Ethics & Compliance Program

Doing the right thing is an ongoing imperative at Capella Healthcare.

For us, nothing less than the highest standards of conduct are acceptable. We have carefully put into place the structures and the programs to instill both a strong corporate culture of ethics and a personal sense of responsibility. Our Ethics and Compliance program serves as the foundation for building a corporation where integrity is the highest priority.

At Capella, our Ethics and Compliance program is based on the personal integrity of each and every one of our employees and stakeholders.

Our code of conduct, which explains our philosophy and underpins our corporate culture, is built around personal honor and integrity.

Capella’s Code of Conduct

The Code of Conduct is updated each year and is required reading for all our employees and contractors.

Click on the link below for a PDF of our Code of Conduct and Ethics.

Code of Conduct

Capella’s Ethics Program

We believe the Ethics and Compliance program should accomplish 3 major objectives:

We should educate our employees and stakeholders on the laws and regulations that affect their role at Capella
We should ensure we are doing everything we can to comply with the laws and regulations that apply to Capella, and
We promote a culture of personal integrity, based on the premises that honest mistakes will be made and we will learn from our mistakes. Employees and stakeholders are encouraged to come forward with honest mistakes and will not be punished for making them.

The educational component of our Ethics and Compliance program encourages every employee or stakeholder to seek information about his or her role at Capella. To that end, we have a policy that allows employees to direct questions directly to our Office of Ethics & Compliance. It is the responsibility of the Office of Ethics & Compliance to receive answers to those questions and report back to the employee.

At Capella, we do not proctor exams or review every work product of our employees. Our Code of Conduct requires our employees to conduct their jobs with honor and integrity. The Code of Conduct also requires our employees to report instances of misconduct. As is the case in many institutions that have a Code of Conduct, the failure to report misconduct is considered just as serious as the misconduct itself.

Capella’s Ethics and Compliance Policies and Procedures (E&C Policies) are comprehensive. We have 145 detailed policies which address areas of hospital legal and regulatory compliance. The annual Code of Conduct is based on an abstract of those policies.

The E&C Policies are provided to Capella hospital Ethics and Compliance Officers for notice and distribution within each facility. They are posted on the Company’s intranet as well as the Company’s external website. Individuals within a facility who have responsibility for a particular area of compliance risk addressed by policy are responsible for implementing relevant policies, conducting necessary monitoring and overseeing corrective action or process improvements.

Capella maintains an Ethics Line to report items of concern or violations of policy. Although we encourage our associates to work with the local Ethics & Compliance Officers on matters of concern, the Ethics Line is an option to ensure such matters are identified and acted upon in a timely and effective manner. The Ethics Line can also be used to pose questions or receive clarification of certain laws and regulations.

You can also use the following contact information to contact the Capella Office of Ethics & Compliance:

Office of Ethics & Compliance

Capella Healthcare, Inc.
Attention, Eugene A. Fay, Ethics and Compliance Officer
501 Corporate Centre Drive, Suite 200
Franklin, Tennessee 37067

Phone: 615-764-3007
Fax: 615-764-3038

Information About False Claims Laws

Capella Ethics Line

Capella Ethics Line 1-866-384-4276

The Capella Ethics Line is your opportunity to report concerns or infractions that you believe are not being handled properly by the facility or in cases where you are uncomfortable discussing these issues with facility personnel. Your call will be handled by Ethics Point, an outside firm that specializes in Ethics Line Calls. Ethics Point is not in any way connected to Capella. Ethics Point will discuss the matter with you and provide the corporate E&C department with a written synopsis. You DO NOT have to give your name and contact information, but if you do, it will allow someone to contact you for follow up information. The Ethics Line is staffed 24 hours a day, seven days a week.

Moreover, you can make an online report directly to Ethics Point.

We thank you for taking the time to report matters of concern to you.

You can be assured we will investigate your concerns promptly.

Joint Commission Public Notice

The Joint Commission has begun conducting unannounced accreditation surveys of hospitals for the purpose of evaluating the organization’s compliance with nationally established Joint Commission standards. The survey results will be used to determine whether, and the conditions under which, accreditation should be awarded to this organization.

Joint Commission standards deal with organization quality and safety of care issues and the safety of the environment in which care is provided. Anyone believing that he or she has pertinent and valid information about such matters may request a public information interview with the Joint Commission’s field representatives at the time of the survey. Information presented at the interview will be carefully evaluated for relevance to the accreditation process. The request must also indicate the nature of the information to be provided at the interview.

Such requests should be addressed to:

Division of Accreditation Operations Office of Quality Monitoring
Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
1-800-994-6610
e-mail: [email protected]

Ethics & Compliance Program
- For Employees
- Ethics & Compliance Booklet