Organizational Code of Conduct

II. PROCEDURES

1. Professional Conduct:
   1. Personnel will respect the rights of persons served by demonstrating full integration of the guidelines contained in the Rights and Responsibility Policy. This includes the right of the consumer to make autonomous decisions and fully participate in every aspect of the service delivery process.
   2. Personnel will provide services in a manner that fully respects the confidentiality of consumers, by demonstrating a functional knowledge of confidentiality policies and guidelines.
   3. Personnel will be fair and honest in their work. They will not exploit, mislead, or violate the rights of persons served.  All personnel will be faithful to their contractual obligations, professional boundaries, corporate responsibilities, and their word.
   4. To prevent and avoid unethical conduct, personnel will consult with, refer to, and participate in supervision or treatment team meetings with other professionals.
   5. Personnel will clarify their professional role or license details, training and experience, and treatment obligations, and be accountable for upholding professional standards of practice.
      
2. Personal/Professional Conduct and Personal Property
   1. All prior personal relationships between staff and persons engaging in services shall be disclosed by personnel and may be subject to review by the appropriate supervisor.
   2. Personnel will limit relationships with persons served to their defined professional roles.
   3. Personnel will not establish ongoing personal or business relationships with consumers receiving services.
   4. Personnel will conduct themselves in a professional, ethical, and moral manner based on the values of the organization.
   5. Sexual relationships between personnel and persons served are never appropriate. Sexual relationships include, but are not limited to the following: engaging in any type of sexual activity, flirting, advances and/or propositions of a sexual nature, comments of a sexual nature about an individual’s body, clothing, or lewd sexually suggestive comments.
   6. Personnel will not accept gifts of value from a consumer, family member, or stakeholder, and cannot accept personal favors or benefits that may be reasonably construed as influencing their conduct or creating an imbalance of power.
   7. Personnel will not take, borrow or remove agency property or personal property not belonging to them from the agency without the permission of the property owner.
   8. Personnel will not solicit persons served for personal causes including but not limited to soliciting funds for a personal or community cause, political fundraising, selling candy and cookies for their children, friends’ children, or other such fundraising items for the personnel’s children.
   9. Life Recovery Center does not engage in any type of fundraising.
   10. Personnel involved with clinical care will not serve as a witness of any document for that client including but not limited to the power of attorney, advance directives, or guardianship. 
   11. When peer support specialists are utilized to deliver services, additional guidelines are identified to support the unique role of these service providers.
   12. Peer support specialists should implement their roles and responsibilities within the behavioral constraints of the organization’s policies and procedures.
   13.  Peer support specialists should refrain from developing relationships other than that found in peer recovery coaching. These relationships may include advocacy for the person served with other treatment providers; sharing meals; attending social events; and communications with persons served (electronic and other).
   14. Peer support specialists should openly share their recovery stories with persons served and use those experiences to support persons served to achieve their own recovery.
   15. Peer support specialists should be able to articulate what constitutes taking too much responsibility for the person’s served recovery.
   16. Peer support specialists should devote a similar amount of time and effort to each person served while also being aware of the possibility of exceptions when necessary (e.g., a person in crisis).
   17. Peer support specialists will not enter dual relationships or commitments that conflict with the interests of the persons served.
   18. All personnel shall respect and safeguard the personal property of clients, visitors, and other personnel as well as the property of LRC.
   19. Employees will not use or allow the use of LRC property or equipment for other than activities approved by the organization.
   20. Theft and destruction of property may be addressed through treatment planning (clients), disciplinary action (personnel), and/or by contacting law enforcement, as appropriate.
   21. LRC is not responsible for personal property that is not safeguarded or left unattended.
       
3. Business Practices
   1. Life Recovery Center will utilize the Corporate Compliance Officer (or designated staff) to ensure that it conducts business in an ethical manner and ensure that any business practices that are questionable are thoroughly investigated utilizing the investigation procedures outlined below. 
   2. All financial practices, facility development, information technology, advocacy efforts, corporate citizenship, and data collection and management practices shall comply with local, state, and federal laws and guidelines.  They will align with standard operations for the field.
   3. All personnel shall adhere to Life Recovery Center’s Workforce Development and Management Policies and Procedures.
      
4. Marketing Practices
   1. Life Recovery Center will conduct marketing practices in an honest and factual manner. Marketing materials and practices will in no way mislead the public or misrepresent Life Recovery Center’s services, providers, contracts, or capabilities.
   2. Life Recovery Center will not claim any service outcomes unless represented by reliable data collection methods and valid research results.
   3. Life Recovery Center will utilize clear and consistent methods of communicating information to consumers, family members, third-party entities, referral sources, funding sources, and community members, and will exhibit sensitivity to educational and cultural considerations when distributing information.
   4. Life Recovery Center will not utilize monetary rewards or gifts to any potential consumer of services in an attempt to entice them to enter programs.
      
5. Clinical Practices
   1. Personnel will adhere to all professional codes of conduct and ethical standards for specified professional discipline as well as any other professional certification or job description.
   2. Professional boundaries are to be utilized in all business related to the organization.
   3. As part of orientation, personnel, and other stakeholders will read the Ethical Codes of Conduct and demonstrate knowledge of the guidelines as evidenced by proper administrative documentation, following policies and procedures, participation in training or continuing education for organization and professional requirements, and conformance to the clinical standards.
      
6. Quality of Care
   1. Life Recovery Center will provide quality behavioral health care in a manner that is appropriate, determined to be necessary, efficient, and effective.
   2. Healthcare professionals will follow current ethical standards regarding communication with consumers (and their representatives) regarding services provided.
   3. Life Recovery Center will inform consumers about alternatives and risks associated with the care they are seeking and obtain informed consent prior to any clinical interventions.
   4. Life Recovery Center recognizes the right of consumers to make choices about their own care, including the right to go without recommended care or to refuse care.
      
7. Necessity of Care
   1. Life Recovery Center shall submit claims for payment to governmental, private, or individual payers for those services or items that are clinically necessary and appropriate.
   2. When providing services, Life Recovery Center personnel shall only provide those services that are consistent with generally accepted standards for treatment and are determined by the professional to be clinically necessary and appropriate.
   3. Service providers may determine that services are clinically necessary or appropriate; however, the funding source may not cover or approve those services. In such a case, the consumer may request the submission of a claim for the services to protect their rights with respect to those services or to determine the extent of coverage provided by the payer.
   4. Coding and documentation will be consistent with the standards and practices defined by the organization in its policy, procedures, and guidelines.
      
8. Coding, Billing, and Accounting
   1. Life Recovery Center personnel involved in coding, billing, documentation and accounting for consumer care services for governmental, private or individual payers will comply with all applicable state and federal regulations and organizational policies and procedures. Training will be provided as needed.
   2. Life Recovery Center will only bill for services rendered and shall seek the amount to which is contracted.
   3. Supporting clinical documentation will be prepared for all services rendered. If the appropriate and required documentation has not been provided, then the service has not been rendered.
   4. All services must be accurately and completely coded and 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 reflect those regulations.
   5. If a billing or coding error occurs, documentation must be logged and properly corrected. Appropriate documentation will be reported to the proper authority and action will be taken according to corporate compliance standards.
   6. Consumers shall be consistently and uniformly charged, and government payers shall not be charged more than the provider’s usual charges.
   7. Billing and collections will be recorded in the appropriated accounts and proper review will occur.
   8. An accurate and timely billing structure and medical records system will ensure that Life Recovery Center effectively implements and complies with required policies and procedures.
      
9. Cost Reports
   1. Designated staff 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, clarify procedures and educate personnel to prevent or minimize the recurrence of those errors.
      
10. Personal and Confidential Information
    1. Life Recovery Center will protect personal and confidential information concerning the organization’s system, personnel, and consumers.
    2. Life Recovery Center personnel shall not disclose confidential consumer information unless at the consumer’s request and/or when authorized by law. Appropriate consent for the use of consumer information for research purposes must be obtained with full disclosure regarding research purpose and use.
    3. Confidential information will only be discussed with or disclosed to persons and entities outside the organization at the request of the consumer. Third-party disclosures are not allowed. Persons outside the organization include the family, business, or social acquaintances of the consumer.
    4. Consumers can request and are entitled to receive copies or summaries of their records except for minors and consumers being treated for alcohol and drug abuse, who may be provided with copies of their records if it is judged appropriate by the provider charged with their care.
    5. Personnel will be familiar with all organizational policies and procedures regarding confidentiality, record keeping, and traveling with documentation, as appropriate.
       
11. Creation and Retention of Records
    1. All records are the property of the organization. Personnel shall not destroy or remove records from the premises.
    2. Respective staff responsible for the preparation of records shall ensure they are accurately prepared, maintained in a lawful manner, and reside in a location as prescribed by law and policy.
    3. Personnel will not knowingly create records that contain any false, fraudulent, fictitious, deceptive, or misleading information. Personnel will not sign someone else’s signature or initials on a record. Appropriate clinical language and documentation is always to be used.
    4. Personnel 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 document the actual date the additional entry was made.
    5. The organization maintains record retention and 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.
       
12. Government Investigation
    1. Life Recovery Center personnel shall cooperate fully with appropriately authorized governmental investigations and audits.
    2. Life Recovery Center will respond in an orderly fashion to the government’s request for information through interviews and documentation review.
    3. Life Recovery Center will respond to the government’s request for information in a manner that enables the organization to protect both the organization’s and consumer’s interests while cooperating fully with the investigation.
    4. When a representative from a federal or state agency contacts Life Recovery Center personnel 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 CEO immediately. If the CEO is not available, the individual will contact the next appropriate staff member.
    5. Life Recovery Center personnel will ask to see the government representative’s identification and business card if the government representative presents in person. Otherwise, personnel should ask for the person’s name, office, address, phone number, and identification number and then contact the person’s office to confirm identity.
       
13. Prevention of Improper Referrals or Payments
    1. Personnel will not accept, for themselves or for the organization, anything of value in exchange for referrals of business or the referral of consumers.
    2. Personnel will not offer, for themselves or for the organization, anything of value in exchange for referrals of business or the referral of 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 behavioral health care provider.
    4. The organization shall establish procedures for the review of all pricing and discounting decisions to ensure that appropriate factors have been considered and that the basis for such arrangements are documented.
    5. Development or initiation of joint ventures, partnerships, and corporations within the organization must be reviewed and approved by appropriate management to ensure compliance with organizational policy and federal regulations.
       
14. Antitrust Regulations
    1. Personnel will comply with all applicable federal and state antitrust laws.
    2. Personnel shall not agree with a competitor to artificially set prices or salaries, divide markets, restrict service output, block new competitors from the market, or share pricing information that is not normally available to the public.
    3. Personnel shall not deny privileges to qualified practitioners or agree to participate with competitors in a boycott of government programs, insurance companies, pharmaceutical drugs, or other products.
       
15. Potential Conflicts of Interest
    1. Persons served will not be hired or allowed to engage in a business relationship with Life Recovery Center while they are active participants in the program.
    2. Life Recovery Center personnel will not engage in outside Behavioral Health Services that are incompatible or in conflict with job duties or values of the organization to the extent that their performance is impacting the identified and agreed upon job description or role.  Disclosure about other interests is to be made and documented in the personnel file.
    3. Private practice shall be done on the personnel’s own time, outside of the organization, and meet ethical and professional standards of practice. 
    4. The private practice activities must not be averse to the interests, goals, and values of Life Recovery Center. Disclosure is to be made and documented in the personnel file.
    5. Personnel will not recruit clients for their private practice within their professional roles as Life Recovery Center personnel.
    6. If personnel ends the relationship with Life Recovery Center and enters another practice, the consumer must be informed of their rights to choose what or how the service continues.  The person served may choose to continue their therapy with former staff. However, the services must be offered with equal accessibility and persons served must be made aware of their rights to be referred to another provider or decline services.
       
16. Avoiding Conflicts of Interest
    1. All personnel shall conduct clinical and personal business in a manner that avoids potential or actual conflicts of interests.
    2. Personnel 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. If there is a known conflict of interest, written disclosure must be made during the onboarding process or as soon as possible after becoming aware. Discussion will occur with appropriate staff members to determine a plan of action, if necessary.
    4. Personnel 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:
    5. 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, consumers, vendors, suppliers, competitors, payers, carriers, and fiscal intermediaries.
    6. Using facilities, resources, or other confidential and private information for reasons other than organization-sanctioned activities or for one’s own gain.
    7. Using Life Recovery Center’s name to promote self inappropriately, sell products, or sell personal services.
    8. Contracting or entering an employment relationship for goods or services with those directly involved in purchasing decisions. This could result in preferential treatment of an individual or entity.
    9. Contracting or entering an employment relationship with a competing interest.
       
17. External Relations
    1. Personnel shall adhere to fair business practices and accurately and honestly represent themselves and the organization’s services.
    2. Personnel 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 based on quality, cost-effectiveness, appropriateness for the identified task or need, and conform to the organization’s policies, procedures, and standards of operation.
    4. Life Recovery Center shall engage in advocacy and corporate citizenship efforts to reduce stigma in the community. Additionally, conformance to utilizing person-centered or “people first” language is evident in our publications, operations, and activities. Life Recovery Center will document participation in advocacy and corporate citizenship by utilizing meeting logs, meeting notes, or other publications.
    5. Life Recovery Center is a member of the following community organizations and/or provides the following type of community services: ICAADA, IPGAP, ICPG, ICADV, and POPAI.
    6. It is with this involvement and participation that Life Recovery Center hopes to reduce and eliminate the stigma often associated with Behavioral Health or other supportive services.
       
18. Workforce Development and Management
    1. Discrimination is prohibited in any work-related decision based on 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 opportunities in a work environment where personnel are treated with fairness, dignity, and respect.
    2. Life Recovery Center will make reasonable accommodations to the known physical, mental, or cultural implications of otherwise qualified individuals with disabilities.
    3. Life Recovery Center does not tolerate harassment or discrimination by anyone based on the diverse characteristics or cultural backgrounds of those who work for the organization pursuant to the organization’s affirmative action policy.
    4. Any form of sexual harassment, workplace violence, and inappropriate professional responsibility is prohibited.
       
19. Code of Conduct Procedures
    1. All personnel, students, volunteers, and governing authority members, as part of the organization’s orientation and onboarding process, will review the Code of Conduct, including the procedures for investigating and acting on alleged ethical or conduct violations.
    2. All personnel 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 individual’s personnel file.
    3. To ensure awareness of ethical practices, review, and continued education will be conducted annually for personnel and other stakeholders.
       
20. Procedures for Investigating and Acting on Suspected or Alleged Ethical Violations
    When any consumer, family member, authorized representative, advocate, or other person believes that an ethical violation has occurred within the facility’s operations, they may report such suspicion directly to any staff member or management.
    When personnel believe a Code of Conduct violation has occurred they are obligated to report it in one of the following ways:
    1. Immediate notification of the alleged incident or violation utilizing the corporate compliance program and reporting mechanisms.
    2. Immediate reporting to their supervisor or corporate compliance officer if the suspected or alleged violation involves their supervisor.
    3. Supervisors who have been informed of a suspected or alleged violation must immediately inform the corporate compliance officer (or designated staff member) of the suspected violation.
    4. If the alleged violation involves a direct and immediate threat to the safety of persons served, personnel, or other visitors, staff must report it immediately to their supervisor and follow appropriate safety procedures, if necessary.
    5. Personnel are required to report any alleged or suspected Code of Conduct violation that they have knowledge of.  However, they are not required to investigate reported violations or follow up with results. That process will be completed by a designated compliance staff member.
    6. Once the alleged violation has been brought to the attention of the supervisor or reported through the corporate compliance procedures, the person reporting the situation will no longer have a responsibility for being involved with the investigation other than providing additional information through a requested interview by the investigator.
    7. Personnel must report each alleged or suspected violation of the Code of Conduct separately, should a violation that has been reported occur again.
    
    When any suspected or alleged violation of the Code of Conduct is reported to a supervisor, the corporate compliance officer or the designated person 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:
    1. Is any client or personnel in any harm or potential harm because of this behavior?
    2. Does the complaint require immediate action to restrict personnel from contacting clients or other persons?
    3. Does the complaint put Life Recovery Center in a potentially liable situation that needs legal consultation?
    4. Code of Conduct investigations and timelines will follow the guidelines outlined in the Life Recovery Center Corporate Compliance Policy and Procedure.
    
21. General Ethical Guidelines and Considerations
    1. The Code of Conduct is shared with persons served during orientation and is posted throughout public areas in all owned, leased, or rented facilities.
    2. Life Recovery Center believes in the importance of ethical practices within the organization. Any personnel who report waste, fraud, abuse, or any other questionable practices will not be subject to reprisal by the management of the organization. To assure that reprisal is not used, the managing staff will serve as advocates for personnel who report questionable practices. The Corporate Compliance Officer (or designated person) will provide assurance and oversight that there are no adverse actions toward person reporting.
    3. The following violations of the Code of Conduct will result in termination of employment: Theft of funds, and/or physical, emotional, or sexual abuse of client or other personnel.
       
22. Media Relations Procedures
    1. All personnel will receive a copy of the organization’s Media Policy, sign a form acknowledging their review and full understanding of the policy, and return the form to be filed in the individual’s personnel file. To ensure the quality and consistency of information disseminated to media sources, the following policy shall be enforced:
    2. All media inquiries are to be handled by an Executive Director or their designee, regardless of who the media representative is, whom they represent, or how innocuous the request is.
    3. All press releases or other promotional materials are to be approved by the Executive Director or their designee prior to dissemination.
    4. Failure to comply with Life Recovery Center’s media policy shall be grounds for disciplinary action up to and including termination of employment.
       
23. Use of Social Media
    Life Recovery Center respects the right of employees to use social media forums for self-publishing and self-expression on personal time. However, unless specifically authorized by the company to do so as part of an employee’s position, employees are not permitted to use forms of social media or technology on the Internet during working hours or at any time on company computers or other company-supplied devices. Employees are expected to follow the guidelines and policies set forth below to provide a clear line between you as the individual and you as the employee:
    1. You are personally responsible for your commentary. You can be held personally liable for commentary that is considered defamatory, obscene, proprietary, or libelous by any offended party. 
    2. You cannot use employer-owned equipment, including computers, company-licensed software or other electronic equipment, nor facilities or company time, to conduct personal communication. 
    3. You cannot harass, threaten, discriminate, or disparage employees or anyone associated with or doing business with Life Recovery Center. 
    4. If you choose to identify yourself as a Life Recovery Center employee, please understand that some readers may view you as a spokesperson for Life Recovery Center.
    5. You cannot post the name, trademark, or logo of the company or any company-privileged information, including copyrighted information or company-issued documents. 
    6. You cannot post photographs of other employees, clients, vendors, suppliers, or company products, nor can employees post photographs of persons engaged in Life Recovery Center business or at company-sponsored events. 
    7. You are to contact management immediately if contacted by the media or press about any post that relates to Life Recovery Center business. 
    8. Violations of any of the guidelines listed in this policy will be subject to corrective counseling and may result in disciplinary action, up to and including termination. 
    9. Where necessary, the company will advise appropriate officials of any violations of law. If you become aware of any violations of this policy, you should report the violation to your supervisor or the Human Resources Department. 
    10. Please note that nothing in this policy, or any other policy in this handbook, does or is intended to prohibit employees from engaging in conduct that is protected by the National Labor Relations Act, such as discussing terms and conditions of employment.
        
24. Speaking Engagements and Public Relations
    To ensure the quality and consistency of information disseminated to the public, the following policy shall be enforced:
    1. All requests for public and private speaking engagements, panel discussions, professional presentations, and other such events are to be handled by an Executive Director or their designee, regardless of who the media representative is, whom they represent, or how innocuous the request.
    2. All promotional and/or educational materials are to be approved by an Executive Director or their designee prior to dissemination.
    3. Should an employee receive a request to be part of a public or private speaking engagement, panel discussion, professional presentation, or other events, they should immediately direct the inquiring party to speak with an Executive Director. 
    4. Failure to comply with Life Recovery Center’s media policy shall be grounds for disciplinary action up to and including termination of employment.
       
25. Contractual RelationshipsContractual Relationships
    1. The agency may contract with an individual to perform specific tasks at an hourly rate or project cost. Individuals under contract are not considered agency staff, and proper credentials and proof of insurance, as appropriate, are required.
    2. The agency may request verification of licensure, certification, accreditation, and/or insurance coverage.
    3. Contractual agreements must be approved and signed by the Executive Director.
    4. A contractor’s relationship to LRC is that of an independent contractor, and no benefits, whether fringe benefits or other types of benefits, will be provided because of the contractual agreement.
    5. The staff of LRC who may work with an independent contractor are encouraged to report any suspected abuse, neglect, waste, or wrongdoing by the independent contractor to their supervisor or Program Director.
       
26. Witnessing of Documents
    1. Employees who are certified as Notary Publics may witness documents such as Power of Attorney, guardianship, advance directives, and/or agency contacts for clients, personnel, and other stakeholders in accordance with applicable state laws.
    2. The person who witnesses a document should be neutral and have no financial or other interest involved.