A Not-for-Profit Agency

BUILDING CONNECTIONS:
The Sexual Assault /
Mental Health Project
www.nyscasa.org

I.  MISSION AND VALUES STATEMENT

The Mental Health Association in Ulster County, Inc. (MHA) is committed to quality care and improvement of human life. Our agency employs teamwork and all other resources to make individualized quality, cost-effective behavioral health services and assistance accessible to individuals in our local communities. Our mission is to engage all people in optimal mental health by providing innovative programs and services that heal, prevent, educate and advocate.

As an agency, we believe and are committed to:

• advocacy, collaboration, diversity, education, respect, responsiveness, and services,
• the uniqueness and intrinsic worth of every individual,
• treating those served with professionalism, dignity, and compassion,
• conducting business and providing services with honesty, integrity, and consistency,
• pledging to consistently treat everyone with professionalism, value, loyalty, respect, and trust.

This Code of Conduct is a guide for everyone and is a resource for performing our duties and responsibilities consistent with appropriate ethical, professional, and legal standards. These obligations apply to relationships with program participants and their family members, providers/colleagues, members of the community, employees, interns, volunteers, Board Members, subcontractors, independent contractors, and agents. This Code is the foundation of our Corporate Compliance Program. It has been developed to assure that ethical and professional standards are met and to comply with applicable funding requirements, laws, and regulations. This Code is intended to be comprehensive and easily understood. The Code may fully cover a particular subject. In many cases, the subject discussed is complex and additional guidance is necessary to provide sufficient direction. This Code is mandatory and must be followed.  

II. LEADERSHIP RESPONSIBILITIES

While all associated with the MHA are obligated to follow our Code, we expect our leaders to set the example, to be in every respect a model. They must ensure that all have sufficient information to comply with law, regulation, and policy; as well as the resources to resolve ethical dilemmas. They must help create a culture within the MHA, which promotes the highest standards of ethics and compliance. This culture must encourage everyone in the agency to raise concerns when they arise. We must never sacrifice ethical and compliant behavior in the pursuit of business objectives.

III. COMMITMENT TO STAKEHOLDERS

As we all are committed to following our mission statement and to the success of our agency we pledge:

To our program participants: to provide quality care and service that is professional, ethical, compassionate, accessible, timely, and cost effective.

To our employees: to maintain a work setting that complies with our Affirmation Action and Compliance Plans; that treats all members with consistency, professionalism, value, trust, and respect; that affords an opportunity for growth and development; and that encourages the sharing and consideration of ideas.

To third-party payors: to demonstrate our commitment to contractual obligations and reflect our concern for quality, accuracy, efficiency and cost-effectiveness. Our third-party payors are encouraged to adopt comparable ethical principles.

To funding sources/regulators: to maintain a corporate environment compliant with contracts, rules, regulations, and sound business practices, to self-govern and monitor adherence to all legal and contractual requirements and to this Code.

To our suppliers/vendors: to promote fair competition among prospective suppliers/vendors and to act as a responsible, good customer.

To our volunteers: to support the concept of voluntary assistance to program participants and their families as an integral part of behavioral healthcare, to ensure that volunteers feel a sense of meaningfulness and value from their work and receive recognition for their efforts.

To our Board Members: to acknowledge and support the time, effort, guidance, and over-sight provided by the governing members of our Board of Directors.

To the communities we serve: to provide professional, ethical, appropriate, timely, accessible, quality services; to serve those in need; to promote good will and further good causes in our communities.

IV. RELATIONSHIPS WITH OUR HEALTHCARE PARTNERS

A. Program Participants

1. Care and Rights of Individuals We Serve

This agency exists to provide quality, professional, ethical, compassionate, timely, accessible, and appropriate services. All individuals will be treated with professionalism, respect, and dignity. The agency will not discriminate against any individual based on race, color, religion, national origin, citizenship, disability, veteran status, marital status, sex, sexual preference, gender identity, or age, in accordance with requirements of Federal and State laws. Services are provided based on identified individual needs, not on economics.

Upon admission, each individual is provided with a written statement of their rights. This statement conforms to all applicable State and Federal laws. We assure their involvement in all aspects of their care and informed consent for services is obtained. Individuals or their legal custodians are provided with information and explanation of services including, but not limited to, diagnosis, service plan, right to refuse or accept services, service decision dilemmas, costs, explanations of service options and service alternatives.

Individuals or their legal custodians have the right to decline services and will be given appropriate information to make an informed decision. Individuals and their representatives are accorded and will receive appropriate confidentiality, privacy, security and protective services, and opportunity for resolution of complaints. Any restrictions placed on individuals by services will be evaluated for therapeutic effectiveness and will be fully explained and agreed upon by them or their representative. They have the right to refuse services.

Individuals will be treated in a manner that is professional, ethical and that preserves their dignity, autonomy, self-esteem, civil rights and involvement in their own care. Employees will receive training regarding individual rights in order to clearly understand their role in providing services. We are committed to supporting the communities we serve. Our agency will promote education and prevention programs in an effort to improve the quality of life for individuals in our communities.

2. Client Information  

As stated in the Personnel Policies and Practices of the Mental Health Association in Ulster County, Inc., client confidentiality is to be respected as a high priority by all staff members of the agency.  It is expected that the clients’ right to privacy shall not be violated in any manner by a staff member or any other individual who participates with the agency. This is to include committee members, appointed advocates, staff members, volunteers, etc.

Client information regarding medical conditions, history, medication, demographics, etc., is necessary for the agency to provide appropriate quality care. The agency recognizes the sensitive nature of said information and is committed to maintaining confidentiality as mandated by law and by ethics. No one will release or discuss client-specific information with others unless necessary to serve the client or as required by law. Individuals must never disclose confidential information that would violate client privacy rights. No one has a right to any client information other than that necessary to perform his/her job. Clients can expect their privacy to be protected and that confidential information will only be released to persons authorized by law or by the client’s written consent.

Any one found to engage in any activity which violates client confidentiality and privacy will be properly notified by his/her supervisor of their violation of client rights. In addition, an immediate review of the violation and its seriousness will be conducted by the supervisor of the program together with the Chief Executive Officer. In any case, violation of client confidentiality and privacy for a client will not be tolerated by this agency.

B. Affiliated Physicians/Providers

Business arrangements with physicians and other providers will be structured to meet all applicable legal requirements. Such arrangements will be in writing and approved by appropriate legal counsel. To meet ethical and legal standards, the agency will not pay for referrals. Admissions to services are based solely on individual needs and the agency’s ability to offer appropriate services and admission criteria will be strictly and consistently followed. Violation of this precept could have significant ramifications for the agency, including civil and criminal penalties and possible exclusion from participation in federally funded programs. Additionally, no payment will be accepted for agency referrals to other providers. No one acting on behalf of the agency is permitted to solicit or receive anything of value, directly or indirectly, in exchange for referral of individuals. The volume or value of referrals that providers have made (or may make) to us will not be a factor in admissions.

C. Third Party Payors

1. Coding and Billing for Services

The agency will assure and is committed to reflecting truth, accuracy, and conformity to all pertinent Federal and State laws and regulations when billing all government and private insurance payors. Knowingly presenting or causing to be presented false, fictitious, or fraudulent claims for payment or approval is expressly prohibited. Oversight systems designed to verify claims submission only for services actually provided and that services are billed as provided will be effectively maintained. Such systems will emphasize the necessity and expectation of complete and accurate service documentation. As a part of this effort, confidential, current, and accurate records will be maintained. Any subcontractor or contractor performing billing or coding services will be expected to adhere to this Code of Conduct and must have the necessary skills, quality assurance processes, systems, and appropriate procedures to assure that all billing for government and commercial insurance programs are accurate, complete, and timely. The agency prefers to contract with agencies that have adopted their own ethics and compliance programs. 

For coding questions, consult your department’s policies and procedures manuals or contact your supervisor. For questions concerning billing issues, consult your department’s policies and procedures manuals or contact the Director of Finance.

2. Cost reports

Our business involves reimbursement under government programs that require the submission of certain reports of our costs of operation. The agency will comply with Federal and State laws and funding source requirements relating to all cost reports. Laws, regulations, and requirements define allowable costs and outline appropriate methodologies to claim reimbursement for the cost of services provided to individuals. Given their complexity, all issues related to completion and settlement of cost reports must be coordinated with the Director of Finance or his/her designee. At no time will the agency misrepresent rates or designation of costs to improperly enhance reimbursement.

D. Regulatory Compliance

Services will be provided pursuant to appropriate Federal, State, and local laws and regulations, and funding source requirements. Such requirements may include, but are not limited to, licenses, permits, access to services, consent to services, individual service record keeping, access to individual records and confidentiality, individuals’ rights, and Medicaid regulations. The agency is subject to numerous other laws, regulations and funding source requirements. The agency will comply with all applicable laws, regulations and requirements. Written policies and procedures have been established to assure compliance, and ongoing education and training are provided to everyone on proper business conduct. All must be knowledgeable about and compliant with all relevant laws, regulations, and requirements, and should immediately report violations or suspected violations to a supervisor or other member of management, the Compliance Officer, a member of the Corporate Compliance Committee, Human Resources staff, or the designated reporting voice mailbox. 

The agency will provide appropriate, complete, factual, and accurate information in response to billing inquiries. The agency will cooperate with and be respectful of all government inspectors and provide these inspectors with the information to which they are entitled during an inspection. During a governmental or any other type of inspection, individuals must never conceal, destroy, or alter any documents, lie, or make misleading statements to the investigator. No one shall cause or attempt to cause another individual to fail to provide accurate information or obstruct, mislead, or delay the communication of information on records relating to a possible violation of law, regulation, requirement, and/or policy. To assure that the agency meets all regulatory obligations, everyone must be informed about stated areas of potential compliance concern. The agency is committed to diligently researching and reviewing resources that provide awareness of areas of regulatory concern, and to maintaining systems that proactively address such concerns. The agency will provide everyone with information, education, and training to fully comply with all applicable laws, regulations, and requirements.

E. Certifying Bodies

The agency will deal with all certifying bodies to which we profess accountability in a direct, open, and honest manner. No action should ever be taken in relationships with certifying bodies that would either directly or indirectly mislead the certifier or survey teams. The scope of agency certification is significant and broader than the scope of this Code. The purpose of this Code is to provide general guidance on compliance subjects of wide interest within the agency. Certification standards will be met and maintained.     

V. BUSINESS INFORMATION AND INFORMATION SYSTEMS

A. Accuracy, Retention, and Disposal of Documents and Records

Each individual is responsible for the timeliness, integrity, and accuracy of our agency’s documents and records, not only to comply with regulatory, funding, and legal requirements, but also in defense of our professional, ethical business practices and actions. No one may alter or falsify information on any record or document. Program Participant and business documents and records are retained in accordance with applicable laws and our retention policies. Program Participant and business documents include paper documents such as letters and memos, computer-based information such as e-mail or computer files on hard drives, disks or tapes, and any other medium that contains information about the organization and/or its business activities. It is important to retain and destroy records according to policy (Please refer to the Program Participant Record Retention Policy in the Corporate Compliance Manual at your worksite). No one should tamper with records, nor move or destroy them prior to the specified timeline.

B. Confidential/Proprietary Information

Confidential/proprietary information about our agency’s strategies and operations is a valuable asset. Individuals may use confidential/proprietary information to perform their jobs, but it must not be shared with others outside of those with a need to know within our agency, unless there is a legitimate need to know this information, approval is provided by the appropriate management staff to release the information, and agreement is made that the released information will be kept appropriately confidential. Confidential/proprietary information includes, but is not limited to, personnel data maintained by the agency, participant lists and information, financial data, research data, strategic plans, marketing strategies, techniques, employee lists and data maintained by the organization, supplier and subcontractor information, and proprietary computer software. This provision does not restrict the individual’s right to voluntarily disclose information about his/her own compensation, benefits, or terms and conditions of employment.

C. Electronic Communications

As stated in the Personnel Policies and Practices of the Mental Health Association in Ulster County, Inc. agency computers, voice mail, cellular phones, pagers, Internet access, and any future e-mail systems (electronic communications) are for business use only. Communications transmitted through these systems must have a business purpose. They are not to be used for personal or other inappropriate purposes.

MHA encourages all employees who are assigned an agency cell phone to carry it with you at all times while you are working for your safety and the safety of the clients. However, when you are driving MHA vehicles, no use of the cell phones is permitted while actively driving. If you receive or need to make a call you must pull off the road before you use the cell phone.

The agency may access its electronic communications systems and obtain the communications within the systems, with or without notice to users of the systems, in the ordinary course of business when the agency deems it appropriate to do so. The reasons for which the agency may obtain such access include, but are not limited to: maintaining the system; preventing or investigating allegations of system abuse or misuse; assuring compliance with software copyright laws; complying with legal and regulatory requests for information; and insuring that the agency’s operations continue appropriately during an employee’s absence.

The agency’s policy prohibiting harassment, in its entirety, applies to the use of our electronic communications systems. No one may use electronic communications in a manner that may be constructed by others as harassment or offensive based on race, national origin, sex, sexual orientation, gender identity, age, disability, religious beliefs or any other characteristic protected by federal, state, or local law.

Since our electronic communications systems are for business use only, these systems may not be used to solicit for religious or political causes, outside organizations or other personal matters unrelated to the agency’s business.

No one may access, or attempt to obtain access, to another individual’s electronic communications without appropriate authorization from the CEO or the Human Resources Department.

Unauthorized duplication of copyrighted computer software violates the law and is strictly prohibited. Software programs and/or hardware programs may not be brought in from other sources and installed on any Agency computer without approval from the CEO or Human Resources Department.

Violators of this Electronic Communications Policy will be subject to disciplinary action up to and including termination of employment.

D. Financial Reporting and Records

The agency maintains a high standard of accuracy and completeness in the documentation and reporting of all financial records. These records serve as the basis for managing our business and are important in meeting our obligations to program participants, staff members, Board Members, suppliers, and others. Agency financial records are externally audited on an annual basis. These records are necessary for compliance with tax and financial reporting requirements. All financial information must reflect actual transactions and conform to generally accepted accounting principles. No undisclosed or unrecorded funds or assets may be established. Our agency maintains a system of internal controls to provide reasonable assurances that all transactions are executed in accordance with appropriate management authorization and are recorded in a proper manner to maintain accountability of the agency’s assets.

VI. WORKPLACE CONDUCT AND EMPLOYMENT PRACTICES

A. Code of Ethics 

The agency Code of Ethics outlines expectations for professional behavior and provision of services. The Code of Ethics is included in the agency’s Personnel Policies and Practices, and all employees are expected to adhere to that code. Ethical conduct is necessary and expected.

B. Conflict of Interest

As stated in the Personnel Policies and Practices of the Mental Health Association in Ulster County, Inc., no staff member or any member of her/his family should accept any gift, entertainment, services, loans, or promises of future benefits from any person who personally or whose employer might benefit or appear to benefit because of the staff member’s connection with the MHA. Staff members are expected to work out for themselves the most gracious methods of declining gifts and entertainment that do not meet this standard.

No staff member should perform for personal gain services for any supplier to the MHA of goods or services, or for any customer, as employee, consultant, or in any other capacity, that provides compensation of any kind. Similar association by a member of the staff member’s family or by any other relative may also be inappropriate.

No staff member, or any member of her/his family, should have any beneficial interest in or substantial obligation toward any supplier, customer of the MHA or any other organization that is engaged in doing business with or serving the agency, unless it has been determined on the basis of full disclosure of the facts that such interest does not give rise to a conflict of interest.

This policy is not intended to apply to situations that do not compromise the staff member, the MHA, or a third party. Nor does it apply to gifts and social entertainment of nominal value that are clearly in keeping with good business ethics and that do not obligate the recipient.

All of the situations as stated above apply to each board member or board committee member or any member of his/her family.

C. Controlled Substances/Drug & Alcohol Free Work Environment

• Some employees have access to prescription drugs, controlled substances, and other medical supplies. These substances are governed and monitored by specific regulatory agencies and must be administered by physician order only. It is vital that these items be handled properly by authorized individuals to minimize risk to the agency. Diversion of drugs from the agency should be reported immediately to your supervisor, the Corporate Compliance Officer, or Human Resources staff.

As stated in the Personnel Policies and Practices of the Mental Health Association in Ulster County, Inc.:

1. Substance Abuse

• It is the policy of the Mental Health Association to prohibit:

· the purchase, sale, or transfer of alcoholic beverages, illegal drugs, controlled substances, drug paraphernalia, or any combination thereof, or

• · the use and possession of any such items except where pursuant of physician's prescription, or
• · being under the influence of alcohol, drugs, or controlled substances

• during the course of performance of employment or on or within Agency premises, work sites and Agency or private vehicles parked on Agency premises or work sites or while used in connection with Agency business.

“Under the influence" is defined as being unable to perform work in a safe and productive manner or being in a physical or mental condition which creates a risk to the safety and wellbeing of the individual, other employees, the public, and Agency property as a result of the use of alcohol, drugs or controlled substances.

A violation of this policy is grounds for discharge for the first offense. The MHA is sensitive to this area and encourages employees to seek assistance or a leave of absence prior to policy violation. The purpose of this policy is to assure the welfare, health, and safety of all employees and clients of the Agency.

2. Drug Free Workplace Policy

STATEMENT OF PURPOSE

The MHA has a vital interest in insuring safe, healthful and efficient working conditions for our employees. In addition, as a federal grantee, we have a duty to comply with the requirements of the Drug Free Workplace Act of 1988. The unlawful presence of controlled substances in the workplace conflicts with these vital interests and constitutes a violation of the public trust. For these reasons, we have established, as a condition of employment and continued employment, the following drug-free workplace policy.

• 1. Prohibition Against Unlawful Presence of Controlled Substances in the Workplace.
• The unlawful manufacture, distribution, dispensation, possession or use of a controlled substance on MHA premises, or on any premises at which MHA employees provide services, in MHA vehicles or while engaged in MHA activities is strictly prohibited.

2. Notification of Workplace Drug Conviction.

• You must notify the Director of Human Resources at MHA of any criminal drug statute conviction of a violation occurring within the workplace within five (5) days of such conviction. Within ten (10) days of such notification or other actual notice, the Mental Health Association will advise the contracting agency of such conviction. In addition, all employees are required to report any drug-related convictions for activity that occurs outside the work place.

3. Compliance as a Condition of Employment.

• All employees are hereby advised that full compliance with the foregoing policies shall be a condition of employment at the Mental Health Association.

4. Sanctions for Violation of Drug-Free Workplace Policy.

• Any employee who violates the forgoing drug-free policy described above shall be subject to discipline up to and including immediate discharge.

5. Required Participation in Drug Rehabilitation.

• At the discretion of the Mental Health Association, any employee who violates this drug-free workplace policy may be required, in connection with or in lieu of disciplinary sanctions, to participate to MHA’s satisfaction in an approved drug assistance or rehabilitation program.

3. Drug-Free Awareness Program

In order to maintain a drug-free workplace, the Mental Health Association has established a drug-free awareness program to educate employees on the dangers of drug abuse in the workplace, our drug-free workplace policy, the availability of any drug free counseling, rehabilitation and employee assistance programs and the penalties that may be imposed for violations of our drug-free workplace policy. (Such education may include: (1) distribution of the MHA drug-free workplace policy at the employment interview; (2) a discussion of the MHA policy at the new employee orientation session; (3) distribution of a list of approved drug assistance agencies, organizations and clinics; (4) distribution of published educational materials regarding the dangers of drug abuse; (5) reorientation of all involved employees in cases in which a drug related accident or incident occurs; (6) inclusion of the policy in employee handbooks and any other personnel policy publications; (7) lectures or training by local drug abuse assistance experts; (8) discussion by MHA safety experts on the hazards associated with drug abuse; and (9) video tape presentations on the hazards of drug abuse.)

D. Copyrights

Everyone will adhere to copyright law and may only make copies of such material in compliance with specific department policies or procedures and with supervisory permission.

E. Diversity, Affirmative Action, and Equal Employment Opportunity 

The agency acknowledges and encourages the complement of cultures and talents that contribute to our success. The agency is committed to Affirmative Action and will comply with the agency Affirmative Action Statement and Plan. The agency will comply with all laws, regulations and policies and assure non-discrimination related to employment actions and issues of accessibility. Such actions include, but are not limited to, hiring, staff reductions, transfers, terminations, performance appraisals, recruiting, compensation, corrective action, discipline, and promotions. No one will discriminate against any individual with a disability with respect to any offer, or term or condition of employment. Agency facilities will adhere to the Affirmative Action Plan regarding accessibility. Reasonable accommodations will be made for qualified individuals with disabilities.

F. Harassment, Sexual Harassment and Workplace Violence

As stated in the Personnel Policies and Practices of the Mental Health Association in Ulster County, Inc., the agency has zero tolerance of any type of harassment, including sexual harassment, and violence and weapons in the workplace. Examples of unacceptable behavior include violence of any type, harassment based on diverse characteristics or cultural backgrounds, degrading or humiliating jokes, slurs, intimidation, etc.

Harassment is verbal or physical conduct that shows hostility or aversion toward an individual because of his/her race, color, religion, gender, ancestry, citizenship, sexual preference, gender identity, marital status, national origin, age or disability, or that of his/her relatives, friends, or associates. It has the purpose or effect of creating an intimidating, hostile, or offensive working environment, unreasonably interfering with an individual’s work performance or otherwise adversely affects an individual’s employment opportunities.

It is agency policy to prohibit sexual harassment of one employee by another employee or supervisor. The purpose of this policy is not to regulate our employees’ personal morality. It is to assure that, in the workplace, no employee harasses another one on the basis of sex.

While it is not easy to define precisely what harassment is, it certainly includes unwelcome jokes or comments, sexual advances, requests for sexual favors, unwanted touching, sexually related postings or pictures, and other verbal, visual or physical conduct of a sexual nature.

Any employee who feels that he/she has been subjected to harassment or workplace violence should immediately report the matter to their supervisor, Human Resources Department, or Chief Executive Officer. Violations of these policies will not be permitted and will result in disciplinary action up to and including discharge. All employees may be assured that no one will be retaliated against for either filing a complaint or participating in an investigation of harassment.

G. Health and Safety

As stated in the Personnel Policies and Practices of the Mental Health Association in Ulster County, Inc., the MHA is committed to providing and maintaining a safe and healthful environment for each employee to work. The agency will not knowingly permit unsafe conditions to exist, nor will it permit employees to indulge in unsafe acts. 

It is the policy of the agency:

• That the safety of employees is paramount.
• That safety will take precedence over expediency or short cuts.
• Every attempt will be made to reduce the possibility of accident occurrences.
• That the agency intends to comply with all safety laws and ordinances.
• That each employee shall be held responsible and accountable for their individual safety as well as the   safety of those they might supervise or train.
• To take all practical steps to safeguard the safety and well-being of its employees.
• To maintain neat, clean, safe, attractive, and healthful working conditions.
• To conduct all operations safely, to prevent injuries to persons and damage to property. 

Since the employee on the job is frequently more aware of unsafe conditions than anyone else, employees are encouraged to make recommendations, suggestions, and criticisms of unsafe conditions to their immediate supervisor so that they may be corrected. Program Directors are responsible for the working conditions within their department. A supervisor should remain alert at all times to dangerous and unsafe conditions, so that he/she may recommend corrective actions, discipline employees who habitually create or indulge in unsafe practices, assess new or changed situations for inherent dangers, and follow up on employee suggestions for corrective action so that unsafe conditions are not instituted or permitted to exist. 

The joint cooperation of employees and management in the observance of this policy will provide safe working conditions and accident-free performance, and will be to the mutual advantage of all.

H. Credentials Verification 

Staff employed in positions that require professional licenses, certifications, or other credentials are responsible for maintaining the current status of their credentials, and forwarding current documentation to Human Resources. These staff shall comply at all times with Federal and State requirements applicable to their respective disciplines.  Documentation of credentials in applicable positions is a condition of employment. The agency does credentials verification when required.

I. Personal Use of Agency Resources

As stated in the Personnel Policies and Practices of the Mental Health Association in Ulster County, Inc., each employee is responsible for preserving the agency’s assets, including time, materials, supplies, equipment, and information. Agency assets are to be maintained for business purposes. 

As a general rule, personal use of agency assets without appropriate Director approval is prohibited. The Chief Executive Officer must approve any community or charitable use of agency resources. Any use of agency resources for personal gain is prohibited.

Negligence in the care and use of agency property may result in discipline up to an including termination. When an employee leaves, all agency property should be returned to the supervisor or a representative from Human Resources.

J. Relationships Among Staff and Other Colleagues

In the normal day-to-day functions of an agency like the MHA, there are issues that arise which relate to how people in the agency deal with one another. It is impossible to foresee all of these, and many do not require explicit treatment in a document like this. A few routinely arise, however. One involves gift giving among staff members for certain occasions. While we wish to avoid any strict rules, no one should ever feel compelled to give a gift to anyone and any gifts offered or received should be appropriate to the circumstances. A lavish gift to anyone in a supervisory role would clearly violate agency policy. Another situation, which routinely arises, is a fund-raising or similar effort, in which no one should ever be made to feel compelled to participate.

K. Relationships with Subcontractors, Suppliers, and Educational Institutions

Relationships with subcontractors and suppliers should be fair, reasonable, and consistent with all applicable laws and good business practices. Competitive procurement to the maximum extent practicable is expected. Selection of subcontractors, suppliers, and vendors will be made on the basis of objective criteria including quality, technical excellence, price, delivery, adherence to schedules, service, and maintenance of adequate sources of supply. Purchasing decisions will be made based on the supplier’s ability to meet agency needs and not on personal relationships and friendships. The highest ethical standards will be utilized in source selection, negotiation,

determination of contract awards, and the administration of purchasing activities. The agency will not communicate to a third-party confidential information provided by our suppliers unless directed to do so in writing by the supplier. The agency will not disclose contract pricing and information to outside parties. The agency will provide subcontractors and suppliers with a copy of this Code. Subcontracts and suppliers are expected to comply with this Code. 

Relationships with educational institutions will be in writing and will define both parties’ roles and responsibilities.

L. Training and Education

The MHA’s Training Policy provides that the agency will assure that all mandatory training, including mandatory Code of Conduct training, is available to staff. Training will be documented, reviewed, and revised as necessary, to include issues raised by compliance reporting data. The Code of Conduct and related training and education will be provided at orientation and on a periodic basis. The agency is committed to assuring that staff receive appropriate training and education based on job duties and responsibilities.

VII. MARKETING PRACTICES

A. Antitrust

Antitrust laws are designed to create a level playing field in the marketplace and to promote fair competition. These laws could be violated by discussing agency business with a competitor, such as how prices are set, disclosing terms of supplier relationships, allocating markets among competitors, or agreeing with a competitor to refuse to deal with a supplier. Our competitors are other community mental health agencies and similar facilities in markets where the agency operates. At trade association meetings, everyone should be alert to potential situations where it may not be appropriate to participate in discussions regarding prohibited subjects with our competitors. Prohibited subjects may include, but are not limited to, any aspect of pricing, our services in the market, key costs such as labor costs, and marketing plans. If a competitor raises a prohibited subject, end the conversation immediately. It is suggested that you document your refusal to participate in the conversation by requesting that your objection be included in meeting minutes and by notifying the Chief Executive Officer of the incident. In general, avoid discussing sensitive topics with competitors or suppliers, unless you are proceeding with the advice of agency legal counsel. No one should provide any information in response to oral or written inquiries concerning an antitrust matter without first consulting the Chief Executive Officer.

B. Obtaining Information Regarding Competitors

It is not unusual to obtain information about other organizations, including competitors, through legal and ethical means such as public documents, public presentations, journal and magazine articles, and other published and spoken information. It is never acceptable to obtain proprietary or confidential information about a competitor through illegal means. It is not acceptable to seek proprietary or confidential information when doing so would require anyone to violate a contractual agreement, such as a confidentiality agreement with a prior employer. It is acceptable for the Chief Executive Officer and Director of Human Resources to seek general salary survey information that is otherwise unavailable from a published, independent source such as a trade journal or research study, directly from a competitor as long as information is obtained by position, and confidentiality regarding the source of the information is appropriately maintained. No one may participate in external surveys without approval from the Chief Executive Officer.

C. Marketing and Advertising

Marketing and advertising activities may be used to educate the public, provide information to the community, increase awareness of our services, and to recruit staff. Only truthful, fully informative, and non-deceptive information will be presented in these materials and announcements. All marketing materials will reflect available services.

D. Environmental Compliance

The agency’s policy is to comply with all environmental laws and regulations as they relate to our operations. The agency will act to preserve our natural resources to the extent reasonably possible. The agency will comply with all environmental laws and operate each facility with the necessary permits, approvals, and controls. The agency will diligently utilize proper procedures with respect to handling and disposal of hazardous and bio hazardous waste. To comply with laws and regulations, everyone must understand how job duties impact the environment, adhere to all requirements for the proper handling of hazardous materials, and immediately alert your supervisor or the Director of Human Resources to any discharge of hazardous substance, improper disposal of waste, or any situation which might be potentially damaging to the environment.

VIII. BUSINESS COURTESIES

Nothing in this Code should be considered as encouragement to make, solicit, or receive any type of entertainment or gift. For clarity, these limitations govern activities with organizations and/or individuals outside of this agency.  A “Business Courtesy” can mean an invitation to attend a social event to further or develop business relationships, an actual gift, meal, entertainment, etc. All business courtesies, whether given or received, should be approved in advance by the appropriate Program Director or Chief Executive Officer.  Providing business courtesies to or receiving business courtesies from referral sources is expressly prohibited. No one may accept cash as a business courtesy.

IX. POLITICAL ACTIVITIES AND CONTRIBUTIONS

Agency funds or resources are not to be used to contribute to political campaigns or for gifts or payments to any political party or any of their affiliated organizations. Agency resources include financial and non-financial donations such as using work time and telephones to solicit for a political cause or candidate or the loaning of agency property for use in political campaigns. It is important to separate personal and corporate political activities in order to comply with appropriate rules and regulations relating to lobbying or attempting to influence government officials. Everyone may participate in the political process on their own time and at their own expense.  When doing so, no one should give the impression they speak on behalf of or represent the agency. No one can seek reimbursement from the agency for any personal contributions for such purposes. At times, the agency may ask individuals to make personal contact with government officials or to write letters to present our position on specific issues. In addition, it is part of the role of some Agency management to interface with government officials. If you are making these communications on behalf of the agency, be certain you are familiar with any regulatory constraints and observe them. Guidance can be sought from the CEO as necessary.

X. SOLICITATIONS  

As stated in the Personnel Policies and Practices of the Mental Health Association in Ulster County, Inc., to avoid disruptions in the work place that can be caused by solicitations and distribution of literature, it is the policy of the MHA that solicitations of employees on agency premises, work sites, work areas, or in immediate or regularly used client care areas, or the distribution of literature are strictly prohibited on working time and at all times in immediate client care areas.

Non employees are strictly prohibited from soliciting and distributing literature, “insignia,” “badges,” or “buttons” on agency premises, work sites, work areas or in client care areas at any time. The terms “insignia,” “badges,” or “buttons” shall include any symbol or ornamentation which identifies or encourages membership in any organization.

XI. THE AGENCY’S CORPORATE COMPLIANCE PROGRAM

A. Program Structure

The Corporate Compliance Program is intended to clearly demonstrate the absolute commitment of the agency to the highest standards of ethics and compliance. This commitment permeates all levels of the agency. The Corporate Compliance Committee includes the Chief Executive Officer, Corporate Compliance Officer, and representatives from the Board of Directors, Human Resources, Finance, Quality Assurance, and Program Directors. All of these individuals are prepared to support the standards documented in this Code. A list of current members of the Corporate Compliance Committee will be posted at all agency facilities. The Committee maintains compliance and investigations, provides the agency’s Board of Directors with annual and any necessary periodic reports to aid in oversight of the Compliance Program, and maintains the agency’s compliance documentation. This program will be reviewed at least annually for consistency, effectiveness and scope.

B. Resources for Guidance and Reporting Violations 

Everyone may obtain guidance on ethics or compliance issues or report suspected violations through several options. Resolutions of issues at the lowest level possible are always encouraged. It is expected practice to raise concerns with your supervisor first. If this is uncomfortable or inappropriate, another option is to discuss the situation with another member of management, with the Corporate Compliance Officer, with Human Resources staff, or with any member of the Corporate Compliance Committee. Everyone is free to leave a message on the designated reporting voice mailbox accessed by dialing the agency phone number (845) 336-4747 and dialing 555. Every effort will be made to maintain, within the limits of the law, the confidentiality of the identity of any individual who reports possible misconduct or violations of this Code. The agency will not tolerate retaliation or discipline for anyone who reports a possible violation in good faith. Anyone who deliberately makes a false accusation will be subject to appropriate discipline pursuant to agency policies.

C. Personal Obligation to Report

The agency is committed to ethical and legal conduct that is compliant with all relevant laws, regulations, and funding source requirements, and to correcting wrongdoing wherever it occurs in the agency. Everyone has an individual duty and responsibility to report any activity by any staff, subcontractor, vendor, or other party that appears to violate, or might violate applicable laws, rules, regulations, or this Code. Anonymous reporting can be made by calling the agency’s telephone number (845) 336-4747 and dialing 555 for the designated reporting voice mailbox or by anonymous written report to the Corporate Compliance Officer.

D. Internal Investigation of Reports

The agency will appropriately investigate all concerns promptly and confidentially, to the extent possible. The Corporate Compliance Officer will coordinate any findings from the investigations and immediately recommend corrective action, discipline or changes that need to be made based on those findings. When the reporting party is known, information about the disposition of the report will be relayed back to that individual. The agency expects everyone to cooperate with investigation efforts.

E. Corrective Action

When an internal investigation results in a substantiated finding, it is the policy of the agency to initiate corrective action, including, as appropriate, making prompt restitution of any overpayment amounts, notifying the appropriate governmental agency, instituting any disciplinary action warranted and administered according to policies and implementing systemic changes to prevent a similar violation from recurring.

F. Discipline

All violators of the Code will be subject to appropriate disciplinary action pursuant to agency policies. Discipline may include the following:

• § Verbal reprimand
• § Written reprimand
• § Suspension
• § Termination
• § Restitution
• § Referral for criminal investigation/prosecution
• § Civil litigation/action

G. Internal Audit and Other Monitoring

The agency is committed to appropriate, consistent monitoring of compliance with its policies. The Corporate Compliance Committee and/or the appropriate program directors will conduct monitoring of policies. All monitoring will be conducted according to established policies, procedures and schedules. The agency routinely seeks other means of assuring and demonstrating compliance with laws, regulations, funding requirements, and agency policy.

H. Acknowledgement Process

The agency requires all employees, interns, volunteers, Board Members, subcontractors, independent contractors, agents, or other individuals to sign an acknowledgement confirming they have received the Code and understand that it represents mandatory policies of the agency. New employees will be required to sign this acknowledgement as a condition of employment. Adherence to and support of this Code of Conduct and participation in related activities and training is required.

XII. QUESTIONS AND ANSWERS

This Code is not intended to provide answers to every question anyone may have about agency policies, or funding requirements, laws, or regulations. The following questions and answers are intended to increase understanding of how specific guidelines must be applied.

A. The Corporate Compliance Program 

If I have a question about workplace conduct or if I see or become aware of something I believe is wrong, who should I contact and must I report?

Everyone is required to report violations of this Code, anything that could be considered unethical or illegal. Several options are available for reporting. Anyone can contact their supervisor or other member of management at your facility, the Corporate Compliance Officer, or Human Resources staff. Anonymous reports can be made in written form to the Corporate Compliance Officer or by leaving a message on the agency’s voice mailbox by dialing the agency telephone number (845) 336-4747 and dialing 555.  A list of the Corporate Compliance Committee will be posted at each facility, and these Committee members may also be contacted. Everyone is encouraged to resolve matters at the lowest level possible and appropriate.

If I make a report that turns out to be wrong, will I get in trouble?

As long as an individual reports an honest concern, policy prohibits being disciplined or retaliated against. As a member of the agency, you have a duty and responsibility to report suspected problems. In fact, you could be subject to discipline pursuant to agency policies if you witness or have knowledge of violations and fail to report them to the agency. The only time someone will be disciplined for reporting is when that individual knowingly makes a false or misleading report. 

What should I do if my supervisor asks me to do something I believe violates the Code of Conduct, agency policy, or is illegal?

Don’t do it. No matter who asks you to do something, if you know it is wrong, you must refuse to do it. If it is your supervisory or management staff, inform them why you are refusing to do what is requested. Immediately report incidents to your supervisor or management staff in your facility, or if that is not appropriate, to the Corporate Compliance Officer or Human Resources staff.

B. General Ethical Behavior

How do I determine if I am on ethical “thin ice?”

If you are worried or concerned whether your actions will be discovered, if you feel uneasy about what you are doing, or if you are rationalizing your activities on any basis (such as “everyone does it”), you are probably on ethical “thin ice.” Stop, consider what you are doing, seek advice, and redirect your action so that you know you are doing the right thing.

C. Accuracy, Retention, and Disposal of Documents

In preparation for a certification visit, my supervisor has asked me to review client records and to fill in any missing signature. May I do this?

No. It is absolutely wrong to sign for another provider. You may sign your own paperwork, but you must date it correctly, even if it is after the event. The agency is committed to and must maintain and provide complete and fully accurate information. Paperwork should be timely. However, when it is not, paperwork must be completed and dated accurately.

A client that is frequently served at our agency wants to give a staff member a gift. May the individual accept it?

Agency policy prohibits anyone from soliciting gifts or favors. Policy provides that any gift be reported to the appropriate Program Director or to the Chief Executive Officer. The recipient and the Program Director or Chief Executive Officer assess motivation of the giver, implications of the giver’s ability to use or benefit from agency services, and the degree to which any appearance of impropriety could be perceived. This applies to any circumstances that might resemble “giving of a gift.”    

May I accept fruit baskets or flowers from clients or suppliers?

Consumable or perishable gifts to programs may be accepted.

D. Conflicts of Interest

I am planning an agency meeting. My relative owns a catering service. May I use this catering service if prices are comparable to other caterers?

No. While this may seem unfair, the appearance of favoritism must be avoided.

Do conflict of interest policies apply to distant relatives or friends?

They may. If any relationship could influence your objectivity or create the appearance of impropriety, the policies must apply.

E. Antitrust Issues

May I discuss contract amounts or fees for services at meetings with other competitors such as professional affiliation/trade association meetings?

No. No one must ever discuss fees or contract amounts with competitors.

F. Client Confidentiality

We live in a small town and most of the community knows each other. If anyone requests client records and they are not providing services, may they have access to the records?

No. Only actual providers or individuals consulting may have access to client files. The same is true for other records, only individuals with a need to know may have access.

Revised 5/7/09

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