CODE OF CONDUCT

NYU LANGONE HEALTH CODE OF CONDUCT DC 10/13/2019 WHO SHOULD READ THE CODE? TABLE OF CONTENTS

This Code of Conduct (the “Code”) applies to employees, trustees, oficers, faculty, medical staf, Introduction residents, fellows, students, volunteers, trainees, vendors, contractors, consultants, sponsored indi- • Letter from the Dean & CEO 1 vidiuals and agents of NYU Langone Health. • NYU Langone Health’s Mission & Values 2

Standards of Conduct with Patients & Colleagues • Foundation Statement – Your Personal Commitment WHO IS COVERED UNDER NYU LANGONE HEALTH? • Quality of Care – Commitment to Our Patients 3 • Conduct with Patients, Colleagues, & Others 5 “NYU Langone Health” includes NYU Langone Health System, NYU Langone Hospitals (including • Emergency Care (EMTALA) 6 all inpatient and ambulatory facilities), NYU School of Medicine, NYU Long Island School of • Pharmaceuticals, Prescription Drugs, & Controlled Substances 7 Medicine, NYU Langone MSO Inc., NYU Imaging Inc., and all entities that are controlled by any of them, except where specifically excluded. This Code has also been adopted by the Family Health • Environmental Health & Safety 7 Centers at NYU Langone Health; therefore, for purposes of this Code, “NYU Langone Health” also includes the Family Health Centers at NYU Langone Health and any entity controlled by it, except Complying with Laws, Regulations, & Policies where specifically excluded. • Laws, Regulations, & Policies 8 • Responsibilities of Managers & Supervisors 9 • Anti-Kickback & Physician Self-Referral 10 • Accurate & Truthful Documentation 10 • Investigations, Accreditations, Surveys, Audits, or Inquiries 11

Safeguarding Protected & Confidential Information • Privacy & Confidentiality 12 • Protection & Use of NYU Langone Health’s Assets 13

Political Participation & Government Afairs • Political Participation 14

Relationships with Vendors, Consultants, & Other Outside Entities • Conflicts of Interest 15

This Code is not a contract of employment nor does it create any rights or expectations regarding Research Integrity & Responsible Conduct continued employment or benefits at NYU Langone Health. All employment is deemed at-will (i.e., can be terminated by the employee or NYU Langone Health at any time, with or without cause) • Scientific & Clinical Research 16 unless a written contract of employment exists setting forth a specific duration and executed by an authorized NYU Langone Health signatory. Notwithstanding the statements in this Code, NYU Reporting Concerns & Enforcement Langone Health remains free to repeal, modify, or amend the Code, and to change wages, benefits, • Responsibility to Report 18 and all other working conditions, without prior notice. • Policy on Afirmative Action/Equal Opportunity 19 • Non-Retaliation Policy 19 NYU Langone Health 2019 printing • Disciplinary Action 20

NYU LANGONE HEALTH CODE OF CONDUCT NYU LANGONE HEALTH CODE OF CONDUCT DC 10/13/2019 LETTER FROM THE DEAN & CEO NYU LANGONE HEALTH’S MISSION & VALUES

Dear Colleague, The mission of NYU Langone Health is to serve, to Values teach, and to discover. We are committed to making We have set the standard for patient care, As dean and CEO of NYU Langone Health, I am world-class contributions that place service to human scientific research, and medical education. We proud to introduce our Code of Conduct, a key health at the center of an academic culture devoted have built a tradition of service that has touched element of our Corporate Compliance Program. to excellence in research, patient care, and education. the lives of countless people in New York City, The Code supports our mission, values, and policies We shall provide the facilities and personnel across the country, and around the world. to promote conduct that is honest, ethical, and necessary to carry out these functions in the most Our strength as an institution is based on the lawful. It is important that you understand your professional manner possible, and in all activities, we individual acts and the spirit of dedication of our personal obligations under this Code. shall maintain the highest standards of excellence physicians, healthcare professionals, scientists, and consideration for the dignity of the individual. employees, and students. NYU Langone Health has a long-standing commitment to demonstrating the highest level of Education To ensure that we remain at the forefront of the ethical and legal conduct and daily decision-making In educating the physician, we shall merge the best medical profession and a place where people can when interacting with our patients, our colleagues, traditions of the past with the most relevant content build successful careers, we have adopted a set our community, and our business partners. Our and vital teaching methods of the present. Our goal of values that are designed to reflect not only our Code explains this commitment in greater detail is to instill in each student a respect for his or her history, but also our commitment to the future. and provides guidance on how to make ethical profession and the people he or she serves, to provide The values are meant to complement, not replace, decisions that are reflective of our core principles. it to your supervisor, the NYU Langone Health for the continuing education of physicians throughout our existing codes of ethics and professional confidential Compliance Helpline at 866-NYU- their careers, and to foster an atmosphere of learning responsibilities. They are intended to be used as a This Code applies to every member of the NYU 1212, or online (form available on InsideHealth), for all staf throughout NYU Langone Health. means to enhance the way we deliver services to our Langone Health community: trustees, oficers, or directly to the Compliance Ofice. We will not patients, their families, visitors, and our colleagues. faculty, employees, medical staf, students, tolerate any form of retaliation against you for Research residents, fellows, volunteers, trainees, consultants, reporting any compliance concerns in good faith. We shall stimulate research into the fundamental We believe the five values—Performance, vendors, contractors, sponsored individuals, and basis of life processes, as well as the nature of Respect, Integrity, Diversity, and Excellence— agents of NYU Langone Health. As you read through this Code, you will see diseases and disorders and the means by which will enable us to build on our tradition of service, that compliance is the responsibility of every they can be overcome. We shall encourage to foster a culture of collaboration and teamwork, While the Code is comprehensive, it cannot cover member of the NYU Langone Health community. collaboration among independent researchers, and to better meet the needs of those we serve. every situation you might encounter. It’s up to Collectively, it takes each of us to achieve the interpret the value of research to patients and each individual to seek advice when faced with a standards set forth in this Code. I am asking the general public, and foster a spirit of inquiry • Performance – Accountable, responsible, and question about any of the principles outlined in the each of you to join me in making a personal throughout NYU Langone Health. dedicated to learning and growing professionally Code. As a member of the NYU Langone Health commitment to uphold this Code of Conduct by collaborating with one another. community, you are also required to familiarize without exception. Patient Care • Respect – Communicates openly and yourself with this Code on at least an annual basis. We shall place the patient at the center of all professionally, shares resources, listens to Sincerely, eforts. In providing direct patient care, we shall one another, and recognizes one another’s Additionally, it is your responsibility to report any Robert I. Grossman, MD serve patients from metropolitan New York and contributions. matters you believe to be a violation of the Code; those referred from other areas of the nation and • Integrity – Fosters a culture of the highest federal, state, or local laws and regulations; or NYU the world. We shall provide professional care and ethical standards, trust, and honesty. Langone Health policies. If you become aware of a treatment for patients in accordance with high • Diversity – Creates a community of cultural potential violation, you should immediately report Dean and CEO standards of medical service, ofer programs of competence and opportunity by embracing a wide health education, and maintain a climate in which breadth of resources, skills, ideas, and knowledge. each member of the healthcare team can learn • Excellence – Passionate about promoting and carry out his or her responsibilities in the quality, innovation, and safety to achieve world- most professional manner possible. class patient care, education, and research.

1 NYU LANGONE HEALTH CODE OF CONDUCT NYU LANGONE HEALTH CODE OF CONDUCT 2 DC 10/13/2019 FOUNDATION STATEMENT — YOUR PERSONAL COMMITMENT

All members of the NYU Langone Health commu- • Consider the consequences before acting. If nity are expected to make decisions that are guid- you are asked to do something that you believe ed by principles of honesty, integrity, high ethical may be a violation of this Code, you should seek standards, and a personal commitment to: advice from the Ofice of Compliance directly, • Maintain honesty and act in good faith in all or via the confidential Compliance Helpline, Hu- aspects of your job. This includes: man Resources, or the Ofice of Legal Counsel - Not making false or misleading statements; as described on page 18. - Not falsifying or altering data; and • Notify your supervisor of any suspected - Not manipulating or concealing information compliance concerns as soon as they are that is essential for conducting investigations identified. It is part of your responsibility to be or work-related activities. proactive in protecting NYU Langone Health’s values and to report compliance concerns.

QUALITY OF CARE — COMMITMENT TO OUR PATIENTS

We are committed to providing high-quality, com- your employment responsibilities or NYU passionate, and skilled patient care in a safe and Langone Health policies and procedures that healing environment. Everyone, even those not work- you do not understand; ing directly with patients, has a responsibility to: • Courteously and professionally assist pa- • Provide patients with care that is medically tients and visitors in person, on the phone, necessary, appropriate to the situation, safe, and by other means of communication; and in compliance with professionally recog- • Protect patients’ privacy and confidentiality. nized standards of care; Protected Health Information (PHI) should only Commission, New York State Department of - Standards and Surveys of The Joint Com- • Involve patients in decisions regarding their care; be used or disclosed as permitted under HIPAA Health, or other regulatory agency. We will not mission, Commission on Accreditation of • Adhere to infection prevention and control and state laws and regulations; take disciplinary action against you if you report Rehabilitation Facilities, College of American practices; • Assist patients in communicating compliance a concern in good faith; Pathologists, Accreditation Council for Grad- • Maintain complete and accurate records of or quality of care-related issues to the • Take pride in your job and do it to the best uate Medical Education, and other accredit- patient information that fulfill the requirements Ofice of Patient Relations or to the Ofice of of your ability. Every member of the NYU ing/certifying agencies of NYU Langone Health policies, accreditation Compliance directly or via the confidential Langone Health community contributes to our - Requirements for accreditation by the Liaison standards, and applicable laws and regulations; Compliance Helpline as described on page 18; success, our mission, and our ability to provide Committee on Medical Education (LCME) • Identify opportunities to improve service and • Inform management of any issues that quality patient care, cutting-edge research, and - Standards adopted by the Magnet Recog- quality of care; may interfere with your ability to fulfill your education to future physicians; and nition Program, recognizing excellence in • Ensure every patient receives important professional responsibilities; • Fulfill your personal responsibilities to report nursing service information about their rights, including but • Report patient care incidents and issues that quality measures. You should promptly and - Measures provided by the National Quality not limited to the documents Your Rights as a do not appear to meet, or that violate, NYU eficiently fulfill your responsibilities regarding Forum Hospital Patient in New York State and the NYU Langone Health’s standards of quality. You compliance with, but not limited to, the standards - Leapfrog Group Hospital Safety Grade Measures Langone Health Notice of Privacy Practices; should report such violations to your supervi- provided below. - Recommendations and guidelines issued by • Maintain current credentials, expertise, edu- sor, the Ofice of Compliance directly or via the - Conditions of Participation for Hospitals (Cen- other regulatory and voluntary groups iden- cation, training, and competence to provide confidential Compliance Helpline as described ters for Medicare and Medicaid Services) tified as appropriate by NYU Langone Health patient care; on page 18, or if appropriate, to the Centers - Hospitals—Minimum Standards (New York • Seek clarification from your supervisor about for Medicare and Medicaid Services, The Joint State Public Health Law)

3 NYU LANGONE HEALTH CODE OF CONDUCT NYU LANGONE HEALTH CODE OF CONDUCT 4 DC 10/13/2019 CONDUCT WITH PATIENTS, COLLEAGUES, & OTHERS What Constitutes Harassment? NYU Langone Health’s values should guide us in • Not engage in disruptive behavior. Disruptive Harassment is doing or saying things that make • Making sexual comments about someone’s our relationships with patients and their families, behavior is any inappropriate behavior, confron- a person feel uncomfortable. Harassment can be clothing, body, appearance, or personal life visitors, colleagues, vendors, and with whomever we tation, or conflict, ranging from verbal abuse to based on race, color, religion, sex, sexual orienta- • Staring in a sexually suggestive or ofensive manner do business. We need every member of the NYU physical, sexual, or other forms of harassment tion, gender and/or gender identity or expression, • Any other uninvited comments, conduct, or Langone Health community’s commitment to: that interfere with an individual’s ability to carry marital or parental status, national origin, ethnicity, behavior about someone’s sex, gender, gender • Strive to create the best possible experience out his/her responsibilities. Examples of disrup- citizenship status, veteran or military status, age, identity, or sexual orientation for our patients, their families, and visitors. tive behavior include but are not limited to: disability, and any other legally protected basis. • Take the initiative to find safe, creative, and - behavior that is abusive, angry, belligerent, or The above list provides just a few examples of sexual efective solutions to patient-related concerns. intended to publicly humiliate the individual Examples of sexual harassment may include the harassment, but harassment in general can be de- • Maintain positive work relationships with col- - public comments about lack of competence following: fined as any verbal or physical behavior that creates leagues, vendors, and others with whom we in front of patients and/or colleagues • Inappropriate or uninvited promise of something a hostile work environment, and should immediately do business. You should demonstrate respect - yelling, cursing, and/or tirades in exchange for a sexual favor (e.g., a promotion) be reported to your supervisor or Human Resources. for your colleagues by communicating positive- - abusive or hostile verbal or physical mistreat- • Telling lewd jokes or making sexual references ly with them and about them, and treating them ment of others such as but not limited to insult- or gestures For additional guidance, please refer to the harass- with dignity in your interactions. ing, teasing, mocking, degrading, or ridiculing • Unwelcome touching or fondling ment policies in the manual in the manual, handbook, • Treat each person respectfully, as a unique - repeated unprofessional written comments • Sharing, sending, or displaying sexually inap- By-Laws, or safety standards applicable applicable to individual. NYU Langone Health will not - throwing items or slamming doors propriate images, videos, emails, or notes your position in the NYU Langone Health community. tolerate discrimination against or harassment - systematic belittling of individuals or repeat- of anyone on the basis of race, color, religion, ed initiation of negative comments instead of sex, sexual orientation, gender and/or gender addressing with supervisory personnel identity or expression, marital or parental sta- - any behavior that fails to support a culture of EMERGENCY CARE (EMTALA) tus, national origin, ethnicity, citizenship status, safety veteran or military status, age, or disability. • Support and promote a positive work envi- The Emergency Medical Treatment and Labor Act If you are in a role working with patients, you are • Comply with NYU Langone Health policies on ronment, free from disruptive behavior by: (EMTALA) is also known as the patient anti-dumping expected to comply with NYU Langone Health’s EM- maintaining an alcohol-, drug-, and smoke-free - promoting respectful, courteous, and colle- statute. This federal statute sets the rules for providing TALA Policy on Screening, Stabilization, and Transfer workplace. gial relationships with all medical services and treatment to individuals with an of Individuals with Emergency Medical Conditions. • Follow the specific guidelines, in addition to - encouraging the reporting and investigation emergency medical condition without consideration of To uphold this policy, you have a responsibility to: this Code of Conduct, on conduct outlined in of disruptive behavior in a non-retaliatory the individual’s insurance coverage or ability to pay. • Honor patients’ rights to receive medical institutional policies, and the policies applicable environment screening examinations, and, if necessary, to your position in the NYU Langone Health - implementing the necessary actions to reme- Patient care must abide by the following criteria: stabilizing treatment, by qualified medical pro- community, such as the Faculty Handbook, dy disruptive behaviors • Exams must not be delayed; fessionals. Patients have this right even if they Residency Training Program Contract, GME • Further examination and treatment required cannot pay and do not have insurance. They are House Staf Manual, Postdoctoral Handbook, to stabilize the emergency condition must be also entitled to these services regardless of race, Student Handbook, By-Laws of the Medical provided; color, religion, sex, sexual orientation, gender Staf, and Patient Care and Safety Standards. • Transfer to another facility requires patient and/or gender identity or expression, marital or consent; and parental status, national origin, ethnicity, citi- • Applicable to pregnancy, psychiatric conditions, zenship status, veteran or military status, age, or any emergent medical condition EMTALA re- disability, diagnosis, or socioeconomic status. quires that a medical screening examination by a • Come to the aid of individuals at any of NYU qualified medical professional be provided to any Langone Health’s emergency services or urgent person who presents to NYU Langone Health un- care facilities who request a medical screening scheduled for an examination to determine if the examination, or whose appearance or behavior individual has an emergency medical condition. indicates that they are in need of emergency

5 NYU LANGONE HEALTH CODE OF CONDUCT NYU LANGONE HEALTH CODE OF CONDUCT 6 DC 10/13/2019 care. You should not discourage such individuals and stabilizing treatments are not delayed LAWS, REGULATIONS, & POLICIES from getting emergency care at the facility where while inquiring about payment method, obtain- you work or redirect them to another facility. ing payment, or checking on insurance status. All members of the NYU Langone Health Manual. Many of our organization-wide policies • Help secure medical transport to an emer- • Arrange appropriate transfer to another community must obey the letter and spirit of the can be found via NYU Langone Health’s gency department for individuals who come to medical facility for patients who cannot be laws, regulations, and policies that are applicable Policies and Procedures intranet site. You an of-campus site requesting treatment for an treated at NYU Langone Health’s emergency to them. Each person has a responsibility to: should also learn and follow the policies and emergency condition. care services or urgent care facilities because of • Familiarize yourself with the laws and procedures within your own department. • Make sure medical screening examinations their capability or capacity. regulations that relate to your position and • Ask questions. If you have questions facility, and uphold both the written words and about laws, regulations, or policies, or your PHARMACEUTICALS, PRESCRIPTION DRUGS, & CONTROLLED SUBSTANCES the meaning behind those words. responsibilities, you should ask your supervisor, • Maintain any licenses and/or credentials Human Resources, the Ofice of Compliance, or If you have responsibility for, or access to, and medical supplies secured at all times and required for your position. the Ofice of Legal Counsel. prescription drugs, controlled substances, over- be sure they are never available to or provided • Familiarize yourself with and avoid the • Inform NYU Langone Health if you become the-counter drugs, or any medical supplies (for to anyone who does not have a valid order from actions that constitute professional excluded from participating in federal or example, needles), you have a duty to: a licensed provider to write prescriptions and/ misconduct if you are a licensed professional state healthcare programs. NYU Langone • Follow the laws, regulations, policies, or a medical need for use of supplies. Controlled governed by a state board. Health receives money from the federal and procedures, and standards that apply to your substances must be secured at all times. • In addition to this Code of Conduct, learn and state government agencies, including entities responsibilities. You should become familiar • Report security problems. If you are aware of, or comply with NYU Langone Health’s policies such as Medicare, Medicaid, Tricare, and with the laws, internal policies, and Patient Care suspect, a lapse of security or the inappropriate that relate to your position. These policies the National Institutes of Health. Because and Safety Standards that govern your work with distribution, handling or diversion of drugs or are included in our mission, values, By-laws we receive these funds, we cannot employ these drugs and medical supplies, including but medical supplies ,you must report it immediately of the Medical Staf, Rules and Regulations of or contract with anyone excluded from not limited to the handling of waste, outdated, to your supervisor, Security, the Ofice of the Medical Staf, GME House Staf Manual, participating in a program funded by the federal deteriorated, or unusable drugs. Compliance directly, or via the confidential Faculty Handbook, Residency Training Program or state government. If you learn that you • Keep all drugs and medical supplies secure. Compliance Helpline as described on page 18. Contract, Postdoctoral Handbook, Student have become excluded, you must immediately You should take particular care to keep drugs Handbook, Patient Care and Safety Standards, contact the Ofice of Compliance directly to and Administrative Policy and Procedures inform NYU Langone Health of your exclusion. ENVIRONMENTAL HEALTH & SAFETY

NYU Langone Health has health and safety • Contract only with reputable, and where policies and procedures to protect the applicable, licensed vendors to evaluate, What Constitutes Professional Misconduct? environment and ensure that patients, students, monitor, remediate, transport, and/or dispose of faculty, employees, and visitors are protected hazardous materials and conditions. Examples of misconduct include but are not limited to: • Being convicted of a crime from undue health risks and unsafe conditions. To • Accurately maintain the records required by • Engaging in acts of gross incompetence or • Failing to return or provide copies of a record maintain these safety standards, we must all: federal and state laws and regulations. gross negligence on a single occasion or more on request • Comply with laws, regulations, and policies • Report suspected violations. If you suspect a than one occasion • Being sexually or physically abusive regarding the shipping, handling, use, storage, violation of an environmental or occupational • Permitting or aiding an unlicensed person to • Abandoning or neglecting a patient in need of transportation, and disposal of all hazardous safety or health law, or an unsafe condition, you perform activities requiring a license immediate care materials, including radioactive materials and must report it immediately to your supervisor • Refusing to provide services because of race, • Performing unnecessary procedures or medical or chemical wastes. or Environmental Health and Safety, the Ofice creed, color, or national origin unauthorized services • Handle and dispose of hazardous materials of Compliance directly, or via the confidential • Practicing beyond the scope of your profession • Practicing under the influence of alcohol or legally and appropriately, if you have Compliance Helpline as described on page 18. • Releasing PHI or other confidential information other drugs responsibilities that include handling and/or • If you work in an of-site location you without authorization disposing of such materials. should comply with the safety standards • Comply with NYU Langone Health’s permits that for your specific patient, client, or resident allow for the safe management of waste discharge. populations.

7 NYU LANGONE HEALTH CODE OF CONDUCT NYU LANGONE HEALTH CODE OF CONDUCT 8 DC 10/13/2019 RESPONSIBILITIES OF MANAGERS & SUPERVISORS ANTI-KICKBACK & PHYSICIAN SELF-REFERRAL

If you have management or supervisory responsi- • Ensure that departmental policies and pro- NYU Langone Health prohibits employees and or indirectly, in exchange for referring patients. bility, you have an additional duty to: cedures are current, maximize eficiency, and service providers from soliciting, receiving, ofering • Not demand or expect anything in return for • Make a diligent efort to keep up with cover all required areas and standards perti- or paying anything of value in exchange for refer- referring business. If you are in a position to regulatory changes that afect your areas of nent to the specialty as well as any anticipat- ring patients, products, or services. If you accept make referrals to another healthcare provider, responsibility by reviewing professional journals, ed areas of risk. or make referrals, you must: you will not take into account the volume or publications, industry organizations, and other • Make sure your department obtains all nec- • Adhere to NYU Langone Health guidelines value of referrals that the provider has made, or resources. essary licenses, permits, and approvals required on accepting referrals. If you are in a position may make, to NYU Langone Health. • Seek out both internal and external profes- for operations. to accept patient referrals and admissions, you • Learn the rules that apply to the Stark Law sional learning and development opportuni- • Support regulatory initiatives including ensur- must do so based solely on the patient’s medi- that governs physician self-referrals for Medi- ties for yourself and those who report to you. ing and advocating that all required education cal needs and our ability to render the services care and Medicaid patients. • Act as a role model in demonstrating your un- and training is completed in a timely manner. needed. You should never ofer anything of val- • Not refer patients for “designated health derstanding of and commitment to comply with ue, directly or indirectly, to physicians or anyone services” to a facility that you have an owner- laws and regulations. else in exchange for referral of patients. ship interest in, or compensation arrangement • Adhere to guidelines on making referrals. If with, if services are being paid for by Medicare you are in a position to make referrals, you will or Medicaid, unless a specific exception applies. not solicit or receive anything of value, directly What Does it Mean to be “Excluded”?

An exclusion means a temporary or permanent • Conviction related to patient abuse What are “Designated Health Services”? sanction, restriction, and/or debarment from a • Conviction of a crime related to federal or state federal health care program or from receiving a healthcare programs The following have been identified by the Centers for • Durable medical equipment and supplies government contract, grant, or award. Employers • Submitting claims for excessive charges, unnec- Medicare and Medicaid Services (CMS) as “designated • Parenteral and enteral nutrients, equipment, that receive federal funding cannot employ, essary services, or services that fail to meet pro- health services” under the Stark Law and regulations: and supplies contract, or do business with excluded individuals fessionally recognized standards of healthcare • Clinical laboratory services • Prosthetics, orthotics, and prosthetic devices or entities, also known as ineligible persons. • Physical therapy services and supplies An exclusion remains in force until an oficial • Occupational therapy services • Home health services NYU Langone Health performs exclusion reinstatement has been granted by the State or • Outpatient speech-language pathology services • Outpatient prescription drugs screenings on prospective and current members Federal Ofice of Inspector General for participation • Radiology and certain other imaging services • Inpatient and outpatient hospital services of the NYU Langone Health community and in Medicare, Medicaid, and any other federal health • Radiation therapy services and supplies external ordering providers to identify excluded care programs. individuals and prevent or terminate their relationship with the institution as appropriate. The Compliance Ofice is responsible for investigating potential and confirmed matches Examples of situations that can result in be- to exclusion lists. In the event that any person ACCURATE & TRUTHFUL DOCUMENTATION coming an ineligible person include but are not subject to the Prohibition Against Employing or limited to: Contracting with Ineligible Persons and Exclusion If you are responsible for documentation, financial condition of NYU Langone Health or any area • Default on a health education loan or scholarship Screening Policy becomes aware that they or any reporting, or coding and billing, you must perform your you are responsible for. • License revocation or suspension other such party is excluded, they must report it to duties accurately and truthfully. You have a duty to: • Ensure that the financial transactions you • Felony conviction related to healthcare fraud the Compliance Ofice immediately. • Create and maintain thorough, accurate report reflect actual transactions and conform to • Felony conviction related to a controlled substance records. Promptly document records as required Generally Accepted Accounting Principles (GAAP). by your job, following legal requirements, ethical • Accurately record all assets and liabilities in professional standards, and departmental policies. their appropriate accounts, including but not • Fairly and accurately represent the financial limited to departmental funds, revenues, and

9 NYU LANGONE HEALTH CODE OF CONDUCT NYU LANGONE HEALTH CODE OF CONDUCT 10 DC 10/13/2019 expenses. Avoid fraudulent financial reporting • Only assign and report billing codes that PRIVACY & CONFIDENTIALITY practices, such as the following: are clearly and consistently supported by - Hiding expenditures, funds, assets, or liabilities documentation in the health record. Protected Information is individually identifiable receive PHI that you are not authorized to have, - Knowingly providing false, inaccurate, or • Avoid coding practices that are considered as information that is required to be protected by law you must immediately report the incident to incomplete information to an employee, fraud or abuse, such as the following: while Confidential Information is NYU Langone the HIPAA Helpline, or the Ofice of Compliance management, auditors, legal counsel, - Using “default codes” or selecting codes Health business or operations not intended for the directly as described on page 18. government agencies, or accreditation because they guarantee payment, instead of public. Every member of the NYU Langone Health Regardless if you work directly with patients or organizations coding and billing the products and services community is responsible for safeguarding Protected not, you have a duty to protect PHI as set forth in - Providing untrue statements of material fact actually provided and Confidential Information about patients (including the Health Insurance Portability & Accountability or omitting material facts - “Upcoding,” or selecting the code for a PHI), research subjects, employees, students, and the Act (HIPAA). You can comply with HIPAA by - Intentionally allocating inaccurate costs more serious diagnosis or more extensive institution itself. We each have a duty to: taking the following actions: or under incorrect accounts on reports or procedure than is actually performed • Safeguard Protected and Confidential • Encrypt all email containing PHI being sent financial statements - “Unbundling” a group of procedures and Information to prevent disclosing it to anyone to recipients outside NYU Langone Health, by • Produce cost reports or financial statements that coding them separately in order to receive a who does not have a business purpose to know. using SendSafe secure email. are true, correct, and complete, and prepared in separate payment for each procedure, when • Follow NYU Langone Health’s privacy and • Securely dispose of equipment that contains PHI accordance with regulatory requirements. one or more are components of a global code security guidelines. Pay particular attention to including but not limited to computers, telephones, • Take responsibility. If coding or billing is done - Billing for medically unnecessary services the specific guidelines included in the following: fax machines, and copiers by contacting MCIT. on your behalf, you should have a thorough - Cutting and pasting or copying forward the – Privacy, Information Security, and • Properly dispose of paper that contains PHI knowledge of the claims and verify that they history of present illness, exam, or medical Confidentiality Statement by shredding it with crosscut shredder or are accurate. You should never sign a document decision making in the electronic health record – Workforce Members IT Policy placing in designated shred bins. without being certain it is accurate and complete. • Immediately report any improprieties that – HIPAA Privacy Policies • Safeguard PHI by locking or logging of your • Bill Medicare, Medicaid, and commercial payors you suspect in accounting, internal controls, or • Access and use Protected Information only to computer, not sharing your passwords and only for medically necessary and/or appropriate auditing to the Ofice of Compliance directly, perform your job responsibilities and for no changingthem often, using unique passwords to the situation services that are performed and or via the confidential Compliance Helpline as other purpose. for your personal and work accounts, and documented within a health record. Promptly described on page 18. • Limit the use and disclosure of Protected locking your doors and drawers. report and return any identified overpayments • Report any activity that you suspect involves Information to the minimum amount needed • Only use mobile and portable devices that do not meet this criteria. the submission of fictitious or fraudulent claims. to accomplish the business purpose. equipped with NYU Langone Health • Refrain from sharing Confidential Information encryption and data erasing software to concerning NYU Langone Health with access NYU Langone Health data. INVESTIGATIONS, ACCREDITATIONS, SURVEYS, AUDITS, OR INQUIRIES representatives from other hospitals, healthcare • Refrain from talking about PHI in public places. providers, medical schools, or other third • Not accessing PHI in the view of NYU Langone Health fully cooperates with requests • Cooperate with representatives from accredit- parties. Among the classes of Confidential unauthorized individuals. from governmental agencies, accrediting organiza- ing associations such as The Joint Commission Information you should keep confidential are: • Only use a NYU Langone Health issued email tions, external auditors, and internal parties concerning (including Standards for Long Term Care), and – Business arrangements. Our financial and address (e.g., @nyulangone.org or @med.nyu.edu) our operations. We need everyone’s commitment to: the Commission on Accreditation of Rehabilitation contractual arrangements with suppliers and to conduct all NYU Langone Health business. • Uphold NYU Langone Health’s policy on Re- Facilities (CARF) in an open and honest manner. managed care companies. • Not transporting PHI on unencrypted portable sponding to Governmental Investigations and • Cooperate with all investigations, examinations, – Plans. Information about our strategic plans, devices and instead accessing PHI through Law Enforcement Requests. and audits from both internal and external parties. potential acquisitions, and planned investments. InsideHealth, or if necessary, transporting PHI on • Report any requests you receive from a govern- • Never destroy or alter records requested for an – Marketing. Our marketing eforts or future plans. a MCIT issued encrypted flash drive (Iron Key). ment investigator to your supervisor, who will investigation, or provide untruthful or misleading – Financial information. Our prices, professional • Not sharing PHI using text messaging or contact the Ofice of Legal Counsel or the Ofice statements on or about those documents. fees, reimbursements, and salary levels. social media. of Compliance for further guidance. • Never pressure or suggest to anyone to hide • Comply with NYU Langone Health’s • Only use MCIT supported and authorized • Follow the direction provided by the Ofice of information from, or provide false information guidelines for reporting breaches of PHI. communication methods when sharing PHI. Legal Counsel if you are asked to surrender to, government investigators, accreditation If you discover that unsecured PHI has been • Access NYU Langone Health Information documents to external investigators. surveyors, internal parties, or external auditors. accessed, used, or disclosed, or if you find or ofsite via webmail or the InsideHealth portal.

11 NYU LANGONE HEALTH CODE OF CONDUCT NYU LANGONE HEALTH CODE OF CONDUCT 12 DC 10/13/2019 What is Protected Health Information (PHI)?

Protected Health Information (PHI) means individually Examples of HIPAA Identifiers include: identifiable health information that is transmitted or • Names maintained in any form (oral, electronic, paper) that: • Photos • Identifies or could be used to identify an individual • Addresses • Is created or received by a healthcare provider, • Certificate/license numbers health plan, employer, or healthcare clearinghouse • Telephone numbers And relates to the: • Vehicle identifiers • past, present, or future physical or mental • Fax numbers health or condition of an individual • Biometric identifiers • provision of healthcare to an individual • Social security numbers • past, present, or future payment for the • Device identifiers & serial numbers provision of that healthcare • Medical record numbers (MRNs) • Web URLs (e.g. social media pages) • Health plan numbers • IP addresses • Account numbers • Email addresses • Dates (admission, discharge, etc.) • Other unique identifiers

What is the HIPAA Privacy Rule? What is the HIPAA Security Rule?

The HIPAA Privacy Rule governs how NYU Langone The HIPAA Security Rule governs the protection Health uses and discloses PHI and provides patients of PHI in electronic form (ePHI) and requires POLITICAL PARTICIPATION with rights related to their health information. implementation of administrative, physical, and technical safeguards to protect ePHI. NYU Langone Health’s funds, time, and equipment • Use your own funds for any political participation should not be used for political activity of any kind, and do not attempt to be reimbursed by NYU including campaigning for (or against) a political Langone Health. This includes contributions candidate. Participation in political campaigns could through professional organizations to Political PROTECTION & USE OF NYU LANGONE HEALTH’S ASSETS jeopardize NYU Langone Health’s tax-exempt Action Committees (PACs). status. This can be prevented by each member of • Refrain from providing or ofering Every member of the NYU Langone Health ofice, medical, cleaning, and food supplies. the NYU Langone Health community complying any benefit in an attempt to influence community is responsible for protecting NYU • Departmental funds - If you are in a with the following guidelines: government oficials. If you are responsible for Langone Health’s assets from loss, damage, theft, supervisory or management position, you will • Participate in political activity only as a conducting transactions or handling contracts misuse and waste. These assets include: maintain careful internal controls and accurate private citizen, not as a representative of NYU with governmental agencies, you should ensure • Time - You will work productively and report records of departmental funds, including cash Langone Health. You are entitled to participate that they are handled honestly and ethically. your time and attendance accurately. and cash equivalents (including gift cards). You in, or contribute to, any political organization • Report inappropriate requests for benefits. If a • Equipment and supplies - You will not will exercise appropriate oversight of financial or campaign you choose. However, you will government representative requests or demands remove NYU Langone Health’s supplies and reports, expense accounts, and timesheets. clearly label any personal communication with any type of benefit from NYU Langone Health, equipment from the premises for personal • Records - You will comply with all record legislators as your own, not as correspondence you should report it immediately to the Ofice of use. These supplies and equipment include retention and destruction policies and coming from NYU Langone Health, and cannot Government and Community Afairs or the Ofice vehicles, machinery, tools, computers, printers, schedules that apply to your job responsibilities. use your NYU Langone Health email address if of Legal Counsel. telephones, and medical devices, as well as sending correspondence electronically.

13 NYU LANGONE HEALTH CODE OF CONDUCT NYU LANGONE HEALTH CODE OF CONDUCT 14 DC 10/13/2019 CONFLICTS OF INTEREST How Can I Recognize a Conflict of Interest Situation? We have a duty to avoid situations in which and research coordinators on IRB applications You may have a conflict of interest if you or a You may also have a conflict of interest if you have our business or personal interests influence (or - Members of any oversight committees related to member of your immediate family is an owner, a the authority to recommend doing business with appear to influence) our ability to act in the best patient care, purchasing, research, or education part-owner, or an employee of—or is receiving an NYU Langone Health vendor or contractor and interest of NYU Langone Health. If you believe - All employees of the Ofices of Compliance, money from—a company that: a member of your immediate family is an owner, you have a conflict of interest, you should disclose Legal Counsel, Government Afairs, and certain • does business with NYU Langone Health a part-owner, or an employee of—or is receiving it. You also have a responsibility to: staf of the Ofice of Science and Research • proposes to do business with NYU Langone Health money from—that vendor or contractor. • Learn to recognize situations with potential - Trustee or oficer of any NYU Langone Health • competes with NYU Langone Health conflicts of interest. entity • solicits employees from NYU Langone Health • Submit an annual disclosure if you are one of - Any other member of the NYU Langone Health the following: community who may have a conflict of interest - Faculty (employed full or part-time) • Refuse personal gifts or benefits from vendors, Why Should I Submit an Annual Disclosure? - Chairs, vice chairs, vice presidents, deans, patients, or others. NYU Langone Health’s You have a duty to protect NYU Langone Health’s members of the NYU Langone Health community associate and assistant deans, and Policy on Acceptance and/or Solicitation of Gifts reputation and carry out its mission with integrity. to submit an Annual Disclosure to the Conflicts of department/division administrators or Benefits from Vendors, Patients, or Other The Policy on Conflicts of Interest in Business Interest Management Unit. - Director-level and above employees Third Parties includes guidelines that outline Afairs furthers this endeavor as it requires certain - Supply Chain Management/Purchasing appropriate practices for receiving and responding employees and anyone involved in purchasing to gifts and/or invitations in alignment with federal decisions and/or contract negotiations on and state laws and regulations. SCIENTIFIC & CLINICAL RESEARCH behalf of NYU Langone Health • Never use your position to profit personally - Investigators and all other key personnel on grants; or to assist others in profiting at the expense of NYU Langone Health is committed to developing and Research Finance (RF), for guidance on investigators, co-investigators, sub-investigators, NYU Langone Health. and conducting research with the highest ethical complying with the many administrative and standards. If you are involved in research, you have fiscal requirements for government-spon- What Should I do if I Think I Have a Potential Conflict of Interest? a responsibility to produce work that is consistent sored research as well as research sponsored with federal, state, and local laws and regulations, as by industry and non-profit organizations You must immediately notify the Conflicts of Interest in Research and Sponsored Programs and stay well as NYU Langone Health policies, and to: - Clinical Research Support Unit (CRSU), which Management Unit for further guidance on how to informed of any laws and regulations related to • Obtain all required approvals and follow all facilitates the conduct of clinical research formally disclose this information for review and conflicts of interest in research. NYU Langone Health guidelines, policies, and studies, such as contract and budget negoti- evaluation. The Conflicts of Interest Management Unit • Disclose any financial interests and/or relationships procedures, including those of the following: ations and business development can be reached at [email protected]. related to Sponsored Programs that you, or your - Institutional Review Board (IRB), for approval • Submit accurate, truthful, and complete ac- immediate family members, have with any entity of all research involving human subjects counting, record keeping, and billing records. that may reasonably appear to afect or be afected Necessary Steps for Research Conflicts of Interest - Institutional Animal Care and Use Committee • Comply with governmental and sponsor require- by the design, conduct, or reporting of the research. If you are a research investigator or other (IACUC), for approval of all research involv- ments, as well as NYU Langone Health policies and research team member involved in research at • Adhere to any stipulations issued in relation ing animals procedures including those relating to: NYU Langone Health campuses, you have an to research that have been implemented to - Institutional Bio-Safety Committee (IBC), for – Clinical Research and Billing obligation to conduct research that is free from manage any potential conflicts of interest that approval of all research involving recombi- – Cost Transfers on Sponsored Projects any appearance of impropriety or conflict of may exist. All potential conflicts of interests must nant DNA and highly infectious agents – Institutional Cost Sharing interest. You also have a responsibility to: be discolsed, evaluated, and managed and/ - Institutional Review Entity (IRE) for approval – Efort Reporting for Sponsored Research • Perform research with objectivity and or eliminated under the Policy on Conflicts of of all research involving dual use research of Projects trustworthiness that maintains the integrity of the Interest in Research and Sponsored Programs. concern (DURC) – Program Income Earned on Sponsored Projects research, as well as the institution, and is in the • Complete any required training, such as - Embryonic Stem Cell Research Oversight – Charging Direct Costs to Sponsored Projects the PHS Investigator training on promoting best interest of the subjects enrolled in the study. Committee (ESCRO) for approval of research • Never participate in research misconduct by • Understand the Policy on Conflicts of Interest objectivity in research. involving human embryonic stem cells fabricating, falsifying, or plagiarizing results. - Sponsored Programs Administration (SPA) 15 NYU LANGONE HEALTH CODE OF CONDUCT NYU LANGONE HEALTH CODE OF CONDUCT 16 DC 10/13/2019 RESPONSIBILITY TO REPORT Which Compliance Areas are of Particular Importance to Researchers? Compliance is the responsibility of every member of The Compliance and HIPAA Helplines are Some high priorities include, but are not limited to: and for the work we have actually performed. the NYU Langone Health community. If you suspect multilingual, toll-free, and available seven • Protecting research participants and upholding • Protection of Human Subjects. Researchers must violations of the Code, NYU Langone Health policies, days a week, 24 hours a day. When calling the their rights during clinical trials and other receive certification of training and education in or federal, state, or local laws, you must immediately Compliance Helpline, you do not need to reveal research and fully informing them of their rights research, ethics and regulations as a prerequisite report it using one of the following methods, even if your identity and can request that your report and responsibilities, risks, expected benefits, to conducting research with human subjects by you are not sure it is a true violation, in compliance remain anonymous. You should give enough and alternatives. completing the required IRB tutorials. with the Compliance Concerns: Reporting, specific information to enable a complete • The humane care and use of laboratory animals in • Data integrity principles. Researchers Investigating, and Protection from Retaliation Policy: investigation of the issue you are reporting. biomedical and behavioral research and education. must keep accurate and complete data, in • Make a report to your supervisor. Schedule Whether your report is anonymous or not, • Compliance with federal and state laws and the accordance with contractual requirements and a meeting, if appropriate, so you can discuss your compliance concern will only be shared terms of sponsored research agreements when applicable policies to ensure research integrity, the issue confidentially and thoroughly. Be with others who have a need to know in order applying for funding, performing research and protect privacy and confidentiality, and protect prepared to present any evidence you have to to conduct an efective investigation and to reporting interim and final results. intellectual property rights. support your allegations. determine an appropriate course of action. In • Maintaining high ethical standards in the • Research misconduct requirements. • Make a report to a representative from the some instances, your identity might need to be responsible conduct of research, including Researchers must not engage in research Ofice of Compliance, Human Resources, revealed in order for an investigation or legal disclosure of financial interests that may create misconduct – meaning fabrication, falsification or the Ofice of Legal Counsel. If you are proceeding to move forward. the appearance of a conflict of interest. or plagiarism – in any scientific activities and uncomfortable talking with the person who must promptly report any instances of scientific supervises your work, you can contact any one If you know of, or suspect, a violation and do not In addition, researchers must be familiar with: misconduct. of the following areas: report it, you could be subject to disciplinary • Appropriate grants stewardship and • There are many requirements that apply to - Ofice of Compliance: 212-404-4079 or action. Failure to report a violation, cooperate accountability. Researchers must ensure funding researchers. Specific regulatory or compliance One Park Avenue, 3rd Floor, New York, NY 10016 with investigations, or complete any required agencies and research sponsors are charged questions should be directed to Compliance. - Compliance Fax: 929-455-9412 trainings and corrective actions are violations in only for what is accurate and satisfactory work; [email protected] or the Compliance - Compliance Email: themselves. and for which the sponsors have agreed to pay Helpline at 866-NYU-1212. [email protected] - Compliance Helpline: 866-NYU-1212 (May be anonymous) or compliancenyulmc.alertline.com/gcs/welcome - HIPAA Helpline: 877-PHI-LOSS or 877-744-5677 or www.incidentform.com/HIPAA.nyulmc.jsp - Human Resources Department—Employee Relations: 212-404-3787 - Ofice of Legal Counsel: 212-404-4075 - Patient Relations: Tisch Hospital: 212-263-6906 NYU Langone Orthopedic Hospital: 212-598-6336 NYU Langone Hospital - Brooklyn: 718-630-7310 NYU Winthrop Hospital: 516-663-2058

17 NYU LANGONE HEALTH CODE OF CONDUCT NYU LANGONE HEALTH CODE OF CONDUCT 18 DC 10/13/2019 POLICY ON AFFIRMATIVE ACTION/EQUAL OPPORTUNITY DISCIPLINARY ACTION

NYU Langone Health is committed to a policy of Act of 1964 and Section 504 of the Rehabilitation Violations of this Code, NYU Langone Health Care and Safety Standards, and the Administrative equal treatment and opportunity in every aspect Act of 1973, and Title IX of the Education policies, or federal, state, and local laws, could Policy and Procedures Manual). of its relations with its faculty, students, and staf Amendments of 1972, not to discriminate on the result in serious disciplinary action. members, without regard to age, citizenship basis of race, color, sex, national origin, or disability Examples of actions subject to disciplinary status, color, disability, marital or parental status, in any educational program or activity. Any member of the NYU Langone Health action specific to this Code include the national origin, race, religion, sex, gender identity, community who violates this Code of Conduct, following: or sexual orientation. This includes, but is not Inquiries regarding the application of Title IX and may be subject to disciplinary action, up to and • Participating in activities that violate this Code limited to, recruitment, hiring or appointment, its implementing regulations may be referred to including termination. The specific disciplinary • Encouraging, directing, facilitating, or permitting selection for training, transfer, layof, promotion, the NYU School of Medicine Title IX Coordinator action will depend on the nature and severity of activities that violate this Code granting of tenure, rates of pay and other forms (Molree Williams-Lender, 212-404-3871, One Park the violation. Disciplinary actions will be consistent • Failing to report suspected violations of this Code of compensation and participation in educational, Avenue, 4th Floor, New York, NY 10016, with the manual and documentation applicable • Failing to detect violations of this Code that social, and recreational programs sponsored by [email protected]), or to the to your position in the NYU Langone Health should have been discovered in the course of NYU Langone Health. Ofice for Civil Rights at [email protected] or community (i.e., Faculty Handbook, Residency your supervisory or management responsibilities 800-421-3481. Training Program Contract, GME House Staf It is the policy of NYU Langone Health, in Manual, Postdoctoral Handbook, Student accordance with Title VI of the U.S. Civil Rights Handbook, By-Laws of the Medical Staf, Patient

NON-RETALIATION POLICY

All members of the NYU Langone Health Reported compliance concerns are considered community are protected from retaliation if in to be made in bad faith if they are reported good faith and with reasonable belief, you report maliciously (with ill intent) or with reckless violations of this Code, NYU Langone Health disregard for their truth or falsity. Individuals policies, or federal, state, and local laws. making reports in bad faith may be subject to disciplinary or other employment action by NYU There will be no retaliation against you if in your Langone Health and may also be subject to legal reasonable belief you raise concerns or questions claims by the individuals about whom the bad about misconduct or report violations of this faith reports were made. Code, NYU Langone Health policies, or federal, state, and local laws. Examples of retaliation If you report a violation and believe you are include but are not limited to termination of experiencing retaliation, you should report it to employment, unjustified negative performance the Ofice of Compliance or Human Resources. reviews, harassment, or exclusion from Anyone who retaliates against someone who has department meetings or social activities. raised a concern or reported a violation of the Code may be subject to disciplinary action or other employment action.

19 NYU LANGONE HEALTH CODE OF CONDUCT NYU LANGONE HEALTH CODE OF CONDUCT 20 DC 10/13/2019 NYU LANGONE HEALTH CODE OF CONDUCT DC 10/13/2019