Introduction:

Columbia Community Mental Health [CCMH] is committed to clinical and service excellence, guided by appropriate ethical standards and applicable laws and regulations. This Code of Conduct provides guidance to all CCMH employees, contractors, trainees and volunteers (CCMH Workforce Members or “Members”) and assists us in carrying out our daily activities with a high standard of ethical behavior and integrity. The code is not intended to be all-inclusive and we rely upon your sense of fairness, honesty and integrity to meet the challenges you may face in providing quality health care. If you are unclear about how these principles apply to a specific activity, you should discuss this with your supervisor, manager, or the Compliance Officer.

While all CCMH Workforce Members are obligated to follow the Code of Conduct, our managers and supervisors have a special responsibility to ensure that those on their team have sufficient information to comply with laws, regulations, and policies. They must help to foster a culture within Columbia Community Mental Health that promotes the highest standards of ethics and compliance and which specifically encourages everyone in the organization to ask questions and raise concerns when they arise.

Compliance with Applicable Laws: CCMH Workforce Members will comply with all applicable rules, laws and regulations, and be knowledgeable about which of these apply to specific areas of responsibility. Members will be proactive in seeking out knowledge of relevant laws and policies, and will attend trainings as scheduled. These legal obligations include, but are not limited to:

Confidentiality of Information:

Environmental Health and Safety:

Employment Practices:

Job-Specific Laws and Regulations:

Conflict of Interest: A conflict of interest occurs when personal interests could interfere with a Member’s ability to make a fair, objective decision on behalf of CCMH or the people we serve. In addition to following specific CCMH policies that address Conflicts of Interest and Dual Relationships, CCMH Workforce Members will report to their supervisor any situation that arises which could lead to a potential conflict of interest or dual relationship. The key to managing a potential conflict of interest is transparency.

In the event that a situation falls outside of the scope of current CCMH policies, the following factors will be used by supervisors and managers to evaluate the potential conflict of interest:

  • Does the situation have the potential to interfere with the judgment or job duties of the CCMH Workforce Member?
  • Does the situation have the potential to cause harm to CCMH, or to any individual receiving services from CCMH?

If any of these factors are present, risk-reduction strategies will be implemented to avoid an adverse outcome. If the risk cannot be satisfactorily managed through other mechanisms, the Member may be asked to take appropriate actions to remove themselves from the situation which has generated the potential conflict of interest and/or dual relationship. The reported potential conflict of interest, and any strategies that will be implemented to avoid an adverse outcome, will be documented in writing and kept on file in the Compliance Officer’s office.

Responsibilities to Consumers: All CCMH Workforce Members will adhere to the policies and procedures of CCMH including Client Rights, Client Services, Protection and Use of Confidential Information, Acceptance of Gifts Policy, Charity Care Policy, Dual Relationship Policy, and the CCMH Mission and Values Statement.

Professional Standards of Behavior: CCMH Workforce Members are expected to treat clients, co-workers, and community members with dignity and respect. When disagreements arise, Members will seek assistance from their supervisor or manager in order to resolve them, if needed. Members will not engage in activities involving retaliation, harassment, exploitation, or other forms of mistreatment toward co-workers, clients, or community members.

Clinical Services: CCMH Workforce Members will provide clinical services which are within their scope of practice, and in compliance with state and federal rules, consistent with CCMH Policies and Procedures, and guided by the rules and Code of Ethics for the Member’s profession or licensing board, when applicable. In addition, Members who provide clinical services will strive for excellence in completing clear, legible clinical documentation which accurately reflects the services that were provided. Deliberate falsification of clinical documentation is not only ethically wrong, but can also lead to criminal and civil liability for the Workforce Member and for CCMH.

Billing and Collection Practices: Throughout the billing and collections process, CCMH Workforce Members will adhere to CCMH Billing and Collections Policies and Procedures, as well as state and federal laws, third-party contracts, and payer agreements as these relate to the performance of their duties. Failure to abide by billing, coding, and collection regulations is not only ethically wrong, but can lead to criminal and civil liability for the Workforce Member and for CCMH.

Business Ethics: CCMH Workforce Members will demonstrate integrity in their business practices in order to instill and preserve trust on the part of our clients and business partners.

Among these practices are:

Audits and Monitoring: All CCMH Workforce Members will cooperate fully and honestly with internal audits and monitoring programs, and with state and federal program reviews, in order to assure compliance with regulatory policies.

Non-Compliance with the Code of Conduct: CCMH Workforce Members are expected to adhere to the principles of the Code of Conduct. All efforts will be made to train Members in the policies, procedures and laws that provide the basis of the elements of the Code and to support their efforts to provide caring, efficient and effective services. When in doubt about what constitutes compliance with the Code of Conduct or the CCMH Ethics and Compliance Plan, Members should consult with their supervisor, manager, or the Compliance Officer.

When a Member does not adhere to the Code of Conduct, depending on the circumstances, sanctions and progressive discipline, up to and including loss of job or termination of contract, will be applied.

The following are some examples of grounds for immediate termination:

Identifying and Reporting Compliance Issues:

  • All Members are expected to review and understand the Code of Conduct, including the possible consequences for failure to comply or failure to report non-compliance, which is itself a violation of the Code.
  • CCMH will document all reports of alleged noncompliance. Any CCMH Workforce Members who reports concerns in good faith is protected by CCMH policy and federal and state law from discrimination, harassment and retaliation by Columbia Community Mental Health. No Member will be penalized as the result of making a good faith report, whether the alleged activity is verified or not. Compliance issues can be reported to a supervisor, a manager, or to the CCMH Compliance Officer.
  • Compliance Improvement Hotline: Columbia Community Mental Health has established a Compliance Improvement Hotline to provide a mechanism, outside of the line of command, for those times when a Member prefers not to, or is unable to, approach a supervisor with a concern. The caller may use the hotline anonymously. Callers are assured that no harassment or other retribution by CCMH will occur as a result of a good-faith report to the hotline. This hotline is intended to be used to report activity/conduct that may be in violation of the Code of Conduct, including, but not limited to:
    • Billing or reimbursement regulations; fraudulent transactions
    • Conflict of Interest
    • Falsification of documents or documentation irregularities

The Compliance Improvement Hotline:

503-438-2242

To report a concern, you may also contact the Compliance Officer directly:

Ginger R. Bandeen, CCMH Compliance Officer

(503) 397-5211, ext 254

GingerB@ccmh1.com

P. O. Box 1234, St. Helens, OR 97051

Revised September, 2010