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					TIFT REGIONAL MEDICAL CENTER




  COMPLIANCE PROGRAM




                         Adopted: March 1999
                     Amended: August 21, 2000
                    Amended: February 19, 2001
                       Amended: May 21, 2001
                       Amended: June 16, 2003
                                          VISION

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

      Becoming clearly recognized as a provider of compassionate individualized care for the
       citizens of Tift County and our surrounding communities.
      Consistently measuring, assessing and improving 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.
      Maintaining 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.
      Cooperating with and supporting other healthcare providers so as to provide for the
       continuum of healthcare services.
      Serving as a major leading resource for information and education within our areas of
       service with particular emphasis on preventative and others as needed.
      Providing comprehensive, accessible inpatient and outpatient healthcare services.
      Assist neighboring counties as requested in the provision of accessible local healthcare.
      Maintaining constant vigilance of corporate compliance by in-depth surveillance,
       monitoring, auditing, and education of the Tift Regional Medical Center Compliance
       Program.
      Developing 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 CENTER
                              COMPLIANCE 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 ..................................................................................                      2
         1.1. Treatment of Patients ........................................................................................             2
         1.2. Privacy of Patients ............................................................................................           2
         1.3. Appropriate Care ..............................................................................................            2
         1.4. Standards of Professional Practice ...................................................................                     2

      PRINCIPLE 2 - HUMAN RESOURCES .......................................................................                              2
         2.1. Equal Employment Opportunities ....................................................................                        2
         2.2. Drugs, Narcotics, and Alcohol .........................................................................                    3

      PRINCIPLE 3 - ENVIRONMENTAL HEALTH AND SAFETY .................................                                                    3
         3.1. Workplace Violence .........................................................................................               3
         3.2. Environmental ..................................................................................................           3

      PRINCIPLE 4 - CORPORATE INTEGRITY ................................................................                                 4
         4.1. Conflict of Interest ............................................................................................          5
         4.2. Market Practices ...............................................................................................           5
         4.3. Protection of Assets ..........................................................................................            5
         4.4. Lobbying/Political Activity ..............................................................................                 6

      PRINCIPLE 5 - REGULATORY COMPLIANCE ........................................................                                       6
         5.1. Regulatory Requirements .................................................................................                  6
         5.2. Tift Regional Medical Center Policies and Procedures ....................................                                  6
         5.3. Tax ....................................................................................................................   6
         5.4. Antitrust ............................................................................................................     7
         5.5. Physicians .........................................................................................................       7


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PRINCIPLE 6 - REFERRALS...............................................................................................                     7
       6.1. Referrals............................................................................................................          7
       6.2. Admissions .......................................................................................................             7

       PRINCIPLE 7 - REIMBURSEMENT CLAIMS ............................................................                                     7
          7.1. Billing Fraud & Abuse .....................................................................................                 7
          7.2. Cost Reports .....................................................................................................          8
          7.3. Medical Necessity.............................................................................................              8

       PRINCIPLE 8 - CONFIDENTIALITY ..........................................................................                            9
          8.1. Patient Information ...........................................................................................             9
          8.2. Proprietary Information ....................................................................................                9

       PRINCIPLE 9 - GOVERNMENT INVESTIGATIONS ................................................ 9
          9.1. Responding to Inquiries .................................................................................... 9
          9.2. Responding to Subpoenas................................................................................. 10

       PRINCIPLE 10 - DOCUMENT RETENTION .............................................................. 10
          10.1. Requirements of Government Programs and Other Third-Party Payors ........ 10
          10.2. 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 ....................................................                                               2
         A. Applicants for Employment ....................................................................................                     2
         B. Current Employees and Contractors .......................................................................                          3
         C. Employee Departures ..............................................................................................                 3
         D. Annual Disclosure ...................................................................................................              3

V.       TRAINING AND EDUCATION ....................................................................................                           3
         A. Responsibility .........................................................................................................           3
         B. Subject Matter .........................................................................................................           4
         C. Methods...................................................................................................................         4
         D. Managers and Supervisors ......................................................................................                    4
         E. Performance of Education/Training Requirements.................................................                                    4




                                                                       ii
VI.     REPORTING AND INVESTIGATING .........................................................................                           4
        A. Compliance Helpline ..............................................................................................           4
        B. Employee Reporting ...............................................................................................           5
        C. Investigation ............................................................................................................   5
        D. Compliance Committee Reports .............................................................................                   5

VII. AUDITING AND MONITORING .................................................................................                          5
     A. Audits ......................................................................................................................   5
     B. Monitoring ..............................................................................................................       6

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

IX.     DISCIPLINARY PROCEDURES ..................................................................................                      6
        A. Disciplinary Policy ..................................................................................................       6

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




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        SECTION ONE


TIFT REGIONAL MEDICAL CENTER
     COMPLIANCE PROGRAM

      CODE OF CONDUCT
June 16, 2003




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.


/s/

William T. Richardson, FACHE
President-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.

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
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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.

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
                                                 3
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 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 must 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. All employees will be required to annually affirm, in writing, that
they have disclosed possible conflicts of interest. The Compliance Committee will determine
                                                 4
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. 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
                                                 5
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.

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
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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.

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.

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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.

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,
including the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).

Standard 8.1 Patient Information. HIPAA requires Tift Regional to take reasonable measures
to protect patients’ protected health information (“PHI”). PHI is defined as individually
identifiable information which is created or received by Tift Regional and relates to past, present
or future physical or mental health or condition of an individual, the provision of health care to
an individual, or the past, present or future payment for the provision of health care to an
individual, and which identifies the individual, or with respect to which there is a reasonable
basis to believe that the information can be used to identify the individual. Tift Regional may
use and disclose PHI: in the course of providing, coordinating, or managing patients’ medical
treatment, including the disclosure of PHI for treatment activities of another health care provider;
to bill and collect payment for the health care services provided; and as part of Tift Regional
operations. Additionally, Tift Regional may use or disclose PHI as specifically authorized by the
patient or: when required by law; for public health activities; for health oversight activities; to
coroners, medical examiners and funeral directors; for organ, eye and tissue donation; to avoid a
serious threat to health or safety; and for specialized government functions. However, all such
                                                 8
uses and disclosures shall be in compliance with Tift Regional policies and procedures. 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 Privacy Officer 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
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,

                                                9
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.




                                               10
        SECTION TWO


TIFT REGIONAL MEDICAL CENTER
     COMPLIANCE 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 Health Information Management       Director of Management Information
      Director of Human Resources                      Systems
      Assistant Vice-President of Patient             Assistant Vice-President of Patient Care
       Financial Services                             Compliance Auditor
      Director of Quality Management                  Compliance Officer
      Vice-President/Chief Financial 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
such information in a manner consistent with the Compliance Program’s goals and all applicable


                                               2
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

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.


                                                3
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; and
       3) 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

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.

                                                4
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
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.

                                                5
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
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.

                                                  6
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 June 16, 2003.

                                                                  TIFT COUNTY HOSPITAL AUTHORITY,
                                                                  TIFTON, GEORGIA


                                                                  By: _/s/____________________________________
                                                                      John B. Prince, III, Chairman

                                                                  ATTEST:


                                                                  By: _/s/____________________________________
                                                                      Lonza Seadrow, Secretary
                                                                                                        [SEAL]
KS\6405\00225 Administration\Compliance Program\Amended Compliance Program 061603.doc




                                                                        7
                                     [ATTACHMENT TO COMPLIANCE PROGRAM]


              FORM of ANNUAL EMPLOYEE COMPLIANCE CERTIFICATION

I certify that I have received and agree to read the TIFT REGIONAL MEDICAL CENTER (“Tift
Regional”) 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.

I acknowledge that:

    1. It is my responsibility to report any alleged or suspected violation of any laws, regulations,
       the Code of Conduct or the Compliance Program, to my Supervisor, the Helpline, or the
       Compliance Officer; and

    2. Unless otherwise noted below, I am not aware of any possible violation of the Code of
       Conduct or the Compliance Program.

I further certify that:

    1. Unless disclosed to the Director of Human Resources, neither I nor my immediate family: (a)
       have a financial relationship (compensation or ownership through debt or equity) either
       directly or indirectly with any entity that transacts business with Tift Regional; (b) own an
       interest in, receive compensation from or provide services to, any entity in competition with
       Tift Regional; or (c) conduct business not on behalf of Tift Regional by or with any Tift
       Regional vendor, supplier, contractor or agency;

    2. I am not presently excluded, debarred, suspended, sanctioned, or otherwise ineligible to
       participate in any federal, state, local, or private healthcare program or plan, including, but
       not limited to, Medicare and Medicaid; and

    3. I am not aware of any circumstance, including any investigative, legal or administrative
       action, that could jeopardize my ability to participate, without restriction or limitation, in any
       federal, state, or local healthcare program, including, but not limited to, the Medicare and
       Medicaid programs.

SIGNATURE:                                                POSITION/DEPARTMENT:
                          Employee

NAME (Print):                                             DATE:

                                                                                  Amended: June 16, 2003

                                                     8

				
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