TIFT REGIONAL MEDICAL CENTER

COMPLIANCE PROGRAM

Adopted: March 1999Amended: August 21, 2000

Amended: February 19, 2001Amended: May 21, 2001

VISION

Tift Regional Medical Center will develop an organizational culture in which systems fulfill and support our mission as evidenced by:

Become clearly recognized as a provider of compassionate individualized care for the citizens of Tift County and our surrounding communities.

Consistently measure, assess and improve patient satisfaction. Remaining cognizant of the evolving status of healthcare changes and maintaining a

proactive response. Becoming clearly recognized as a leader in information management and integration of

services of the hospital and the physicians' practices, and other identified partners in healthcare management.

Maintain status as a major regional leader in providing the most comprehensive participation in healthcare delivery and utilization management across the continuum of care.

Becoming clearly recognized as the highest quality healthcare system in the region. Cooperate with and support other healthcare providers so as to provide for the continuum

of healthcare services. Serve as a major leading resource for information and education within our areas of

service with particular emphasis on preventative and others as needed. Provide comprehensive, accessible inpatient and outpatient healthcare services. Assist neighboring counties as requested in the provision of accessible local healthcare. Maintain constant vigilance of corporate compliance by in-depth surveillance,

monitoring, auditing, and education of the Tift Regional Medical Center Compliance Program.

Develop systems to proactively identify and manage potential risk to patient safety by promoting an environment of reporting and prevention.

MISSION

The philosophy of Tift Regional Medical Center is based on the belief that the primary and fundamental purpose of the Medical Center’s existence is to serve the health needs of the patient as well as those of the community. The Tift County Hospital Authority has the complete legal and moral duty and responsibility to see that Tift Regional Medical Center renders an adequate range of services that include preventive, inpatient, and outpatient services; to see that these services are delivered with a consistent, high level of quality; and, to ensure the hospital’s financial viability and cost effectiveness. The Medical Center also strives to assist in the provision of an adequate number of primary care and specialty physicians in the region in order to facilitate access to healthcare services. Insofar as Tift Regional Medical Center is a regional referral facility serving the healthcare needs of the many citizens in South Central Georgia, the Hospital Authority recognizes its responsibility in a multi-county region. In this role, the Medical Center strongly supports the development and accreditation of quality continuing medical education programs. The Medical Center is expected to adopt new and innovative methods of healthcare delivery consistent with the identified needs of the region.

SECTION ONE TABLE OF CONTENTS

TIFT REGIONAL MEDICAL CENTERCOMPLIANCE PROGRAM CODE OF CONDUCT

I. INTRODUCTION....................................................................................................... 1

II. ADDRESSING ISSUES AND CONCERNS.............................................................. 1

III. HELPLINE................................................................................................................. 1

IV. REPORTING.............................................................................................................. 1

V. COMPLIANCE AS AN ELEMENT OF PERFORMANCE....................................... 2

VI. PRINCIPLES AND STANDARDS............................................................................ 2

PRINCIPLE 1 - PATIENT CARE.............................................................................. 21.1. Treatment of Patients..................................................................................... 21.2. Privacy of Patients......................................................................................... 21.3. Appropriate Care........................................................................................... 21.4. Standards of Professional Practice................................................................. 2

PRINCIPLE 2 - HUMAN RESOURCES.................................................................... 32.1. Equal Employment Opportunities.................................................................. 32.2. Drugs, Narcotics, and Alcohol....................................................................... 3

PRINCIPLE 3 - ENVIRONMENTAL HEALTH AND SAFETY............................... 43.1. Workplace Violence...................................................................................... 43.2. Environmental............................................................................................... 4

PRINCIPLE 4 - CORPORATE INTEGRITY............................................................. 44.1. Conflict of Interest........................................................................................ 44.2. Market Practices............................................................................................ 54.3. Protection of Assets....................................................................................... 64.4. Lobbying/Political Activity........................................................................... 6

PRINCIPLE 5 - REGULATORY COMPLIANCE...................................................... 65.1. Regulatory Requirements.............................................................................. 75.2. Tift Regional Medical Center Policies and Procedures.................................. 75.3. Tax................................................................................................................ 75.4. Antitrust........................................................................................................ 75.5. Physicians...................................................................................................... 7

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PRINCIPLE 6 - REFERRALS.................................................................................... 76.1. Referrals........................................................................................................ 76.2. Admissions.................................................................................................... 8

PRINCIPLE 7 - REIMBURSEMENT CLAIMS......................................................... 87.1. Billing Fraud & Abuse................................................................................ 87.2. Cost Reports.................................................................................................. 87.3. Medical Necessity......................................................................................... 9

PRINCIPLE 8 - CONFIDENTIALITY....................................................................... 98.1. Patient Information........................................................................................ 98.2. Proprietary Information................................................................................. 9

PRINCIPLE 9 - GOVERNMENT INVESTIGATIONS.............................................. 99.1. Responding to Inquiries................................................................................ 99.2. Responding to Subpoenas.............................................................................. 10

PRINCIPLE 10 - DOCUMENT RETENTION........................................................... 1010.1. Requirements of Government Programs and Other Third-Party Payors....... 1010.2. Tift Regional Document Retention Policies................................................. 10

SECTION TWO TABLE OF CONTENTS

TIFT REGIONAL MEDICAL CENTER COMPLIANCE PROGRAM

I. PURPOSE................................................................................................................... 1

II. PROGRAM STRUCTURE.......................................................................................... 1

III. IMPLEMENTATION.................................................................................................. 2

IV. EMPLOYEE AND CONTRACTOR DISCLOSURE.................................................. 2A. Applicants for Employment................................................................................. 2B. Current Employees and Contractors..................................................................... 3C. Employee Departures........................................................................................... 3D. Annual Disclosure............................................................................................... 3

V. TRAINING AND EDUCATION................................................................................. 4A. Responsibility...................................................................................................... 4B. Subject Matter..................................................................................................... 4C. Methods............................................................................................................... 4D. Managers and Supervisors................................................................................... 4E. Performance of Education/Training Requirements............................................... 4

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VI. REPORTING AND INVESTIGATING...................................................................... 5A. Compliance Helpline........................................................................................... 5B. Employee Reporting............................................................................................ 5C. Investigation........................................................................................................ 5D. Compliance Committee Reports.......................................................................... 6

VII. AUDITING AND MONITORING.............................................................................. 6A. Audits.................................................................................................................. 6B. Monitoring........................................................................................................... 6

VIII. RESPONSE TO REPORT OF VIOLATIONS............................................................ 6

IX. DISCIPLINARY PROCEDURES............................................................................... 7A. Disciplinary Policy.............................................................................................. 7

X. MODIFYING AND AMENDING THE COMPLIANCE PROGRAM........................ 7

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SECTION ONE

TIFT REGIONAL MEDICAL CENTERCOMPLIANCE PROGRAM

CODE OF CONDUCT

May 21, 2001

Tift Regional Medical Center (“Tift Regional”) is committed to providing quality healthcare services in accordance with the law. To achieve this objective, Tift Regional developed this Code of Conduct to be followed by employees and others who work with Tift Regional. The development and implementation of a Compliance Program and this Code of Conduct should not be interpreted as a concern that present management systems are inadequate. The development of a Compliance Program and this Code of Conduct is simply another element in our continuing efforts to improve quality and performance.

Although this Code of Conduct cannot, nor was it intended to, cover every situation you may encounter, this Code of Conduct does provide guidance to the complex legal and business ethics issues we face and provides alternatives for resolution of issues or concerns you may have about Tift Regional operations.

We are committed to the ideals reflected in our Vision, our Mission and in this Code of Conduct and ask you to assist us and all our colleagues at Tift Regional in supporting the values and principles which are critical to achieving our Vision and our Mission.

William T. Richardson, FACHEPresident-CEO

I. INTRODUCTION

Adherence to this Code of Conduct is a condition of employment and will be an important factor in each employee’s performance evaluation. Conduct in violation of the Principles and Standards set forth below is beyond the scope of an employee’s job and may lead to serious sanctions, including termination. However, the Principles and Standards cannot, nor were they intended to, cover every situation.

II. ADDRESSING ISSUES AND CONCERNS

The numerous, ever-changing regulations and rules that govern each department of Tift Regional can create areas of uncertainty for employees, professional staff members and agents who carry out daily operations. When such questions or uncertainty exists, it is each person’s obligation to seek guidance. Employees with issues or concerns regarding this Code of Conduct or any of the Principles or Standards should contact any member of the Compliance Committee or the Helpline.

III. HELPLINE: 386-6250

Employees, professional staff members and agents may anonymously call the Helpline to report ethical or legal concerns or to report any potentially improper action on the part of any Tift Regional officer, agent, employee, contractor or representative. A person who makes a report to the Helpline has a continuing obligation to update the report as additional information is available. Callers will be given a number so that they can call for an update at a later date. The Compliance Committee, assisted by the appropriate department, will investigate all calls.

Although information reported to the Compliance Committee or Helpline in accordance with the Compliance Program shall be kept confidential to the extent that confidentiality is possible, there may be a point where a person’s identity may become known or have to be revealed to further the investigation. No adverse action will be taken against a Helpline caller on the basis of a call, if the call is made in good faith. Any person who deliberately makes a false accusation with the purpose of harming or retaliating against another person will be subject to discipline, up to termination.

IV. REPORTING

Tift Regional employees, professional staff members and agents are expected to promptly report any perceived or alleged violation of the Compliance Program, Code of Conduct and/or Tift Regional policies and procedures to someone in their chain of command, the Compliance Committee or the Helpline. Managers and supervisors shall report to the Compliance Committee all compliance issues received from members of their department which require investigation or corrective action. Any employee, professional staff member or agent who is instructed, directed, or requested to engage in conduct prohibited by the Compliance Program, the Code of Conduct and/or Tift Regional policies and procedures shall promptly report such information to the Compliance Committee or the Helpline.

V. COMPLIANCE AS AN ELEMENT OF PERFORMANCE

The promotion of and adherence to the Compliance Program is the job responsibility of all employees and is a factor in evaluating the performance of employees, agents and contractors. Adherence to the Compliance Program includes reporting problems or noncompliance with applicable policies or legal requirements to someone in the employee’s chain of command, the Compliance Committee or the Helpline.

Violations of the Compliance Program, the Code of Conduct, Tift Regional policies or procedures or applicable laws or regulations will be grounds for disciplinary action up to privilege revocation (subject to applicable peer review procedure), discharge or contract termination, depending on the circumstances of each violation. Disciplinary action for noncompliance shall be taken consistently on a fair and equitable basis. Disciplinary action will be taken not only against employees, professional staff members and agents who authorize or participate directly in a violation but also against such persons who deliberately fail to report a violation or any responsible employee whose failure to detect a violation is attributable to his or her negligence or reckless conduct. Managers and supervisors will be sanctioned for failure to adequately instruct members of their department or for failure to detect noncompliance with applicable policies and legal requirements where reasonable diligence on the part of the manager or supervisor would have led to an avoidance of or an earlier discovery of a problem or violation.

VI. PRINCIPLES AND STANDARDS

PRINCIPLE 1 - PATIENT CARE

Compassionately deliver appropriate, effective, quality care to our patients.

Standard 1.1 Treatment of Patients. Patients deserve to be treated at all times with dignity, respect and professionalism.

Standard 1.2 Privacy of Patients. Patients’ privacy will be respected.

Standard 1.3 Appropriate Care. Patient care must be appropriate and designed to meet the intended outcome of the patient’s treatment plan.

Standard 1.4 Standards of Professional Practice. Tift Regional employees shall observe all applicable standards of professional practice in all Tift Regional facilities and programs.

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PRINCIPLE 2 - HUMAN RESOURCES

Tift Regional is a drug-free work place and an equal opportunity employer. Tift Regional will comply with applicable laws concerning employment, promotion, transfers, demotions and wages.

Standard 2.1 Equal Employment Opportunities. Harassment or abuse of any kind is prohibited in the Tift Regional workplace. Tift Regional prohibits discrimination in any work-related decision on the basis of sex, race, age, color, religious beliefs, disability status, national origin or any other illegal basis. Tift Regional expects everyone associated with Tift Regional to treat co-workers and patients with respect and courtesy and to respect and protect the privacy of Tift Regional employees and patients. Tift Regional does not tolerate discrimination or harassment on Tift Regional property by or against any person and will discipline or discharge those who violate this Standard. Freedom from harassment specifically includes freedom from sexual advances, requests for sexual favors, sexual innuendo, jokes of a sexual nature, or other verbal, graphic or physical forms of a sexual nature.

If an employee, contractor or agent perceives that inequitable or unfair conduct is occurring in the workplace, he/she should utilize Tift Regional’s existing grievance process already available. If the employee, contractor or agent feels that use of these resources does not resolve the matter, he/she may contact the Human Resources Director, the Compliance Committee or the Helpline.

Standard 2.2 Drugs, Narcotics, and Alcohol. All employees, agents and contractors must report for work free of the influence of alcohol and illegal drugs. Reporting to work under the influence of any illegal drug or alcohol, having an illegal drug in your system, or using, possessing or selling drugs while on Tift Regional work time or property may result in immediate discharge or termination of contract. Any person reporting to work or discovered at work in a condition that suggests he or she is under the influence of narcotics, drugs or alcohol will not be permitted to report to or remain on the job. Drug testing may be used as a means of enforcing this Standard.

In order to ensure the safety of all Tift Regional employees and patients, any employee who has been directed by a physician to take a prescription drug that may adversely affect or impair performance on the job must report that circumstance to his/her immediate supervisor. Reasonable accommodation will be made for employees suffering from any disability, so long as the accommodation does not create an undue risk of harm to the employee, patients or others.

If an employee, professional staff member, agent or contractor has concerns regarding possible violations of this Standard, he/she should contact someone in his/her chain of command, the Compliance Committee or the Helpline.

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PRINCIPLE 3 - ENVIRONMENTAL HEALTH AND SAFETY

Standard 3.1 Workplace Violence. Tift Regional is committed to maintaining a work environment free from workplace violence. Workplace violence includes threats of violence or violent acts such as robbery, stalking, violence directed at employees or Tift Regional, terrorism, and hate crimes committed by current or former employees. Tift Regional prohibits the possession of firearms, other weapons, explosive devices, or other dangerous materials on Tift Regional premises. Persons who experience or observe any form of violence should report the incident to someone in their chain of command, the Director of Security, the Compliance Committee or the Helpline.

Standard 3.2 Environmental. Tift Regional strives to manage and operate its business in a manner which respects our environment and conserves natural resources. In Tift Regional operations, employees, professional staff members and agents shall 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 appropriate authorities to remedy any environmental contamination for which Tift Regional may be responsible.

PRINCIPLE 4 - CORPORATE INTEGRITY

Standard 4.1 Conflict of Interest. Each Tift Regional employee has a duty of loyalty to Tift Regional. Employees must avoid conflicts of interest and the appearance of conflicts of interest.

a. Outside Financial Interests. A conflict of interest occurs if an outside activity or personal interest may influence or appear to influence your ability to make objective decisions or meet your job responsibilities for Tift Regional. A conflict of interest may also occur if the demands of any outside activities hinder or distract you from the performance of your job responsibilities or cause you to use Tift Regional resources for any purpose other than Tift Regional purposes. Participation in activities that conflict with your employment responsibilities at Tift Regional is not acceptable. While not inclusive, the following will serve as a guide to the types of activities by an employee which might cause a conflict of interest:

1. Ownership. Tift Regional employees should not own stock in, serve as a director or officer of, receive compensation from, or provide consulting or other services to hospitals or firms in competition with Tift Regional without the written consent of the Director of Human Resources. However, Tift Regional employees may own less than one percent of the outstanding shares of any class of equity security of a competitor or supplier listed on a national securities exchange or regularly traded in the over-the-counter market.

2. Suppliers. Tift Regional employees who deal with suppliers must do so in a professional and legal manner. Tift Regional employees should not conduct any business not on behalf of Tift Regional with any vendor, supplier, contractor, or agency, or any of their officers or directors. To avoid even the appearance of impropriety, Tift Regional employees should decline gifts of more than nominal

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value, including discounts, of which the acceptance would raise even the slightest doubt of improper influence. Discounts that are available to all Tift Regional employees and employees of other companies may be accepted.

3. Business Information. Tift Regional employees may not use for their personal benefit any information about Tift Regional or information acquired as a result of the employee’s relationship with Tift Regional. Employees should disclose business information only as required in the performance of their job or as expressly authorized by Tift Regional. Violation of this policy may result in personal liability to the employee for any benefit gained from improper use of such information or any damages sustained by Tift Regional as a result of improper disclosure of such information.

b. Disclosure of Possible Conflict of Interest. Employees should disclose possible conflicts of interest involving themselves or their immediate families to the Director of Human Resources. The Director of Human Resources will investigate and report possible conflicts to the Compliance Committee. The Compliance Committee will determine whether significant conflicts of interest do occur and take the necessary steps to protect Tift Regional.

If a Tift Regional employee has concerns about possible conflicts of interest, the employee should contact the Director of Human Resources, the Compliance Committee or the Helpline.

Standard 4.2 Market Practices. Tift Regional will comply with applicable laws concerning advertising and will forgo any business which can only be obtained by improper or illegal means.

a. Compliance with state and federal requirements. Employees must submit all advertising and marketing materials to the Director of Physician and Marketing Services for approval before use.

b. Tift Regional advertising must be truthful and not misleading. Specific claims about the quality of Tift Regional’s services must be supported by evidence to substantiate the claims made. All price advertising must accurately reflect the true charge for services provided.

If an employee has concerns regarding possible unethical or unlawful marketing practices, the employee should contact the Director of Physician and Marketing Services, the Compliance Committee or the Helpline.

c. Tift Regional will forego any business which can only be obtained by improper and illegal means. Tift Regional will not make any unethical or illegal payments to anyone to induce the use of Tift Regional services. To avoid the appearance of impropriety, Tift Regional will not provide any payment or reimbursement for expenses incurred by any government representative or employee. Tift Regional also will not provide gifts or payment of any kind to or on behalf of any government representative or employee. Tift Regional will not offer, make, accept or receive payments or anything of value in order to obtain a competitive advantage with regard to contracts that involve the provision of healthcare services to Medicare or Medicaid beneficiaries.

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Tift Regional employees should contact the Chief Financial Officer, the Compliance Committee or the Helpline immediately if unethical or illegal payments are requested or made.

Standard 4.3 Protection of Assets. Employees shall use Tift Regional property and assets for Tift Regional purposes only and shall strive to preserve and protect the assets of Tift Regional by making prudent and effective use of Tift Regional resources and properly and accurately reporting its financial condition.

a. Financial Reporting. All financial reports, accounting records, expense accounts, time sheets and other documents must accurately reflect the facts or the true nature of the transaction. Improper or fraudulent accounting, documentation or financial reporting is contrary to the policy of Tift Regional and may be in violation of applicable laws. Employees must not engage in any arrangement that results in false, artificial, or misleading entries being made in any records.

b. Personal Use of Tift Regional Assets. Tift Regional property is made available to employees only for authorized Tift Regional business purposes and should not be used for personal reasons. This applies to physical assets such as office equipment, computers, software and supplies or medical supplies, as well as other types of property such as company records, patient information and customer lists. All property and business of Tift Regional shall be conducted in the manner designed to further Tift Regional’s interest rather than the personal interest of an individual employee. Tift Regional property must not be removed from Tift Regional without approval of a supervisor.

Standard 4.4 Lobbying/Political Activity. No individual may contribute any money, property, or services of any officer or employee at Tift Regional’s expense to any political cause in violation of applicable law. Tift Regional employees may personally participate in and contribute to political organizations or campaigns, but must do so as individuals, with their own funds, and not as representatives of Tift Regional. Additionally, such political activities must not interfere with the employee’s ability to perform his or her duties at Tift Regional and must be in accordance with governing laws, regulations and policies.

At times, Tift Regional may ask employees to make personal contact with government officials or to write letters to present Tift Regional’s position on specific issues when our experience may be helpful, and Tift Regional may analyze and take positions on issues that have a relationship to the operations of Tift Regional when Tift Regional’s experience contributes to the understanding of the issues.

PRINCIPLE 5 - REGULATORY COMPLIANCE

Tift Regional will strive to ensure that all activity by or on behalf of Tift Regional is in compliance with applicable laws.

Employees are required to comply with all applicable laws and all Tift Regional policies and procedures whether or not specifically addressed in these Principles and Standards.

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Standard 5.1 Regulatory Requirements. Tift Regional and its employees are subject to numerous federal and state regulatory requirements relating to the provision of and reimbursement for healthcare services. Tift Regional employees are expected to be familiar with the applicable federal and state regulatory requirements and the penalties for failure to comply with such requirements. Questions regarding federal or state regulatory requirements should be directed to the Compliance Committee or the Helpline.

Standard 5.2 Tift Regional Policies and Procedures. Tift Regional maintains policies and procedures concerning specific Tift Regional departments and overall operations. Such policies and procedures are intended to be in compliance with current laws, rules and regulations. Tift Regional employees, professional staff members and agents are expected to be familiar with applicable Tift Regional policies and procedures and to conduct their actions on behalf of Tift Regional in compliance with such policies and procedures.

Standard 5.3 Tax. As a nonprofit entity, Tift Regional’s policy is to fully comply with all federal and state tax laws and regulations. Tift Regional’s activities should further its charitable purpose and ensure that its resources are used in a manner which furthers the community interest rather than the private or personal interests of any individual. Employees should avoid compensation relationships, other transactions in excess of fair market value and any other activities that might jeopardize the tax-exempt status of Tift Regional. All tax and information returns will be filed in a manner consistent with applicable laws.

Standard 5.4 Antitrust. Tift Regional’s policy is to fully comply with all antitrust and similar laws which regulate competition. These laws could be violated by discussing Tift Regional’s business with a competitor; i.e., how Tift Regional’s prices are set, disclosing the terms of supplier relationships, allocating markets among competitors, agreeing to fix prices, bid rigging or price sharing with competitors, unfair trade practices including bribery, misappropriation of trade secrets, and deception, or agreeing with a competitor to refuse to deal with a supplier.

Standard 5.5 Physicians. Any business arrangement with a physician must be structured to ensure precise compliance with legal and regulatory compliance. Such arrangements must be in writing and approved by the President-CEO.

PRINCIPLE 6 - REFERRALS

Tift Regional does not pay for referrals, nor does it pay patients.

Standard 6.1 Referrals. Tift Regional does not pay anyone for referrals, and Tift Regional does not accept payment for referrals Tift Regional makes. Tift Regional employees should refrain from any conduct which may violate the fraud and abuse laws, which prohibit direct, indirect or disguised payments in exchange for the referral of patients. The term “payments” includes money, supplies, services or any other thing of value (excluding legitimate patient refunds). Tift Regional only pays for services provided for or on behalf of Tift Regional or its patients. Violation of this standard may have severe consequences for Tift Regional and the individuals involved, including civil and criminal penalties, and possible exclusion from federally funded healthcare programs.

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Section 6.2 Admissions. Tift Regional does not waive insurance co-payments or provide other benefits to patients in return for admissions.

PRINCIPLE 7 - REIMBURSEMENT CLAIMS

Tift Regional will strive to comply with federal and state laws and regulations regarding the submission of claims and Medicare cost reports.

Standard 7.1 Billing Fraud & Abuse. Tift Regional bills only for services actually rendered and follows the accepted coding standards as established by the Official ICD-9-CM Guidelines for Coding and Reporting. Employees shall refrain from conduct which may violate fraud and abuse laws, including the submission of false, fraudulent or misleading claims to any government entity or third party payor, including claims for services not rendered, claims which characterize the service differently than the service actually rendered (such as “upcoding”) or claims which do not otherwise comply with applicable program or contractual requirements. Billing must comply with the requirements of state and federal payors and conform to all payor contracts and agreements.

Employees have an obligation to ensure that all bills submitted to patients, government programs, and other payors, including private healthcare plans, are accurate and have an obligation to properly document services billed. Substantiating medical documentation must be provided for all services rendered.

All employees must exercise care in any written or oral statement made to any government agency or other payor. Tift Regional will not tolerate false statements by employees to a government agency or other payor. Deliberate misstatements to government agencies or other payors may expose the involved employee to criminal penalties.

Any Tift Regional employee who discovers an error or inaccuracy in any claim for payment for healthcare services that has been submitted to a patient, government program or other payor should alert his/her manager or supervisor, the Compliance Committee or the Helpline immediately. Managers or supervisors who receive reports of errors or inaccuracies should first correct the error or inaccuracy and then report to the Compliance Committee the error or inaccuracy and the corrective action taken.

Standard 7.2 Cost Reports. Tift Regional claims reimbursement for costs based on appropriate and accurate documentation. Employees are obligated to ensure that cost reports are accurate, i.e., allocations of costs to cost centers are accurately made and supported; unallowable costs are not claimed; costs are properly classified; fiscal intermediary prior year audit adjustments are implemented; and all related parties are identified.

Standard 7.3 Medical Necessity. Claims should only be submitted for services Tift Regional has reason to believe are medically necessary and that were ordered by a physician or other appropriately licensed individual.

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PRINCIPLE 8 - CONFIDENTIALITY

Tift Regional employees shall strive to maintain the confidentiality of patients and other confidential information in accordance with applicable laws and ethical standards.

Standard 8.1 Patient Information. Never disclose confidential patient information to any unauthorized person. If questions arise regarding an obligation to maintain the confidentiality of information or the appropriateness of releasing information, employees should seek guidance from their supervisor, the Compliance Committee or the Helpline.

Standard 8.2 Proprietary Information. Information, ideas and intellectual property assets of Tift Regional are valuable assets of Tift Regional. Information obtained, developed or produced by Tift Regional and its employees and information supplied by others for the benefit of Tift Regional are confidential. Information pertaining to Tift Regional’s competitive position or business strategies, payment and reimbursement information is confidential. This information should not be shared with anyone outside of Tift Regional and should be shared only with employees having a legitimate need to know such information in order to perform their job responsibilities and who have agreed to maintain the confidentiality of the information. 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.

PRINCIPLE 9 - GOVERNMENT INVESTIGATIONS

Tift Regional will comply with the law and cooperate with government auditors and investigators in a reasonable and diligent manner, while preserving the legal rights of Tift Regional and employees involved.

Standard 9.1 Responding to Inquiries. Tift Regional and Tift Regional employees shall cooperate with government auditors and investigators in a reasonable and diligent manner, while protecting and preserving the legal rights of Tift Regional and employees involved. If an employee is approached by any person who identifies himself or herself as a government investigator, the employee should contact the President, any Tift Regional Vice President or the Compliance Committee immediately. The Compliance Committee will assist in verifying the credentials of the investigator and determining the legitimacy of the investigation, and following proper procedures for cooperating with the investigation.

In some cases, employees may be contacted outside the workplace by government investigators or persons presenting themselves as government investigators. The law gives us all a right to be represented by legal counsel. Do not feel pressured to talk with the person under such circumstances without first contacting the Compliance Committee for legal assistance. Tift Regional should have legal representation at the earliest stage. Employees are entitled to legal guidance before being subjected to government questioning. While the decision about granting an interview is up to each employee, a Tift Regional attorney can assist the employee in scheduling and properly preparing for an interview, if the employee so desires. Also, when

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appropriate, Tift Regional may elect to pay the expense of a private lawyer to represent the employee individually (as permitted by applicable law).

We will cooperate with and be courteous to all government inspectors and provide them with the information to which they are entitled during an inspection. During a government inspection, employees must never conceal, destroy or alter any documents, lie or make misleading statements to the government representative.

Standard 9.2 Responding to Subpoenas. Should a Tift Regional employee receive a subpoena or other written request for information concerning Tift Regional or Tift Regional operations, the employee should contact the President, any Tift Regional Vice President or the Compliance Committee immediately and before responding.

PRINCIPLE 10 - DOCUMENT RETENTION

Tift Regional complies with the document retention requirements of state and federal law and requirements of government programs and other third-party payors.

Standard 10.1 Requirements of Government Programs and Other Third-Party Payors. Each employee is responsible for the integrity and accuracy of Tift Regional’s documents and records. No one may alter or falsify information on any record or document.

Medical and business documents and records are retained in accordance with the document retention requirements of state and federal law, state or federal government healthcare programs or other third-party payors.

Standard 10.2 Tift Regional Document Retention Policies. Tift Regional, from time to time, will establish internal document retention policies. Employees should retain records pursuant to these policies.

No employee should ever destroy or alter any Tift Regional documents in anticipation of a request for those documents from any government agency or court. If any employee believes that such conduct has occurred or may occur, the employee should contact the Compliance Committee or the Helpline immediately.

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SECTION TWO

TIFT REGIONAL MEDICAL CENTERCOMPLIANCE PROGRAM

I. PURPOSE

The Hospital Authority of Tift County is committed to conducting the operations of Tift Regional Medical Center in compliance with the law. In some circumstances, the interpretation and application of the law is highly technical, and the common concepts of right and wrong lend little guidance. Thus, employees, physicians and agents who believe that they are conducting themselves properly may, in fact, be violating applicable laws. Violations of the law by employees, physicians and agents, even unwitting violations, can subject the Authority to the risk of penalties and embarrassment.

In order to avoid violations of law, the Authority believes that a formal Compliance Program concerning Tift Regional operations should be implemented. The Board’s action in directing the Administrative Staff to proceed with the development and implementation of a Compliance Program should not be interpreted as concern that present management systems are inadequate. Rather, development and implementation of a Compliance Program is an element in the Authority’s continuing effort to improve quality and performance. The Authority also recognizes that federal agencies responsible for enforcement of Medicare and Medicaid laws and regulations applicable to healthcare providers recently have encouraged the development and implementation of Compliance Programs by healthcare providers.

WHEREFORE, IT IS HEREBY RESOLVED:

1. The Administrative Staff of Tift Regional is directed to create and develop an effective Compliance Program (the “Program”) designed to prevent and detect violations of federal or state law in the conduct of Tift Regional operations by employees, physicians and agents.

2. The Administrative Staff of Tift Regional is directed to retain counsel for the purpose of seeking legal advice, and auditing services if necessary, for use in the creation and implementation of the Program.

-Resolution of Tift County Hospital Authority, adopted February 16, 1998.

II. PROGRAM STRUCTURE

The Compliance Program is administered by the Compliance Committee composed of the individuals who hold the following positions:

Director of Medical RecordsDirector of Human ResourcesAssistant Vice-President of Patient Financial ServicesDirector of Quality Management

Vice-President/Chief Financial OfficerDirector of Management Information SystemsAssistant Vice-President of Patient CareCompliance Officer

Karen Summerlin shall serve as the Compliance Officer of the Program.

The Tift County Hospital Authority Board of Trustees (“Board of Trustees”) shall review the composition of the Compliance Committee annually, and if necessary to maintain the effectiveness of the Compliance Program, the Board of Trustees shall replace one or more members of the Compliance Committee.

The Compliance Officer shall have overall responsibility for managing and overseeing the Compliance Program. The Compliance Committee shall be responsible for operating the Compliance Program on a daily basis and will have, at its disposal, appropriate resources necessary to discharge the Committee’s responsibilities under the Compliance Program.

The Compliance Committee shall develop and provide appropriate education and training programs for employees, professional staff members and agents; respond to inquiries from any employee, professional staff member or agent regarding compliance issues; and shall investigate all allegations of possible impropriety and/or violations of the Compliance Program, the Code of Conduct or Tift Regional policies or procedures. The Compliance Officer is responsible for assuring that the Compliance Committee fulfills its responsibilities.

Tift Regional shall instruct its employees to report to the Compliance Committee any and all information regarding a suspected, known, or potential violation of the Compliance Program, the Code of Conduct and/or Tift Regional policies and procedures. The Compliance Committee shall have complete authority to investigate alleged violations and, in consultation with Administration, shall be empowered to take immediate remedial or other action as warranted under the circumstances. The Compliance Officer shall have the authority to review all documents and other information that are relevant to compliance activities, including but not limited to, patient records, billing records, and records concerning marketing efforts of Tift Regional and Tift Regional’s arrangements with other parties, including employees, professional staff members, independent contractors, suppliers, agents and hospital-based physicians.

III. IMPLEMENTATION

The Compliance Committee is responsible for implementing the Compliance Program and for ensuring that all employees, professional staff members and agents are fully informed about the Program.

IV. EMPLOYEE AND CONTRACTOR DISCLOSURE

A. Applicants for Employment

In order to become an employee of Tift Regional, an applicant shall disclose, in writing, whether he or she previously has been convicted of a crime. All new employees who have discretionary authority to make decisions that may involve compliance with the law or compliance oversight must submit to a background investigation, including a reference check, as part of the employment application process. Such new employees must disclose any criminal conviction or exclusion action. Persons who have been recently convicted of a criminal offense related to healthcare or who are listed as debarred, excluded or otherwise ineligible for participation in federal healthcare programs may not be employed by Tift Regional. Tift Regional will evaluate

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such information in a manner consistent with the Compliance Program’s goals and all applicable laws and regulations. Failure to make a complete and accurate disclosure shall disqualify the applicant from employment consideration.

B. Current Employees and Contractors

The Compliance Committee may request, in accordance with any applicable laws and/or regulations, that a background check be conducted of any current employee or agent in connection with the investigation of any potential or alleged violation of the Compliance Program, Code of Conduct and/or Tift Regional policies and procedures.

If a current employee or agent is charged with a criminal offense related to healthcare or is proposed for debarment, exclusion or other ineligibility from participation in federal health care programs, such individual shall be removed from direct responsibility for or involvement in any federal healthcare program. If resolution of the matter results in conviction, debarment or exclusion, such person’s employment shall be terminated or other contract arrangements made.

If a Tift Regional employee violates or deliberately fails to report a violation of the Compliance Program, the Code of Conduct, or Tift Regional policies and procedures, appropriate disciplinary action will be taken, including but not limited to, modification of job responsibilities and discretionary authority, suspension or discharge.

C. Employee Departures

When a Tift Regional employee resigns voluntarily or is dismissed for a reason other than for violating the Compliance Program, the Code of Conduct, or Tift Regional policies or procedures, Tift Regional shall conduct an exit interview to determine whether the employee knows of any violation of the Compliance Program, the Code of Conduct or Tift Regional policies or procedures, or whether the resignation or dismissal is related to any refusal by the employee to violate the Compliance Program or Code of Conduct or to conceal such a violation.

D. Annual Disclosure

Each employee will be required annually, and each member of the medical staff, upon appointment or re-appointment, will be required to confirm his or her compliance with the Compliance Program and to execute a statement acknowledging that he or she has not violated the Compliance Program, the Code of Conduct, or Tift Regional policies and procedures and is not aware of a violation by any Tift Regional employee, professional staff member or agent.

V. TRAINING AND EDUCATION

A. Responsibility

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The Compliance Officer is responsible for proper coordination and supervision of the training and education efforts for the Compliance Program. The determination of the level of education needed by particular classes of employees will be made by the Compliance Committee. All training undertaken by Tift Regional as part of the Compliance Program shall be documented by the Compliance Officer.

B. Subject Matter

All employees, professional staff members and agents shall receive training concerning the Compliance Program, the Code of Conduct and procedures for alerting the Compliance Committee to problems and concerns. Employees will receive additional training clarifying and emphasizing the areas of law and regulations that directly impact upon their specific duties.

C. Methods

A variety of teaching methods may be utilized to communicate information about the Compliance Program, the Code of Conduct, Tift Regional policies and procedures and applicable laws and regulations to employees, professional staff members and agents of Tift Regional, as determined by the Compliance Committee.

D. Managers and Supervisors

Managers and supervisors shall:1) Discuss with all supervised employees the compliance policies and legal

requirements applicable to their function;2) Inform all supervised personnel that strict compliance with these policies and

requirements is a condition of employment; and3) Disclose to all supervised personnel that Tift Regional will take disciplinary

action up to and including termination or revocation of privileges for violation of these policies or requirements.

E. Performance of Education/Training Requirements

Educational and training programs designed and provided by the Compliance Committee shall be mandatory. Satisfactory completion of such programs is a condition of continued employment or contractual arrangement. Adherence to the educational and training requirements shall be a factor in each employee’s performance evaluation. Tift Regional personnel subject to periodic professional education requirements imposed by statute or regulation must also fulfill such requirements.

VI. REPORTING AND INVESTIGATING

A. Compliance Helpline

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Tift Regional maintains a Helpline for Tift Regional employees, professional staff members and agents to report ethical or legal concerns or to report any potentially improper action on the part of any Tift Regional officer, agent, employee, contractor or representative. All calls to the Helpline will be logged, and a report to the Compliance Committee will be made on each call. Callers will be given a number so they can call for an update at a later date. The Compliance Committee will ensure appropriate follow-up in connection with the calls. The Compliance Committee, in consultation with legal counsel as appropriate, will determine the appropriate response to the call and the course of action. The nature of the investigation and the response should be documented and maintained in the Helpline Log.

Calls can be made on an anonymous basis. While Tift Regional will strive to maintain the confidentiality of a caller’s identity, there may be a point where the caller’s identity may become known or may have to be revealed in certain instances when governmental authorities become involved. There will be no retribution or discipline for anyone as a result of a report to the Helpline if the report is made in good faith.

B. Employee Reporting

Tift Regional employees, professional staff members and agents are expected to promptly report any perceived or alleged violations of the Compliance Program, Code of Conduct or Tift Regional policies and procedures to someone in their chain of command, the Compliance Committee or the Helpline. Managers and supervisors shall report all compliance issues received from members of their department which require investigation or corrective action to the Compliance Committee. Any employee, professional staff member or agent who is instructed, directed, or requested to engage in conduct prohibited by the Compliance Program, the Code of Conduct or Tift Regional policies and procedures shall promptly report such information to the Compliance Committee or the Helpline.

C. Investigation

The Compliance Committee and/or legal counsel, assisted by the appropriate Tift Regional department if necessary, shall promptly investigate all reported concerns. If, after investigation, it is determined that a provision of the Compliance Program, Code of Conduct or Tift Regional policies and procedures has been violated, the Compliance Committee shall develop recommendations concerning any appropriate remedial or other action warranted under the circumstances, any necessary communications to employees, and any amendments to the Compliance Program.

D. Compliance Committee Reports

At the conclusion of the investigation, a report shall be issued by counsel or the Compliance Officer (pursuant to consultation with legal counsel, if necessary). The report shall reveal the substance of the allegations, the Compliance Committee’s findings, and the remedial and/or

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disciplinary measures taken, if any. In addition, the Compliance Officer shall report quarterly to the Board of Trustees a year-to-date summary of all reports of any perceived or alleged violations of the Compliance Program, the Code of Conduct and Tift Regional policies and procedures, the nature of the alleged violations, the findings of any investigation, and the action taken.

VII. AUDITING AND MONITORING

A. Audits

An annual compliance audit shall be conducted by the Compliance Committee with the assistance of legal counsel, who shall make a reasonable inquiry to determine whether the elements of the Compliance Programs have been satisfied. The annual audit will verify actual conformance by all departments with the Compliance Program and should disclose whether deviations from the Program were discovered in a timely manner.

The Compliance Committee shall also conduct, directly or through internal or external auditors, regular, periodic audits of Tift Regional’s programs and departments, specifically those with substantial exposure to government enforcement actions.

B. Monitoring

The Compliance Committee shall utilize monitoring techniques such as sampling protocols that permit the Compliance Committee to identify and review variations from established baselines. Significant variations shall trigger further inquiry to determine the cause of the deviation.

VIII. RESPONSE TO REPORT OF VIOLATIONS

The Compliance Committee, or legal counsel where necessary, shall promptly respond to and investigate, directly or through its designee(s), all allegations, reports or reasonable indications of suspected noncompliance to determine whether a material violation of law or the requirements of the Compliance Program has occurred. Where an internal investigation substantiates a reported violation, it is Tift Regional’s policy to initiate corrective action, including, as appropriate, making prompt restitution of any overpayment amounts, notifying the appropriate governmental agency, instituting whatever disciplinary action is necessary, and implementing systemic changes to prevent a similar violation from recurring.

IX. DISCIPLINARY PROCEDURES

A. Discipline Policy

All employees will be required to annually affirm, in writing, that they agree to abide by the guidelines set forth in the Compliance Program, the Code of Conduct and Tift Regional policies

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and procedures and that they have so complied during the previous year. As a condition of appointment and re-appointment, members of the Medical Staff must agree to abide by the Compliance Program and Code of Conduct.

Employees, professional staff members and agents are strictly prohibited from engaging in any activity that violates the Compliance Program, the Code of Conduct, Tift Regional policies or procedures or applicable laws or regulations. Violations will be grounds for disciplinary action up to privilege revocation (subject to applicable peer review procedure), discharge or contract termination, depending on the circumstances of each violation. Disciplinary action for noncompliance shall be taken consistently on a fair and equitable basis.

Disciplinary action will be taken not only against employees, professional staff members and agents who authorize or participate directly in a violation but also against such persons who deliberately fail to report a violation or any responsible employee whose failure to detect a violation is attributable to his or her negligence or reckless conduct. Managers and supervisors will be sanctioned for failure to adequately instruct members of their department or for failure to detect noncompliance with applicable policies and legal requirements, where reasonable diligence on the part of the manager or supervisor would have led to an avoidance of or an earlier discovery of a problem or violation. Disciplinary action for noncompliance shall be taken consistently on a fair and equitable basis.

The Compliance Committee, in consultation with legal counsel as necessary, shall recommend any appropriate remedial or other action as warranted under the circumstances.

X. MODIFYING AND AMENDING THE COMPLIANCE PROGRAM

The Compliance Committee, with the assistance of legal counsel, shall annually review and recommend necessary modifications or amendments to the Compliance Program, including the Code of Conduct and Tift Regional policies and procedures, based on new legal requirements, the experiences of the Compliance Program over the past year, or new or expanded activities of Tift Regional. Legal counsel for the Committee shall consider and report to the Compliance Committee any and all Special Fraud Alerts issued by the OIG that relate to hospitals. The Compliance Committee, with assistance of legal counsel, shall conduct an audit of Tift Regional operations at issue in any such Special Fraud Alert to determine whether Tift Regional operations adhere to the Special Fraud Alert. Modifications and amendments to the Compliance Program must be adopted by the Board of Trustees.

THIS IS TO CERTIFY that this Compliance Program, as amended, was duly adopted by the Tift County Hospital Authority on May 21 , 2001.

TIFT COUNTY HOSPITAL AUTHORITY, TIFTON, GEORGIA

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By: /s/

John B. Prince, III, Chairman

Attest: _ /s/

Lonza Seadrow, Secretary

[SEAL]

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COMPLIANCE CERTIFICATION

I certify that I have received and agree to read the Tift Regional Medical Center Code of Conduct, the Compliance Program and Tift Regional policies and procedures.

I promise to comply with the Compliance Program, the Code of Conduct and Tift Regional policies and procedures and understand that compliance with these policies, principles and standards is a condition of my continued employment or association with Tift Regional. I understand that violation of these policies, principles or standards may lead to disciplinary action up to and including termination. I also understand that Tift Regional reserves the right to occasionally amend, modify or update the Compliance Program, the Code of Conduct and Tift Regional policies and procedures.

I also understand that the Compliance Program, the Code of Conduct and Tift Regional policies and procedures are only statements of principles for individual and business conduct and do not, in any way, constitute an employment contract or an assurance of continued employment or association with Tift Regional.

SIGNATURE: Employee

NAME (Print):

DEPARTMENT:

DATE: /tt/file_convert/5f3576f5e53f2d7d123ac672/document.doc

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