Code Of Conduct

The Enrichment Center Personnel Policy
Code of Conduct I-02

I. POLICY:

It is the policy of The Enrichment Center that all full and part-time employees, contractors, students, volunteers (collectively referred to as “organization”), and
members of the Board of Directors are expected to perform their designated functions in a manner that reflects the highest standards of ethical behavior. The ethical standards contained in this policy shape the culture and norms of The Enrichment Center administrative operations and clinical practices, and both staff and members of the governing authority will be held fully accountable to these standards. In addition to the specific guidelines contained in the policy, professionals are expected to follow the ethical standards required by their specific licensing and certification boards. The Code of Conduct is to ensure that all employees’ actions reflect a competent, respectful, and professional approach when serving the individuals served, their families and/or representatives, working with other providers of services, and interacting within the communities we serve. It is expected that staff and members of the governing authority will perform their duties in compliance with all federal, state, and local regulations in accordance with guidelines set forth in this policy. Violation of guidelines within the Code of Conduct can lead to disciplinary actions, including termination of employment.

 

II. PROCEDURES:

 

A. Professional Conduct:

  1. Employees will respect the rights of individuals served by demonstrating full integration of the guidelines contained in the Clients Rights Policy. This includes the right of individuals served to make autonomous decisions and fully participate in every aspect of the service delivery process.
  2. Employees will provide services in a manner that fully respects the confidentiality of individuals served by demonstrating a functional knowledge of confidentiality policies and guidelines.
  3. Employees will be fair and honest in their work. They will not exploit or mislead, and will be faithful to their job duties and their word.
  4.  To prevent and avoid unethical conduct, employees will consult with, refer to, and cooperate with other professionals. The Enrichment Center employees will clarify their professional roles and obligations and be accountable for upholding professional standards of practice.

Established: 3/23/2009; Updated 4/20/09

B. Personal/Professional Conduct:

  1. All prior personal relationships between staff and persons entering the Organization’s programs shall be disclosed by the staff member and subject to review by the appropriate supervisor.
  2. Staff will limit relationships with persons served to their defined professional roles.
  3. Staff will not establish monetary relationships with individuals receiving services.
  4. Staff will conduct themselves in a professional, ethical, and moral manner.
  5. Sexual relationships between staff and people served are never appropriate. Sexual relationships include, but are not limited to, the following: engaging in any type of sexual activity, unwelcome personal touching, flirting, advances and/or propositions of a sexual nature, comments of a sexual nature about an individual’s body or clothing, or lewd or sexually suggestive comments or gestures.
  6. Staff will not accept gifts of value from an individual served, family member, or stakeholder, and cannot accept personal favors or benefits that may reasonably be construed as influencing their conduct.

C. Business Practices:

  1. The Enrichment Center will utilize the Corporate Compliance Officer to ensure that it conducts business in an ethical manner and ensure that any business practices that are questionable are thoroughly investigated in accordance with the ethical investigation procedures that follow in this policy.
  2. All financial, purchasing, personnel, facility development, and information technology practices shall comply with local, state, and federal law and guidelines.
  3. All employees shall adhere to The Enrichment Center’s Personnel Policies and Procedures.

D. Marketing Practices:

  1. The Enrichment Center will conduct marketing practices in an honest and factual manner. Marketing materials and practices will in no way mislead the public or misrepresent The Enrichment Center’s abilities to provide services. The Enrichment Center will not claim any service outcomes unless supported by valid and reliable outcome data and/or research studies.
  2. The Enrichment Center will utilize clear and consistent methods of communicating information to individuals served, family members, thirdparty entities, referral sources, funding sources, and community members, and will exhibit sensitivity to the educational and reading levels of all persons when preparing information.
  3. The Enrichment Center will not utilize monetary rewards or gifts to any potential recipient of the Organization’s services in an attempt to entice them to enter programs.

E. Clinical Practices:

  1. Staff will adhere to all professional codes of conduct and ethical standards for his/her specified professional discipline.
  2. As part of new employee orientation, and annually there after, staff will read the Organization’s Code of Conduct.

F. Potential Conflicts of Interest:

  1. The Enrichment Center employees will not engage in outside professional activities that are incompatible or in conflict with such employees’ job duties within the Organization.
  2. Private practice, by employees, if any must be performed on the staff’s own time and outside The Enrichment Center premises. Such private practices may not be adverse to the interests and goals of The Enrichment Center.
  3. Staff will not recruit individuals served for their private practice.
  4. No staff shall engage in any other employment or activity on the Organization’s premises or to an extent that affects, or is likely to affect, his or her usefulness as an employee of the Organization.

G. Quality of Care:

  1. The Enrichment Center will provide quality behavioral health care in a manner that is appropriate, determined to be necessary, efficient, and effective.
  2. The Enrichment Center recognizes the right of individuals served to make choices about their own services, including the right to refuse services.

H. Service Delivery/Necessity of Care:

  1. The Enrichment Center shall submit claims for payment to governmental, private, or individual payers for those services or items that are necessary and appropriate.
  2. When providing services, The Enrichment Center employees shall only provide those services that are consistent with generally accepted standards for treatment and are determined by the professional to be necessary and appropriate.

I. Coding, Billing, and Accounting:

  1. The Enrichment Center employees involved in coding, billing, documentation and accounting for individuals served will comply with all applicable state and federal regulations and organizational policies and procedures.
  2. The Enrichment Center will only bill for services rendered and shall seek only the amount to which it is entitled.
  3. Supporting documentation will be prepared for all services rendered.
  4. All invoices for services must be accurately and completely submitted to the appropriate payer in accordance with applicable regulations, laws, contracts, and organizational policies and procedures. Federal and state regulations take precedence, and organizational policies and procedures must not be inconsistent those regulations.
  5. Government payers shall not be charged in excess of the provider’s usual charges.
  6. Billing and collections will be recorded in the appropriate accounts.
  7. An accurate and timely billing structure and medical records system will ensure that The Enrichment Center effectively implements and complies with required policies and procedures.
  8. The Enrichment Center when charging all individuals, for services, shall consistently and uniformly charge; except when using the sliding scale.

J. Cost Reports:

  1. The Enrichment Center will ensure that all preparation and cost reports submitted to governmental and private organizations are properly prepared and documented according to all applicable federal and state laws.
  2. All cost reports will be submitted and prepared with all costs properly classified, allocated to the correct cost centers, and supported by verifiable and auditable cost data.
  3. All cost report preparation or submission errors and mistakes will be corrected in a timely manner and, if necessary, The Enrichment Center will clarify procedures and educate employees to prevent or minimize recurrence of those errors.

K. Personal and Confidential Information:

  1. The Enrichment Center will protect personal and confidential information concerning the Organization’s system, employees, and individuals served.
  2. The Enrichment Center personnel shall not disclose confidential information unless it is at the request of the individual served and/or when authorized by law. Appropriate use of information for research purposes must be obtained with the informed consent of individuals who are the subject of the information.
  3. Confidential information will only be discussed with or disclosed to persons and entities outside the Organization through the request of the individual served.
  4. Individuals served can request, and are entitled to receive copies or summaries of their records. A fee may apply for the cost of the copies.
  5. All personnel will be familiar with all organizational policies and procedures regarding confidentiality.

L. Creation and Retention or Individuals Served and Institutional Records:

  1. Records are the property of The Enrichment Center. Personnel responsible for the preparation and retention of records shall ensure that those records are accurately prepared and maintained in a manner and location as prescribed by law and organizational policy.
  2. Employees will not knowingly create records that contain any false, fraudulent, fictitious, deceptive, or misleading information.
  3. Employees will not delete any entry from a record. Records can be amended and material added to ensure the accuracy of a record in accordance with policy and procedures. If a record is amended, it must indicate that the notation is an addition or correction, and record the actual date that the additional entry was made.
  4. Employees will not sign someone else’s signature or initials on a record.
  5. Employees shall not destroy any record of the Organization.
  6. The Organization will maintain record retention and record destruction policies and procedures consistent with federal and state requirements. Premature destruction of records could be misinterpreted as an effort to destroy evidence or hide information.

M. Government Investigation:

  1. The Enrichment Center employees shall cooperate fully with appropriately authorized governmental investigations and audits.
  2. The Enrichment Center will respond in an orderly fashion to the government’s request for information through employee interviews and documentation review.
  3. The Organization will respond to the government’s request for information in a manner that enables the Organization to protect both the Organization and individuals served interests, while cooperating fully with the investigation.
  4. When a representative from a federal or state agency contacts an Enrichment Center employee at home or at their office for information regarding the Organization or any other entity with which the Organization does business, the individual will contact the Executive Director immediately. If the Executive Director is not available, the individual will contact their direct supervisor.
  5. The Enrichment Center employees will ask to see the government representative’s identification and business card if the government representative presents in person. Otherwise, the employee should ask for the person’s name, employing organization, office, address, phone number, and identification number and then contact the person’s office to confirm his/her identity.

N. Prevention of Improper Referrals or Payments:

  1. The Enrichment Center employees will not accept, for themselves or for the Organization, anything of value in exchange for referrals of business or the referral of clients.
  2. Employees must not offer or receive any item or service of value as an incentive for the referral of business or consumers.
  3. Federal law prohibits anyone from offering anything of value to a Medicare or Medicaid consumer that is likely to influence that person’s decision to select or receive care from a particular behavioral health care provider.
  4. Development or initiation of joint ventures, partnerships, and corporations within the Organization must be reviewed and approved by The Enrichment Center Directors to ensure compliance with organizational policy and federal regulations.

O. Antitrust Regulations:

  1. The Enrichment Center will comply with all applicable federal and state antitrust laws.
  2. Employees should not agree or attempt to agree with a competitor to artificially set prices or salaries, divide markets, restrict output, or block new competitors from the market, share pricing information that is not normally available to the public, deny staff privileges to qualified practitioners, or agree to or participate with competitors in a boycott of government programs, insurance companies, or particular drugs or products.

P. Avoiding Conflicts of Interest:

  1. All Enrichment Center employees shall conduct clinical and personal business in a manner that avoids potential or actual conflicts of interests.
  2. Employees shall not use their official positions to influence an organizational decision in which they know, or have reason to know, that they have a financial interest.
  3. Employees must be knowledgeable about activities that may be an actual or potential conflict of interest. Examples of such activities may include, but are not limited to, the following:
    a) Giving or receiving gifts, gratuities, loans, or other special treatment of
    value from third parties doing business with or wishing to do business
    with the Organization. Third parties may include, but are not limited
    to, individuals served, vendors, suppliers, competitors, payers, carriers,
    and fiscal intermediaries.b)Using The Enrichment Center facilities or resources for other than
    Organization sanctioned activities.c)Using The Enrichment Center’s name to promote or sell products or
    personal services.

    d)Contracting for goods or services with family members of any
    individuals participating in or influencing the purchasing decision.

Q. External Relations:

  1. The Enrichment Center employees shall adhere to fair business practices and accurately and honestly represent themselves and the Organization’s services.
  2. The Enrichment Center employees will be honest and truthful in all marketing and advertising practices pertaining to the business practices of the Organization’s service delivery system.
  3. Vendors who contract to provide goods and services to the Organization will be selected on the basis of quality, cost effectiveness, and appropriateness for the identified task or need, in accordance with Organization policy.

R. Human Resources:

  1. The Enrichment Center prohibits discrimination in any work related decision on the basis of race, color, national origin, religion, sex, physical or mental disability, ancestry, marital status, age, sexual orientation, citizenship, or status as a covered veteran. The Organization is committed to providing equal employment opportunity in a work environment where each employee is treated with fairness, dignity, and respect.
  2. The Enrichment Center will make reasonable accommodations to the known physical and mental limitations of otherwise qualified individuals with disabilities.
  3. The Enrichment Center does not tolerate harassment or discrimination by anyone based on the diverse characteristics or cultural backgrounds of those who work for the Organization.
  4. Any form of sexual harassment is prohibited.
  5. Any form of workplace violence is prohibited.

S. Code of Conduct Procedures:

  1. All employees, and Board of Directors, as part of the Organization’s initial orientation, will review the Code of Conduct, including the procedures for investigating and acting on allegations of violations.
  2. All employees will receive a copy of the Code of Conduct, sign a form acknowledging their review and full understanding of the Code, and return the form to be filed in the employee’s personnel file.

T. Procedures for Investigating and Acting on Violations of the Code of Conduct:

  1. When any individual served, family member, authorized representative, advocate or other person believes that an ethical violation has occurred within the operations of the Organization, they should report such suspicion directly to any employee.
  2. When any employee believes a violation of the Code of Conduct has occurred, they are obligated to report the violation in one of the following ways:
    a. Immediate notification of the incident or violation through the
    Organization’s Corporate Compliance Program and reporting
    mechanisms.
    b. Immediate reporting to their supervisor or to the Corporate
    Compliance Officer if the suspected violation involves their
    supervisor.
  3. Supervisors who have been informed of a suspected violation are required to immediately inform the Corporate Compliance Officer of the suspected violation.
  4. If the violation involves a recognized threat to the safety of any individual, employees are obligated to report the alleged violation immediately to their supervisor.
  5. Staff is required to report any suspected violation of the Code of Conduct; however, they are not required to investigate or know for certain that a violation has occurred.
  6. Once the questionable behavior has been brought to the attention of the supervisor or reported through the Corporate Compliance Program’s procedures, staff reporting the situation will no longer have a responsibility for being involved with the investigation other than providing additional information as and when requested.
  7. Staff must report each suspected violation of the Code of Conduct separately, should a suspected violation that has once been reported occur again or have been suspected to have occurred again.
  8. When any suspected violation of the Code of Conduct is reported to a supervisor, program sponsor or the Corporate Compliance Officer, the Corporate Compliance Officer will begin an investigation of the matter immediately. While investigating the complaint, the following issues should be considered and action taken depending on the situation:
    a. Is any individual in any recognizable danger of harm or potential harm because of the alleged behavior?
    b. Does the complaint require immediate action to remove an employee or other person from contact with the individual served?
    c. Does the complaint put The Enrichment Center or its employee in a potentially liable situation that needs legal consultation?
  9. Code of Conduct investigations will follow the guidelines outlined in The Enrichment Center’s Corporate Compliance Policy and Procedure.

U. General Ethical Guidelines and Considerations:

  1. The Code of Conduct is shared with persons served during individual orientation and is posted throughout public areas in all owned, leased, or rented facilities.
  2. The Enrichment Center believes in the importance of ethical practices within the Organization. Any employee who reports waste, fraud, abuse or any other questionable practices will not be subject to reprisal or retaliation by the Organization. To assure that reprisal or retaliation is not used, the Organization’s governance authority will serve as advocates for any employee who reports questionable practices. The Corporate Compliance Officer will provide assurance and oversight that there are no adverse actions toward the employee.
  3. The following violations of the Code of Conduct will result in termination of employment: Theft of funds, and/or physical, emotional, or sexual harassment or abuse of an individual served or employee.

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