QUALITY FIRST

A PLEDGE
TO IMPROVE QUALITY THROUGH
ACCOUNTABILITY, COMPASSION, AND LEADERSHIP

As providers of long-term care and short-term skilled nursing care, we recognize our unique obligations to the individuals we serve. Through dedicated care staff, many of whom live on the margins of poverty, we care for a vulnerable population that, in many cases, is frail and poor and paid for, at least in part, by government-funded programs. Because of the nature of the care we provide and the people we serve as well as the government resources available, we have different obligations than do other health care providers. Providing care to vulnerable individuals requires more than clinical expertise; it requires us to attend to the emotional, spiritual, social, psychological, and physical needs of our patients. To succeed in that mission, and to engender the trust of the American people, we hereby embrace a single set of voluntary principles beyond those required by law to guide our companies now and into the future. By articulating the principles contained in this covenant, we pledge our commitment to the people we serve, and we agree to lead our companies in ways that benefit the frail and vulnerable, our employees, and society as a whole.

We, the undersigned, acknowledge our quality commitment, adopt this Code of Conduct, and commit to its timely implementation in our organizations.

Our Quality Commitment

1. We are committed to making patient health and well-being paramount priorities in our organization's management. We also are committed to a philosophy of management that stimulates continuous quality improvement through the establishment of uniform quality measures, the creation of annual quality improvement goals, and the identification and use of clinical "best practices" in an effort to achieve appropriate patient outcomes.

2. We are committed to continuing to disclose information on quality to patients, employees, and the public, and we will assist them in accessing this information in a timely manner, while protecting confidentiality and complying with other legal requirements.

3. We are committed to clearly articulating and honoring patient and family rights, and working to ensure that our employees understand and uphold those rights.

4. We are committed to enhancing the human potential of our employees through education and training programs that strive to improve the quality of care delivered, and we are committed to sensitizing our staff to the special needs of frail and vulnerable patients.

5. We are committed to seeking the input of consumers as we work to improve quality, and we will work with others - in the private and public sectors - to identify, understand, and, ultimately, to resolve concerns associated with care practices or patient outcomes.

6. We are committed to developing and implementing organization-specific programs that promote ethical and lawful conduct, and we will lead in the development of responsible laws, regulations, and other standards supporting the quality of care in the facilities we manage.

7. As providers of care to a unique patient population that is funded in large part by government programs, we are committed to acting as responsible stewards of scarce financial resources. We also recognize our responsibility to serve as champions for public financing levels that will support improved quality and enhanced staffing.

Charter Signatories:

Advocat, Inc.
Beverly Enterprises, Inc.
Centennial HealthCare Corp.
Extendicare Health Services, Inc.
Genesis Health Ventures, Inc.
Harborside Healthcare
HCR Manor Care Corp.
Integrated Health Services, Inc.
Kindred Healthcare
Mariner Health Care, Inc.
Medical Facilities of America
National Healthcare Corp.
Sun Healthcare Group, Inc.
Tandem Health Care, Inc.

Additional Signatories:

NHS Management
UHS Pruitt Corp.

CODE OF CONDUCT AND
ETHICAL MANAGEMENT PRACTICES

1. Commitment to Patient Well-Being Through Quality Care

a. Leadership Commitment to Quality - Management exhibits leadership by playing an active role in the establishment and implementation of a code of conduct that articulates the organization's expectations of all employees, a statement of principles that guides the organization's operations and reflects its values, and the development and implementation of clear policies and guidelines that support a commitment to high quality performance. Management's involvement demonstrates that the organization places a high priority on quality care, quality improvement, and organizational integrity.

i. Management and Organization Commitment to Improvement

1. Policies reflect management's commitment to quality.
2. The ethic of continuous quality improvement is evident throughout the organization and is embedded in its policies and communications.
3. Management believes and demonstrates that quality performance supports strong financial performance.
4. Management's commitment to standards for quality is visible to employees, patients, family members, and government.
5. Management demonstrates its commitment to quality care and to ongoing improvement through the identification and sharing of best practices throughout the organization and the long term care provider community.

ii. Organization Policies Regarding Quality

1. Organization policies related to quality and quality improvement state implicitly or explicitly that each employee is charged with responsibility to comply with current laws, regulations, and with the organization's quality standards.
2. The organization has developed a process to ensure routine review and evaluation of organization policies and practices related to quality care and quality improvement.

iii. Quality Goals

1. Management sets annual quality improvement goals based on data reflecting organization-wide performance as well as input from employees, patients, and family members.
2. Quality goals address both clinical quality as well as patient and/or family satisfaction levels.
3. Goals are shared with employees, patients, families, shareholders, and the public.
4. The organization has created a monitoring system for evaluating quality performance against quality goals.
5. The organization reports the results of its efforts to the public.

b. Continuous Quality Improvement - The organization routinely evaluates clinical performance and assesses patient, family member, and employee concerns about performance. The organization also has developed processes to identify and assess legislation, regulation, and changes in standards of practice to determine the adequacy of resources available for implementation.

i. Quality Improvement Process

1. The organization has developed and implemented an organization-wide quality improvement process.
2. The organization has a system for verifying quality improvement process implementation.
3. The quality improvement process includes the development of annual quality improvement goals.

ii. Quality Improvement Responsibility

1. The organization has individuals with clear responsibility for assessing quality trends using pre-identified quality indicators.
2. These individuals routinely monitor performance and make recommendations for quality improvement targets, process changes, and policy reform.

iii. Quality Monitoring

1. The organization uses clinical outcomes data and other available information to assist in the routine monitoring of clinical quality performance.
2. The organization conducts quality performance assessments at least annually.
3. The organization conducts more frequent focused quality assessments when data indicate issues related to achieving anticipated clinical and other quality of care outcomes.
4. The organization, at the appropriate level, develops quality improvement plans to address issues related to achieving anticipated clinical and other quality outcomes.
5. The organization has a documented protocol for investigating accidents and other incidents to discover root causes and for recommending corrective and/or preventive action.
6. The organization communicates with employees about the outcome of quality assessments and plans for quality improvement.

iv. Quality Policy and Process Evaluation

1. The organization routinely evaluates policies and processes vis-à-vis their impact on quality improvement.
2. The organization evaluates annually the impact of its quality improvement processes on quality.
3. The organization has a process for investigating, responding to, and reporting of identified areas of concern.

c. Quality Improvement Goals - The establishment of quality goals is critical to stimulating sustainable quality improvement. Therefore, the organization will seek input as it establishes annual quality targets and quality improvement goals. As part of the establishment of annual targets and goals, the organization will evaluate data from the following sources, among others:

i. Government-developed clinical quality measures,
ii. Government inspection reports,
iii. Customer satisfaction surveys,
iv. Patient, family, and employee communications,
v. Internal quality monitoring information.

d. Uniform Measures of Quality - In addition to complying with applicable federal and state government standards as well as organization-established standards, the organization will work with others to create and refine quality measures that are:

i. Reliable,
ii. Uniform,
iii. Risk adjusted,
iv. Easy for consumers to access and understand,
v. Meaningful with regard to the quality of care being delivered in our facilities.

2. Public Disclosure and Accountability - The organization recognizes the important role public disclosure of quality information plays in accountability. The organization currently discloses significant amounts of quality information and will continue to disclose that information, while protecting confidentiality and complying with other legal requirements. As part of its disclosure process, the organization has developed policies and systems for routinely disclosing quality performance information and will assist our employees, our patients, their family members, and the general public in accessing this quality information in a timely manner.

3. Patient and Family Rights - Patients and families have a set of rights, which the organization articulates clearly upon admission and makes available within the facility and upon request. These rights are articulated in current federal and state law and regulation and may include additional protections deemed appropriate by the organization and which are available in writing to consumers, their families, and employees. Basic patient rights cover the following areas:

a. Access to care in a safe and supportive setting
b. Freedom from abuse and neglect
c. Patient choice and involvement in care-related decisions
d. Access to personal medical information
e. Privacy and confidentiality protections
f. Freedom from physical and chemical restraints
g. Freedom to create patient/family councils
h. Protection of resident funds and financial affairs/information
i. A grievance process
j. Self-determination and advance directives
k. Access to social, spiritual activities
l. Dignity in caregiving

4. Workforce Excellence - The organization develops and implements systems to meet government and organization-defined quality requirements to achieve patient care and quality goals, to ensure the integrity of the organization's workforce, and to safeguard the welfare of patients. These management systems include the recruitment and ongoing training of employees, while respecting federal and state laws.

a. Employee Recruitment, Assessment

i. The organization actively recruits candidates that have a demonstrated commitment to caring for elderly and frail patients.
ii. The organization evaluates candidates using screening tools, including the administration of background checks and the verification of certifications and licenses, consistent with state and federal laws, before hiring employees who have access to patients or their possessions or who have discretionary authority to make decisions that may involve compliance with the law or regulation.
iii. The organization requires prospective employees and current employees to disclose any criminal conviction or exclusion from participation in federal health care programs, as permitted by state and federal laws.
iv. The organization has a policy regarding employee drug testing.

b. Employee Training

i. The organization ensures that each employee receives and certifies that he/she has read organization policies and procedures related to quality of care and organization obligations related to federal and state laws and regulations.
ii. The organization has a process for clearly identifying employee roles and responsibilities in the execution of quality-related and care-related tasks.
iii. Employee training programs include an orientation program that clearly articulates the organization's philosophy about and commitment to patient care and quality performance as well as ongoing improvement.
iv. Employee training programs cover task-specific skills and competencies, as well as awareness of regulatory requirements appropriate to care-related tasks.
v. Employee training programs address patient rights and dignity protections.
vi. Training programs address activities designed to minimize occupational health and safety risks faced by employees.
vii. Training programs for management and health care professionals address the organization's compliance program, fraud and abuse laws, and federal health care program requirements.

c. Commitment to Employees

i. The organization recognizes that its ability to deliver high quality services is largely dependent upon having trained direct care staff.
ii. The organization has developed plans and processes to educate employees about occupational health and safety hazards associated with health care settings and protection against harm from those hazards.
iii. The organization has systems in place to recognize and reward employees for exceptional performance.
iv. The organization has established, documented, and clearly articulated policies to prevent instances of discrimination, harassment, or other types of exploitation of employees.
v. The organization supports public policy initiatives that will allow providers to offer levels of compensation that are commensurate with levels offered by hospitals and other health care providers.

5. Public Input on Quality - The organization recognizes that the creation of mechanisms for public input and advice is essential to quality improvement. Therefore, nursing home organizations participating in this initiative will create a National Commission on Nursing Home Quality, consisting of approximately 15 individuals, including consumers, family members, health professionals, academics, business executives, employee representatives, and others from different regions of the country. The panel will be charged with:

a. Reviewing quality-related information and data to identify profession-wide clinical successes and opportunities for improvement.
b. Advising on national quality improvement targets.
c. Advising annually on national quality improvement goals.
d. Assessing the impact of the voluntary quality initiative on quality of care.
e. Reporting via annual public letter on the impact the initiative is having on quality.
f. Recommending changes and improvements in the voluntary initiative.
g. Participating in structured visits to facilities to ensure an accurate understanding of the current long-term care/post-acute environment.
In addition, organizations will create their own committees to provide advice on quality improvements.

6. Ethical Practices - The organization and its management will play a leadership role in the development of responsible laws, regulations, and other standards addressing the quality of care provided in the skilled nursing facilities we own or manage. The organization makes a formal commitment to developing and implementing a program which is designed to prevent fraud and abuse from occurring, which is evaluated routinely for effectiveness, and which includes the following:

a. Standards of conduct
b. Identification of a compliance officer
c. Employee education and training
d. A process for handling complaints
e. Audits and other monitoring methods
f. Processes and policies related to disciplinary action

7. Financial Stewardship - The organization recognizes the important and unique role it plays in health care by caring for a vulnerable population whose care is funded at least in part by government programs. As providers of care to this unique population, the organization must act as a responsible steward of scarce financial resources.

a. The organization is committed to accurate and timely billing and claims documentation.
b. The organization is committed to maintaining the complete, accurate, and timely documentation of care services, including subcontracted services, as well as minimum data set (MDS) information.
c. The organization maintains records, including billing and claims documentation, audit data that support and explain cost reports, and other records necessary to demonstrate the integrity of the nursing facility's financial management system.
d. The organization maintains compliance with anti-kickback laws.
e. The organization supports efforts to secure adequate public financing to support quality long-term care.