CMS Pub. 100-18, ch. 9, § 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.