The purpose of our Corporate Compliance Program is to promote organizational adherence to applicable federal and state law, and private payer healthcare requirements. An effective compliance program can help protect practices against fraud, abuse, waste, and other potential liability areas. At MHA in Ulster, Inc. we are committed to establish a culture of honesty and accountability that promotes prevention, detection and resolution of instances of conduct that do not conform to federal and state law, and federal, state, and private payer healthcare program requirements, as well as ethical and business policies.
Our compliance program is built upon the following eight elements:
- Implementation of written compliance policies, procedures, and standards of conduct;
- Designation of a compliance officer and compliance committee, who will be responsible for monitoring compliance efforts and enforcing practice standards;
- Conducting effective training and education on the compliance policies, procedures, and standards of conduct;
- Development of effective lines of communication to facilitate communication with staff and allow anonymous reporting mechanisms;
- Conducting internal monitoring and auditing by performing periodic self-audits;
- Enforcing standards for employees through well-publicized disciplinary guidelines;
- Responding promptly to detected offenses and develop corrective action plans; and
- Enforcing a policy of non-intimidation and non-retaliation for good faith participation in the compliance program.
Code of Conduct
MISSION AND VALUES STATEMENT
The Mental Health Association in Ulster County, Inc. (MHA) is committed to quality care and improvement of human life. MHA employs teamwork and all other resources to make individualized quality, cost-effective behavioral health services and assistance accessible to individuals in our local communities. MHA’s vision is a responsible and respectful society where the stigma of mental illness is eliminated. Our mission is to engage all people in achieving their optimal mental health by providing innovative and compassionate services that educate, advocate, prevent and heal.
As MHA, 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 not 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.
While all associated with MHA (employees, interns, volunteers, Board Members, subcontractors, independent contractors, and agents) 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 MHA, which promotes the highest standards of ethics and compliance. This culture must encourage everyone in MHA to raise concerns when they arise. We must never sacrifice ethical and compliant behavior in the pursuit of business objectives.
COMMITMENT TO STAKEHOLDERS
As we all are committed to following our mission statement and to the success of MHA 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.
RELATIONSHIPS WITH OUR HEALTHCARE PARTNERS
A. Program Participants
1. Care and Rights of Individuals We Serve
MHA exists to provide quality, professional, ethical, compassionate, timely, accessible, and appropriate services. All individuals will be treated with professionalism, respect, and dignity. MHA will not discriminate against any individual based on race, color, creed/religion, pregnancy related condition, genetic information, predisposition and carrier status, national origin, citizenship, disability, military or veteran status, marital status, sex, sexual orientation, gender identity or transgender status, age, or any other classification protected by applicable law. 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. MHA 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 MHA, It is the policy of MHA that client confidentiality is respected as a high priority by all staff members of MHA, in accordance with HIPAA privacy and security regulations and procedures. The client's right to privacy shall not be violated in any manner by a staff member or any other individual who acts on behalf of MHA. This is to include committee members, appointed advocates, staff members, volunteers, etc.
Client information regarding medical conditions, history, medication, demographics, etc., is necessary for MHA to provide appropriate quality care. MHA recognizes the sensitive nature of protected health information and is committed to maintaining confidentiality as mandated by law and by professional standards. No one will release or discuss client-specific information with others except in compliance with HIPAA policies and procedures. Individuals must never disclose confidential information that would violate client privacy rights. No one has a right to access or use any client information except to the extent necessary to perform his/her job. Clients have the right to expect their privacy to be protected and that confidential information will only be used and disclosed in accordance with applicable state and federal laws, regulations, and MHA policies.
Under New York law, disclosure of HIV-related information is subject to special restrictions. In accordance with New York State Public Health Law, Article 27-F, "Release of confidential HIV related information means a written authorization for disclosure of confidential HIV related information which is signed by the protected individual, or if the protected individual lacks capacity to consent, a person authorized pursuant to law to consent to health care for the individual. Such release shall be dated and shall specify to whom disclosure is authorized, the purpose for disclosure and the time period during which the release is to be effective. A general authorization for the release of medical and other information shall not be construed as a release of confidential HIV related information, unless such authorization specifically indicates its dual purpose as a general authorization and an authorization for the release of confidential HIV related information and complies with this definition." Form DOH-2557 (6/89) will be used for this purpose.
Anyone found to engage in any activity which violates client confidentiality and privacy will be subject to discipline, in accordance with MHA policies and procedures. Violation of client confidentiality and privacy for a client will not be tolerated by MHA.
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, MHA will not pay for referrals. Admissions to services are based solely on individual needs and MHA’s ability to offer appropriate services and admission criteria will be strictly and consistently followed. Violation of this precept could have significant ramifications for MHA, including civil and criminal penalties and possible exclusion from participation in federally funded programs. Additionally, no payment will be accepted for MHA referrals to other providers. No one acting on behalf of MHA 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
MHA 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. MHA prefers to contract with agencies that have adopted their own ethics and compliance programs.
Among other things, knowingly submitting false or fraudulent claims for payment to a government may constitute a violation of the Civil False Claims, 31 U.S.C. § 3729(a). A person acts “knowingly” under this law not only if they have actual knowledge of a false or fraudulent claim, but also if they act with deliberate ignorance or reckless disregard. In sum, the False Claims Act imposes liability on any person who submits a claim to the federal government that he or she knows (or should know) is false.
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. MHA 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 MHA 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. MHA is subject to numerous other laws, regulations and funding source requirements. MHA 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.
MHA will provide appropriate, complete, factual, and accurate information in response to billing inquiries. MHA 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 MHA meets all regulatory obligations, everyone must be informed about stated areas of potential compliance concern. MHA 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. MHA will provide everyone with information, education, and training to fully comply with all applicable laws, regulations, and requirements.
E. Certifying Bodies
MHA 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 MHA 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 MHA. Certification standards will be met and maintained.
F. Overview of Relevant Laws:
The False Claims Act (31 U.S.C. §§ 3729-3733)
The False Claims Act is a federal law designed to prevent and detect fraud, waste and abuse in federal healthcare programs, including Medicaid and Medicare. Under the False Claims Act, anyone who “knowingly” submits false claims to the Government is liable for damages up to three times the amount of the erroneous payment plus mandatory penalties of $5,000 to $10,000 for each false claim submitted.
False Claims suits can be brought against individuals and entities. The False Claims Act does not require proof of a specific intent to defraud the Government. Providers can be prosecuted for a wide variety of conduct that leads to the submission of a false claim.
Some examples include:
• Knowingly making false statements;
• Falsifying records;
• Submitting claims for services never performed or items never furnished;
• Double-billing for items or services;
• Using false records or statements to avoid paying the Government;
• Falsifying time records used to bill Medicaid; or
• Otherwise causing a false claim to be submitted.
Whistleblower or “Qui Tam” Provisions:
In order to encourage individuals to come forward and report misconduct involving false claims, the False Claims Act contains a “Qui Tam” or whistleblower provision.
The Government, or an individual citizen acting on behalf of the Government, can bring actions under the False Claims Act. An individual citizen, referred to as a whistleblower or “Relator,” who has actual knowledge of allegedly false claims may file a lawsuit on behalf of the U.S. Government. If the lawsuit is successful, and provided certain legal requirements are met, the whistleblower may receive an award ranging from 15% - 30% of the amount recovered.
The False Claims Act prohibits discrimination by MHA against any employee for taking lawful actions under the False Claims Act. Any employee who is discharged, demoted, harassed, or otherwise discriminated against because of lawful acts by the employee in False Claims actions is entitled to all relief necessary to make the employee whole. Such relief may include reinstatement, double back pay, and compensation for any special damages, including litigation costs and reasonable attorney fees.
Administrative Remedies for False Claims (31 USC Chapter 38. §§3801-3812).
This federal statute allows for administrative recoveries by federal agencies including the Department of Health and Human Services, which operates the Medicare and Medicaid Programs. The law prohibits the submission of a claim or written statement that the person knows or has reason to know is false, contains false information or omits material information. MHA may impose a monetary penalty of up to $5,500 per claim and damages of twice the amount of the original claim.
Unlike the False Claims Act, a violation of this law occurs when a false claim is submitted, not when it is paid. Also unlike the False Claims Act, the determination of whether a claim is false, and imposition of fines and penalties is made by the administration of MHA, and not by prosecution in the federal court system.
New York State False Claims Act (State Finance Law §§187-194).
The New York State False Claims Act closely tracts the federal False Claims Act. It imposes fines on individuals and entities that file false or fraudulent claims for payment from any state or local government, including health care programs such as Medicaid. The penalty for filing a false claim is $6,000 - $12,000 per claim and the recoverable damages are between two and three times the value of the amount falsely received. In addition, the false claim filer may be responsible for the government’s legal fees.
The Government, or an individual citizen acting on behalf of the Government (a “Relator”), can bring actions under the New York State False Claims Act. If the suit eventually concludes with payments back to the government, the party who initiated the case can recover 15% - 30% of the proceeds, depending upon whether the government participated in the suit. The New York State False Claims Act prohibits discrimination against an employee for taking lawful actions in furtherance of an action under the Act. Any employee who is discharged, demoted, harassed, or otherwise discriminated against because of lawful acts by the employee in furtherance of an action under the False Claims Act is entitled to all relief necessary to make the employee whole.
Social Service Law §145-b False Statements
It is a violation to knowingly obtain or attempt to obtain payment for items or services furnished under any Social Services program, including Medicaid, by use of a false statement, deliberate concealment or other fraudulent scheme or device. The State or the local Social Services district may recover up to three times the amount of the incorrectly paid claim. In the case of non-monetary false statements, the local Social Service district or State may recover three times the amount incorrectly paid. In addition, the Department of Health may impose a civil penalty of up to $2,000 per violation. If repeat violations occur within five years, a penalty up to $7,500 may be imposed if they involve more serious violations of the Medicaid rules, billing for services not rendered, or providing excessive services.
Social Service Law §145-c Sanctions
If any person applies for or receives public assistance, including Medicaid, by intentionally making a false or misleading statement, or intending to do so, the person’s and the person’s family needs are not taken into account for a period of six months to five years, depending upon the number of offenses.
B. Criminal Laws
Social Service Law §145 Penalties
Any person who submits false statements or deliberately conceals material information in order to receive public assistance, including Medicaid, is guilty of a misdemeanor.
Social Service Law § 366-b, Penalties for Fraudulent Practices
Any person who, with intent to defraud, presents for payment any false or fraudulent claim for furnishing services or merchandise, knowingly submits false information for the purpose of obtaining Medicaid compensation greater than that to which he/she is legally entitled to, or knowingly submits false information in order to obtain authorization to provide items or services shall be guilty of a Class A misdemeanor.
Any person who obtains or attempts to obtain, for himself or others, medical assistance by means of a false statement, concealment of material facts, impersonation, or other fraudulent means is guilty of a Class A misdemeanor.
Penal Law Article 155, Larceny
The crime of larceny applies to a person who, with intent to deprive another of property, obtains, takes or withholds the property by means of a trick, embezzlement, false pretense, false promise, including a scheme to defraud, or other similar behavior. This law has been applied to Medicaid fraud cases.
Penal Law Article 175, Written False Statements
There are four crimes in this Article that relate to filing false information or claims. Actions include falsifying business records, entering false information, omitting material information, altering MHA’s business records, or providing a written instrument (including a claim for payment) knowing that it contains false information. Depending upon the action and the intent, a person may be guilty of a Class A misdemeanor or a Class E felony.
Penal Law Article 176, Insurance Fraud
This Article applies to claims for insurance payment, including Medicaid or other health insurance. The six crimes in this Article involve intentionally filing a false insurance claim. Under this article, a person may be guilty of a felony for false claims in excess of $1,000.
Penal Law Article 177, Health Care Fraud
This Article establishes the crime of Health Care Fraud. A person commits such a crime when, with the intent to defraud Medicaid (or other health plans, including non-governmental plans), he/she knowingly provides false information or omits material information for the purpose of requesting payment for a health care item or service and, as a result of the false information or omission, receives such a payment in an amount to which he/she is not entitled. Health Care Fraud is punished with fines and jail time based on the amount of payment inappropriately received due to the commission of the crime.
New York Labor Law §740
An employer may not take any retaliatory personnel action against an employee if the employee discloses information about the employer’s policies, practices or activities to a regulatory, law enforcement or public official.
This law offers protection to an employee who:
• discloses, or threatens to disclose, to a supervisor or to a public body an activity, policy or practice of the employer that is in violation of law, rule or regulation that presents a substantial and specific danger to the public health or safety, or which constitutes health care fraud (knowingly filing, with intent to defraud, a claim for payment that intentionally has false information or omissions);
• provides information to, or testifies before, any public body conducting an investigation, hearing or inquiry into any such violation of a law, rule or regulation by the employer; or
• objects to, or refuses to participate in any such activity, policy or practice in violation of a law, rule or regulation.
The employee’s disclosure is protected under this law only if the employee first brought up the matter with a supervisor and gave the employer a reasonable opportunity to correct the alleged violation. The law allows employees who are the subject of a retaliatory action to bring a suit in state court for reinstatement to the same, or an equivalent position, any lost back wages and benefits and attorneys’ fees. If the employer is a health care provider and the court finds that the employer’s retaliatory action was in bad faith, it may impose a civil penalty of $10,000 on the employer.
New York Labor Law §741
Under this law, a health care employer may not take any retaliatory action against an employee if the employee discloses certain information about the employer’s policies, practices or activities to a regulatory, law enforcement or public official. Protected disclosures are those that assert that, in good faith, the employee believes constitute improper quality of patient care.
The employee’s disclosure is protected under this law only of the employee first brought up the matter with a supervisor and gave the employer a reasonable opportunity to correct the alleged violation, unless the danger is imminent to the public or patient and the employee believes in good faith that reporting to a supervisor would not result in corrective action. If the employer takes a retaliatory action against the employee, the employee may sue in state court for reinstatement to the same, or an equivalent position, any lost back wages and benefits and attorneys’ fees. If the employer is a health care provider and the court finds that the employer’s retaliatory action was in bad faith, it may impose a civil penalty of $10,000 on the employer.
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 MHA’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 MHA 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 MHA, 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 MHA, 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/Acceptable Use Policy
As stated in the Personnel Policies and Practices of MHA, It is the policy of MHA that computers, network, e-mail, voice mail, cellular phones, text messaging, pagers, and Internet access (cumulatively referred to as Electronic Communication Systems) are provided to employees to facilitate their efforts and the completion of their job responsibilities. These resources are not to be used for any unlawful purpose or reason inconsistent with the mission or policies of the Agency.
This policy applies to all Electronic Communication Systems that are owned or leased by MHA, that are used on or accessed from MHA premises or work sites, or that are used on MHA business. This policy also applies to all activities using any MHA-paid accounts, subscriptions, or other technical services, such as Internet access, voice mail, and e-mail, whether or not the activities are conducted from MHA premises.
MHA encourages all employees who are assigned an MHA cell phone to carry it with you at all times while you are working for your safety and the safety of the clients. However, employees are prohibited from talking on or otherwise using a hands-held mobile phone while operating an MHA vehicle or a personal vehicle on MHA business or at any time when using a mobile phone owned or provided by MHA. This prohibition applies to all mobile phone use including receiving or placing calls, checking voicemail, sending or receiving email or text messages, and accessing the Internet.
Your use of MHA’s Electronic Communication Systems must not interfere with your productivity, the productivity of any other employee, or the operation of MHA’s systems.
MHA’s policy prohibiting harassment, in its entirety, applies to the use of MHA’s Electronic Communications Systems. No one may use these systems in a manner that may be constructed by others as harassment or offensive based on race, national origin, gender, sexual orientation, age, disability, religious beliefs or any other characteristic protected by applicable law. Sending, saving, or viewing offensive material is prohibited. Messages stored and/or transmitted by the Electronic Communications Systems must not contain content that may reasonably be considered offensive.
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. Similarly, you should only access the libraries, files, data, programs, and directories that are related to your work duties. Unauthorized review, duplication, dissemination, removal, installation, damage, or alteration of files, passwords, computer systems or programs, or other MHA property, or improper use of information obtained by unauthorized means, is prohibited.
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 MHA computer without approval from the CEO or Human Resources Department.
Employees will not, under any circumstances, absent the express written consent of MHA, cause or allow confidential and proprietary information to be saved and/or stored on a computer, drive, device, server, or other digital and cloud based means of data storage (expressly including without limitation Dropbox, OneDrive, Google Drive and Box) other than those in which MHA maintains, controls and provides me secured access.
MHA's Electronic Communications Systems, and the data stored on or transmitted over them are and remain at all times the property of MHA and should not be considered private or confidential. MHA 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 MHA deems it appropriate to do so. The reasons for which MHA 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 MHA’s operations continue appropriately during an employee’s absence.
Employee use of MHA’s Electronic Communication Systems constitutes consent to MHA’s accessing, intercepting, monitoring and disclosing any matter stored in, created, received or sent over those systems.
Employees who violate this Electronic Communications Policy will be subject to disciplinary action up to and including termination of employment.
D.) Personal Cellphone Use
It is a violation of MHA’s Code of Conduct for staff to use their personal cell phones for work purposes. Staff are prohibited from texting each other on their personal cell phones regarding work related questions/issues related to clients or any other confidential information. Under MHA’s policies and procedures for compliance with the HIPAA privacy and security regulations, staff members are strictly prohibited from using personal cell phones to access, use, transmit, communicate, or store any protected health information related to clients. Employees assigned Agency cell phones or other assigned MHA electronic devices are expected to use them for all work related electronic communications.
Employees are permitted to use their personal cell phone during scheduled work time only during their meal break and in case of an emergency. Employees are prohibited from talking on or otherwise using a handheld cell phone while operating an Agency vehicle or a personal vehicle on Company business. This prohibition applies to all cell phone use including receiving or placing calls, checking voicemail, sending or receiving email or text messages, and surfing the internet.
Employees are permitted to use their personal cell phone to notify their supervisor when they will be late for or will not report for their scheduled shift.
D. Computer Asset Control Policy
MHA determines the computer system needs of employees and how those needs will be met. The purpose of this policy is to outline the acceptable movement of computer and electronic equipment at MHA. MHA reserves authority to establish and enforce procedures and rules for employee use of MHA-owned computer systems, software, and data. These rules are in place to protect the employee and MHA.
This policy applies to MHA staff members who include contractors, consultants, interns, students, trainees, temporary employees, and other workers at MHA. This policy applies to all equipment that is owned or leased by MHA.
The asset control policy will not only enable organizational assets to be tracked concerning their location and who is using them but it will also protect any data being stored on those assets. This Asset Policy also covers disposal of assets.
Assets subject to tracking include:
1. Desktop workstations
2. Laptop mobile computers
3. MHA Smartphones
4. Printers, Copiers, FAX machines, multifunction machines
6. Hard drives
7. Tapes with data stored on them including system backup data
All employees must also agree to handle memory sticks, and CD ROM disks in a responsible manner and follow these guidelines:
• Never place sensitive data on them without authorization. If sensitive data is placed on them, special permission must be obtained from the CEO or Director of HR and the memory device must be kept in a secure area. As soon as work is completed on the memory device the information must be saved back onto MHA’s network to be backed-up and protected according to MHA policy and procedures.
MHA Director of IT is responsible to maintain a current inventory of all computers and printers for HIPAA purposes and their location. In addition, assets must remain within the program which purchased the asset for auditing purposes. It is for these reasons that relocation or movement of assets not be completed without approval from the Director of Human Resources and Finance and the knowledge and assistance of the Director of IT.
E. Financial Reporting and Records
MHA 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. MHA 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. MHA 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 MHA’s assets.
IMPROPER USE OF MHA FUNDS or ASSETS
Use of MHA’s funds or assets for any improper purpose is strictly prohibited. If you are aware of or have reason to believe that funds or assets are being improperly used, you must report this immediately to your supervisor or the Compliance Officer. MHA funds may not be utilized for the purchase of firearms, illicit substances, alcohol or cigarettes.
POLITICAL ACTIVITIES AND CONTRIBUTIONS
MHA 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. MHA 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 MHA 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 MHA. No one can seek reimbursement from MHA for any personal contributions for such purposes. At times, MHA 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 MHA management to interface with government officials. If you are making these communications on behalf of MHA, be certain you are familiar with any regulatory constraints and observe them. Guidance can be sought from the CEO as necessary.
SOLICITATIONS AND DISTRIBUTION OF LITERATURE
As stated in the Personnel Policies and Practices of MHA, to avoid disruptions in the work place that can be caused by solicitations and distribution of literature, it is the policy of MHA that employees may not distribute or circulate any non-MHA written or printed material on working time or in any work areas at any time and employees may not engage in solicitation of another employee for any purpose during their working time, or during the working time of the employee at whom the solicitation is directed.
Non-employees are strictly prohibited from soliciting and/or distributing any material or literature on our premises, work sites, work areas or in client care areas at any time.
For purposes of this policy, “working time” includes all time for which an employee is scheduled to be performing services for the Agency; it does not include meal periods.
The Bulletin boards are located in MHA buildings to communicate information to employees about Agency-related matters. Only Agency-related material may be posted on employee bulletin boards and no employee may post on the Bulletin Board without the prior approval of Human Resources. Please check the bulletin boards on a regular basis to keep informed of upcoming events and other items of interest. Employees are not to remove material from the bulletin boards.
WORKPLACE CONDUCT AND EMPLOYMENT PRACTICES
A. Code of Ethics
MHA Code of Ethics outlines expectations for professional behavior and provision of services. The Code of Ethics is included in MHA’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 MHA, It is the policy of MHA, that no Directors, Officers, Key Employees, staff members 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 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 Directors, Officers, Key Employees, or Staff members should perform for personal gain services for any supplier to 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 and therefore must be disclosed.
No Directors, Officers, Key Employees, or Staff members, 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 MHA, 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. The Conflict of Interest disclosure form must be used in for this purpose.
A Conflict of Interest Disclosure Form must be used for reporting any potential conflicts. The conflict of Interest Disclosure Form is completed upon hire for new employees and, annually thereafter. Any potential Conflicts of Interest which arise in the interim must be reported immediately using the aforementioned form which may be obtained from and submitted to any Program Director, or the Compliance Officer. The form and potential conflict is reviewed by the Corporate Compliance Officer, Director of Finance, Director of Human Resources and the CEO and appropriate action is taken. The resolution of the conflict is documented and shall include: (a) the names of the person who disclosed or otherwise were found to have a financial interest in connection with the actual or possible conflict of interest, the nature of the financial interest, any action taken to determine whether a conflict of interest was present, and the decision as to whether a conflict of interest in fact existed; the content of the discussion, including any alternatives to the proposed transaction or arrangement, and will be made part of the personnel file.
In the case of Board Members, the Conflict of Interest Form is completed prior to the initial election and annually thereafter. For any potential Conflicts of Interest which arise in the interim, the form may be obtained from and submitted to the Board Secretary who will provide a copy of the written statements to the Board. The existence and resolution of all conflicts of interest shall be properly documented in the Board Minutes and shall include: (a) the names of the person who disclosed or otherwise were found to have a financial interest in connection with the actual or possible conflict of interest, the nature of the financial interest, any action taken to determine whether a conflict of interest was present, and the Board’s or Executive Committee’s decision as to whether a conflict of interest in fact existed; and (b) the names of the persons who were present for discussions and votes relating to the transaction or arrangement, the content of the discussion, including any alternatives to the proposed transaction or arrangement, and a record of any votes taken in connection with the proceedings. In addition, any Board Member with an applicable conflict of interest may not be present at or participate in Board or Committee deliberations or voting on the matter considering such a conflict and is prohibited from any attempt to influence Board deliberations.
RELATED PARTY TRANSACTIONS
As a non-profit organization, MHA is prohibited from participating in Related Party Transactions unless the transactions are determined by the Board to be fair, reasonable and in the organization’s best interest at the time of the transaction. A “related party transaction” is any transaction, agreement or any other arrangement in which a related party has a financial interest and in which the corporation or any affiliate of the corporation is a participant. A “related party” is (1) any director, officer or key employee of the corporation, (2) any relative of any director, officer or key employee of the corporation or any affiliate of the corporation, or (3) any entity in which any individual described in (1) or (2) has a thirty-five percent (35%) or greater ownership or beneficial interest or, in the case of a partnership or professional corporation, a direct or indirect ownership interest in excess of five percent. Any director, officer or key employee who has an interest in a related party transaction must disclose to the Board or an authorized committee thereof, the material facts concerning such interest. The Board is required to:
• Consider alternative transactions (if available) prior to entering into the transaction;
• Approve the transaction by a majority vote of the Board at the meeting; and
• Contemporaneously document in writing the basis for the approval including the alternatives considered.
No related parties may participate in the deliberations or voting relating to these transactions. However, they can be available to present information concerning the transaction prior to the commencement of deliberations or voting.
No Directors, Officers, Key Employees or Staff members 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 MHA. Individuals are expected to work out for themselves the most gracious methods of declining gifts or gratuity valued in excess of ten dollars ($10).
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 MHA. 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.
This policy is not intended to apply to situations that do not compromise directors, officers, key employees, or staff member, 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.
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 a physician order only. It is vital that these items be handled properly by authorized individuals to minimize risk to MHA. Diversion of drugs from MHA should be reported immediately to your supervisor, the Corporate Compliance Officer, or Human Resources staff.
As stated in the Personnel Policies and Practices of MHA:
1. Drug and Alcohol Free Workplace Policy
STATEMENT OF PURPOSE
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 and alcohol-free workplace policy.
1. Prohibited Conduct
• Whenever employees are working, are in an MHA vehicle, are present on MHA premises or worksites, or are conducting MHA-related work offsite, they are prohibited from:
a. Buying, selling, manufacturing, distributing or dispensing or attempting to buy, sell, manufacture, distribute or dispense, a controlled substance, illegal drug or drug paraphernalia
b. Possessing, consuming or using alcohol, a controlled substance or an illegal drug
c. Being under the influence of alcohol, a controlled substance or an illegal drug
d. Using or being under the influence of legal drugs that are being used illegally, including but not limited to using drugs prescribed for another person
• Illegally possessing or using a drug, whether on or off MHA time or premises
• Testing positive on a drug and/or alcohol test required under this policy
• Refusing to submit to a drug and/or alcohol test or screen as directed by MHA (which includes but is not limited to refusing to sign necessary paperwork or release information regarding a required drug and/or alcohol test; failing to immediately report to the collection site; failing [without a valid medical explanation] to provide adequate specimens for testing; engaging in conduct that obstructs the testing process; and/or substitution or adulteration of a specimen)
• Violating any Agency rule or policy regarding alcohol and drug use
2. Reporting Obligation
In furtherance of MHA-wide commitment to maintaining a safe work environment, employees who have knowledge or reason to believe that a co-worker is in violation of this policy are expected to immediately contact Human Resources, or another member of management.
3. Use of Prescription and Over-the-Counter Medication
It is recognized that the use of prescription (and some over-the-counter [OTC]) drugs may affect the ability of an employee to work safely. Accordingly, employees working in safety sensitive positions who are taking prescription or over-the-counter medication must ascertain if doing so will affect his/her ability to perform the essential functions of his/her position and create a risk of harm (e.g., drowsiness or impaired reflexes or reaction time). Such employees should disclose their use of medication to their supervisor and the possible effects such medication may have on job performance, as well as the expected duration of use. Employees need not identify the medication they are taking or the underlying medical condition necessitating medication. If the medication poses a significant risk of substantial harm, the employee may be temporarily assigned different duties or provided an alternate accommodation.
MHA will not take disciplinary action against employees solely for the certified medical use of marijuana. However, like all other employees, employees who are certified patients may be subject to disciplinary action if they are under the influence of a controlled substance, including medical marijuana, on MHA property or on working time.
MHA may require drug and/or alcohol testing as a means of enforcing this policy:
• When a reasonable suspicion exists that an employee is working in an impaired condition or has otherwise violated this policy;
• When an accident, near-miss, or incident occurs while performing work for MHA, while on MHA premises or worksites, or operating an MHA vehicle or personal vehicle on MHA business, that gives rise to a reasonable suspicion that the accident, near-miss, or incident was due to the employee being under the influence;
• After any employee has participated in MHA’s Employee Assistance Program or other rehabilitation program; and
• When otherwise required by a state or federal law or regulation.
The results of drug and alcohol testing, as well as information concerning counseling or treatment, are considered confidential information. Such information will not be disclosed without a legitimate business reason or as compelled by law.
6. Notification of Workplace Drug Conviction.
You must notify MHA’s Director of Human Resources of any conviction under a criminal drug statute or other drug or alcohol related conviction including, but not limited to those arising out of violations occurring on MHA premises or worksites or while conducting MHA business. Such a report must be made within five (5) days of such conviction. Within ten (10) days of such notification or other actual notice, MHA will advise the contracting Agency of such conviction. After learning of an employee's conviction, MHA will promptly, in its sole discretion, discipline the employee, up to and including termination of employment; and/or require the employee to satisfactorily participate in and complete a drug abuse assistance or rehabilitation program.
7. Compliance as a Condition of Employment
Full compliance with the foregoing policy is a condition of employment at MHA.
8. Disciplinary Action
Any employee who violates the forgoing policy shall be subject to discipline up to and including immediate termination. MHA may also bring the matter to the attention of appropriate law enforcement authorities. An employee may be in violation of this policy regardless of whether his/her conduct is illegal or whether he/she is criminally prosecuted or convicted for it.
MHA wishes to assist employees who recognize they may have a problem with alcohol or drug use. Employees may make a self-referral for counseling or treatment under MHA’s Employee Assistance Program (EAP) or contact a Manager or Human Resources representative for assistance. Employees will be granted leave consistent with MHA’s medical leave policies and procedures and applicable law. Employees who voluntarily seek assistance before violating this or any other MHA policy will not be penalized for requesting help. At the same time, a voluntary request for assistance will not protect an employee from termination or discipline where that employee has violated this or any other MHA policy.
At MHA’s discretion, any employee who violates this policy may be required, in connection with or in lieu of disciplinary sanctions, to participate to MHA’s satisfaction in an approved drug and or alcohol assistance or rehabilitation program. Upon returning to work, such an employee may also be subject to periodic unannounced drug and/or alcohol testing.
DRUG-FREE AWARENESS PROGRAM
In order to maintain a drug-free workplace, MHA 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 MHA drug-free workplace policy at the employment interview; (2) a discussion of 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.)
Any questions regarding our drug-free workplace compliance efforts should be directed to the Director of Human Resources.
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
MHA acknowledges and encourages the complement of cultures and talents that contribute to our success. MHA is committed to Affirmative Action and will comply with MHA Affirmative Action Statement and Plan. MHA 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. MHA facilities will adhere to the Affirmative Action Plan regarding accessibility. Reasonable accommodations will be made for qualified individuals with disabilities.
F. Sexual and other Prohibited Harassment
As stated in the Personnel Policies and Practices of MHA, MHA is committed to ensuring its workplace is free of prohibited harassment and other forms of harassment because of race (including traits typically associated with race), color, religion, national origin, citizenship, disability, genetic information, predisposition or carrier status, military or veteran status, marital or familial status, the status of being a victim of domestic violence, gender, sexual orientation, gender identity, the status of being transgender, age, known relationship or association with any member of a protected class, and any other classification protected by applicable law. Any such harassment or discrimination may violate the law. In addition, MHA considers discrimination, harassment, and retaliation to be employee misconduct that will not be tolerated.
This policy applies to all employees, applicants for employment, interns, contractors, subcontractors, vendors, consultants or other person providing services in the workplace pursuant to a contract. This policy prohibits workplace harassment whether it involves co-worker harassment, harassment by a supervisor or manager, or harassment by persons doing business with or for MHA. Conduct prohibited by this policy is unacceptable in the workplace, at MHA functions, whether on or off MHA premises, and each and every situation that may impact the work environment, including business trips, business meetings, and business-related social events.
In furtherance of MHA’s commitment to maintain a harassment free workplace, MHA will provide this policy to all employees, post it prominently in all work locations (to the extent practicable), and provide it to new employees upon hiring.
Sexual harassment includes harassment on the basis of sex, sexual orientation, self-identified or perceived sex, gender expression, gender identity and the status of being transgender and is defined as unwanted sexual advances, requests for sexual favors, or other sexual or gender-based visual, verbal, or physical conduct. Such conduct is unlawful when: (1) submission to the conduct is made a term or condition of employment; (2) submission to or rejection of the conduct is used as basis for employment decisions affecting the individual; (3) the conduct has the purpose or effect of subjecting an individual to inferior terms, conditions or privileges of employment because of their protected status; or (4) the conduct has the purpose or effect of unreasonably interfering with the individual's work performance or creating an intimidating, hostile, or offensive working environment. This definition includes many forms of offensive behavior, such as:
• unwanted sexual advances;
• offering employment benefits in exchange for sexual favors;
• making or threatening reprisals after a negative response to sexual advances;
• visual conduct such as leering, making sexual gestures, or displaying sexually suggestive objects, pictures, cartoons, or posters;
• written conduct, such as authoring threatening, sexually suggestive, or obscene letters or correspondence (including e-mails, text messages and social media posts), invitations, etc.;
• verbal conduct such as sexual advances or propositions, making or using derogatory comments, epithets, slurs, sexually explicit jokes, or comments about an individual's body or dress;
• physical conduct such as touching, assault, or impeding or blocking movements; and
• hostile actions taken against an individual because of that individual’s sex, sexual orientation, gender identity or status of being transgender, such as bullying, yelling, or name calling, and sabotaging or otherwise interfering with an individual’s work.
Sexual harassment can occur between any individuals, regardless of their sex or gender.
In investigating reports of sexual harassment, MHA will ensure due process for all parties, as outlined below.
OTHER FORMS OF PROHIBITED HARASSMENT
Harassment on the basis of race (including traits typically associated with race), color, religion, national origin, citizenship, disability, genetic information, predisposition or carrier status, military or veteran status, marital or familial status, the status of being a victim of domestic violence, age, known relationship or association with any member of a protected class, and any other classification protected by applicable law includes behavior similar to sexual harassment, such as:
• written conduct such as authoring threatening letters or correspondence (including e-mails, text messages and social media posts), invitations, etc.;
• verbal conduct such as threats, epithets, derogatory comments, or slurs;
• visual conduct such as derogatory posters, photographs, cartoons, drawings, or gestures;
• physical conduct such as assault, unwanted touching, or blocking normal movement; and
• conduct via electronic media such as email, text messages or social media.
This policy prohibits not only behavior that constitutes unlawful harassment, but also other inappropriate or unprofessional behavior that may reasonably be considered offensive or otherwise objectionable. Such behavior will be subject to disciplinary action, up to and including termination of employment.
Anyone who feels that they have been subjected to conduct that violates this policy or who is aware of such conduct is expected to immediately report the matter to an appropriate Agency representative other than the alleged wrongdoer. Appropriate Agency representatives include the individual’s supervisor, Human Resources Department, or Chief Executive Officer. Reports may be submitted either verbally or in writing. A form for submission of a written report is attached to this policy and individuals are encouraged, but not required, to use this form.
As soon as a member of management is made or becomes aware of a suspected violation of this policy, they must immediately notify the Director of Human Resources or, if the concern involves the Director of Human Resources, the Chief Executive Officer. Any supervisor or manager who fails to report suspected violations of this policy or otherwise knowingly allows policy violations to continue will be subject to corrective action up to and including termination.
In the event an individual has a harassment or retaliation concern that directly or indirectly involving the Chief Executive Officer or otherwise reasonably believes that a report cannot be made to any of the above-referenced Agency representatives, the individual is expected to contact the President of MHA’s Board of Directors.
If an individual reports a suspected violation of this policy and the person to whom the report is made does not respond in a manner the individual deems satisfactory or consistent with this policy, the reporting individual is required to report the situation to another appropriate Agency representative other than the alleged wrongdoer.
All reports of prohibited harassment will be investigated and all employees, including supervisors and managers, are required to cooperate with MHA’s investigation. Investigations will be prompt and thorough, commenced immediately and completed as soon as possible and will generally include: an immediate review of the allegations and, where appropriate, interim actions; obtaining, reviewing and preserving relevant documentation; interviewing all parties involved, including relevant witnesses; and documenting the investigation and its resolution and preserving such. Upon completion of the investigation, a determination regarding the reported harassment will be made and communicated to the individual who complained, the subject of the report, and to the accused harasser(s).
Confidentiality will be maintained throughout the complaint process, to the extent practicable under the circumstances. Confidentiality cannot, however, be guaranteed.
PROHIBITION OF RETALIATION
MHA encourages individuals to express freely, responsibly and in an orderly way, opinions and feelings about any problem or complaint of discrimination, including harassment. Retaliation includes any conduct, whether or not workplace or employment-related, directed at someone because they opposed a discriminatory practice, made or encouraged another individual to make a good faith report of discrimination, or participated in an investigation or proceeding related to such a report, that might deter a reasonable worker from making or supporting a charge of harassment or discrimination.
MHA will not in any way retaliate and forbids retaliation against any individual who opposed a discriminatory practice, made or encouraged another individual to make a good faith report of discrimination, or participated in an investigation or proceeding related to such a complaint.
Retaliation is a serious violation of policy and the law, and should be reported immediately. Anyone who believes they have been subjected to retaliation or who is aware of retaliation directed at another individual is expected to report such to the Director of Human Resources or Chief Executive Officer. Any persons found to have engaged in retaliation will be subject to discipline, up to and including termination.
Should MHA determine that this policy has been violated, it will take prompt and effective remedial action. Appropriate action will also be taken to deter any future discrimination, harassment or retaliation. Any employee found to have violated this policy will be subject to appropriate disciplinary action, up to and including termination. Any manager or supervisor who knew about harassment and took no action to stop it or failed to report the harassment to Human Resources may also be subject to discipline up to and including termination.
In addition, MHA will take all reasonable steps to prevent or eliminate harassment by non-employees including customers, clients, temporary Agency/contractor workers, and suppliers who are likely to have contact with our employees.
LEGAL PROTECTIONS AND EXTERNAL REMEDIES
Sexual harassment is not only prohibited by MHA it is also prohibited by state, federal, and, where applicable, local law. Aside from the internal process described in this policy, individuals may also choose to pursue legal remedies with the following governmental entities at any time.
The New York State Division of Human Rights (DHR) enforces the Human Rights Law (HRL), codified as N.Y. Executive Law, art. 15, § 290 et seq., which applies to employers in New York State and protects employees, paid or unpaid interns and non-employees providing services in the workplace pursuant to a contract, regardless of immigration status. A complaint alleging a violation of the HRL may be filed either with DHR, subject to a one-year statute of limitations (three years for sexual harassment), or in New York State Supreme Court, subject to a three-year statute of limitations. Complaining internally to your employer does not extend your time to file with DHR or in court. The one year or three years is counted from date of the most recent incident of harassment. An attorney is not needed to file a complaint with DHR, and there is no cost to file with DHR. The DHR will investigate the complaint to determine if unlawful harassment occurred. If unlawful harassment is found after a hearing, the DHR or the court may award relief, which may include requiring your employer to take action to stop the harassment, and redress the damage caused by paying monetary damages, attorney’s fees and civil fines. DHR’s main office contact information is: NYS Division of Human Rights, One Fordham Plaza, Fourth Floor, Bronx, New York 10458, (718) 741-8400 www.dhr.ny.gov. The DHR can be contacted at (888) 392-3644. More information about filing a complaint is available at dhr.ny.gov/complaint. The website has a complaint form and contact information for DHR’s regional offices across New York State.
The United States Equal Employment Opportunity Commission (EEOC) enforces federal anti-discrimination laws, including Title VII of the 1964 federal Civil Rights Act (codified as 42 U.S.C. § 2000e et seq.). An employee must file a charge with the EEOC within 300 days from the conduct giving rise to the complaint. There is no cost to file a complaint with the EEOC. The EEOC also investigates complaints, but does not hold hearings or award relief. The EEOC may take other action including pursuing cases in federal court on behalf of complaining parties or issuing a Right to Sue Letter that allows an individual to pursue his/her claims in federal court. Federal courts may award remedies if discrimination is found to have occurred. The EEOC can be contacted at 1-800-669-4000 (1-800-669-6820 (TTY)), via email at email@example.com, or by visiting their website at www.eeoc.gov. If an individual filed an administrative complaint with DHR, DHR will file the complaint with the EEOC to preserve the right to proceed in federal court.
Many localities enforce laws protecting individuals from harassment and discrimination. An individual may contact the county, city or town in which they live to find out if such a law exists.
MHA does not consider conduct in violation of this policy to be within the course and scope of employment or the direct consequence of the termination of one's duties. Accordingly, to the extent permitted by law, MHA reserves the right not to provide a defense or pay damages assessed against employees for conduct in violation of this policy.
G. Health and Safety
As stated in the Personnel Policies and Practices of MHA, MHA is committed to providing and maintaining a safe and healthful environment for each employee to work. MHA will not knowingly permit unsafe conditions to exist, nor will it permit employees to indulge in unsafe acts.
It is the policy of MHA:
• That the safety of employees is paramount.
• MHA will work to reduce the possibility of accident occurrences as much as feasibly possible.
• That MHA 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 are supervising or training.
• To take all practical steps to safeguard the safety and wellbeing of its employees.
• To maintain neat, clean, safe, 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 likely to be the first to encounter any unsafe conditions, employees must report any unsafe conditions immediately to their immediate supervisor or Human Resources so that they may be corrected.
Program Directors are responsible for the working conditions within their department. A Program Director should remain alert at all times to the possibility of dangerous or unsafe conditions, so that he/she may recommend or take corrective action as appropriate, discipline employees who take part or engage 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. MHA does verification and will require proof and documentation of all licenses, certifications, credentials and college degrees. Required proof and documentation is a condition of employment.
In addition, MHA performs diligent screening of all prospective employees, contractors, volunteers and vendors to include checking whether they have been excluded from participation in the federal healthcare programs. The LEIE,
EPLS and OMIG exclusion lists are then re-checked on a monthly basis for all employees, contractors, vendors and volunteers.
I. Personal Use of MHA Resources
As stated in the Personnel Policies and Practices of MHA, each employee is responsible for preserving MHA’s assets, including time, materials, supplies, equipment, and information. MHA assets are provided for business purposes.
As a general rule, personal use of MHA assets without appropriate Director approval is prohibited. The Chief Executive Officer must approve any community or charitable use of MHA resources. Any use of MHA resources for personal gain is prohibited.
MHA properties and equipment are expected to be treated with pride and respect. Taking care of MHA resources is the responsibility of all employees, and using them must be done with safety and care while always maintaining them in good condition. A clean and safe work place must be a concern and the responsibility of all.
Negligence in the care and use of MHA property may result in discipline up to an including termination.
When an employee leaves, all MHA 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 MHA, there are issues that arise which relate to how people in MHA 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 MHA 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 MHA 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. MHA will not communicate to a third-party confidential information provided by our suppliers unless directed to do so in writing by the supplier. MHA will not disclose contract pricing and information to outside parties. MHA 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
MHA provides training that will assure 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. MHA is committed to assuring that staff receives appropriate training and education based on job duties and responsibilities.
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 MHA 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 MHA 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 MHA 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
MHA’s policy is to comply with all environmental laws and regulations as they relate to our operations. MHA will act to preserve our natural resources to the extent reasonably possible. MHA will comply with all environmental laws and operate each facility with the necessary permits, approvals, and controls. MHA 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.
MHA’S CORPORATE COMPLIANCE PROGRAM
A. Program Structure
The Corporate Compliance Program is intended to clearly demonstrate the absolute commitment of MHA to the highest standards of ethics and compliance. This commitment permeates all levels of MHA and all individuals associated with MHA who in turn will, at all times, act in a way to meet the requirements of the mandatory compliance program law and regulation. Conduct contrary to the aforementioned expectation will be considered a violation of the compliance program, and related policies and procedures and will be subject to discipline as stated below. 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 MHA facilities. The Committee maintains compliance and investigations, provides MHA’s Board of Directors with annual and any necessary periodic reports to aid in oversight of the Compliance Program, and maintains MHA’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. Supervisors and others who receive reports are required to bring the issues to the Compliance Officer. Everyone is free to contact MHA’s third party vendor Lighthouse Services at 844-490-0002 (English) 800-216-1288 (Spanish); Website: https://www.lighthouse-services.com/mhainulster; E-mail: firstname.lastname@example.org (must include company name with report); Fax: (215) 689-3885 (must include company name with report). 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. MHA 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 MHA policies. However, prompt and forthright disclosure of an error by an employee, even if the error constitutes inappropriate or inadequate performance, will be considered a positive constructive action by the employee.
C. Policy of Non-intimidation and Non-retaliation (Whistleblower Policy)
MHA has a policy of non-intimidation and non-retaliation against individuals for good faith participation in the Compliance Program, including but not limited to:
a. Reporting potential issues,
b. Investigating issues,
e. Remedial actions, and
f. Reporting to appropriate officials as provided in sections 740 and 741 of the NYS Labor Law
All MHA Directors, Officers, Employees, contractors, interns and volunteers shall be allowed to freely discuss and raise questions to supervisors or to the appropriate personnel about situations they feel are in violation of federal and state law, MHA policy, and/or regulatory requirements. No Directors, Officers, Employees, Interns or Volunteers of MHA who in good faith report any action or suspected action taken by or within MHA that is illegal, fraudulent, or in violation of any adopted policies shall suffer intimidation, harassment discrimination, or other retaliation or, in the case of employees, adverse employment consequences. Any violations of this policy should be immediately reported to the Corporate Compliance Officer, who will administer this policy and preserve the confidentiality of reported information. Reports may be made in person, by phone, letter, email, or by calling the designated hotline. The Corporate Compliance Officer will report to the Board any violations of this policy. A copy of the Whistleblower Policy shall be distributed to all Directors, Officers, Employees, and Volunteers who provide substantial services to MHA.
D. Personal Obligation to Report
MHA 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 MHA. Everyone: employees; executives; Board Members; and all persons associated with the Agency have an individual duty and responsibility to report any activity by any staff, Board Member, contractor, subcontractor, vendor, or other party that appears to violate, or might violate applicable laws, rules, regulations, or this Code. Anonymous and confidential reporting can be made by contacting MHA’s third party vendor; Lighthouse Services telephone number 844-490-0002 (English), 800-216-1288 (Spanish); Website: https://www.lighthouse-services.com/mhainulster; E-mail: email@example.com (must include company name with report); Fax: (215) 689-3885 (must include company name with report)
E. Internal Investigation of Reports
MHA is committed to resolve confirmed compliance problems and will appropriately investigate and resolve all problems/ concerns promptly and thoroughly. The Corporate Compliance Officer will sufficiently detail the results of investigations and root cause analyses to identify who the participants are and who may be encouraging, directing, facilitating, or permitting Non-Compliant behavior. The Compliance Officer will coordinate any findings from the investigations and immediately recommend and implement corrective action, discipline or changes that need to be made to policies, procedures and business practices based on those findings. Results will be reported to the CEO and the Board of Directors. When the reporting party is known, information about the disposition of the report will be relayed back to that individual.
Investigations which involve a member of the Board of Directors will be conducted by the Board President in cooperation with the Compliance Officer. In the event the Board President is the subject of the investigation, the investigation will be conducted by the Vice President for Planning in coordination with the Compliance Officer.
MHA expects everyone to cooperate with investigation efforts.
F. Corrective Action
When an audit or internal investigation results in a substantiated finding, it is the policy of MHA to initiate corrective action in a prompt and thorough fashion; 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. The Compliance Officer will monitor the effectiveness of implemented plans of correction.
All violations of the Code which includes failure to report suspected problems, participation in non-compliant behavior or encouraging, directing, facilitating or permitting, either actively or passively, non-compliant behavior will be subject to appropriate disciplinary action pursuant to MHA policies. Compliance related discipline applies to all associated individuals, will be fairly and firmly enforced and may include the following:
• Verbal reprimand
• Written reprimand
• Termination of employment or relationship with Agency
• Referral for criminal investigation/prosecution
• Civil litigation/action
H. Internal Audit and Other Monitoring
MHA is committed to appropriate, consistent monitoring of compliance with its policies. The Corporate Compliance Officer, Committee and/or the appropriate program directors will conduct monitoring of policies as well as monitoring of corrective actions plans which have been implemented. All monitoring will be conducted according to established policies, procedures and schedules. MHA routinely seeks other means of assuring and demonstrating compliance with laws, regulations, funding requirements, and MHA policy.
I. Acknowledgement Process
MHA 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 MHA. 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.
QUESTIONS AND ANSWERS
This Code is not intended to provide answers to every question anyone may have about MHA 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 and confidential reports can be made by contacting MHA’s third party vendor, Lighthouse Services by phone, web, e-mail or fax. 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 MHA, you have a duty and responsibility to report suspected problems. In fact, you could be subject to discipline pursuant to MHA policies if you witness or have knowledge of violations and fail to report them to MHA. 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, MHA 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. MHA 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.
D. Conflicts of Interest
A client that is frequently served at MHA wants to give a staff member a gift. May the individual accept it?
MHA 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 MHA 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.
I am planning an MHA 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.
Can I joke about or vent to my coworkers about my clients and their families?
Employees shall refrain from revealing any personal or confidential information concerning recipients of services unless supported by legitimate business or client care purposes and in accordance with law.