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VOLUNTEER ORIENTATION &

RE-ORIENTATION 2019

My signature on this form acknowledges that I have received, understand & agree to adhere to all policies and procedures outlined within, including HIPAA

and the Mount Sinai Code of Conduct.

Name Date

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WELCOME

We welcome youas avolunteer at MountSinai MedicalCenter.Youarenowpartofour proudtradition. Throughout theyears volunteershave donated thousands ofhourstoMount SinaiMedical Center.They befriend the lonely,the bereaved,and comforted the helpless.They have doneclerical work,manneddesks,served coffee and snacks to patients and pushed wheelchairs and book carts. Now, you have made the sametime-honoredcommitment tohelpingothers.TheboardoftrusteesandtheadministrationofMount Sinai MedicalCenter wishtothank you foryourconsideration.Wefeel certainthat inreturnyou will find fulfillment and new friends as you join hands with other loyal members of our Mount Sinai volunteers.

THE BENEFITSOFBECOMINGAVOLUNTEER

We are pleased that you have chosen to become a volunteer at Mount Sinai Medical Center. Volunteers havebeen a traditional part of Mount Sinai’s history since its early years. These volunteers have chosen to devotetheir time and expertise to helping patients and assisting staff members. As a volunteer, you are a member ofthe MountSinai family,and entitled to the followingbenefits.

• Vouchered meals for volunteers who work a minimum of 4 hours a day • Free parking • Free seasonal flu vaccinations • Free annualtuberculosis testing • Pharmacydiscount • Trainingandon-goingin-service • Recognitionandawardsfor servicesrendered

Aside from these benefits, when you or a member of your family is a patient or in need of medical services,notify the Volunteer Services Office so that we may keep in touch or be of assistance to you. However, the most important benefit is intangible. It is the personal satisfaction volunteers receive from their work with patients, families and staff and the warm bond of friendship that is formed among the volunteers and personnel.

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GENERAL INFORMATION

More thanseventy areas of the medicalcenter receive supplementaryassistance fromthe volunteers.The goalofboththestaffandthevolunteersistoprovidethepatientwithqualitycareandcomfort.Ourvolunteersrangeinagefrom14-year-oldteenagersto90+year-oldretiredmenandwomenwhobringtotheir assignments experience,skills and their desire to helpothers.The manager of Volunteer Services tries to match the volunteer to the jobso thatthe greatestdegree of mutualsatisfactionis achieved.

MountSinai’s Board of Trustees and the Administration express their appreciation of your service throughanannualawards ceremony.In ordertodocument thehoursyou work andreceivefull credit forthem,it is yourresponsibilitytosign in.

PLEASEREMEMBER:

• PUTYOURCELLPHONEONVIBRATE. • DO NOT USE CELL PHONES WHILE IN PUBLIC AREAS. • USEOFEARPHONESIS NOT PERMITTED WHILEON DUTY.

Asavolunteer,youmustagreetothefollowing:

• Assignment: Devote at least four hours one day a week for a minimum of 100 hours.

• Verification of hours,including letter of recommendation, is given for 100 hours and above ONLY.

• IdentificationBadge: Youmustbringaphoto ID to secure anidentificationbadge.

• BackgroundCheck: All volunteers must agree to a criminal background check.

• Orientation &Re-Orientation: Asanewvolunteer ofMountSinaiMedicalCenter,youarerequired to read and signanorientationpackage designed to acquaintyouwith our medicalcenter,policies, benefitsandsafetyregulations. Orientationwillalso be reviewed duringyour interview.

Youwillbe givenare-orientationpackageannuallytokeepyou uptodateregardinganynew procedures,policies,regulations and changes inthemedicalcenter. Thesechangeswill alsobe posted inthevolunteer office.

• Tuberculosis Test: For the protection of our patients, staff and volunteers, it is arequirementthatallvolunteersreceiveanannual tuberculosis test. If youhaven’thad atuberculosis testwithinthepast six months, you will be required to take the test.

• MMR & VaricellaVaccines: ProvideproofofMMR(measles,mumps&rubella)ifbornafter 1957 and Varicella vaccine if born after 1980.

• Permission: Volunteersbetweentheagesof14and17must submit parental permission.

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• Communications: Problemsconcerningyour assignment,vacations or absences orsituationswhich youobservethat mayinvolvestaffaretobereportedtothemanagerofVolunteerServices.

• Sign-in-Procedure: Itis mandatorythatyousigninuponarrivalandsignoutbeforeleaving so thatyourpresencemaybeverifiedaswell asdocumentedat anytimeduring your tour of duty. Therewillbeno lettersfor school without this documentation.

• Violation of the guidelines of any specific service is grounds for transfer fromthe area.Itis also the prerogative oftheManagerofVolunteerServicestotransfera volunteernolongerabletocarryout the prescribed duties of aspecific area. Weekend and eveningvolunteers,please keepthe Volunteer Office upto date with yourhours.Make sure your sign-insheetsaresubmittedtothevolunteeroffice by the end of each month.

• Parking: Volunteers will be assigned parking in the employee parkinglots.

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GUIDELINES FOR VOLUNTEERS

Confidentiality: Certain relationships are, by law, confidential, and information about them may not bedisclosed. Among these are the patient and doctor/medical facility. It is not just immoral and unethicalto disclose information concerning patients, but it is also illegal. Any breach of a patient's inviolate rightto privacy is cause for dismissal.

The medical center keeps confidential information on patients, employees and volunteers. This includesnames,addresses,insurance,wagesandsalaries,employmenthistory,diagnoses and other tests.

Access to this information is on a “need to know” basis. Anyone who has access to confidential informationofanynatureisexpectedtomaintaintheconfidentialityofthat information.

Tips & Gifts: Solicitingtipsor giftsfor servicestopatients/visitorsisnot permitted.Volunteersmay notsolicitpatientsor visitorsfor anycause,privateemploymentarrangementsor distributeany literature to them onbehalf of any cause or organizationatany time.Tips and gifts offered bypatients/visitors to volunteers should be courteously declined. If apatientor visitor wants to contributemerchandiseormoniestoMount Sinai,direct him/hertotheFoundation.

Dress Code: When reporting for duty you are expected to be clean, neat with well groomed hair andnails. Excessive use of perfume, cosmetics and jewelry is to be avoided. Clothing is to be clean, odor-free,wrinkle free and professional.

Uniform: PROFESSIONALATTIRE - NO JEANS, SHORTS, SHORT SKIRTS OR OPEN-TOE SHOES

I.D.Badge: Identificationbadges mustbewornvisibleand at shoulder height atalltimes. Emblem: Sewnonleftsleeveofuniform. Women: Pink volunteeruniformmust beworn overwhitetopandwhiteslacksorskirt. Men: White volunteer uniformwornwith dark colored pants. Teens: Girls – blue vest overwhitetopandlongwhitepantsorskirt (below knee).

Boys – blue vest overwhitetop (tuckedin) and darkpants. Cologne & Pleaseavoidhighlyscentedperfumeorcologne. Jewelry: Minimal amountof jewelry -followthe rule: two is too many.

Leave ofAbsence: Volunteers who are absent for a period of more than six weeks are subject toreassignmentbythemanager ofVolunteer Services.

No Solicitation: Solicitationisprohibitedbytherulesofthemedicalcenter withoutprior written approvalof medicalcenter administration.

DO NOT: 1. giveapatientanythingtoeator drink unless authorized byanurseor physician; 2. discuss anything about a patient with anyone; 3. push apatientinagurneyor apatientwith anI.V.drip; 4. assist a patient in or out of a bed, wheelchair or automobile. 5. accepttips or gifts for services rendered.

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Media Policy: Allstoriesfor themediamustbesubmittedtoandcoordinatedbythePublicRelations Department of the medical center. No volunteer or member of a volunteer's family should independentlyarrangeformedia coverage. Suggestionsfor featurestoriesor other itemsmustbe submitted to the Volunteer Services Department for approval. Once accepted, the concept or setting of appointmentswill behandledbythePublicRelationsDepartment.

AuxiliaryMembership: Volunteers are encouraged to become members of the Mount Sinai MedicalCenter Auxiliary. For more information, volunteers may contact the Auxiliary president or a member ofthe Auxiliary Board through the Volunteer Office.

Performance Improvement: Our mission is to provide quality service to our patients. If you see something that you think needs improvement, you should notify your manager or department head orcall thePerformanceImprovement Department at extension5-7951.

InfectionControl:

• Wash your hands before and after contact withpatients. • Cleanclothesandgoodpersonalhygieneareimportantincontrollinginfection. • Observe writtenprecautions posted inIsolationrooms,usingglovesand/ormask ifnecessary. • Do not come to work if you have been exposed to any communicable disease as colds or flu.

WHEELCHAIR SAFETYTIPS

Before using a wheelchair, check to make sure it is completely operational.Ifnot,return thewheelchair to the volunteer officeandnotifystaff.

Whenever apersonis gettinginor outof a wheelchair, LOCKBOTHWHEELS and FOLD FOOTRESTUP. NEVER LEAVE APERSONINAWHEELCHAIR UNATTENDED, not even for a moment.

If you must turn your attention away from your patient, place your hand on their shoulderwhile youlookaway.

Entering or leaving elevators, going over any threshold, or going down a ramp – gobackwards. Volunteers may push a patient in a wheelchair, however only an employee may assist them inandout ofthewheelchair.

NOSMOKING

MountSinai MedicalCenter is a smoke-free environment. Smoking is not allowed in anyinterior areaof anybuildingon any campus or any exterior location, such as parking lots or walkways.

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SAFETY AND SECURITY

We wantMountSinai MedicalCenter to be asafe place for volunteers,employees,patients and visitors.

• Watch for untidy, unsafe or unsanitary conditions or activities anywhere in the hospital andnotifythedepartmentheadinchargeofthearea.

• Remindpatients/visitorsofthenosmokingrules. • Walk,do notrun. • Do not play tricks or engage in "horseplay." Use correct bodymechanicsforlifting. • Useall safetyequipmentprovidedforyourjob. • Observe MountSinai's 10 mileperhourspeedlimit,all trafficsignsandlights. • Usecrosswalkswhencrossingstreets. • In case of an emergency, dial 123 (noothernumbersarenecessary).

HelpSecurityOfficers byreporting:

• Unknownpersonsinnon-publicareas withoutI.D.badges. • Unauthorizedpersonsinanyarea. • Suspiciouspersonsor activities. • Loss of personal, hospital or patient property. • Vandalism. • Dangerous conditions.

OurSecurityOfficerswillhelpby:

• Patrollingandmaintainingsecurity. • Investigatingincidents or losses. • Controlling traffic and enforcing traffic regulations. • Assistingwithcontrolof disturbances. • Assistingor helpingyoucallfor assistanceifyour car won'tstart. • Escortingyoutoyour car if youworkaneveningor nightshift.

If anemergencysituationoccurs and youneed immediateassistancefromSecurity,callext.52305, brieflystatethesituationandgiveyourlocation.Helpwill bedispatchedpromptly.Ifpossible,stayon the line and give further information.

On-dutyAccidentReports:

If anaccidentoccurs whileonduty,reporttheaccidenttoyour immediatesupervisor and to the managerofVolunteerServices.AnInjuryReportFormwill befilledoutandyouwill besenttothe EmergencyDepartmentfor treatment,if necessary.

Asecurity officer may respond to your supervisor's call when an accident occurs.

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Fire Alarms • The fire alarm will only sound/strobe on the floor of activation, the floor above and the floor

below within the same building. So, if the alarm is activated on 2 Main,youwillhear the alarm and see the strobes on 1 Main and 3 Main; however, keep in mind you will NOThear/see the alarm on 2 Greenspan or 2 Blum. If there is smoke or fire on 2 Main, the alarmwill activate on 1, 2 & 3, to begin with, but IF the smoke/fire travels through the hallto another building additional smoke and heat detectors will activate causing the alarm to also“spread”.

• When the alarm is activated in the buildings listed below, the following automatic messagewillplay: “Attention please, there has been an emergency alarm activated in this area,remain calm and stand by for instructions from staff.”

• De Hirsch Meyer • Warner • Blum • Greene • Greenspan • Radiology • SkolnickSurgicalTower • Emergency Department • Gumenick/Ambulatory • Cardiac Research Center

• All other buildings (listed below) will hear the following automated message: “BEEP, BEEP,BEEP…May I have your attention please? May I have your attention please? Therehasbeena fire emergency reported in thebuilding,pleaseevacuatethebuildingbythenearestexit. Do not use the elevators. BEEP,BEEP,BEEP.” Once the alarm has been cleared, youwill hear the following automatic message three times: “CODE RED-ALL CLEAR.”

• Simon Medical Office Building • Ascher • Jacobson Building • MRI/WienCenter • EnergyBuilding • Pearlman Research Facility • Childcare Center • Security Administration

• When you hear an alarm in your area, activate R.A.C.E. (see below); preparetoassistfor a vertical evacuation. Use fire extinguishers only for small, controllable fires - see instructions below (P.A.S.S).

• Stayinyour ownareaanddonotusetelephonesfor routinecalls. Assistasneededand directed by supervisor withinthe areawith any fire preparation(closingdoors,preparingfor evacuation,etc).

• DO NOT USE ELEVATORS.

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It is very important for volunteers to know and understand RACE and PASS asinspectors/regulators may ask you what you would do in case of a fire. Your response would be“We practice RACE and if we must use an extinguisher, we use the acronym PASS.”

R– A– C– E

R - Rescue - helpstaffremovepatients. A - Alarm - activate alarm - report fire. C - Confine - closedoorstoisolatesmoke. E – Extinguish - assistinputtingoutfire whenappropriate.

P– A– S– S

P - PULL: Aim at the base of the fire A - AIM: Aim at the base of the fire S - SQUEEZE: Squeezethehandle S - SWEEP: Sweepsidetoside

Fire prevention andpromptaction in case offire are important.

• Knowthe locationof alarmboxes and fire extinguishers inyour area.

• Knowwhere the exits and stairs are located.

SKOLNIK SURGICAL TOWER ONLY

• Elevator Smoke Curtain: Elevator smokecurtains areelectricallyoperated,automatic curtainsthat areactivatedinresponsetoafirealarmintheimmediatearea.Theyprovideameansofdivertingsmokeawayfromtheelevator shaft to protect an infiltration of smoke intootherareasofthehospital.

• Elevator Smoke Curtain locations:

1. Visitor Elevators 1 & 2 2. StaffElevators3& 4 3. StaffElevators5& 6 – onlyon2nd floor 4. StaffElevators7& 8 – onlyon1st floor 5. Staff Elevators9&10

• Won Doors: AWonDoor isahorizontalslidingfirewall.Itcoversalargespacefromfloor to ceiling.It automaticallyclosesuponactivationofthefirealarmwithinthearea.

• Won DoorLocations: SkolnickSurgicalTower 1st floor,withintheMainConcourseandonthe 2nd floor landing overlooking the atrium.

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PLEASE REMEMBER WHEN YOU HAVE COMPLETED YOUR ASSIGNMENT (And will not be returning) TO:

• Notify the volunteeroffice. • Return your ID badge to the Security Office. • Returnyour uniform to thevolunteeroffice.

OUR MISSION STATEMENT

To provide quality health care to our diverse community enhanced through teaching, research,charitycareandfinancial responsibility.

VISION

Tobe ahighlyrespected regionalreferralcenter providingqualityhealth care,teachingand research.

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Operation Excellence: Total Customer Satisfaction

StandardsofPerformance

PERSONALAPPEARANCE

1. Wear name badge, photo up, at shoulder height. 2. Wear jewelry in accordance with hospital dress code policy (two is too many). 3. Dress professionally in clean, neatly pressed clothes or uniform, as outlined in the dress code

policy.4. Do not eat or drink within the sight of visitors/patients; carry food/drink items in covered

containers. 5. Do not chew gum at any time.

ENVIRONMENT

1. Return equipment and/or supplies to their proper place; regulatorystandards require hallways to be kept clear.

2. Clean up spills and/or soiled areas whenever possible, otherwise notify housekeeping. 3. Pick upanddisposeoflitterwhenyouseeit inthehallways and/or onthe grounds.

COMMUNICATION

1. Wear a smile on your face and in your voice;offera greetingtoeveryone. 2. Develop and maintain a "can do" attitude. 3. Be courteous to everyone at all times. 4. Ask "is there anything else I can do for you before Ileave"attheend of eachencounter. 5. Listen carefully to what customers say; do not interrupt. 6. Listen attentively; keep eye contact and ask clarifying questions during all verbal complaints.

Be sure to apologize for anyinconvenience.Thankthe individual(s) for bringingthe issue to your attention. Take immediate action.

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TELEPHONE ETIQUETTE

1. Know how to operate telephone system. 2. Answer calls within three rings. 3. Answer all calls with a greeting (Good Morning, Good Afternoon) identify your

department and your name and ask “How may I help you?” 4. Use "please" and "thank you" all the time. 5. Ask permission before putting a caller on hold and upon returning to the line, thank the

caller for holding. 6. Acknowledge callers on hold at least every 30 seconds. 7. Ask the caller for permission to be placed on speaker phone; do not answer your phone

usingthespeaker. 8. Return all calls and messages as per departmental standards and no later than the endofthe

business day. 9. Do not drink or eat while using the telephone.10. Brief the colleagues who willbe coveringphones for youso that they are prepared for any

calls that you may expect, and take detailed messages.11. When transferring a phone call, make surethatthepersonyouaretransferringtois

available and inform them who is calling and the reason for the call.12. Do not make or receive personal calls in public areas. This includes cell phones.

HALLWAY ETIQUETTE

1. Offer to assist anyone who appears lost or puzzled. 2. Escort lost visitors to their destination or find someone who can. 3. Avoid conversations regarding hospital or patient business in all public areas, including the

shuttle bus. 4. Avoid inappropriate personal conversations in the presence of patientsand/orvisitors. 5. Speak in low voice tones at all times. 6. Address conflicts behind closed doors.

ELEVATOR ETIQUETTE

1. Allow visitors to enter the elevator first. 2. Smile & speak to fellow riders; the elevator is an opportunity to make a favorable

impression. 3. Face patients in wheelchairs toward the elevator door. 4. Hold elevators doors open and allow visitors/patients to enter/exit before you. 5. Utilizepatient serviceelevators for patienttransport. 6. Pausebrieflybeforeboardingtheelevatorandholdthedooropenorpressthe"opendoor"

button; waitfor passengers to exitprior to boarding. 7. Do not discuss hospital or patient issues on the elevator.

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CONFIDENTIALITY

1. Information about patients is confidential and should not to be discussed with anyone other than the patient's direct caregivers.

2. Hospital business/issues are confidential and should not be discussed. 3. Information regarding patients and their conditions may be released only in accordance with

hospital policy. 4. Always knock before entering a room, even if the door is open. Upon leaving the room, ask

the patientif he/she would like the door openor closed.

RESPONDING TO CUSTOMERS

1. Greet colleagues, visitors, and patients immediately upon entering your work area. 2. Keep wait time to a minimum. Each department will develop & abide by standards that

reflect reasonable timeframes. 3. Whenever a patient/visitor must wait, explain the reason for the delay and update the

patient/visitor every 15 minutes. 4. When outpatients are finished with their procedure, walk them back to the lobby or to the

exit of the department; offer directions to their next destination or escort them, if necessary.

ALLVOLUNTEERS

1. Address each patient by Mr., Mrs., Ms., or by his/her preferred name; make eye contact at everyencounter. Do not call patients, Honey, Sweetie, Mami, Papi, etc.

2. Introduce yourself by name and position to each patient and family member. 3. Do not shift responsibility. Refrain from using phrases such as, "I don't know…, we're really

busy…, we're working short.., not my fault…, I can't believe they...” 4. If possible,speakinthepatient’s nativeor preferred language.5. Identify and communicate patient's preferences to other caregivers.

Respectpatients'privacy.

FAMILY

1. Respond as if the patient is a member of your family. 2. Offer support to families, understanding their fear and anxiety.

REMEMBER THE SINAI WAY

S SMILE – be positive and show that you care.

I INTRODUCE –state your name and role.

N NARRATE – explain what you are doing and what is next.

A ANSWER – answer all questions.

I IMPACT – “I am here for you.”

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HIPAA (HEALTH INSURANCE PORTABILITY and ACCOUNTABILITY ACT)

What is HIPAA?

Health insurance portability and accountability act of 1996 – Federal Law

What does it cover?

• Privacy and security of patient information • Protects patients’ privacy and confidentiality of protected health information. • Privacyand security rules punish individuals or organizations that fail to keep patient

information confidential – Federal law

Who enforces HIPAA?

• Office of Civil Rights (OCR) in the Department of Health and Human Services (HHS) enforcesHIPAA regulations.

What are the penalties for non-compliance?

• Civil and criminal penalties • Maximum of 10 years in jail and a $250,000 fine for serious offenses • Wrongful disclosure can include fines and jail time • Gaining access to health information under false pretenses can resultin5 years injailand

$100,000fine • Disciplinary action per hospital policy

What is our commitment?

• We are committed to protecting patient privacy and confidentiality • Tobuildtrust • Communicate with or about patients. Involving patient health information should be private

and limited to those who need to know for treatment, payment and health care operations

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What is confidential information?

• Individually identifiable health information includes = written, spoken, electronic:

• Name • Address • Employee • Relatives’ names • Date of birth • Telephone and fax number • E-mail address • Social security number • Medical record number • Member or account number • Certificate number • Voiceprint • Fingerprints • Photos • Codes • Any other characteristics, such as occupation, which may identify the individual

Notice of Privacy Practices:

• PrivacyNotice – explains how patients’ protected health information is used for treatment, payment and health care operations.

• Giventopatientsonfirst visit tothefacility(bothinpatientsandoutpatients) • Lists patients rights • Lists hospital responsibilities

What are the patient’s rights?

• May requestrestrictions onuse and disclosure • Obtainacopyof the PrivacyNotice • Inspect and copy their medical record • Request an amendment to medical record • Obtainalistof who has received their record • Ask to have mail sent to another address • Optoutof directorylisting

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What are our responsibilities?

• Keep patient information confidential • ProvidepatientswithNoticeof PrivacyPractices – onweb,posted,inperson • Abide by terms of notice • Obtain patient acknowledgement of receiving notice • Use minimum necessary when using and disclosing patient information (except for

treatment purposes)

Are there other responsibilities?

• Provide patients with a means of submitting complaints regarding privacy • Notify patient if we cannot agree to a restriction request • Accommodate reasonable requests for contacting patient at other address

What are the HIPAA policies and procedures?

• Designate a Privacy Officer – JOSE CAMPS,EXT. 52722 • PrivacyNotice • Minimum necessary-based onneed to know • Audit trail for tracking disclosures • Patient access to medical record • Request amendments to medical record • Confidentiality and release of patient information • Verification of identity and authority of persons requesting patient information • Authorization for release of information

How can we protect patient’s privacy?

• Don’t leave patient records lying around • Don’t discuss patients in public areas (elevators,bus,cafeteria,hallways) • Don’t leave information about patient’s health on an answering machine • Don’t access information inappropriately • Don’t share passwords • Close curtains • Log off computer when finished • Dispose of patient information inlockedcontainersforshredding • Keeppasswords secret • Use minimum necessary information. • Place computer screens so that they cannot be viewed by public • Ask for identification, verify authority • Refer privacy complaints to the Privacy Officer, JOSE CAMPS

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HIPAA SECURITY RULE By now, you know about the HIPAA Privacy Rule – federal standards that protect our fundamental right to privacy and confidentiality. The Department of Health and Human Services (HHS) issued asecond set of federal standards to protect health information in electronic form. It’s called the HIPAA Security Rule. We also have a third set of federal standards – The health Information Technology for Economic and Clinical Health Act, or the HITECH Act. HITECH expands the HIPAA privacyand securityprotections and includes:

• Additional patient rights • New requirements for business associates • Breach notification requirements • New marketing provisions • Stiffer penalties for noncompliance

SECURITY BASICS Let’s look at who and what isprotectedbytheSecurityRule, so you’re not opening the door to breaches inprivacy or security.

TheSecurityRuleprotects:

• Confidentiality of electronic PHI, or also called EPHI (Electronic Patient Health Information)

• Integrityof EPHI – Meaningonce EPHIis created,itcan’tbe tampered with

• Availability of EPHI, so it can only be accessed by people with the authority to do so whenever it’s needed.

Like the Privacy Rule, health information is protected when it contains personal information thatconnects the patient to the information,suchas;

• Patient’s name and address • Social security number • Billing information

• Physician’snotes • Any information that can identify the patient

Important procedures that must be followed when working with medical center computers:

1- Never share yourpasswordwithanyone 2- Never share EPHI with anyone 3- Never leave the computer unattended 4- Always logoff the computer when you are finished

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COMPLIANCE HOTLINE

CODE OF CONDUCT

The Code of Conduct demonstrates how Mount Sinai conducts business in a proper manner,following state, federal and accreditation standards, as well as Medical Center policy. We areexpected to behave honestly, ethically, and in compliance with applicable laws,which is why itis important for all of us to take time to review and become familiar with the Code of Conduct as well as MedicalCenter policies and procedures.

The Medical Center requires that all officers, trustees, employees, volunteers, physicians,alliedhealthprofessionals,contractors,subcontractors,agentsandotherpersonswhoprovidepatientcare items or services or who perform billing or coding functions report any suspected violations ofFederal healthcare program requirements or of MountSinai’s ownpolicies and procedures to an appropriate representative of the MedicalCenter.

ETHICS AND COMPLIANCE COMMITTEE

The Ethics and Compliance Program is supported and monitored by the Ethics and ComplianceCommittee. The Ethics and Compliance Committee is chaired by the Chief Compliance Officer andinvolvesall operational areasoftheMedical Center.

What is the Compliance Hotline?The Compliance Hotline is a simple way for Mount Sinai employees, volunteers and associates toconfidentially report activities that may involve ethical violations or unlawful conduct at theMedical Center. The Compliance Hotline is managed and operated by an independent firm hired byMount Sinai to ensure effective communication, integrity and confidential reporting. TheCompliance Hotline is available toll-free, 24 hours a day, in both the English and Spanish languages.A trained operator takes each call, gathers the needed information, and ensures that the report isimmediately sent to the Mount Sinai’s Ethics and Compliance Departmentfor investigation and appropriate action.

Who May Utilize the Compliance Hotline?The Compliance Hotline is available for use by any employee, volunteer or associate of the MedicalCenter. Everyone has an individual responsibility for reporting any activity that appears to violateapplicable laws,rules,regulations,accreditationstandards, MedicalCenter policy and this Code of Conduct.

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What should be reported to the Hotline?Users may call the Compliance Hotline to report suspected violations of the Code of Conduct,policies and regulations related to:

• Fraud and Abuse •Conflicts of Interest •Confidentiality,Privacy and Security of Health Information •Suspected instances of IdentityTheftor Fraud • Environmental Health and Safety•Billingand CodingIntegrity• Patient Rights/Patient Neglect and Abuse• Safeguarding Property and Medical Center Assets• Record Keeping Problems•Business and ProfessionalEthics •Ineligible PersonsorEntities•Research

Reporting Compliance ConcernsThere are several options for an employee, volunteer or associate to report a compliance concern.As a first step, an employee, volunteer or associate has the choice to report any concerns to asupervisor, or to the Chief Compliance Officer at (305) 674-2916. Any person who feelsuncomfortable reporting via these means is able to call the confidential Compliance Hotline.

Investigation of Hotline ReportsCalls to the Compliance Hotline are answered by anindependent,third-party communicationsspecialist. This specialist documents the information received and generates a written report that istransmitted to the Chief Compliance Officer for investigation. In addition, the caller is given a casenumber for their use to provide additional information or to inquire about the status of the report.Every report received from the Confidential Hotline is investigated, and the results of theinvestigationareprovidedtothecallervia theHotline.Depending on the outcome of theinvestigation, appropriate action(s) may be taken to correct or to prevent any improper behaviorrevealed by the report. Results of the investigations are shared with the Ethics and ComplianceCommittee and senior leadership of the MedicalCenter.

Non-Retaliation The Medical Center is committed to investigating all reported concerns promptly and confidentiallyto the extent possible. There will be no retaliatory or disciplinary action taken against an employeeorvolunteerfor making a good-faith report to the Confidential Hotline.

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MOUNTSINAIMEDICALCENTERTANDARDSOFCONDUCTCONFIDENTIALITY,PRIVACYAND SECURITY

Confidential information includes, but is not limited to:

•Medicalrecords (“hard copy”or electronic);• Individually Identifiable Patient Information including: Names; Address; Dates (birth,death, admission, discharge, etc.); Phone(Including Fax); Financial Account, MedicalRecord, Health Plan Beneficiary Numbers;• Social Security Numbers;• License Numbers;• Full face photographic images or comparable mages;• Any other unique identifying number or characteristic; •Personnel& Payrollrecords; and • Minutes of meetings at which confidential information is discussed.

For questions regardingprivacy&confidentiality,contact thePrivacyOfficerat 305-674-2776. Please dispose of confidential information in the special, locked consoles or shredders in yourdepartment, and follow your departmental records retention policies for electronicfilesandrecords. All employees and volunteers whose duties bring them into contact with electronicallystored patient information are expected to observe all security rules regarding safeguardingconfidential patient information in electronic form. Portableelectronicstoragedeviceswhichareauthorized to contain patient records and other confidential information must be secure at alltimes. For additional information, please contact the Information Security Officer at 305-674-2947.

PatientInformation As employees, volunteers and associates of the Medical Center, we are privileged to have access toinformation that is personal and private. Our patients trust us to keep their informationconfidential. This means we should share records or patient information with authorized personsonly.Thesearepeoplewhoareinvolvedinthe careofthepatient andthosewhohavealegal rightto know. It’s our duty to be sure that we use personal information only for the purpose for which itisprovided.Pleasebesurethat all ofyourconversationswhichconcernpatients’careareheldinaplace that protects patient privacy and confidentiality. Be careful not to leave private informationwhere it may be seen or taken by people who do not have a right to it. Whensharing confidential health information, with those with a right to know the information, please besure to share only the minimum information necessary for the purpose. Any requests forinformation concerning our patients should be directed to the Health Information ManagementDepartment where the requests can be processed in keeping with legal and policy requirements.

MedicalCenterInformation Medical Center information should not be discussed or shared with the news media. Pleasereferall callstothe Public Relations Department at 305-674-2600. Requests forinformation about an employee should be directed to the Human Resources Department, includingrequests for employment references and personal information. If youhaveanyquestions or concerns about privacy, security and/or confidentiality, or if you are aware of any improper releaseof confidential information, please tell your supervisor or manager. You are encouraged to contactthe Department of Ethics and Compliance.

You may also report any violations of Mount Sinai policy to the anonymous Compliance Hotline. 20

Identity TheftIt is Mount Sinai policy to comply with the federal and state laws requiring us to respondappropriatelywhenfacts suggestthatanindividualis presentingfalseidentityor other information for the purpose of obtaining services at Mount Sinai Medical Center. Employees andvolunteersaretoreport anyindicationsofpossibleidentitytheft or similar fraud to theirdepartment manager and/or director.

QualityPatientCareMount Sinai promotes health care quality, patient safety, and cost efficiency through focusedinitiatives. Furthering Mount Sinai’s mission provides an opportunity for all employees andvolunteers to make a positive difference in the community. The Medical Center quality assessmentand improvement processes are integrated into overall policies and operations. The results of theevaluations are reviewed by the Quality and Patient Safety Committee and the Medical Staff QualityPerformance Committee.

Here are a few things we can do to improve the service we provide to our patients:• Report medication or treatment errors according to Medical Center policy.• Keep information about a patient private.•Be polite to patients and loved ones. •Maintain a safe patient care environment.• Report problems with medical equipment to Clinical Engineering.• Inform patients about their role in patient Safety.

Patient RightsTheMedical Centerbelievesthat recognizingandrespectingpatient rightsisan important aspect ofcare that encourages patients to become more involved and informed in their care. Recognizing andrespecting patient rights directly affects the provision of care. Care, treatment and services shouldbe provided inaway thatrespects and fosters the patient’s dignity, autonomy, positive self-regard,civil rights and involvement in his or her care. Further the Medical Center believes that care,treatment, and services should also be carefully planned and provided with regard to the patient’spersonalvalues,beliefs,and preferences.

Care at Mount Sinai Medical Center includes addressing processes and activities as they relate topatientrights by:

• Informing patients of their rights and responsibilities.•Helpingpatients understandandexercisetheir rights. •Respectingpatients’values,beliefs,and preferences.• Informing patients of their responsibilities regarding their care, treatment, and services.Some of the ways we meet standards of care related to patient rights include:• Respecting patients’ right to receive visitors they designate including, but not limitedto a spouse, a domestic partner (including a same sex domestic partner), anotherfamily member, or a friend, subject to reasonable or clinically necessary restrictions.• Honoring the patient’s right to give or withhold informed consent.• Informing patientsabout advancedirectives. • Complying with end of life decisions made by patients and surrogates.• Complying with decisions made by patients and families about organ donation.• Respecting the patient’s right to receive information in a manner he or she understands. •Respectingthe patient’s rights duringresearch,investigationand clinicaltrials. • Providing a process to have complaints reviewed by the Medical Center.

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PatientSafetyHotlineTheMedical Centerrecognizesthat Patient Safetyisa priorityfor theorganizationand strives for continued improvement in the quality of care it provides to patients. While the Medical Centerbelieves policies and procedures and compliance with state, federal and Joint Commissionstandards establishes a foundation for a strong patient safety program it believes that feedbackfrom stakeholders can only improve the program. As a consequence, the organization has establisheda Patient SafetyHotlinesothat patients, family members, physicians, nurses and allemployees are encouraged to express any safety concerns. Callers may remain anonymous. Thetelephone number is toll free and managed by a third party. The number is 888-234-2959.

Fraud and Abuse Mount Sinai is committed to full compliance with all federal, state and local health care programrequirements. “Fraud” involves the making of a false statement in order to receive some benefit towhich one is not entitled. “Abuse” includes practices which directly or indirectly result in unnecessarycosts toa government health care program. Examples of fraud and abuse include: •Billingfor services or supplies which were notprovided or furnished;• Altering claims forms or receipts in order to receive higher payments;• Duplicate billing to the government health care program and the patient or another insurer;and•Offering,paying,soliciting,or receivingbribes,kickbacks or rebates,directly or indirectly,toinducereferralsofpatientsorthepurchaseofgoodsorservicespaidforby government health care programs. Mount Sinai expects thatallindividuals associated with the Medical Center will avoid fraudulent or abusive practices and promptly report these practiceswhen they occur. All providers and suppliers participating in federal and state healthcareprograms are required to follow specific requirements to combat fraud and abuse. Fraud andabuse may be prosecuted under state and federal law and can result in restitution, fines, and, insome cases, jail time. Such cases can also result in exclusion of individuals or institutions fromparticipation in government health care programs.

Fraud and abuse guidelines state that we must:• Provide only services that are documented as being medically necessary, when requiredby applicable regulations.

• Document accurately and completely the services that we provide.• Perform complete, accurate and consistent coding of medical records in accordancewith regulatory requirements and guidelines.

•Reportallcosts accordingto generally accepted accountingpractices and accordingto MedicalCenter policy.

•Maintaininternalaccountingcontrols.•Maintainaccurate billingto government payers, commercial insurance payers, and patients, aswell as conform to pertinent Federal and state laws and regulations. All of these measures improve our level of service, while helping to assure that we remain on firm legal and ethicalgrounds. For additional guidance or information regarding fraud and abuse, you areencouragedto consult Mount Sinai’swrittenpoliciesonthesetopics,or tocontactthe Department of Ethics and Compliance.

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Ineligible Persons/EntitiesMount Sinai will not contract with, employ, or bill for services rendered directly or indirectly by aperson or organization which has been excluded from, or is ineligible to participate in, governmenthealthcare programs as indicated on the Department of Health and Human Services List of ExcludedIndividuals/ Entities or the General Services Administration’s List of Parties Excluded from Federal Programs, or has been convicted of a crime related to the provision of healthcare items or services.Employees, volunteers, contractors,vendorsandindividualsholdingclinical privilegesat Mount Sinai must report if they become excluded or otherwise ineligible for participation in a governmenthealthcare program, or if they have been convicted of a crime involving the provision of healthcareitems or services.

Human Research Mount Sinai complies with all federal, state and local regulations regarding human subjects’ research, investigations and clinical trials involving our physicians or professionalstaff.MountSinaistrives to protect all individuals involved in research and to assure that their safety, welfare andrights are respected. All human subjects’ research to be conducted wholly or, in part, at Mount SinaiMedical Center must be submitted to the Mount Sinai Medical Center Institutional Review Board for review. This requirement is waived for non-employed physicians whose research project isconductedentirelywithintheirofficerecruitingtheirownprivatepractice patients.

MountSinai works to ensure thatpatients or third party payers are notbilled for the costof research-related tests, procedures, and supplies which are paid for by a study sponsor or which areotherwisenot appropriatetobechargedtothepatient or the patient’s insurance or governmenthealth care programs. For assistance with billing issues related to research, please contact the officeof Research Administration at 305-674-2790.

Record keepingMount Sinai maintains many types of records. These include medical records, documents, andinformation that are received via electronic methods, including e-mail. Stateandfederalregulationsimpose specific requirements for keeping and destroying specific types of records. Becausedepartments maintain various types of records, we should take time to become familiar with thedepartmental policies that apply to the documents we use, manage and create every day. There area number of rules that commonly apply to everyone. Please keep the following in mind:

• Do not falsify facts or make false record entries.• Do not remove any Medical Center files or documents from the premises.•Keeprecords confidential. •Maintainand destroy records accordingto record the applicable retentionpolicy. •Give records only to those people who are authorized by policy and regulatory requirements tohaveaccess.

Safeguarding medical center and patient propertyAll employees, volunteers and associates are expected to use Medical Center property andresources responsibly and only for an appropriate purpose. In addition, employees are expected touse facilities and equipment correctly to avoid injury. Medical Center property may not be used fornon-Medical Center purposes without written permission. Medical Center time, facilities, orequipment may not be used for unapproved purposes. Ask your supervisor if you have anyquestionsabout properuseofMedical Centerpropertyandresources.

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Workplace health and safetyThe Medical Center strives to maintain a working environment which is free from hazards or unsafeconditions. All of us must follow safety standards and regulations and take extracare to:

• Dispose of medical waste, environmentally sensitive and other hazardous material correctly.•Use personal protective equipment to protect you and others from exposure to dangeroussubstances.

• Prepare and react timely to internal and external disasters, such as fires andhurricanes.

• Be familiar with Mount Sinai’s Emergency Preparedness Plan. Please report allincidents and accidents involving people, equipment and property to Risk Managementat305-674-2555.

PoliticalactivityandlobbyingMountSinai advocates for legislative issues thataffectthe MedicalCenter.However,MountSinai is anot-for-profitMedicalCenter and does notcontributefunds tosupportpoliticalparties,individuals running for office, or for the advancement of controversial political issues. MedicalCenter employees, volunteers and associates are free to support political campaigns or issuesoutsideoftheirdutiesat Mount Sinai.However, employees and volunteers are expected to ensure thatprivate politicalactivities are notcarried oninsuch a way as to suggest an endorsement by the MedicalCenter.

Tobacco-freeenvironment Itis thepolicyof theMedicalCenter toeducatestaff and thepublicatlargeaboutthehazards of smoking and tobacco use and to provide smoking cessation assistance. As ahealth care providerand as an employer the Medical Center is committed to providing patients, visitors, staff andvolunteers with an environment that promotes healthy behaviors. For this reason, Mount SinaiMedical Center campuses are Tobacco Free. As ofJuly1,2010,all individualsontheMedical Center propertyareprohibited from using any tobacco products while on any campus.

Gifts Itis inappropriatefor us togiveor receive,directlyor indirectly,anygifts (includingcash,services, favors, or other things of value) that may improperly influence, or appear to influence,business relationships. Some small perishable items may be allowed, however, you must notify yoursupervisor if you are offered a gift of any kind. Never request or accept gifts from a patient inexchange for services. If someone offers you cash, do not take it. If they insist, notify yoursupervisor or manager. The giving of gifts to, or receiving gifts from, individuals or businesses who are doingbusiness with (or who are seeking to do business with) the Medical Center, or who mayrepresent a possible source of referrals for patients or other business may be contrary to law.Please check with your Supervisor or the Department of Ethics and Compliance with any questionsabout such gifts.

Conflicts of interest Employees, volunteers and associates of the Medical Center sometimes have personal or financialinterests which make it inappropriate for those persons to be involved in certain activities andtransactions of the MedicalCenter.These situations are called “conflicts of interest.”Here are two examples of what may be considered a conflict of interest:

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• A situation in which an employee or associate (or a member of that employee,volunteerorassociate’sfamily) has a financial interest in a company that doesbusiness with MountSinai.

• A situation in which a Mount Sinai employee, volunteer or associate also works part-time for a Mount Sinai vendor, competitor or supplier. It is extremely importantthatany employee, volunteer or associate of the Medical Center promptly disclose anyconflict ofinterest toasupervisor,eveniftheconflict isjust apossibility.

Relationships with vendors and competitorsInformation that is used bytheMedicalCenter is private.This includes business strategies,costs,finances, and other economic matters. Business information about the Medical Center may not bediscussed with anyone outside our organization.

Only Administration may enter intocontractswithanother businessentity.

Dealing honestly with customers, vendors and consultantsRespect for our patients, guests and business associates requires that we only make statements that we knoware honestand accurate.We also prepare written documents in a timely manner and keepall business information, records and reports complete and truthful. Likewise, it is important thatwe abide by trademark and copyright laws and licensing requirements. We support ethical businessbehavior by properly representingourselves to the public.Inorder to effectively controlboth internal and external printed materials, all proposed printed material to be used by any MedicalCenter department with any outside audience must be presented to the Director of Marketingat305-674-2388 for consultation and approval prior to production.

Respect and dignity in the workplaceIt is the policy of the Medical Center to maintain a work environment free from all forms of unlawfulharassment. Comments or conduct relatingtoaperson’srace,ethnicbackground,gender,religion,age,handicap,or sexualorientation,which failto respectthe dignityand feelings of the individual are unacceptable. Employees, patients, volunteers and visitors are to be treated with dignity,respect, and courtesy.

Sexual harassment is a violation of the law and will not be tolerated or condoned. This behavior is defined as unwanted sexual advances, requests for sexual favors and all other verbal or physicalconduct ofasexual nature,especiallywhere it:

• Becomes a term or condition of employment.• Is used to make decisions affecting someone’s job.• Creates an intimidating, hostile, or offensive work environment. Sexual harassmentalso includes comments, jokes, suggestions, sexually oriented statementsor other remarks or actions that are offensive.

The Medical Center will do everything possible to prevent discrimination and harassment of anykind. All of us have the right to work in an environment of mutual respect and professionalism.Please report any activities involving discrimination or harassment to your supervisor, manager,the Human Resources department at 305-674-2500, or the Compliance Hotline.

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Disruptive behaviorDisruptive behavior affects morale or staff turnover and can be harmful to patient care.Behavior such as intimidation, verbal or physical abuse, sexual misconduct, or the creation of ahostile or offensive work environment will not be tolerated. Individuals working at all levels of theMedicalCenter, including management, clinical and administrative staff, licensed independentpractitioners,and governingbody members are expected to conduct themselves in a professionalmanner so that the workplace is free from behaviors that could have a negative impact on patientsafety.

Solicitation and distribution Itis our purposetoprovideundivided attentiontoour responsibilityof caringfor patients.Solicitation includes, but is not limited to, handing out, dispensing, selling, or requesting anotherperson to take, acknowledge or buy materials, literature, substances, goods or items. Employeesand volunteers may not solicit patients or visitors for any cause or private employmentarrangements. It is the policy of Mount Sinai to prohibit any solicitation of an employee, volunteer,patient,or the patient’s relatives and/or friends. Personal items or notices from any source otherthan Administration may not be posted on Medical Center bulletin boards. Items that promote anyorganization or commercial, political ideology, religious, or other cause, or a certain message orslogan that may disturb patients or otherwise interfere with patient careservices may not be displayed.

Drug-freeworkplaceThe Medical Center is committed to a drug free work place.Itis our policytofoster an environment of zero tolerance for the unlawful manufacture, distribution, dispensing, possession,oruseofalcohol,controlledsubstancesorillegal drugsinthework place.

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Dear Volunteers:

MountSinai MedicalCenter has always takengreatpride intheir volunteerservices.Youreffortsaddsomuchtoouraccomplishments.

Somegiveeconomicsupport;somegivetime;andothersprovidethetender lovingcare and loyalty thatmake our medicalcenter so vital totheMiamiBeachcommunity.

We need and appreciate each of youwith your very specialtalents. Thank you forchoosingMount SinaiMedical Center.

Volunteers are the best medicine!

Sincerely,

Edie EdieShapiro,ManagerVolunteer Services Department

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Please print this page and keep with you at all times.

Make sure you are always prepared in case of an emergency!

KNOW WHERE THE FIRE EXTINGUISHERS, ALARMS AND EXIT

DOORS/STAIRWELLS ARE LOCATED IN YOUR WORK AREA!!!

FIRE: Code Red Response - R.A.C.E. & PASS ••Rescue:

••Alarm:

••Confine:

••Extinguish:

Rescue people from immediate danger. Alert the facility of the fire. Confine the fire to the smallest area possible. Extinguish fire without endangering safety. VOLUNTEER OFFICE: 305.674.2080

••Pull:

••Aim:

Pull the pin to free the upper handle. Aim the nozzle at the base of the fire.

••Squeeze:

••Sweep:

Confine the fire to the smallest area possible. Extinguish fire without endangering safety.

HIPAA - Privacy and security of patient information.

INFECTION CONTROL: The best way to prevent the spread of infection

is HANDWASHING!

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DIRECTORY: Pages 1 Signaturepage – pleasebringtovolunteer office. 2 Blank(for notes) 3 Welcome & benefits 4-5 General Information (Assignments, tests and vaccinations, parking.) 6-7 GuidelinesforVolunteers(Confidentiality, Dress Code, Media Policy, Infection Control,

Do’s & Don’ts in patient care, media policy, wheelchair safety, smoking policy.) 8 SAFETY & SECURITY(Keep workplace safe, helping security, accident reporting.) 9-10 FIRE ALARMS (when the fire alarm is activated, RACE, PASS,Skolnick SurgicalTower Won

Doors and Elevator Smoke Curtains.) 11 Our Mission& Vision Statements 12-14 Standards of Performance 15-18 HIPAA (patient confidentiality) 19-27 Code of Conduct 28 Welcome letter 29 Fire response procedure – please print and keep with you at all times.

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