards for financial record keeping and the personal use of ric assets if you have any questions or concerns about the code of conduct please contact the compliance officer.

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i compliance with the laws you are required to comply with the applicable laws related to any activity performed on behalf of ric at all times you are required to comply with all applicable laws and rules and regulations of federal state and local governments whether or not specifically addressed in this handbook you may be expected to attend educational programs offered by ric and to certify your intention to comply with the legal requirements and ethical standards of business behavior as required by this code of conduct if you have questions regarding the existence of interpretation or application of any law rule or regulation or any of the following standards you should contact the compliance officer standard 1.1 general laws you must comply with all applicable laws rules and regulations of federal state and local authorities you must comply with all applicable laws and regulations regarding safety the environment and business practices involved in the delivery of health care or related services these laws include but are not limited to · antitrust laws · compliance with medicare/medicaid conditions of participation · laws affecting tax-exempt corporations · laws affecting the regulation of the delivery of health care including licensing · laws affecting employment labor and benefits · laws relating to environmental health and safety · laws relating to privacy and confidentiality · laws relating to identity theft · laws relating to the conduct and administration of research · other laws reflecting the relationship between ric and its partners standard 1.2 antitrust laws and regulations ric will promote fair competition and comply with all applicable federal and state antitrust laws you must comply with all applicable antitrust and similar laws that regulate competition examples of conduct prohibited by the laws include · agreements to fix prices salaries or bids with competitors · attempts to agree or collude with a competitor including sharing of information related to price or salary that are not normally available to the public · boycotts certain exclusive dealing and price discrimination agreements · unfair trade practices including bribery misappropriation of trade secrets deception intimidation and similar unfair practices you are expected to seek advice from the senior vice president general counsel and government affairs when confronted with business decisions involving a potential risk of violation of the antitrust laws 07

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08 standard 1.3 tax-exempt laws ric is a tax-exempt organization you must comply with the applicable laws to preserve that status as you may be aware ric is a nonprofit tax-exempt entity any such entity has particular laws and regulations that it needs to comply with in order to maintain its nonprofit tax-exempt status these include · ensuring that money it generates is not given to an individual as a windfall sometimes referred to as private inurement rather if money is given it is based upon fair market value for a service provided · activities it engages in must further its charitable purpose · that its resources e.g money facilities etc are used in a manner that furthers the public good rather than the private or personal interests of any individual · certain restrictions on lobbying activities · prohibitions against intervention in political campaigns · accurately reporting payments to appropriate taxing authorities · filing all tax and information returns in a manner consistent with applicable laws you are expected to conduct yourself while an employee and carrying out the activities of ric in a manner consistent with the laws and regulations related to the nonprofit tax-exempt status of ric standard 1.4 preventing improper referrals kickbacks and the submission of false claims also known as fraud and abuse you must conduct all activities in a manner that avoids the receipt of payment of anything of value in exchange for referrals of business including but not limited to the referral of patients federal and state regulations outline compliance expectations when submitting health care claims for federal or state funded services these laws and attention paid by organizations and their employees to these laws are one way that governmental funds remain protected prevention and detection of fraud waste and abuse are paramount to the solvency of these health care funding sources the false claims act establishes civil and/or criminal penalties for the submission of false fraudulent or misleading claims to any government entity or third-party payor including · knowingly making using or causing a false record or statement to be rendered for payment · submitting claims for services not rendered · submitting claims that characterize the service differently than the service actually rendered · submitting claims that are not documented properly or do not otherwise comply with applicable program or contractual requirements there are laws designed to protect those individuals who report such fraud or abusive practices additional information on the federal and state false claims act may be found at www.taf.org/federalfca.htm the compliance officer or any staff member of the office of general counsel are available to answer questions you may have regarding fraud and abuse or the false claims act and what it entails for reporters of alleged misconduct you are expected to refrain from conduct that may violate the fraud and abuse laws these laws prohibit · the direct indirect or disguised payments in exchange for the referral of patients therefore you must not offer or receive any item of value or services that may be viewed as a bribe kickback or inducement for the referral of business or patients · making false representations to any person or entity in order to gain or retain participation in a program or to obtain payment for any service

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standard 1.5 prohibition regarding unlawful discrimination ric prohibits discrimination in any work-related decision on the basis of race color religion gender national origin age marital or veteran status disability medical condition sexual orientation or any other legally protected status to the extent required by law ric believes that the fair and equitable treatment of employees patients and all persons is critical to fulfilling its vision and goals it is a policy of ric to treat all individuals including patients and visitors without regard to the race color religion sex ethnic origin age or disability of such person or any other classification prohibited by law it is a policy of ric to recruit hire train promote assign transfer and terminate employees based on their own performance achievement experience and conduct without regard to race color religion sex ethnic origin age or disability or any other classification prohibited by law as a federal contractor ric is required to provide equal employment opportunity and affirmative action in its employment policies and practices no form of harassment workplace violence or discrimination on the basis of sex race color disability age religion ethnic origin disability or any other classification prohibited by law will be permitted any allegation of harassment or discrimination will be promptly investigated in accordance with applicable ric human resources policies standard 1.6 other labor laws ric is committed to ensuring compliance with any applicable law regulation or rule related to employment you must comply with all other applicable labor and related laws that regulate employment examples of such laws include · wage and hour requirements that regulate pay practices such as overtime pay · unfair labor practices that regulate employment practices such as minimum wage child labor equal pay · state and federal civil rights laws that regulate employment actions such as hiring and termination · family and medical leave act that provides leave time for employees with certain family/medical issues · occupational safety and health administration that regulates safety and health issues in the workplace standard 1.7 occupational and environmental safety laws the activities of ric are subject to various state and federal laws and regulations regarding occupational and environmental health and safety you must comply with applicable occupational and environmental related laws that regulate safety in the workplace and the environment examples of these laws include prohibiting the discharge of certain materials into the air or water and laws protecting employees and patients from exposure to toxic and other environmental exposures such laws include regulation of the disposal of medical waste potential exposure to blood-borne pathogens radiation safety and safe working procedures all ric employees must strive to utilize resources appropriately and efficiently to recycle where possible and otherwise dispose of all waste in accordance with applicable laws and regulations and to work cooperatively with the appropriate authorities to remedy any environmental contamination for which ric may be responsible 09

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10 standard 1.8 lobbying/political activity ric complies with all reporting registration and disclosure laws and regulations regarding lobbying and ensures appropriate lobbying activities due to its tax-exempt status ric expects each of its employees to refrain from engaging in activities that may jeopardize the tax-exempt status of the organization including a variety of lobbying and political activities no individual may make any agreement to contribute any money property or services of any officer or employee at ric s expense to any political candidate party organization committee or individual in violation of any applicable law officers and employees may personally participate in and contribute to political organizations or campaigns but they must do so as individuals not as representatives of ric and they must use their own funds where its experience may be helpful ric may publicly offer recommendations concerning legislation or regulations being considered in addition ric may analyze and take public positions on issues that have a relationship to the operations of ric when ric s experience contributes to the understanding of such issues ric has many contacts and dealings with governmental bodies and officials all such contacts and transactions shall be conducted in an honest and ethical manner any attempt to influence the decisionmaking process of governmental bodies or officials by an improper offer of any benefit is absolutely prohibited all registered ric lobbyists must maintain records and disclose the names of the officials with whom a lobbying contract was made also any expenses associated with such contacts must be disclosed any requests or demands by any governmental representative for any improper benefit should be immediately reported to ric s senior vice president general counsel and government affairs standard 1.9 laws related to the conduct and administration of research you must conduct and administer research activities in accordance with applicable federal state and local laws and ric policies participating in research is critical to leading the discovery of innovative treatments in rehabilitation ric receives research funding from international federal state local and philanthropic sources there are federal regulations local laws ric policies and procedures and ethical principles relating to the conduct and administration of research you must be aware of and adhere to research-related requirements for · fiscal administration expending accounting and documenting of sponsored project funding · human research regulatory and ethical conduct of research with human research participants · investigational drugs and devices conduct of research using investigational drugs or devices · environmental health and safety safety and compliance in the hospital and research laboratory environments relating to safety chemicals radiation biological materials and drugs · conflict of interest disclosing external interests and addressing potential or actual conflicts of interest · intellectual property reporting intellectual property discovered through sponsored research and adhering to ric s policy for licensing and commercial arrangements · research integrity promoting integrity in research and appropriately handling allegations of research misconduct such as fabrication falsification and plagiarism

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ii business ethics in furtherance of ric s commitment to the highest standards of business ethics and integrity you will accurately and honestly represent ric and will not engage in any activity or scheme intended to defraud any person or entity of money property or honest services standard 2.1 honest communication ric promotes honest communication throughout the system of care and with any business associate you shall not intentionally make any false or misleading statements to any patient person or entity doing business with ric about other patients persons or entities doing business or competing with ric or about the products or services of ric or its competitors ric requires complete candor and honesty from individuals in the performance of their responsibilities and in all communication particularly with our attorneys and auditors section 2.2 misappropriation of proprietary information you shall not misappropriate confidential or proprietary information belonging to another person or entity nor utilize any publication document computer program information or product in violation of a third party s interest in such product you are responsible for ensuring that you do not improperly copy for your own use documents or computer programs in violation of applicable copyright laws or licensing agreements you shall not utilize confidential business information obtained from competitors including patient lists price lists salary information contracts or other information that might provide an unfair competitive advantage to or against ric 11 iii confidentiality you shall strive to maintain the confidentiality of patients employees and other confidential or proprietary information in accordance with applicable legal and ethical standards ric and you are in possession of and have access to a broad variety of confidential sensitive and proprietary information the inappropriate release of which could be injurious to individuals ric s business partners and ric itself you have an obligation to actively protect and safeguard confidential sensitive and proprietary information in a manner designed to prevent the unauthorized disclosure of information also if you are uncertain whether there is an obligation to maintain the confidentiality of information or whether certain information should be released you should review the request with your supervisor or the compliance officer if confidential or proprietary information is inadvertently disclosed or compromised you should immediately contact the compliance officer standard 3.1 patient information such information may only be accessed or disclosed when authorized under ric policies or in accordance with a valid legal or authorized request you have an obligation to conduct yourself in accordance with the principle of maintaining the confidentiality of patient information and such information should only be accessed discussed or disclosed on a limited need to know only basis or in accordance with a valid legal or authorized request you shall refrain from accessing or revealing any personal or confidential information

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12 concerning patients or employees unless supported by legitimate business or patient care purposes unless permitted by a valid legal or authorized request at no time should confidential patient or employee information be discussed with or disclosed to non-ric personnel including the family or business and social acquaintances of ric employees customers vendors or others should any questions arise regarding the release of patient information refer to hipaa policies throughout the administrative policies and procedures or contact the compliance officer standard 3.2 creation and retention of patient and ric records adherence to all applicable laws rules or regulations is required to create and retain patient and ric records all patient and institutional records are the property of ric ric employees shall be responsible for the preparation and retention of records as well as for the maintenance of those records in accordance with the applicable laws and ric policy ric s records shall not contain any false fraudulent fictitious deceptive or misleading information there are no circumstances that permit any individual to sign the signature or initials of another person on a record furthermore unless authorized according to ric policy no ric employee shall destroy alter after the fact or remove from the premises any ric record it is unlawful to knowingly make false entries in any record ric employees must not delete any information from records medical records can only be amended to ensure the accuracy of a record in accordance with ric and medical staff policies and procedures whenever an ric employee amends a medical record he or she must indicate that the notation is an addition or correction and record the actual date that the additional entry was made standard 3.3 proprietary information information obtained due solely to your role with ric may be proprietary to ric and therefore shall not be disclosed unless required by law or authorized by ric information ideas and intellectual property assets of ric are important to organizational success information pertaining to ric s competitive position or business strategies payment and reimbursement information and information relating to negotiations with employees or third parties should be protected and shared only with employees who need to know such information in order to perform their job responsibilities employees should exercise care to ensure that intellectual property rights including patents trademarks copyrights and software are carefully maintained and managed to preserve and protect their value standard 3.4 personnel actions/decisions human resources and employee information shall be treated as confidential unless appropriately authorized or legally required to be disclosed salary benefit and other personal information relating to employees shall be treated as confidential personnel files payroll information disciplinary matters and similar information shall be maintained in a manner designed to ensure confidentiality in accordance with applicable laws.

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iv conflicts of interest you owe a duty of undivided and unqualified loyalty to ric you may not use your position to profit personally or to assist others in profiting in any way at the expense of ric conflict of interest refers to situations in which external financial or other personal interests may bias or compromise or have the possible appearance of biasing or compromising one s professional judgment relative to clinical practice research leadership and/or purchasing actions taken by the individual conflicts of interest may prioritize or give the appearance of prioritizing the personal interests of the individual ahead of the individual s obligations to ric ric s mission and the public interest if you have a question regarding a potential perceived or actual conflict of interest it should be directed to the compliance officer you must complete and submit a conflict of interest disclosure form before your employment begins at ric on an annual basis as new external interests arise and during the research proposal process if applicable you can obtain conflict of interest disclosure forms from the corporate compliance office or the office of general counsel while not all encompassing the following examples demonstrate the types of activities that may result in a prohibited conflict of interest · using your role to influence an ric decision in which you know or have reason to know that you have a financial interest ownership in or employment in or by another company or entity that does business with ric may result in a potential or actual conflict this does not apply to stock or other investments held in a publicly held corporation provided the value of the stock or other investments does not exceed 5 of the corporation s stock ric may following a review of the relevant facts permit ownership interests that exceed these amounts if management concludes such ownership interests will not adversely impact ric s business interest or the judgment of the person who owns such interest · without proper authorization conducting any business including buying goods or services not on behalf of ric with any other ric employee board member vendor supplier contractor or agency · using ric facilities or resources for anything other than ric activities · using ric s name or logo to promote or sell non-ric products or services · representing ric in any transaction in which you or a related party such as a member of your family has a substantial personal interest · disclosing or using confidential special or inside information of or about ric particularly for personal profit or advantage by you or a related party · competing with ric directly or indirectly in the purchase sale or ownership of property property rights or interests or business investment opportunities · being involved in the design conduct or reporting of research activity sponsored by an entity in which you or a related party have a significant financial interest 13

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