CMS Pub. 100-16, ch. 21, § 50.1.1

42 C.F.R. §§ 422.503(b)(4)(vi)(A), 423.504(b)(4)(vi)(A)

Standards of Conduct, also known in some organizations as the “Code of Conduct” or by

other similar names, state the overarching principles and values by which the company

operates, and define the underlying framework for the compliance policies and

procedures. Standards of Conduct should describe the sponsor’s expectations that all

employees conduct themselves in an ethical manner; that issues of noncompliance and

potential FWA are reported through appropriate mechanisms; and that reported issues

will be addressed and corrected.

The Standards of Conduct may be stated in a separate Medicare-specific stand-alone

document or within the corporate Code of Conduct. Sponsors should update the

Standards of Conduct to incorporate changes in applicable laws, regulations, and other

program requirements, such as those listed in Appendix B.

Standards of Conduct communicate to employees and FDRs that compliance is

everyone’s responsibility from the top to the bottom of the organization. For that reason,

and because Standards of Conduct are the most fundamental statement of the sponsor’s

governing principles, Standards of Conduct should be approved by the sponsor’s full

governing body.

It is a best practice of some sponsors to include a resolution of the full governing body

stating the sponsor’s commitment to compliant, lawful and ethical conduct. This

communicates to employees and FDRs that compliance and ethics are valued and

important to those at the highest levels of authority in the company.