This code of conduct applies to all SPBHS operational activities and administrative actions, and includes those activities that come within federal and state regulations relating to health care providers. Of particular importance to SPBHS is to maintain a health care and business environment that is committed to integrity and ethical conduct, particularly in the areas of legal compliance, business ethics, confidentiality, conflict of interest, business and consumer relationships, documentation and billing practices, personnel and confidential employee information, investigation and response, discipline and evaluation, and professional ethics. Therefore, this code of conduct applies to all SPBHS employees, volunteers, trainees, interns, in the performance of work for SPBHS that is under the direct control of SPBHS. All contract providers and subcontractors that provide services directly or indirectly to persons served are expected to follow principles that promote ethical health care, and uphold the integrity of ethical business practice.
The code of conduct is intended to establish ethical standards of care and ethical business practices as a framework for SPBHS employees, volunteers, trainees, and interns in the performance of work. It is not intended to set forth all of the substantive practices that are an intricate fiber of high quality care. Each SPBHS employee, volunteer, trainee, and intern is expected to be familiar with and is obligated to adhere to the standards set forth in this Code of Conduct or incorporated by reference herein and in SPBHS policies.
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3948 Ben Walters Lane
Homer, AK 99835
Obligation of SPBHS Employees, Volunteers, Trainees, and Interns
- Each individual is obligated to conduct themselves in accordance with:
• Standards set forth in this Code of Conduct;
• Applicable federal and state laws and regulations;
• SPBHS policies, including general policies and those applicable to specific job, position or function;
• Standards of conduct incumbent upon an individual by virtue of holding state licensure or registration; and
• Ethical standards binding on an individual as a practitioner of a particular profession.
An employee who is a member of a health care profession required to be licensed or registered under the Alaska Department of Commerce, Community and Economic Development’s Division of Professional Licensing is responsible for obtaining his or her license or registration and renewals thereof on a timely basis. A health care professional shall render professional services only within the scope of his or her license or registration and in a manner that conforms to applicable standards of care and to the ethics of his or her profession. No employee that is a licensed professional is permitted to render professional services unless he or she possesses all valid, current and unrestricted state and federal licenses, registrations and certifications necessary to legally practice his or her profession and has been credentialed and privileged as provided in SPBHS policies.
Each individual is obligated to report violations and suspected violations. Any individual that becomes aware of or has reasonable grounds to suspect a violation of any of the standards above by another individual is obligated to report the violation or suspected violation by one of the following methods:
- Directly to any supervisor;
- Directly to the Compliance Officer at the following address:
Compliance Officer South Peninsula Behavioral Health (The Center):
South Peninsula Behavioral Health
3948 Ben Walters Lane Homer, AK 99603
Phone: (906) 235-9234
E-Mail: email@example.com; or
- Anonymously through the Ethics Hotline (1-907-399-9400).
All reports will be treated as confidential to the extent allowed by law, and will only be shared with others on a bona-fide need-to-know basis. Under no circumstances will SPBHS tolerate retribution against any employee or agent simply for making a “good faith” report to the Compliance Officer.
Obligations are also identified and defined in the Board approved South Peninsula Behavioral Health Services Inc. Compliance Program which has been provided to each individual staff, and is available on the web site at http://www.spbhs.org/.
Responsibility to Persons Served
Each SPBHS employee, volunteer, trainee, and intern has an affirmative obligation to:
- Treat persons served and family members with dignity and respect.
- To provide service that meets the people’s medically necessity, as identified through behavioral health assessment; and when the consumer meets the requirements for the service, the service is included in the plan of care or service.
- Not discriminate based on race, color, national origin, ancestry, religion, age, sex, marital status, physical or mental handicap by an employee, volunteer, and intern in the provision of services, including admission to and discharge from services or discrimination is prohibited.
- Provide persons served and families with all information concerning services and treatment when and to the extent required by applicable Federal and State laws and regulations and/or by sound clinical practice.
- Protect individually identifiable health information from unauthorized use or disclosure except as required or permitted by law.
- Report suspected abuse and neglect as required by law.
- Protect peoples’ rights and furnish services in a manner that does not violate their legal rights as defined in AS 47:30.
- Not have relationships of a sexual nature of any kind with a person served. Relationships of a sexual nature with a consumer are prohibited. (See attachment A for additional clarification.)
- Not engage in or permit any third party to engage in studies, surveys or clinical investigations involving persons served or their personally identifying information (collectively, “research”) without the prior written approval of the Department of Health and Human Services Institutional Review Board. All research must be conducted in compliance with all applicable Federal and State laws and regulations, in accordance with applicable professional ethics, and with due respect for the legal rights of affected persons served.
Financial Standards – All financial information must reflect actual transactions and conform to generally acceptable accounting principles. No undisclosed or unrecorded funds or assets may be established. Transactions must be authorized, recorded and documented as provided by law and SPBHS policy.
Kickbacks – Each SPBHS employee, volunteer, trainee, and intern is prohibited from offering, soliciting, or accepting money or anything else of value from an SPBHS vendor or provider except as provided herein. (See attachment B for additional clarification.)
An employee, volunteer, trainee, and intern may share in a gift of goods or services from a vendor or provider if, and only if:
- The gift consists of goods delivered to SPBHS premises;
- Is used or consumed on the premises;
- The gift is not intended for the personal use or benefit of specific individuals;
- The gift does not violate federal and state laws and regulations that prohibit soliciting or accepting anything of value in exchange for influencing a purchase of goods or services or the referral of consumers for services.
Marketing and Media – SPBHS news releases, marketing campaigns and advertising materials shall not be deceptive or misleading by omission or commission.
Market Competition – To ensure compliance, SPBHS policy and business practices prohibit setting charges in collusion with competitors and entering into certain exclusive arrangements with vendors. Additional information concerning antitrust issues can be obtained from the Compliance Officer.
Outside Employment – SPBHS employees shall not represent or act as an agent, compensated or uncompensated, for any outside interest in any transaction in which SPBHS has a direct or substantial interest, pecuniary or otherwise. Nor shall any employee accept any outside engagement or employment the pursuit of which conflicts with the ability of the employee to discharge properly his or her duties to SPBHS. Outside employment shall be disclosed to and approved as defined in the SPBHS policies.
Procurement – Vendors of goods and services shall be selected based on objective criteria including quality, technical excellence, price, delivery, and adherence to schedules, service, and maintenance of adequate sources of supply. Where required by law or contract, procurement shall be by competitive bid. Where procurement is by secret bid, no employee, volunteer, trainee, or intern shall directly or indirectly disclose any information to any bidder or potential bidder if such disclosure would confer or tend to confer any competitive advantage.
Trading on Inside Information – SPBHS employees may not engage in or retain the profits of any private activity, business or transaction arising out of or in any way related to information acquired in the course and scope of their employment or other relationship with SPBHS.
Improper Referrals – Referrals of consumers for services outside SPBHS are important to the delivery of proper care to persons served. If a referring health care professional or a member of his or her immediate family has an ownership or financial interest in an entity to which a consumer is referred, and payment for the referred services will be made by any federally-funded health care program (e.g., Medicare, Medicaid), federal and state laws may forbid the referral. No employee may make a referral in violation of such laws. Additional information concerning referral restrictions can be obtained from the Compliance Officer.
Billing and Claims – SPBHS is committed to charging, billing and submitting claims for reimbursement only when the services have been provided and documented in the manner required by laws, regulations, policies and applicable standards of care. All employees should know and carefully follow the applicable rules for submission of bills and claims for reimbursement, whether those claims are submitted to SPBHS for payment or to a third party for payment by SPBHS. Any employee that knows or suspects that a bill or claim for reimbursement is incorrect is required to report the matter immediately to a supervisor or to the Compliance Officer.
Identifying and Confidential Information – Except as otherwise required by law, identifying and confidential information on persons served shall not be released without an appropriately signed “Authorization to Disclose Confidential Information” or official judge’s court order.
Disclosure of Business and Personnel Information – Except as otherwise required by law (e.g. the Freedom of Information Act), personnel information and business information about the operations of SPBHS acquired by a employees, volunteers, trainees, or interns from any source shall be disclosed within SPBHS only on a need to know basis and solely for purposes related to the performance of job duties. Such information may be disclosed outside the agency only as permitted or required by law and SPBHS policy.
Workplace Conduct and Employment Practices
Employment Discrimination – SPBHS and its employees, volunteers, trainees, interns shall abide by any and all applicable federal and/or state equal opportunity statutes, rules, and regulations including, without limitation, Title VII of the Civil Rights Act of 1964, the Equal Employment Opportunity Act of 1972, the Age Discrimination in Employment Act, the Fair Labor Standards Act, the Americans with Disability Act, the Rehabilitation Act of 1973, and the Occupational Health and Safety Act of 1970, all as may from time to time be modified or amended.
Controlled Substances – SPBHS prohibits the consumption of alcohol and the unlawful possession, use, manufacture or distribution of illicit drugs or alcohol on or in its property, including SPBHS owned or leased vehicles. In addition, no employee, volunteer, trainee, intern shall consume alcohol or be under the influence of illicit drugs or alcohol while acting in the course and scope of his or her employment or while operating a SPBHS vehicle. All health care professionals, including those who maintain DEA registration, must comply with all Federal and State laws regulating controlled substances. An employee, volunteer, trainee, intern who knows or suspects the consumption, unlawful or unauthorized possession, use, manufacture or distribution of illicit drugs or alcohol by another employee, volunteer, trainee, intern in violation of this paragraph must promptly notify his or her supervisor or the Compliance Officer.
Harassment – Unlawful harassment is any unwelcome conduct, whether verbal, physical or visual, that is based on a person’s race, color, religion, sex, age, national origin, height, weight, marital status, veteran status or disability or any other legally protected characteristic.
Sexual Harassment – Sexual harassment is prohibited. Sexual harassment consists of unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature when submission to or rejection of such conduct explicitly or implicitly affects an individual’s employment, interferes with an individual’s work performance or creates an intimidating, hostile or offensive work environment.
Weapons – In order to ensure a safe environment for employees and clients, The Center prohibits the wearing, transporting, storage or presence of firearms or other dangerous weapons in facilities either owned or staffed by The Center. Any employee in possession of a firearm or other weapon while in Center facilities or while fulfilling job responsibilities may face disciplinary action, up to and including termination. Under no circumstances can an employee transporting a client carry any weapon in their own vehicle or a Center- owned vehicle.
A client or visitor who violates this policy may be removed from the property and reported to police authorities. Possession of a valid concealed weapons permit authorized by the State of Alaska is not an exemption. “No Firearms or Other Dangerous Weapons” signs are conspicuously posted on the main entry doors of all Center facilities. This prohibition does not apply to any law enforcement personnel engaged in official duties or required to carry their weapon. Weapons include, but are not limited to, guns, swords, knives with blades over 4 inches in length or explosives.
Personal Use of SPBHS Resources – Except as provided herein, an employee, volunteer, trainee, intern’s use of SPBHS property, equipment or other tangible assets for personal purposes without the prior written approval of the employee, volunteer, trainee, intern’s supervisor is prohibited. The occasional personal use of SPBHS property, equipment and tangible assets (e.g., making local phone calls and sending personal e-mail over organization communications equipment) is acceptable where SPBHS incurs no direct expense in connection with such personal use. Employees, volunteers, trainees, interns may not contribute SPBHS funds or property to any charity without prior written authorization of the CEO or his or her designee.
Nepotism – An employee, volunteer, trainee, intern shall not advocate a relative for appointment, employment, promotion, or advancement. An employee, volunteer, trainee, intern shall not appoint, employ, promote, or advance a relative to any position over which he or she has supervisory responsibility. For the purpose of this section, the term “relative” means an individual related to the employee by blood or marriage. For the purpose of this section, the term “advocate” means the referral or recommendation of a relative to a employee, volunteer, trainee, intern standing lower in the same chain of command for appointment, employment, promotion, or advancement.
Political Activities and Contributions – An employee, volunteer, trainee, or intern may not directly or indirectly contribute SPBHS property, equipment, funds, resources or other tangible or intangible assets or the use thereof to political campaigns, candidates, political parties or any agent or affiliate thereof. Prohibited conduct includes, but is not limited to, the use of work time and/or SPBHS equipment to solicit or canvas on behalf of a political cause or candidate. No employee, volunteer, trainee, intern shall publicly or privately represent his or her political views as those of the SPBHS.