UNC Health Care in Chapel Hill, North Carolina, has just revised its policy on vendor representatives[1] and its vendor code of conduct (see below). “The UNC Health Care Code of Conduct is a critical component of our overall compliance program,” said Patrick Kennedy, executive director of hospital compliance. Contact Kennedy at patrick.kennedy@unchealth.unc.edu.
Appendix A: Vendor Representative Code of Conduct
The UNC Health Care Code of Conduct is a critical component of our overall compliance program. UNC Health Care expects vendor representatives to conduct themselves in a professional and ethical manner at all times. Vendors and their representatives must comply with all laws, rules and regulations that apply to the health care industry.
All vendor representatives are expected to be familiar with UNC Health Care’s Vendor Visitation policy and adhere to professional behavior as follows:
Vendor Credentialing
All vendor representatives must be credentialed prior to entering a UNC Health Care entity. All requirements, including mandated immunizations, must be completed and verified annually.
Prior UNC Health Care Employment
Effective 00/00/2021, vendor representatives with prior UNC Health Care employment may not represent a vendor at any UNC Health Care entity where they were assigned to work as a UNC Health Care employee for a period of one year from the date of last employment. Such vendor representatives may represent a vendor at other UNC Health Care entities where they were not assigned to work immediately upon leaving employment with UNC Health Care, unless otherwise stipulated by management.
Entertainment, Gifts, Food, Favors
Vendor representatives must adhere to all policies that govern vendor relations and seek advice from the applicable Network Entity Compliance Office when questions arise.
Compliance With Laws
Vendors are required to conduct business activities in compliance with all applicable laws and regulations, including laws that are applicable to individuals and entities receiving Medicare, Medicaid and other federal funds.
Confidentiality
In the course of the vendor representative’s relationship with UNC Health Care, the vendor representative may incidentally witness confidential information. Federal and state laws protect the privacy and confidentiality of all patient protected health information.
Vendor representatives who are responsible for providing services to UNC Health Care are accountable for the requirements of the Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security rules and state laws that provide more stringent protection of personal health information (PHI).
Vendor representatives are prohibited from accessing UNC Health Care computers or electronic medical records, unless otherwise arranged by management and when their business requires access. Accordingly, vendor representative’s access to UNC Health Care is contingent upon continuously meeting code of conduct provisions and the following requirements:
-
Treat all confidential information and protected health information to which the vendor is exposed while working on-site at the UNC Health Care facility as private, privileged and confidential.
-
Abide by the UNC Health Care HIPAA policies and procedures, including the UNC Health Care Code of Conduct
-
Not make any use or disclosure of confidential information or protected health information without prior written authorization from UNC Health Care, including, but not limited to, marketing or communications for other commercial purposes.
-
Not contact any present or former patient of UNC Health Care for marketing or any other purpose (other than in direct treatment relationships the vendor may have with the patient) without UNC Health Care’s prior authorization.
-
Not remove from or in any way divulge copy, release, sell, loan, review, alter or destroy any protected health information or confidential information obtained during approved business activities except as otherwise necessary for the vendor to provide treatment or services to the patient directly (if applicable).
Breach of the aforementioned may result in immediate termination of the representative’s access to UNC Health Care and subject them to further legal action. Representative’s obligations under this agreement shall survive the expiration or termination of the representative’s relationship with UNC Health Care as a vendor.
Eligibility to Participate in Federal and State Health Care Programs
UNC Health Care will not conduct business with any supplier excluded, debarred or ineligible to participate in federal or state health care programs such as Medicare and Medicaid, or whose officers, directors or employees are excluded from participating in federal or state health care programs. Vendors are responsible for taking all necessary steps to ensure personnel involved in providing goods and services to UNC Health Care, directly or indirectly, remain eligible to participate in federal and state health care programs.
Fraud, Waste and Abuse (FWA)
UNC Health Care will promptly investigate any reports of alleged violations of law, regulations or UNC Health Care policies involving a vendor or a vendor’s personnel, including allegations of FWA involving federal or state health care programs. Vendors are expected to fully cooperate in such investigations and, where appropriate, in taking corrective actions in response to confirmed violations. The federal False Claims Act states it is a crime to present a false claim to the government for payment. This law also protects whistleblowers from retaliation. UNC Health Care policies prohibit retaliation of any kind against individuals exercising their rights under the federal False Claims Act or similar state laws.
Deficit Reduction Act of 2005 (DRA) Requirements
The DRA requires UNC Health Care to provide detailed information to its employees, contractors and agents regarding the federal False Claims Act and applicable state false claims laws. Vendors are responsible for reviewing the False Claims Act and for sharing this information with their representatives conducting business with UNC Health Care.
Publicity
Unless prior written approval is obtained from an authorized UNC Health Care director or leadership, vendors are not permitted to distribute advertising, press releases or any other general public announcement regarding its products or services to UNC Health Care facilities.
Business Record Retention
UNC Health Care requires vendors to retain and make available records related to business activities with UNC Health Care in accordance with applicable law, regulation and contract requirements.
Smoking and Tobacco Use
Smoking, including vaping, and any form of tobacco use is prohibited on all UNC Health Care properties.
Parking
Vendor representatives will park in visitor parking spaces and are responsible for any incurred parking fees.
Personal Fragrances
The use of scented personal products (e.g., body lotion, hair products), colognes, or perfumes is prohibited on all UNC Health Care properties.
Illness
Vendor representatives will refrain from visiting a UNC Health Care facility if they are ill.
Recording Devices
The use of any recording device is strictly prohibited by vendor representatives in any area of the hospital and hospital property without the expressed written consent of a director or administrator. Recording devices may be noted as the below, but they are not limited to these devices:
-
Digital recorders
-
Cell phones
-
Cameras (conventional, digital, camera phones, etc.)
-
Tape recorders
Electronic Devices
The use of electronic devices (cell phones, laptop computers, iPads, etc.) within a UNC Health Care facility should not be used in any areas where patients or visitors are present. All electronic devices must be turned off prior to entering any procedural areas.
Conducting Business in UNC Health Care Facilities
Vendors may not conduct business in any public areas such as facility main lobbies, waiting rooms, cafeterias or cafes unless as part of a short-term event specifically approved by entity leadership (e.g., auxiliary sponsored sales events) or when the vendor is waiting between prescheduled appointments (e.g., vendor representative provides medical device support during morning and afternoon surgeries).
Reporting Code of Conduct Violations
The UNC Health Care Code of Conduct applies to every person who represents UNC Health Care: staff, providers, officers, board members, volunteers, residents and students, and many contractors. The Code of Conduct can be found on the UNC Health Care internet site. The Compliance Hotline is available 24 hours a day, 365 days a year. Hotline callers and web reporters may remain anonymous.