Standards of Conduct

COMMITMENT TO COMPLIANCE

The HASC Diagnostic and Treatment Center, Inc. d/b/a The Blanche Kahn Family Health Center and the Rambam Family Health Center (collectively, the “Center”) is committed to providing high quality and caring services pursuant to the highest ethical, business, and legal standards, including Federal health care program requirements (e.g., Medicare and Medicaid).

These high standards apply to our interactions with everyone with whom we deal. This includes our patients, the community, other healthcare providers, companies with whom we do business (i.e., our “Contractors”), government entities to whom we report, and the public and private entities from whom reimbursement for services is sought and received.

We expect and require all Contractors to be law-abiding, honest, trustworthy, and fair in all business dealings. In short, we do not and will not tolerate any form of unlawful or unethical behavior by anyone associated with the Center.

Our Compliance Program is designed to help us prevent fraud and abuse in Federal health care programs. If fraud or abuse is detected, the Program provides us with a system for investigation and implementing corrective action. This Code of Conduct is one component of the Program and is designed to assist our Contractors in navigating the various compliance obligations of the highly regulated industry in which we do business. By adhering to the Code of Conduct, our Contractors enable the Center to continue to achieve its goals of providing excellent service to our patients in a legal and ethical fashion.

To the extent that Contractors meet the definition of an “affected individual,”1 they are subject to this Compliance Program. Failure of an affected individual to meet the Program’s requirements may result in termination of contract or affiliation with the Center.

“Affected individuals” means all persons who are affected by the Center’s compliance risk areas (which are discussed in this Handbook at p. 5). This includes our employees, the Chief Executive Officer, senior administrators, managers, contractors, agents, subcontractors, independent contractors, volunteers, the Board of Directors and corporate officers. Contractors are subject to the Compliance Program to the extent that it is related to their contracted role and responsibilities within the Center’s risk areas.

Code Of Conduct

All Contractors should adhere both to the spirit and the language of the Code, maintain a high level of integrity in their conduct, and avoid any actions that could reasonably be expected to adversely affect the integrity or reputation of any of the Center

Responsibility of Our Contractors. Contractors are expected to comply and be familiar with all federal and state laws, rules, and regulations that govern their work for the Center. All Contractors are also expected to comply with this Code of Conduct, and any applicable compliance standards and policies. Compliance with the Code is a condition of association with the Center, and violating the Code will result in discipline being imposed, including, termination of contract or affiliation.
Honesty and Lawful Conduct. Contractors should avoid all illegal conduct and not take any action that they believe violates any statute, rule, or regulation. Contractors should strive to avoid the appearance of impropriety, and never act in a dishonest or misleading manner.
Reporting Requirements. If Contractors become aware of or suspect misconduct or possible violations of the Center’s Compliance Program, it is a requirement that such concerns are reported to a Center manager or supervisor, a member of senior management or the Compliance Officer. Contractors may also report their concern through the Compliance “Hotline.” Questions or concerns may be raised anonymously, if you wish, via the Compliance Hotline. The identity of callers to the Hotline will be kept confidential, whether requested or not, unless the matter is subject to a disciplinary proceeding, referred to or under investigation by the NY State Medicaid Fraud Control Unit (MFCU), the Office of Medicaid Inspector General (OMIG) or law
No Retaliation or Intimidation. The Center maintains a policy of non- retaliation and non-intimidation for good faith participation in the Compliance Program. Good faith participation includes, but is not limited to reporting actual or potential compliance issues to appropriate personnel (e.g., the Compliance Officer); cooperating or participating in the investigation of compliance issues; assisting with or participation in self-evaluations and audits; assisting with or participation in remedial actions/resolution of compliance issues; reporting instances of retaliation/intimidation; and reporting potential fraud, waste or abuse to appropriate State or Federal entities. Acts of retaliation or intimidation should be immediately reported to the Compliance Officer or to the Hotline and, if substantiated, the individuals responsible will be disciplined appropriately.
Respecting the Patients. All affected individuals must strive to provide quality health care services that are medically necessary to attain or maintain the patient’s well- being. Affected individuals must provide each patient with a dignified existence that promotes freedom of choice, self-determination, and reasonable accommodation of individual needs.
Accurate Records and Documentation. All of the Center’s records, documents and reports must be accurate, complete and in compliance with all legal requirements. Claims for services provided must be based on the service actually provided and supported by adequate documentation to justify the claim.
Exclusion Checks. The Center conducts appropriate background checks on certain Contractors and requires those Contractors who assign staff that may be providing services to patients on behalf of the Center to check applicable federal and state databases prior to assignment and on a monthly basis thereafter to ensure Contractor employees are not excluded from participating in federal health care programs (e.g., Medicaid). Contractors are required to maintain documentation demonstrating compliance with this condition and immediately disclose to the Compliance Officer if the Contractor or any of its staff becomes excluded or otherwise ineligible. The applicable databases are:
- https://exclusions.oig.hhs.gov/ (the United States Department of Health and Human Services, Office of Inspector General’s List of Excluded Individuals/Entities); and
- https://omig.ny.gov/medicaid-fraud/medicaid-exclusions (the New York State Office of the Medicaid Inspector General’s Medicaid Exclusion List).
Compliance with the Deficit Reduction Act of 2005 (the “DRA”). In accordance with the DRA, the Center has established written policies for all employees and contractors that provide detailed information about the federal False Claims Act, federal administrative remedies for false claims and statements, the New York State false claims provisions, state penalties (both civil and criminal) for false claims and statements, whistleblower protections under such laws, and the role of these laws in preventing and detecting fraud, waste and abuse in federal health care programs (e.g., Medicare and Medicaid). A copy of the DRA policy is posted on our website. We ask that you review this policy and if applicable review it with your staff that provide services to the Center.
Gifts and Benefits. Our personnel are prohibited from offering, paying or receiving any gifts or benefits to or from any person or entity: (i) that makes referrals to the Center, (ii) to which the Center makes referrals, or (iii) with which the Center does business, under circumstances where the gift or benefit is offered, paid or received with a purpose of inducing or rewarding referrals of health care goods, items or services, or other business between the parties. This guiding principle is also applicable to our Contractors: Contractors may not be involved with gifts or benefits that are undertaken in return for or to induce referrals or the purchasing, leasing, ordering or arranging (or the recommending of any of the foregoing) of any item or service.
Confidentiality. Contractors who learn confidential information about the Center or our patients may not share that information with anyone, including family or friends.

How The Compliance Program Operates

The Compliance Program includes our Code of Conduct and the following operational elements:

Written Standards and Procedures

The Center has developed and distributed written standards of conduct, as well as written policies and procedures that promote our commitment to compliance, address specific areas of potential fraud and abuse, and give guidance to affected individuals about how the Compliance Program operates and how compliance issues are investigated and resolved. The written policies and procedures are available to all affected individuals. A list of current Program policies and procedures is included at the end of this Summary.

Oversight

The Center has designated a Compliance Officer and a Compliance Committee charged with the responsibility for developing, operating, and monitoring the Compliance Program. The Compliance Officer and the Committee are accountable to and report directly to the Center’s Board of Directors and Chief Executive Officer.

Mandatory Education and Training

The Center has developed and conducts effective education and training programs that cover, among other things, compliance risk areas, expectations, disciplinary standards and the operation of the Compliance Program.

Reporting System

The Center has established and implemented effective lines of communication, ensuring confidentiality, that are accessible to all affected individuals and all patients receiving services from the Center. This includes an anonymous method for reporting (i.e., the Hotline) and allows for questions regarding compliance issues to be asked and for compliance issues to be reported.

Disciplinary Standards

The Center has established well-publicized disciplinary standards to encourage good faith participation in the Compliance Program by all affected individuals. It is our policy that discipline is enforced fairly and consistently. Note that the Center will escalate disciplinary actions as warranted based on the severity of the misconduct, with intentional or reckless behavior subject to more significant sanctions. Contractors who violate the Code of Conduct or commit illegal acts are subject to discipline, including contractual or financial penalties and/or termination of contract or affiliation with the Center. Discipline will be enforced for:

Failure to report suspected problems;
Participation in non-compliant behavior;
Encouraging, directing, facilitating or permitting either actively or passively non-compliant behavior;
Failure by a violator’s supervisor(s) to detect and report a compliance violation, if such failure reflects inadequate supervision or lack of oversight;
Refusal to cooperate in the investigation of a potential violation;
Refusal to assist in the resolution of compliance issues; and
Retaliation against, or intimidation of, an individual for their good faith participation in the Compliance Program.

It is our policy that contracts governing relationships with independent contractors, and all applicable laws, rules and regulations governing the relationship, are respected.

Auditing and Monitoring System

The Center routinely uses audits and/or other risk evaluation techniques to monitor compliance and identify compliance risk areas, such as coding, billing and documentation and payment practices; issues relating to quality of care and medical necessity of services; the credentialing process; compliance with mandatory reporting requirements; governance standards; contractor oversight and other potential compliance risk areas that may arise from complaints, risk assessments, or that are identified by specific compliance protocols or through other means.

Response System

The Center has established and implemented procedures and a system for promptly responding to compliance issues as they are raised, investigating potential compliance problems as identified in the course of self-evaluations and audits, correcting such problems promptly and thoroughly, including reporting of any violations of state or federal law. These steps reduce the potential for recurrence, and ensure ongoing compliance with Federal health care program requirements (e.g., the Medicaid Program).

Policy of Non-intimidation and Non-Retaliation

Intimidation and Retaliation Are Prohibited. We expect all affected individuals to comply with this Program, including the reporting of any potential misconduct, illegal conduct or other compliance-related concerns. Retaliation or intimidation in any form against an individual who in good faith reports potential compliance issues or for other good faith participation in the Program is strictly prohibited and is itself a serious violation of the Code of Conduct. Acts of retaliation should be immediately reported to the Compliance Officer and, if substantiated, will be disciplined appropriately. The Center’s Whistleblower and Non-Retaliation/Non- Intimidation Policy is posted on our website. We ask that you review this policy and if applicable review it with your staff that provide services to the Center.

Background/Purpose

The HASC Diagnostic and Treatment Center, Inc. d/b/a the Blanche Kahn Family Health Center and the Rambam Family Health Center (collectively, the “Center”) is committed to complying with the requirements of Section 6032 of the Federal Deficit Reduction Act of 2005, and preventing and detecting any fraud, waste, or abuse. To this end, the Center maintains a Compliance Program and strives to educate its work force on fraud and abuse laws, including the importance of submitting accurate claims and reports to the Federal and State governments. The Center has instituted various procedures, which are set forth in our Compliance Manual and various Compliance Program policies and procedures, to ensure compliance with these laws and to assist us in preventing fraud, waste and abuse in federal health care programs. In furtherance of this policy and to comply with the Deficit Reduction Act, the Center disseminates this policy to all personnel (including management, contractors and other agents) to ensure that such persons are aware of certain relevant Federal and State laws, and that submission of a false claim can result in significant administrative and civil penalties under the Federal False Claims Act and other Federal and New York State laws.

Policy

To assist the Center in meeting its legal and ethical obligations, any Personnel who reasonably suspects or is aware of the preparation or submission of a false claim or report or any other potential fraud, waste, or abuse related to a Federally or State funded health care program is required to report such information to the Compliance Officer. Any personnel who report such information will have the right and opportunity to do so anonymously and will be protected against retaliation and intimidation for coming forward with such information both under our internal Compliance Program policies and procedures and Federal and State law. However, the Center retains the right to take appropriate action against any personnel who has participated in a violation of Federal or State law or the Center’s Compliance Program.

The Center is committed to investigating any suspicions of fraud, waste, or abuse swiftly and requires all personnel to assist in such investigations. Corrective action will be promptly and thoroughly implemented, as necessary and appropriate. Failure to report or assist in an investigation or resolution of fraud and abuse is a breach of the personnel’s obligations to the Center and may result in disciplinary action, up to, and including termination of employment, contract or affiliation with the Center.

Relevant Laws:

I. Federal Laws

A. The Federal False Claims Act (31 USC §§ 3729-3733)

The False Claims Act (“FCA”) provides, in pertinent part, as follows:

$3729. False claims

(a) Liability For Certain Acts.--

(1) IN General. – Subject to paragraph (2), any person who --

knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval;
knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim;
conspires to commit a violation of subparagraph (A), (B), (D), (E), (F), or (G);
has possession, custody, or control of property or money used, or to be used, by the Government and knowingly delivers, or causes to be delivered, less than all of that money or property;
is authorized to make or deliver a document certifying receipt of property used, or to be used, by the Government and, intending to defraud the Government, makes or delivers the receipt without completely knowing that the information on the receipt is true;
knowingly buys, or receives as a pledge of an obligation or debt, public property from an officer or employee of the Government, or a member of the Armed Forces, who lawfully may not sell or pledge property; or
knowingly makes, uses, or causes to be made or used, a false record or statement material to an obligation to pay or transmit money or property to the Government, or knowingly conceals or knowingly and improperly avoids or decreases an obligation to pay or transmit money or property to the Government, is liable to the United States Government for a civil penalty of not less than $5,000 and not more than $10,000, as adjusted by the Federal Civil Penalties Inflation Adjustment Act of 1990 (28 U.S.C. 2461),1 plus 3 times the amount of damages which the Government sustains because of the act of that person.

Although the statutory provisions of the Federal False Claims Act authorize a range of penalties of from between $5,000 and $10,000, those amounts have been adjusted for inflation and increased by regulation to not less than $13,508 and not more than $27,018 for penalties assessed after January 30, 2023, whose associated violations occurred after November 2, 2015. See 28 C.F.R. §85.5.

(2) Reduced Damages. --If the court finds that—

the person committing the violation of this subsection furnished officials of the United States responsible for investigating false claims violations with all information known to such person about the violation within 30 days after the date on which the defendant first obtained the information;
such person fully cooperated with any Government investigation of such violation; and (C) at the time such person furnished the United States with the information about the violation, no criminal prosecution, civil action, or administrative action had commenced under this title with respect to such violation, and the person did not have actual knowledge of the existence of an investigation into such violation, the court may assess not less than 2 times the amount of damages which the Government sustains because of the act of that person.

(3) Costs Of Civil Actions. --A person violating this subsection shall also be liable to the United States Government for the costs of a civil action brought to recover any such penalty or damages.

(b) Definitions. --For purposes of this section--

(1) the terms “knowing” and “knowingly” –

(A) mean that a person, with respect to information--

has actual knowledge of the informatio
acts in deliberate ignorance of the truth or falsity of the information; or
acts in reckless disregard of the truth or falsity of the information; and

(B) require no proof of specific intent to defraud;

(2) the term “claim”—

(A) means any request or demand, whether under a contract or otherwise, for money or property and whether or not the United States has title to the money or property, that—

is presented to an officer, employee, or agent of the United States; or
is made to a contractor, grantee, or other recipient, if the money or property is to be spent or used on the Government’s behalf or to advance a Government program or interest, and if the United States Government—
1. provides or has provided any portion of the money or property requested or demanded; or
2. will reimburse such contractor, grantee, or other recipient for any portion of the money or property which is requested or demanded; and

(B) does not include requests or demands for money or property that the Government has paid to an individual as compensation for Federal employment or as an income subsidy with no restrictions on that individual’s use of the money or property;

(3) the term “obligation” means an established duty, whether or not fixed, arising from an express or implied contractual, grantor-grantee, or licensor-licensee relationship, from a fee-based or similar relationship, from statute or regulation, or from the retention of any overpayment; and

(4) the term “material” means having a natural tendency to influence, or be capable of influencing, the payment or receipt of money or property.

(c) Exemption From Disclosure. --Any information furnished pursuant to subsection (a)(2) shall be exempt from disclosure under section 552 of title 5.

(d) Exclusion. --This section does not apply to claims, records, or statements made under the Internal Revenue Code of 1986

While the False Claims Act imposes liability only when the claimant acts “knowingly,” it does not require that the person submitting the claim have actual knowledge that the claim is false. A person who acts in reckless disregard or in deliberate ignorance of the truth or falsity of the information also can be found liable under the Act. 31 U.S.C. 3729(b).

In sum, the False Claims Act imposes liability on any person who submits a claim to the federal government, or submits a claim to entities administering government funds that he or she knows (or should know) is false. An example may be a physician who submits a bill to Medicare for medical services she knows she has not provided. The False Claims Act also imposes liability on an individual who may knowingly submit a false record in order to obtain payment from the government. An example of this may include a government contractor who submits records that he knows (or should know) are false and that indicate compliance with certain contractual or regulatory requirements. The third area of liability includes those instances in which someone may obtain money from the federal government to which he may not be entitled, and then uses false statements or records in order to retain the money. An example of this so-called “reverse false claim” may include a hospital which obtains interim payments from Medicare or Medicaid throughout the year, and then knowingly files a false cost report at the end of the year in order to avoid making a refund to the Medicare or Medicaid progra

In addition to its substantive provisions, the FCA provides that private parties may bring an action on behalf of the United States. 31 U.S.C. 3730 (b). These private parties, known as “qui tam relators,” may share in a percentage of the proceeds from an FCA action or settlement.

Section 3730(d)(1) of the FCA provides, with some exceptions, that a qui tam relator, when the Government has intervened in the lawsuit, shall receive at least 15 percent but not more than 25 percent of the proceeds of the FCA action depending upon the extent to which the relator substantially contributed to the prosecution of the action. When the Government does not intervene, section 3730(d)(2) provides that the relator shall receive an amount that the court decides is reasonable and shall be not less than 25 percent and not more than 30 percent

B. Administrative Remedies for False Claims (31 USC Chapter 38. §§ 3801–3812)

This statute allows for administrative recoveries by federal agencies. If a person submits a claim that the person knows is false or contains false information, or omits material information, the agency receiving the claim may impose a penalty of up to $5,000 for each claim.2 The agency may also recover twice the amount of the claim

Unlike the False Claims Act, a violation of this law occurs when a false claim is submitted rather than when it is paid. Also unlike the False Claims Act, the determination of whether a claim is false, and the imposition of fines and penalties is made by the administrative agency, not by prosecution in the federal court system.

II. New York State Laws

New York’s false claims laws fall into two categories: civil and administrative; and criminal laws. Some apply to recipient false claims and some apply to provider false claims, and while most are specific to healthcare or Medicaid, some of the “common law” crimes apply to areas of interaction with the government.

A. Civil And Administrative Laws

1. NY False Claims Act (State Finance Law, $187–194)

The NY False Claims Act closely tracks the federal False Claims Act. It imposes penalties and fines on individuals and entities that file false or fraudulent claims for payment from any state or local government, including health care programs such as Medicaid. The penalty for filing a false claim is equal to the amount that may be imposed under the federal FCA (as may be adjusted for inflation) and the recoverable damages are between two and three times the value of the amount falsely received. In addition, the false claim filer may have to pay the government’s legal fees.
The Act allows private individuals to file lawsuits in state court, just as if they were state or local government parties. If the suit eventually concludes with payments back to the government, the person who started the case can recover 25-30% of the proceeds if the government did not participate in the suit of 15-25% if the government did participate in the suit.

Social Services Law §145-b -- False Statements
1. It is a violation to knowingly obtain or attempt to obtain payment for items or services furnished under any Social Services program, including Medicaid, by use of a false statement, deliberate concealment or other fraudulent scheme or device. The state or the local Social Services district may recover three times the amount incorrectly paid. In addition, the Department of Health may impose a civil penalty of up to ten thousand dollars per violation. If repeat violations occur within five years, a penalty of up to thirty thousand dollars per violation may be imposed if the repeat violations involve more serious violations of Medicaid rules, billing for services not rendered, or providing excessive services.
Social Services Law § 145-c – Sanctions
1. If any person applies for or receives public assistance, including Medicaid, by intentionally making a false or misleading statement, or intending to do so, the needs of the individual or that of his family shall not be taken into account for the purpose of determining his or her needs or that of his family for six months if a first offense, for twelve months if a second offense (or if benefits wrongfully received are at least one thousand dollars but not more than three thousand nine hundred dollars), for eighteen months if a third offense (or if benefits wrongfully received are in excess of three thousand nine hundred dollars), and five years for any subsequent occasion of any such offense.
B. Criminal Laws
1. Social Services Law $145 – Penalties
  - Any person who submits false statements or deliberately conceals material information in order to receive public assistance, including Medicaid, is guilty of a misdemeanor.
2. Social Services Law $366-b – Penalties for Fraudulent Practices
  - Any person who obtains or attempts to obtain, for himself or others, medical assistance by means of a false statement, concealment of material facts, impersonation or other fraudulent means is guilty of a Class A misdemeanor.
  - Any person who, with intent to defraud, presents for payment and false or fraudulent claim for furnishing services, knowingly submits false information to obtain greater Medicaid compensation or knowingly submits false information in order to obtain authorization to provide items or services is guilty of a Class A misdemeanor.
3. Penal Law Article 155 – Larceny
  The crime of larceny applies to a person who, with intent to deprive another of his property, obtains, takes or withholds the property by means of trick, embezzlement, false pretense, false promise, including a scheme to defraud, or other similar behavior. It has been applied to Medicaid fraud cases
  1. Fourth degree grand larceny involves property valued over $1,000. It is a Class E felony.
  2. Third degree grand larceny involves property valued over $3,000. It is a Class D felony.
  3. Second degree grand larceny involves property valued over $50,000. It is a Class C felony.
  4. First degree grand larceny involves property valued over $1 million. It is a Class B felony.
4. Penal Law Article 175 – False Written Statements
  Four crimes in this Article relate to filing false information or claims and have been applied in Medicaid fraud prosecutions:
  1. $175.05, Falsifying business records involves entering false information, omitting material information or altering an enterprise’s business records with the intent to defraud. It is a Class A misdemeanor.
  2. $175.10, Falsifying business records in the first degree includes the elements of the § 175.05 offense and includes the intent to commit another crime or conceal its commission. It is a Class E felony.
  3. $175.30, Offering a false instrument for filing in the second degree involves presenting a written instrument (including a claim for payment) to a public office knowing that it contains false information. It is a Class A misdemeanor.
  4. $175.35, Offering a false instrument for filing in the first degree includes the elements of the second degree offense and must include an intent to defraud the state or a political subdivision. It is a Class E felony.
5. Penal Law Article 176 – Insurance Fraud
  Applies to claims for insurance payment, including Medicaid or other health insurance and contains six crimes.
  - Insurance Fraud in the 5th degree involves intentionally filing a health insurance claim knowing that it is false. It is a Class A misdemeanor.
  - Insurance fraud in the 4th degree is filing a false insurance claim for over $1,000. It is a Class E felony.
  - Insurance fraud in the 3rd degree is filing a false insurance claim for over $3,000. It is a Class D felony.
  - Insurance fraud in the 2nd degree is filing a false insurance claim for over $50,000. It is a Class C felony.
  - Insurance fraud in the 1st degree is filing a false insurance claim for over $1 million. It is a Class B felony.
  - Aggravated insurance fraud is committing insurance fraud more than once. It is a Class D felony.
6. Penal Law Article 177 – Health Care Fraud
  Applies to claims for health insurance payment, including Medicaid, and contains five crimes:
  - Health care fraud in the 5th degree is knowingly filing, with intent to defraud, a claim for payment that intentionally has false information or omissions. It is a Class A misdemeanor.
  - Health care fraud in the 4th degree is filing false claims and annually receiving over $3,000 in aggregate. It is a Class E felony.
  - Health care fraud in the 3rd degree is filing false claims and annually receiving over $10,000 in the aggregate. It is a Class D felony.
  - Health care fraud in the 2nd degree is filing false claims and annually receiving over $50,000 in the aggregate. It is a Class C felony.
  - Health care fraud in the 1st degree is filing false claims and annually receiving over $1 million in the aggregate. It is a Class B felony.

Iii. Whistleblower Protections

A. Federal False Claims Act (31 U.S.C. $3730[h])

The Federal False Claims Act provides protection to qui tam relators (individuals who commence a False Claims action) who are discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of their employment as a result of their furtherance of an action under the FCA. 31 U.S.C. 3730(h). Remedies include reinstatement with comparable seniority as the qui tam relator would have had but for the discrimination, two times the amount of any back pay, interest on any back pay, and compensation for any special damages sustained as a result of the discrimination, including litigation costs and reasonable attorneys’ fees.

B. NY False Claim Act (State Finance Law $191)

The New York State False Claim Act also provides protection to qui tam relators (individuals who commence a False Claims action) who are discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of their employment as a result of their furtherance of an action under the Act. Remedies include reinstatement with comparable seniority as the qui tam relator would have had but for the discrimination, two times the amount of any back pay, interest on any back pay, and compensation for any special damages sustained as a result of the discrimination, including litigation costs and reasonable attorneys’ fees.

C. New York Labor Law $740

Labor Law Section 740 prohibits the taking of “retaliatory” action by an employer against an employee (including former employees and natural persons working as independent contractors), whether or not the employee is acting within the scope of his or her job duties, because the employee does any of the following:

Discloses or threatens to disclose to a supervisor or to a public body an activity, policy or practice of the employer that the employee reasonably believes is in violation of law, rule or regulation or that the employee reasonably believes poses a substantial and specific danger to the public health or safety;3
Provides information to, or testifies before, any public body conducting an investigation, hearing or inquiry into any such activity, policy or practice by such employer; or
Objects to, or refuses to participate in, any such activity, policy or practice.

Under Section 740, “retaliatory action” is defined to mean an adverse action taken by an employer or his or her agent to discharge, threaten, penalize, or in any other manner discriminate against any employee or former employee exercising his or her rights under Section 740. This includes: (i) adverse employment actions or threats to take such adverse employment actions against an employee in the terms of conditions of employment (including but not limited to discharge, suspension, or demotion); (ii) actions or threats to take such actions that would adversely impact a former employee’s current or future employment; or (iii) threatening to contact or contacting United States immigration authorities or otherwise reporting or threatening to report an employee’s suspected citizenship or immigration status or the suspected citizenship or immigration status of an employee's family or household member.

If an employer takes a retaliatory action against the employee, the employee may bring a civil action within two years after the alleged retaliatory action was taken. The parties to such an action are entitled to a jury trial. A court may order: an injunction to restrain continued violation of the law; the reinstatement of the employee to the same position held before the retaliatory action, or to an equivalent position or “front pay;” the reinstatement of full fringe benefits and seniority rights; the compensation for lost wages, benefits and other remuneration; the payment by the employer of reasonable costs, disbursements and attorneys’ fees; a civil penalty not to exceed $10,000; and/or the payment by the employer of punitive damages, if the violation was willful, malicious or wanton.

D. New York Labor Law $741

Labor Law Section 741 prohibits certain defined health care employers from taking “retaliatory action” against an employee because the employee does any of the following:

discloses or threatens to disclose to a supervisor, to a public body, to a news media outlet, or to a social media forum available to the public at large, an activity, policy or practice of the employer or agent that the employee, in good faith, reasonably believes constitutes improper quality of patient care or improper quality of workplace safety; or
objects to, or refuses to participate in, any activity, policy or practice of the employer or agent that the employee, in good faith, reasonably believes constitutes improper quality of patient care or improper quality of workplace safety.

Section 741 defines “retaliatory action” to mean the discharge, suspension, demotion, penalization or discrimination against an employee, or other adverse employment action taken against an employee in the terms and conditions of employment.

An employee will not be protected under Section 741 unless he or she has brought the improper quality of patient care or improper quality of workplace safety to the attention of a supervisor and has afforded the employer a reasonable opportunity to correct the activity, policy or practice.

However, such notice and opportunity to correct is not required in connection with disclosures or threats to disclose an activity, policy or practice of the employer or agent that the employee, in good faith, reasonably believes constitutes improper quality of patient care or improper quality of workplace safety where it presents an imminent threat to public health or safety or to the health of a specific patient or specific health care employee and the employee reasonably believes in good faith that reporting to a supervisor would not result in corrective action.

The same relief and enforcement provided for under Labor Law Section 740 (described above) are applicable to retaliatory actions under Section 741.

I. Policy

The purpose of this Policy is to ensure that all personnel understand HASC Diagnostic and Treatment Center, Inc. d/b/a/ the Blanche Kahn Family Health Center and the Rambam Family Health Center’s (collectively, the “Center”) commitment to prohibiting intimidation, retaliation, harassment and discrimination for “good faith participation in the Compliance Program” (as defined below).

Intimidation or retaliatory action in any form by any individual associated with the Center is strictly prohibited and is itself a serious violation of the Code of Conduct and this Policy. This includes, but is not limited to, any adverse employment action and any other negative treatment resulting from good faith participation in the Compliance Program.

Ii. Participation In The Compliance Program

“Good faith participation in the Compliance Program” includes, but is not limited to:

reporting actual or potential issues or concerns, including but not limited to, any action or suspected action taken by or within the Center that is illegal, fraudulent or in violation of any adopted Center policy to appropriate personnel (as indicated below);
cooperating with or participating in the investigation of potential compliance issues;
assisting with or participating in self-evaluations, audits, and/or implementation of remedial actions;
reporting potential fraud, waste or abuse to the appropriate State or Federal entities, including the appropriate regulatory officials as provided in New York Labor Law $ 740 and 741.1

Iii. Reporting And Confidentiality

As required by the Center’s Compliance Program, all Affected Individuals are expected to report suspected misconduct or possible violations of the Compliance Program to the Compliance Officer, at the phone number or e-mail address below. Affected Individuals may also report compliance issues or concerns to the Compliance Hotline. Affected Individuals may report compliance issues or concerns anonymously, if they choose (by way of the Hotline or otherwise).

If you report compliance issues, your identity will be kept confidential, whether requested or not, unless the matter is subject to a disciplinary proceeding, referred to, or under investigation by, MFCU, OMIG or law enforcement, or disclosure is required during a legal proceeding.

Iv. Procedure

A. Investigation of Intimidation/Retaliation Complaints

All allegations of intimidation or retaliation for good faith participation in the Compliance Program will be promptly investigated. The Compliance Officer, or designee, will oversee the investigation and take all necessary and appropriate actions. The Compliance Officer, or designee, will be assisted by internal staff and/or may solicit the support of external resources (including counsel), as necessary and appropriate.
All individuals who may have relevant information will be promptly interviewed. At the outset of the interview process, the interviewee will be reminded that retaliation and intimidation is unlawful and a violation of the Center’s Code of Conduct. The interviewee will also be reminded of the Center’s disciplinary policy regarding failure to cooperate (See the “Protocols for Investigations and Implementing Corrective Action, Including Discipline”).
All documentation related to the investigation will be kept secured in a central location under the control of the Compliance Officer or designee. Such investigative files will be kept separate from personnel files.
If the Compliance Officer determines that an individual was improperly intimidated or retaliated against for good faith participation in the Compliance Program, the Center will, in accordance with the Center’s Compliance Program, take all appropriate corrective action as to the individual who was intimidated or retaliated against.
In addition, if the Compliance Officer determines that an individual was intimidated or retaliated against for good faith participation in the Compliance Program, appropriate disciplinary action will be taken against the offending person, in accordance with the Center’s Compliance Program.
The Center may terminate contracts and affiliations as a result of retaliation or intimidation.

B. Reporting to the Board of Directors

The Compliance Officer will advise the Board of Directors regarding any alleged acts of retaliation or intimidation in violation of this Policy on an on-going basis.

Appendix:

A Brief Summary Of New York Labor Law Sections 740 & 7412

New York Labor Law Sections 740 and 741 are laws that provide protection to “whistleblowers” in certain cases. This Appendix provides a brief summary of these laws.

New York Labor Law Section 740

Section 740 prohibits the taking of “retaliatory action” by an employer against an employee (including former employees and natural persons working as independent contractors), whether or not the employee is acting within the scope of his or her job duties, because the employee does any of the following:

discloses or threatens to disclose to a supervisor or to a public body an activity, policy or practice of the employer that the employee reasonably believes is in violation of law, rule or regulation or that the employee reasonably believes poses a substantial and specific danger to the public health or safety;
provides information to, or testifies before, any public body conducting an investigation, hearing or inquiry into any such activity, policy or practice by such employer; or
objects to, or refuses to participate in, any such activity, policy or practice.

Under Section 740, “retaliatory action” is defined to mean an adverse action taken by an employer or his or her agent to discharge, threaten, penalize, or in any other manner discriminate against any employee or former employee exercising his or her rights under Section 740. This includes: (i) adverse employment actions or threats to take such adverse employment actions against an employee in the terms or conditions of employment (including but not limited to discharge, suspension, or demotion); (ii) actions or threats to take such actions that would adversely impact a former employee’s current or future employment; or (iii) threatening to contact or contacting United States immigration authorities or otherwise reporting or threatening to report an employee’s suspected citizenship or immigration status or the suspected citizenship or immigration status of an employee’s family or household member to a federal, state, or local agency.

Conditions and Exceptions Under New York Labor Law Section 740

An employee’s disclosure to a public body of an activity, policy or practice of the employer that the employee reasonably believes is in violation of law, rule or regulation or that the employee reasonably believes poses a substantial and specific danger to the public health or safety will not be protected under Section 740 unless the employee has made a good faith effort to notify his or her employer. Specifically, when such notice is required, the employee is required to bring the activity, policy or practice to the attention of a supervisor of the employer and to afford the employer a reasonable opportunity to correct it. However, such employer notification is not required where:

there is an imminent and serious danger to the public health or safety;
the employee reasonably believes that reporting to the supervisor would result in a destruction of evidence or other concealment of the activity, policy or practice;
such activity, policy or practice could reasonably be expected to lead to endangering the welfare of a minor;
the employee reasonably believes that reporting to the supervisor would result in physical harm to the employee or any other person; or
the employee reasonably believes that the supervisor is already aware of the activity, policy or practice and will not correct it.

New York Labor Law Section 741

Section 741 prohibits certain defined health care employers from taking “retaliatory action” against an employee because the employee does any of the following:

discloses or threatens to disclose to a supervisor, to a public body, to a news media outlet, or to a social media forum available to the public at large, an activity, policy or practice of the employer or agent that the employee, in good faith, reasonably believes constitutes improper quality of patient care or improper quality of workplace safety; or
objects to, or refuses to participate in, any activity, policy or practice of the employer or agent that the employee, in good faith, reasonably believes constitutes improper quality of patient care or improper quality of workplace safety.

Conditions and Exceptions Under New York Labor Law Section 741

Relief/Enforcement Under Both New York Labor Law Sections 740 and 741

Under both Sections 740 and Section 741, an employee who has been the subject of retaliatory action in violation of the law may bring a civil action within two years after the alleged retaliatory action was taken. The parties to such an action are entitled to a jury trial.

In connection with such an action, a court may order: an injunction to restrain continued violation of the law; the reinstatement of the employee to the same position held before the retaliatory action, or to an equivalent position, or “front pay”; the reinstatement of full fringe benefits and seniority rights; the compensation for lost wages, benefits and other remuneration; the payment by the employer of reasonable costs, disbursements and attorneys’ fees; a civil penalty not to exceed $10,000; and/or the payment by the employer of punitive damages, if the violation was willful, malicious or wanton.

Under both Sections 740 and 741, it is a defense that the retaliatory action was predicated on grounds other than the employee’s exercise of the rights that these sections of the law protect.3