SH personnel will be educated and informed about their responsibilities under this Code through:

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1 SUSQUEHANNA HEALTH CHAPTER: Administrative Policy and Procedure Manual SUBJECT: CODE OF ETHICS Policy Number: ADM-110 PURPOSE The purpose of the Code of Ethics is to articulate the standards of professional conduct applicable to employees, volunteers, medical staff, management personnel, and board members, as Susquehanna Health ("SH") works to achieve its stated mission of extending God's healing love by improving the health of those we serve. This Code of Ethics is intended to assemble all relevant SH policies and procedures which address decisions on the health and well-being of patients ("patients" refers to patients/residents), service partners, and the community. POLICY All personnel are committed to supporting the mission of SH and to protecting and advocating the values of human life and dignity. Further, as stated in the 2008 Susquehanna Health "System Creation Agreement," all services performed or conducted at Divine Providence Hospital and Muncy Valley Hospital shall comply with the Ethical and Religious Directives for Catholic Health Care Services. This Code of Ethics is based on the conviction that health care is a human right to which all persons are entitled and on the professional ethic that maintains the priority of community and patient interest over provider interest wherever applicable. The Bylaws of each hospital contain sections addressing the ethical obligations associated with the practice of medicine at each of the respective institutions. RESPONSIBILITY All persons associated with SH have an obligation to act in a manner that merits the trust and confidence of peers, patients, and the community which we serve. It is the policy of SH that all personnel be familiar with the policies and procedures contained within this Code which relate to their specific job functions or areas of responsibility and that they will be universally applied in clinical and management decision making, including, but not limited to patient rights, admissions, transfers, discharge planning, employment, billing practices, relationships with other health care providers, educational institutions, and payers, conflicts of interest, marketing, and business practices. PROCESS SH personnel will be educated and informed about their responsibilities under this Code through: 1. A review of the policy at New Employee Service Partner Onboarding

2 2. A review of the policy at departmental orientation of new service partners 3. Annual service partner education through the Mission, Ethics, and CARE computerbased learning module 4. Elective HealthImprove University service partner education courses regarding ethics offered to all staff SH resources available for staff with questions regarding ethics include: 1. Office of Medical Affairs: Risk Management, Legal Services: Pastoral Care: Mission Integration: On a periodic basis, or as requested, departments will submit to the SH Mission and Ethics Committee and/or the SH Medical Ethics Sub-Committee for review operating policies and procedures that are in compliance with the Code of Ethics. The SH Mission and Ethics Committee and the SH Medical Ethics Sub-Committee are available to provide advice, consultation, education, and policy recommendations as may be necessary to further the goals and application of the Code of Ethics. GUIDING POLICIES AND PROCEDURES PATIENT RIGHTS Susquehanna Health, in accordance with Federal and State Law, recognizes patients' rights to make decisions regarding their medical treatment, including the right to accept or refuse medical treatment in the event the patient becomes incapacitated, permanently unconscious, or suffers from a terminal condition. Patient Rights policies are implemented through staff education, provision of pamphlets in common areas, staff/community education, consultation with SH Medical Ethics Sub-Committee, Risk Manager, Privacy Officer, Social Services, Pastoral Care, and Legal Services. Policies regarding Patient Rights include, but are not limited to: Advance Directives (ADM ) Code Status Designation ( ) Informed Consent and General Consent for Treatment (ADM ) Investigational Studies Involving Human Subjects (ADM ) Medically Futile Treatment (ADM ) Patient Complaints and Grievances Resolution Process (ADM ) Patient Rights and Responsibilities (ADM ) Protection of Patients Involved in Clinical Trials (AC 104)

3 Restraint and Seclusion (MS ) SH Legal Health Record (ADM ) Visitors (ADM ) Withholding and /or Withdrawing Life Sustaining Treatment for Patients with a Terminal Illness (ADM ) ADMISSIONS Patients treated on an inpatient or outpatient basis are provided with the level of care appropriate to the severity of their disease or condition, impairment or disability. Patient care, treatment, and rehabilitation is planned and based on the patient's individual needs and characteristics (including age, culture, and religion). Policies related to admission practices include, but are not limited to: Communication Services for Patients with a Hearing, Language, and Visual Need (ADM ) Patient Care, Treatment and Services (ADM ) TRANSFERS All patients are transferred in a confidential and ethical manner based on physician discharge and transfer instructions, giving due respect to the patient's privacy and dignity. Transfer of patients to another facility will be planned if the proposed medical care cannot be provided by the facility, or if the patient chooses to be transferred. Patients will not be transferred for economic reasons. All patients transferred to another facility shall be afforded appropriate medical care according to SH policies and procedures and the Emergency Medical Treatment and Active Labor Act (EMTALA) of Policies related to transfers include, but are not limited to: Emergency Medical Condition and Stabilization EMTALA (ADM ) Patient Care, Treatment and Services (ADM ) Patient Choice Home Health Equipment and Referrals (ADM ) Patient Rights and Responsibilities (ADM ) Transfer and Transportation of Patients (ADM ) DISCHARGE PLANNING The discharge planning process begins prior to the patient's admission and continues throughout the patient's hospitalization with appropriate referrals made to ensure that the

4 patient's continuing care needs are met. All patients are discharged in accordance with physician discharge instructions, giving due respect for the patient's right to privacy and dignity. All patients are discharged to the appropriate level of care based upon the patient and family needs and capabilities. Policies related to the discharge process include, but are not limited to: Continuum of Care Planning Meetings (MS ) Patient Care, Treatment and Services (ADM ) Patient Choice Home Health Equipment and Referrals (ADM ) EMPLOYMENT SH treats its service partners respectfully and justly. This responsibility includes: equal employment opportunities for anyone qualified for the task, irrespective of a person's race, sex, age, national origin, or disability; a workplace that promotes employee participation; a work environment that ensures employee safety and well-being; and just compensation and benefits. Policies related to Human Resources include, but are not limited to: Applicant Selection (201) Compensation Administration (405) Conditions of Employment (202) Employee Non-participation in Treatment Procedures (306) Employee Service Partner Confidentiality (303) Employee Service Partner Problem Solving Procedure (307) Equal Employment Opportunity Statement (205) Flexible Benefits Program (104) Sexual Harassment (323) Work Force Reduction Issues/Procedures (329) BILLING PRACTICES All patients receiving care at SH facilities will be billed using standard charges for the services received. Internal controls will be maintained to ensure that the patient, guarantor, or third party payer is billed only for the services received, as documented in the health record, as determined and entered by service department staff. All billing will remain compliant with local, state, and federal rules and regulations with the emphasis placed on practices that avoid fraud

5 and abuse, as stated in the SH Compliance Program. Appropriate mechanisms will be in place to prevent any duplication of billing. All guarantor statements will include the patient name, date of service, and balance due for a particular service date. Itemized bills will be provided at the request of the patient and/or guarantor, contingent on circumstances. Service partners are expected to know and adhere to all regulations and statutes applicable to their duties and responsibilities. Appropriate service partners are required annually to participate in billing educational programs in accordance with the SH Compliance Program. Service partners will ensure that billing reports and other documents are accurate, complete, and reflect the integrity of SH. When a patient, relative, or guarantor has a concern about a charge or payment of a bill, SH has procedures in place to review the issues in accordance with SH values and to discuss them without real or perceived harassment. If the question cannot be answered to the satisfaction of the person, it will be referred to a manager to assist in the explanation. It is the responsibility of the patient or guarantor to pay for any self pay balances or to make arrangements with SH billing representatives to determine how patient obligations will be met. SH billing representatives are trained to work with patients/guarantors to determine how best to meet their obligations. When patients/guarantors refuse to work with billing representatives, or choose to ignore any interactions to acknowledge the patient's liability, then SH has no choice but to refer balances to third party collection agencies. Patients/guarantors willing to work with Patient Billing representatives will find the process to be accommodative, providing settlement options for patients. Policies related to billing practices include, but are not limited to: Billing Inquiry Complaint (ADM ) Charity Care Assistance Program (Finance Policy) Compliance Program (ADM ) RELATIONSHIPS WITH OTHER HEALTHCARE PROVIDERS AND EDUCATIONAL INSTITUTIONS All contracts with healthcare providers and others, including educational institutions, shall be examined on their individual merits and with respect to the SH mission, vision, and values. Policies regarding relationships with other healthcare providers and educational institutions include, but are not limited to: Academic Affiliation Oversight of Clinical Academic and Observation Requests (ADM ) Conflict of Interest (ADM ) Contracts with Outside Providers of Patient Care Services (ADM )

6 Request for Physician Referral (ADM ) RELATIONSHIPS WITH PAYERS All contracts with healthcare payers and insurers shall be examined on their individual merits with respect to the SH mission, vision, and values. SH will not establish any relationship with a payer which would cause SH to compromise the quality of care offered to the patients we serve or impinge the financial security of SH. CONFLICT OF INTEREST Personnel authorized to enter into contracts or approve other contractual or hospital relationships agree to disclose any actual or potential conflict of interest and/or refrain from voting on approval. In order to avoid unfair favoritism, hospital service partners and departments are not permitted to accept gratuities from hospital vendors or potential vendors. Vendors and service partners are informed of this policy. The Purchasing Department does not contract for services with service partners or their family members due to the risk of conflict of interest. Contracts with other providers of services define the conditions of participation binding each of the parties. Policies related to Conflict of Interest include, but are not limited to: Conflict of Interest (ADM ) Gratuities and Gifts (309) SH Compliance Program Policy (ADM ) Solicitation/Distribution (324) MARKETING Marketing practices are conducted with truth, fairness, and responsibility to patients, the community, and the public at large. Marketing materials reflect only services available at the time of publication and comply with applicable laws and regulations of truth in advertising and non-discrimination. Marketing materials are reviewed for accuracy by the Marketing and Communications Department prior to publication. Policies related to marketing and public relations practices include, but are not limited to: Communication with the Media Issuing News Releases and Release of Patient Information (ADM ) Corporate Sponsorship (ADM ) BUSINESS PRACTICES

7 SH will conduct its business affairs in a manner that assures the organization's current and future ability to deliver patient services in a safe and effective manner, while expecting that its staff and credentialed providers conduct themselves with the highest degree of personal integrity and stewardship. Contracts with payers and providers alike will be negotiated with vigilance toward social justice, equality, and fairness. Leadership behaviors will reflect thoughtful and informed decision-making, the development of reliable, respectful relationships between the medical staff and administration, and an obsessive attention to quality and service for the well-being of the community and its citizenry. All organizational disciplines will be expected to be familiar with and apply their professional association's Code of Ethics. Policies related to Business Practices include, but are not limited to: Behavior Expectations for Employee Service Partners and Leadership (ADM ) Medical Director and Other Professional Service Agreements (ADM ) Bidding Process for Construction and Renovation Projects (ADM ) Decision Making, Implementation, and Follow-Up at Susquehanna Health (ADM ) Joint Venture Arrangements (ADM ) Hospital Vendor Relations (ADM ) Office Space Rental (ADM ) Referrals to Any SH Service (ADM )