Isabella Geriatric Center, Inc.

Code of Conduct

Adopted: May 18, 2026 · Download the PDF version

This Code of Conduct sets forth the standards of conduct that all Affected Individuals must adhere to and follow.

I. Code of Conduct: Commitment to Compliance

• Rooted in Jewish values and traditions and consistent with the highest standards of quality care, Isabella seeks to be the premiere provider of health services in the greater New York area, ensuring access to health, supportive and community-based services across the continuum of need.
• The Facility strives to provide high quality services to our residents without regard to age, race, color, sexual orientation, marital status, religion, sex, or national origin. We have a commitment to conduct our business in compliance with all applicable laws, rules and regulations and in accordance with ethical principles. The Facility expects the same from all Affected Individuals. We do not and will not tolerate any form of unlawful or unethical behavior by anyone associated with the Facility. We will follow the letter and spirit of applicable laws, rules and regulations, conduct our business ethically and honestly, and act in a manner that enhances our standing in the community.

II. Code of Conduct: Scope of Application to Affected Individuals

• The Compliance Program – and specifically this Code of Conduct – applies to all Affected Individuals. The term Affected Individuals is defined in this Compliance Manual.
• All Affected Individuals have a responsibility to help create and maintain a work environment in which compliance concerns may be openly raised, and promptly reviewed, discussed and addressed.

III. Code of Conduct: Standards

General Standards

• You must be honest and lawful in all of your business dealings and avoid doing anything that could create even the appearance of impropriety.
• You must: comply with the Code of Conduct; refuse to participate in any action you think may be possibly unethical, illegal or in violation of the Code of Conduct, a Compliance Policy and Procedure or the Compliance Program; report compliance issues and any unethical or illegal conduct to the Compliance Officer; cooperate with compliance inquiries and investigations; and work to correct any improper practices that are identified. The Facility expects and requires your good faith participation in the Compliance Program.
• Acts of retaliation or intimidation for good faith reporting of any suspected violation of, or for other good faith participation in, the Compliance Program will not be tolerated and are themselves a violation of the Compliance Program. For more information, see the Non-Retaliation, Non-Intimidation for Good Faith Participation in the Compliance Program Policy.

Standards Related to Quality of Care/Credentialing/Medical Necessity

• All residents will have access to admission and treatment without regard as to race, color, religion, sex, national origin, disability, sexual orientation, source of payment, or sponsorship.
• Each resident will receive medically necessary services that are required to assure the resident attains or maintains the highest practicable physical, psychosocial and mental well-being.
• The Facility provides care that conforms to acceptable clinical and safety standards.
• Comprehensive assessments of each resident’s medical condition(s) will be conducted upon admission and throughout their stay, in accordance with all applicable federal and state regulations and time limits, including instructions needed to provide effective and person-centered care which meets professional standards. The Facility will timely, accurately and completely document the care provided to its residents.
• Rehabilitative services, such as physical therapy, occupational therapy, speech- language pathology and mental health services, are provided, but only to the extent that these services are reasonable and necessary for the treatment of the resident.
• The Facility will protect and promote the rights of all residents, including, but not limited to, the right to respect, privacy, a dignified existence, self-determination, and the right to participate in all decisions about their own care and treatment.
• The Facility has implemented and maintains an effective, comprehensive, data- driven Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life.
• The Facility maintains an emergency preparedness program that meets Federal and State requirements, including, but not limited to: (i) an emergency plan; (ii) policies and procedures; (iii) a communication plan; and (iv) a training and testing program.
• All professional staff associated with the Facility will be properly licensed, certified and/or registered as required by applicable laws, rules and regulations. The Facility will take steps on a regular basis to monitor and ensure such compliance.
• In addition to the general credentialing process, the Facility will confirm the identity and determine the exclusion status of all Affected Individuals. In doing so, we will review the following State and Federal databases at least every thirty (30) days: (a) the OMIG Exclusion List; (b) the U.S Department of Health and Human Services Office of Inspector General’s (the “OIG”) List of Excluded Individuals and Entities (c) the General Services Administration’s System for Award Management. Our Contractors are also required to comply with these requirements. The results of such checks will be promptly shared with the Compliance Officer and other appropriate compliance personnel. For more information, see our Compliance Reviews for Excluded or Ineligible Individuals/Entities Policy.
• The Facility’s Director of Nursing Services will be responsible for overseeing quality of care issues. In consultation with quality improvement personnel, the Compliance Officer (or his or her designee(s)) will ensure that quality assurance reviews are conducted, issues are addressed, and corrective actions are implemented.
• The Facility will only submit claims for payment to payers for services that are medically necessary or that otherwise constitute a covered service and are consistent with the payer’s applicable policies and requirements.

Standards Related to Coding, Billing and Documenting Services

• The Facility will comply with the coding, billing, documentation and submission rules and requirements of all of its payers, including government payers such as Medicare and Medicaid, and commercial payers, as well as all applicable Federal and State laws, rules and regulations governing the coding, billing, documentation and submission of claims. For more information, see our Billing, Coding and Documentation Policy.
• The Facility is committed to preparing accurate claims, consistent with such requirements. All coding, billing and documentation of services must be accurate and truthful.
• Specifically, among other rules, we follow 18 NYCRR § 521-1.3(d):
• Risk areas. The compliance program shall apply to the required provider’s risk areas, which are those areas of operation affected by the compliance program and shall apply to: (1) billings; (2) payments; (3) ordered services; (4) medical necessity; (5) quality of care; (6) governance; (7) mandatory reporting; (8) credentialing; (9) contractor, subcontractor, agent or independent contract oversight; (10) other risk areas that are or should reasonably be identified by the provider through its organizational experience.
• Based on our organizational experience, other risk areas include, but are not limited to: (1) therapy services; (2) incident reporting; (3) documentation; (4) employee screening; (5) staffing levels; (6) referral relationships; (7) emergency preparedness; and (8) accurate cost reporting.
• You may never misrepresent charges or services to or on behalf of the government, a patient or a payer. False statements, intentional omissions or deliberate and reckless misstatements to government agencies, payers or others will expose those involved to disciplinary action. As but one example, no Affected Individual will knowingly engage in any form of upcoding of any service in violation of any law, rule, regulation or requirement. Among other things, any Affected Individual involved in such activities is subject to potential termination of employment or contract, and potential criminal and civil liability.
• Billing codes – including CPT, HCPCS and ICD diagnostic codes – should never be selected on the basis of whether the given code guarantees or enhances payment. Rather, only those codes that correspond to the actual service rendered and documented should be selected.
• Only those services that are consistent with accepted standards of care may be billed. In this regard, billing and coding must always be based on adequate documentation of the justification for the service provided and for the bill submitted, and this documentation must comply with all applicable requirements.
• We also comply with all associated and applicable Federal and State laws, rules and regulations that relate to the coding, billing and documentation of services including, but not limited to those concerning: the ordering of services; waiving coinsurance or other patient financial responsibility amounts; providing professional courtesy to physicians or their families; obtaining Advance Beneficiary Notices from Medicare residents for non-covered services; and gathering insurance information from residents.
• In addition, the following standards must be maintained with respect to all billing and documentation:
  1. A comprehensive person-centered and up-to-date plan of care is maintained for each resident in a skilled nursing unit which assesses both strengths and needs, includes measurable objectives and timetables to meet the residents’ medical, nursing, physical, mental and psychosocial needs, as identified in the comprehensive assessment, incorporates the resident’s personal and cultural preferences and facilitates participation by the resident’s representative if one has been appointed.
  2. All resident assessment documents, including but not limited to Minimum Data Sets (MDS) and Care Area Assessments (CAA), must be fully, timely, and accurately completed in accordance with all applicable federal, state, and local rules and regulations.
  3. Under no circumstances may any Personnel knowingly misrepresent any information on any resident assessment forms, or in any other document, in an attempt to ensure reimbursement or obtain a higher reimbursement rate.
  4. Only those medical services to residents that are consistent with acceptable standards of medical care may be billed.
• In accordance with Federal and New York State law,¹ the Facility provides to all Affected Individuals a detailed description of: (i) the Federal False Claims Act; (ii) the Federal Program Fraud Civil Remedies Act; (iii) State civil and criminal laws pertaining to false claims; and (iv) the whistleblower protections afforded under such laws. The Facility also provides Affected Individuals with detailed provisions regarding our policies and procedures for detecting and preventing fraud, waste, and abuse. The employee handbook also includes specific discussion of the laws described above, the rights of employees to be protected as whistleblowers, and the Facility’s policies and procedures for detecting and preventing fraud, waste and abuse.
• The Facility does not retain any payments to which it is not entitled. The Facility will timely report, return and explain any identified overpayments in accordance with applicable law, rules, regulations and requirements. For more information, see “Mandatory and Other Reporting” below; and For more information, see the Billing, Coding and Documentation Policy; the Waiving/Reducing Coinsurance, Copayment and Deductible Amounts Policy; the Compliance with Anti-Referral Laws Policy; and the Compliance with Federal and State False Claims Laws (Overview of the Laws Regarding False Claims and Whistleblower Protections/Policy.

Standards Relating to Business Practices

• All business records must be accurate, truthful and complete, with no material omissions.
• The Facility will forego any business transaction or opportunity that can only be obtained by improper or illegal means, and will not make any unethical or illegal payments to induce or reward the use of our services.
• No Affected Individuals will engage, either directly or indirectly, in any corrupt business practices intended to influence the manner in which the Facility performs services, or otherwise engages in business practices. For more information, see the Billing, Coding and Documentation Policy; the Compliance with Anti-Referral Laws Policy; the Compliance with Federal and State False Claims Laws (Overview of the Laws Regarding False Claims and Whistleblower Protections/Policy; the Gifts and Benefits Policy; and the Conflict of Interest Policy.

Standards Relating to Record Retention and Access to Records

• The Facility will comply with all applicable laws, rules, regulations and requirements relating to the retention of billing and medical records.
• The Facility will make available to the New York State Department of Health (“DOH”), the OMIG and the MFCU, upon request, all records demonstrating that we have adopted, implemented and operate an effective compliance program and have satisfied the requirements of 18 NYCRR Subpart 521. Such records will be retained by the Facility for a period not less than six (6) years from the date the program was implemented, or any amendments thereto were made, in accordance with 18 NYCRR § 521-1.3(b), or for such longer period of time as may be required by applicable laws, rules, regulations or contractual requirement.
• In order to help ensure the effectiveness of the Compliance Program, the Compliance Officer and appropriate compliance personnel will have access to all records, documents, information, facilities and Affected Individuals that are relevant to carrying out their Compliance Program responsibilities.

Patient Referrals/Marketing Activities

• In general, Federal and State anti-kickback laws prohibit offering, paying, soliciting or receiving any remuneration to induce or reward referrals of items or services that are reimbursed by a Federal health care program (including, but not limited to, Medicare and Medicaid). This includes the giving of any form of remuneration, including virtually anything of value, in return for a referral. The decision to refer residents is a separate and independent clinical decision made by physicians or other appropriate licensed practitioners. In certain situations, there may be exceptions and/or “safe harbors” to the anti-kickback laws. The Facility does not offer, pay, solicit or receive remuneration to or from physicians, or anyone else, either directly or indirectly, for patient referrals, in violation of applicable laws, rules and/or regulations. For more information, see our Compliance with Anti- Referral Laws Policy; and our Compliance with Federal and State False Claims Laws (Overview of the Laws Regarding False Claims and Whistleblower Protections) Policy.
• All marketing activities and advertising by Affected Individuals must be truthful and not misleading, must be supported by evidence to substantiate any claims made and must otherwise be in accordance with applicable laws, rules and regulations. In this regard, our best “advertisement” is the quality of the services we provide. You should never disparage the service or business of a competitor through the use of false or misleading representations.
• You may not offer, pay, solicit or receive any gifts or benefits to or from any person or entity that would compromise the Facility’s integrity (or even create an appearance that the Facility’s integrity is compromised), or under circumstances where the gift or benefit is offered, paid, solicited or received with a purpose of inducing or rewarding referrals or other business between the parties, in violation of applicable laws, rules, regulations or requirements. The guiding principle is simple: Affected Individuals may not be involved with gifts or benefits that are undertaken to influence any business decision in a manner that violates the law. Cash or cash equivalents may not be given or accepted under any circumstances. For more information, see our Gifts and Benefits Policy; and our Compliance with Anti-Referral Laws Policy.

Mandatory and Other Reporting

• As part of its commitment to providing high quality care and services, the Facility complies with all applicable Federal and State mandatory reporting laws, rules and regulations. To this end, the Facility will ensure that all incidents and events that are required to be reported are reported in a timely manner, and will monitor compliance with such requirements. This includes required reporting to appropriate government agencies or parties.
• The Facility will also ensure its compliance with the requirement that, upon enrollment and annually thereafter, it certifies that it has met the requirements of New York Social Services Law (i.e., N.Y. Social Services Law § 363-d and 18 NYCRR Subpart 521-1). Further, the Facility will provide a copy of the certification required by 18 NYCRR § 521-1.3 to each Medicaid Managed Care Organization (including managed care providers and managed long term care plans) (collectively, “MMCO”) for which it is a participating provider upon signing the participating provider agreement with the MMCO, and annually thereafter. As applicable, the Facility will also comply with other State and Federal certification requirements that are or may become applicable to it.
• The Facility will ensure that all identified overpayments are timely reported, returned and explained in accordance with applicable laws, rules, regulations and requirements. For example, it is our policy to exercise reasonable diligence in identifying overpayments, not to knowingly retain any funds which are received as a result of overpayments and to report, return and explain any overpayments received from Federal health care programs (including, for example, but not limited to, Medicare and Medicaid) within 60 days from the date the overpayment is identified (or within such time as is otherwise required by law or contract). Any such monies that are improperly collected will be refunded, in accordance with applicable laws, rules, regulations and requirements, to the appropriate party at the correct address. For more information, see our Protocols for Investigation and Implementing Corrective Action, Including Discipline Policy.
• Moreover, in appropriate circumstances (e.g., after an internal investigation confirms possible fraud, waste, abuse or inappropriate claims), the Facility will utilize the appropriate self-disclosure process and report, as necessary and appropriate, to the OMIG, OIG, the Centers for Medicare and Medicaid Services, or other appropriate payer/agency. In such circumstances, the Facility may consult with legal counsel or other experts, as needed. For more information, see our Protocols for Investigation and Implementing Corrective Action, Including Discipline Policy.

Standards Relating to Confidentiality and Security

• In compliance with Federal and State privacy laws, all Affected Individuals will keep patient information confidential and secure.
• The Facility has also implemented and maintains a HIPAA Compliance Program that addresses privacy and security. All Affected Individuals must adhere to the standards of the HIPAA Compliance Program.
• Confidential information acquired by Affected Individuals about the business of the Facility must also be held in confidence and not used for personal gain, either directly or indirectly, or in any manner that violates applicable laws, rules, regulations or requirements.

Government Inquiries

• It is the Facility’s policy to comply with applicable laws, rules, regulations and requirements, and to cooperate with legitimate government investigations or inquiries. All responses to requests for information must be accurate and complete, and must not omit any material information. Any action by Affected Individuals to destroy, alter, or change any of the Facility’s records in response to a request for such records is strictly prohibited and will subject them to immediate termination of employment or contract and possible criminal prosecution, among other things.
• You may speak voluntarily with government agents, and the Facility will not attempt to obstruct such communication. It is recommended, however, that you contact the Compliance Officer before speaking with any government agents.
• You must receive authorization from the Compliance Officer before responding to any request to disclose the Facility’s documents to any outside party.
• It is the Facility’s policy to comply with applicable laws, rules, regulations and requirements, and to cooperate with legitimate government investigations or inquiries. All responses to requests for information must be accurate and complete, and must not omit any material information. Any action by Affected Individuals to destroy, alter, or change any of the Facility’s records in response to a request for such records is strictly prohibited and will subject them to immediate termination of employment or contract and possible criminal prosecution, among other things.
• It also is our policy to comply with all lawful directives of the DOH, OMIG or other appropriate government agencies with respect to the adoption, implementation and maintenance of our Compliance Programs pursuant to applicable laws, rules and regulations, including, but not necessarily limited to, 18 NYCRR Subpart 521-1. For more information, see our Responding to Government Inquires Policy.

Specific Compliance Provisions for Agreements with Contractors

• It is the policy of the Facility to ensure that all contracts with our Contractors specify that the Contractor is subject to our Compliance Program, to the extent that the Contractor is affected by our risk areas (within the scope of the contracted authority and affected risk areas). We will follow OMIG’s guidance regarding agreements in place prior to the effective date of OMIG’s updated compliance regulations. For more information, see our Contractor Requirements Policy.
• In addition, such contracts will also include termination provisions for the failure to adhere to our Compliance Program requirements.

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