Director of Corporate Compliance & Quality Assurance
518-747-2284 ext. 253
CORPORATE COMPLIANCE PROGRAM OVERVIEW
This gives an overview of the Corporate Compliance Program at WWAMH. Click the link below for the full overview.
NOTICE OF PRIVACY PRACTICES
Describes how medical information about you may be used and how you can get access to this information.
The Compliance Hotline is confidential and anonymous. It is available 24 Hours a day, 7 Days a Week. Toll-Free Telephone:
CODE OF CONDUCT
The Mission of Warren Washington Association for Mental Health (sometimes referred to as “WWAMH” or “the Agency”) is to improve the quality of life for those affected by mental illness and to promote the awareness and importance of mental well being in the community.
- We will operate in a client-centered manner with respect for the individual’s rights to self-determination and self-expression.
- We will treat individuals with respect and with recognition of their human dignity and we will strive to dismantle barriers between providers and recipients of services.
- We believe in the ability of individuals to improve and grow when positive conditions for growth are created.
- We will work in active partnership with recipients of services as well as with families and other agencies and organizations.
- We will provide services and develop environments that help mediate stress and reduce the incidence of psychiatric crisis and need for hospitalization by improving the quality of life of people in the community through meaningful treatment and community support programs.
- We will work to expand the resources available to individuals and opportunities for personal development and growth.
- We will work to educate the public and the legislators as to the legitimate needs and rights of people with psychiatric disorders or problems as well as to the real nature of mental illness, the efficiency of treatment, and the importance of mental health to society.
WWAMH’s Code of Conduct applies to all employees, volunteers, interns, Board Members, and independent contractors. The Code of Conduct was approved by WWAMH’s Board of Directors and is a formal statement of WWAMH’s commitment to the standards and rules of ethical conduct.
WWAMH is committed to providing safe and respectful environments that support the health and well-being of all people receiving our services. WWAMH seeks to institute guidelines and resources for staff and enforce zero tolerance for those actions which may jeopardize the health, safety or welfare of any person receiving services.
The Code of Conduct outlines expectations for staff to exercise safe, responsible and respectful behavior in their interactions with people receiving services. The agency culture modeled by all levels of management reinforces the Code of Conduct. The following standards are meant to further guide staff during their interactions with people receiving services. These guidelines do not and cannot outline every situation encountered while on the job, thus requiring staff to act with a certain degree of personal discretion. Because a certain action is not prohibited in this section does not mean it is acceptable behavior. WWAMH reserves the right to take disciplinary action against staff whose actions are found to be inappropriate regardless of whether they appear in this section. While these standards addressed in the Code of Conduct are intended to guide employees in the course of their day-to-day responsibilities, they do not replace any other WWAMH program policies and procedures. Please read this Code of Conduct carefully. Should you have any questions regarding this Code of Conduct or about situations that are not covered by these rules, please consult with your supervisor or the Director of Corporate Compliance & Quality Assurance.
All employees must comply with this Code of Conduct, as well as immediately report any alleged violations of wrongdoing (such as suspected neglect and/or abuse of clients, situations which may jeopardize quality service delivery, misuse of agency resources and/or agency policies and procedures, any situation or action which may be perceived as being detrimental to the purpose of the agency or situations which may prevent someone from performing his/her job. All employees must assist management and compliance personnel in investigating allegations of wrongdoing when required. Any employee who violates the Code of Conduct (including employees who neglect to report a violation) will be disciplined (up to and including termination).
It is the policy of WWAMH to observe all laws and regulations applicable to its business and to conduct business with the highest degree of integrity. To accomplish this, all employees and contractors must obey the laws and regulations that govern their work and always act in the best interest of the people we serve, their families and the Agency.
Guidelines for employees and contractors:
- You are expected to keep management staff informed of what you are doing; to document or record all services or transactions accurately; and to be honest and forthcoming with the Agency, regulatory agencies, and internal and external auditors.
- You are expected to comply with the Agency’s policies and procedures, accounting rules, and internal controls.
- You are expected to function with honesty in your work for the Agency and with people we serve, providers, suppliers and all others with whom the Agency does business.
- You have a duty to be productive during the time that is paid for by the Agency.
Quality Health Care Services
- WWAMH’s employees shall strive to deliver quality health care that maintains our reputation for exemplary service delivery.
- WWAMH’s employees shall respect the dignity of all clients and will treat him or her with consideration, courtesy and respect.
- WWAMH shall only employ or work with persons with proper credentials, experience and expertise. Employees are expected to have those credentials and experience, and should expect other employees to have them.
- It is everyone’s job to maintain WWAMH’s integrity and reputation.
- Clients have the right to choose what is done to their body, and by whom. This includes the choice of health care providers.
- Clients have the right to know what they need to know to make informed decisions. That includes receiving information about WWAMH and its policies, procedures and charges, and who will provide services on behalf of WWAMH.
- No deficiency or error should be ignored or covered up. A problem should be brought to the attention of those who can properly assess and resolve the problem.
- Employees deserve clear instructions about what is expected of them.
- WWAMH’s highest priority is the health and safety of our clients and ourselves. We shall strive to do our jobs so that no harm is caused to ourselves, our clients, or the public.
Interactions and Conduct:Respectful Interactions:
- Employees treat all people who receive services with respect and consideration. Treatment must be fair and equitable, and must not impose bias due to gender, race, religion, sexual orientation, or economic or social status.
- Diligent effort is made to avoid preferential treatment or the appearance of such.
- Employees do not use harsh, demeaning or inappropriate language, degrading punishment or any type of unauthorized restraining device in the name of behavior management.
- Employees do not participate in or allow others to engage in any form of hazing, unwelcome teasing, ostracism or bullying.
- Employees do not intentionally connect with a person receiving services outside of the course of their work and limit unintentional contact to brief greetings and conversation.
- Employees do not connect with a person receiving services via social media.
- Employees do not share sleeping locations with people who receive services, except as deemed necessary by the individual’s treatment team and guardian to meet the individual’s current needs. This includes beds, tents, hotel rooms and other similar areas. Employees may sleep in open areas with people who receive services as long as the area is large enough for the employees to have their own defined sleeping areas and other employees are also present.
- Employees do not engage in certain types of physical contact that may be unwelcome or misconstrued by the individual or others. This includes bear hugs, pats on the head, pinching cheeks, pat on the buttocks, etc.
- Employees, to their best ability, identify when circumstances are beyond their capacity to address in a productive manner, and request support from peers or a supervisor to manage any risk of abusing or neglecting a person receiving services.
- Employees intervene and provide support when they observe co-workers exhibiting a loss of ability to safely and effectively manage a challenging behavior, or other circumstances involving a person(s) they are providing care for.
- Employees do not use physical punishment in any form. The only time physical force is allowed with a person who receives services is when their actions are placing themselves or others at an immediate risk for serious harm, consistent with agency policies and procedures.
- Employees do not have any sexual contact with people who receive services, including touching of non-sexual body parts for the purpose of sexual stimulation for either party.
- Employees address and manage their own sexual reactions to a person receiving services by: requesting support from their supervisor as needed, requesting limited contact or no 1:1 contact as needed, or other safeguards to maintain appropriate professional boundaries.
- Employees do not dress, undress, shower or bathe with, or in the presence of people who receive services.
- Employees do not discuss their own sexual history, preferences or fantasies, nor their use of illicit or pornographic materials while in the company of people who receive services.
- Employees do not possess any sexually oriented materials (e.g. books, magazines, videos, clothing) when conducting business in the name of WWAMH.
While representing WWAMH, employees shall not possess, distribute, use or allow others to use any alcohol or drugs. Employees shall not engage in anything that would prevent them from being able to perform the duties of their position satisfactorily. This includes:
- Drinking or using drugs while on duty,
- Drinking or using drugs before coming to work or while on breaks from work**Please refer to the Agency’s policy, “Drug Free Workplace” for more specific information.
Conflict of Interest:
- Employees, volunteers, interns, Board Members, and contractors must not allow any outside financial interest, or competing personal interest to influence their decisions or actions taken on behalf of the Agency.
- Employees, volunteers, interns, and contractors must avoid any situation where a conflict of interest exists or might appear between their personal interests and those of the Agency. The appearance of a conflict of interest may be as serious as an actual conflict of interest.
- Employees, volunteers, interns and contractors shall not engage in placing business with any firm in which there is a family relationship at it may constitute a conflict of interest. Advance disclosure and Board of Directors’ approval are required in such a situation.
- It is a conflict of interest for employees to personally take for themselves opportunities that are discovered through the use of Agency property, information or position with the Agency; to use Agency property or information for personal gain; or to compete with the Agency.
- There are many types of situations where potential conflicts may arise. Employees must promptly report any actual or potential conflicts of interest to their immediate supervisor or directly to the Director of Corporate Compliance and Quality Assurance.
- Outside Activities and Employment
- Employees may not conduct outside activities during work time. Such activities interfere with their regular duties and negatively impact the quality of their work.
- Employees are a representative of the Agency in their everyday life and must represent the Agency positively in the community. Activities during non-working hours should not discredit in any way the community perception of the Agency, or reveal personal or confidential information regarding any of the individuals the Agency provides services to. This includes social networking, via dialogue, chatting, blogging, posting pictures, etc. on internet websites.
- Outside employment must not conflict in any way with an employee’s responsibilities to the Agency or its clients. Employees may not compete against WWAMH or have any ownership interest in a competitor. Please refer to WWAMH’s “Conflict of Interest” policy for further details.
- If an employee works for a competitor as in the instance of direct care personnel, said employment must be disclosed to the Director of Human Resources and approval must be sought from the Director of Corporate Compliance and Quality Assurance.
Use of Agency Funds and Resources
- WWAMH’s assets are to only be used for the benefit of the Agency and the people we serve. Assets include not only funds, equipment, inventory, and office supplies; but also concepts, business plans and strategies, information about people served, financial information, computer property rights, and other business information about the Agency.
- Employees may not use Agency assets for personal gain or give them to any other persons or entities, except in the ordinary course of business as part of an approved transaction. All employees, consultants and vendors are personally responsible and accountable for the proper expenditure of Agency funds and for the proper use of company property.
- All employees and contractors must obtain authorization prior to committing or spending Agency funds.
- Any improper financial gain to the employee through misconduct involving misuse of WWAMH’s or a client’s property is prohibited, including the outright theft of property or embezzlement of money.
- Medical waste or other hazardous materials shall be disposed of properly.
- Employees and contractors may not use WWAMH’s or a client’s resources for personal or improper purposes, or permit others to do so.
- Surplus, obsolete or junked property shall be disposed of in accordance with WWAMH’s procedures. Unauthorized disposal of property is a misuse of assets.
- During employment, an employee may acquire confidential information about WWAMH, its staff and people we serve that must be handled in strict confidence and not discussed with outsiders. The protection of confidential business, staff and consumer information is very important. Please refer to the Agency’s privacy policies.
- Employees and contractors shall not use or reveal any confidential information concerning WWAMH or use, for personal gain, confidential information obtained as an employee or contractor of WWAMH.
- Employees and contractors should be honest and forthright in any representations made to clients, vendors, payers, or other employees or agents, and the community.
- All reports or other information required to be provided to any federal, state or local government agency authorized to receive such information, shall be accurate, complete, and filed on time.
Business Dealings Between WWAMH and Employees
- WWAMH will not be inappropriately influenced with goods or services from any business in which an employee or their immediate family members have a substantial interest.
- Property and resources of WWAMH should only be used for the benefit of the Agency or the people we serve.
Maintenance of Records
- Employees, volunteers, interns, and contractors must record and report all agency, consumer and financial information fully, accurately, and honestly.
- Records include, but are not limited to, records of the people we serve, documentation of services, accounting books or records, financial statements, timesheets or records, expense reports, vouchers, bills, payroll, claims payment records, correspondence, and any other method of communication.
- Employees, volunteers, interns, or contractors must not omit or conceal any relevant information.
Guidelines for Employees, Volunteers, Interns, and Contractors
- Many of WWAMH forms are legal documents used to prove that a service was provided, to bill for a service to a client, to record a job task, or to record specific happenings. Employees must document accurately and honestly, and only for those services that were provided or for those events that employee was involved in.
Falsification of Records
- Employees must not make any false entries in any of WWAMH’s records or in any public record for any reason.
- Employees may not alter any permanent entries in the Agency’s records.
- Employees may only approve payments or receipts on behalf of the Agency that are described in documents supporting the transaction. “Slush funds” or similar of-book accounts, where there is no accounting for receipts or expenditures on the agency books, are strictly prohibited.
- Employees may not create or participate in the creation of any records that are intended to mislead or to conceal anything that is improper.
- Employees must always charge expenses accurately and to the appropriate cost center or account, regardless of the financial status of the program, project or contract, or the budget status of a particular account or line item.
Retention of Records
- The retention, disposal, or destruction of records of or pertaining to the Agency must always comply with legal and regulatory requirements and Agency policy.
- Employees may not destroy records pertaining to litigation or government investigations or audit without express written approval of the Director of Corporate Compliance and Quality Assurance.
Protection of Confidential Information
- The Agency has developed policies and procedures to assure that the confidentiality of Agency information and information about the people we serve is protected and released only with the appropriate authorization or for lawful reasons, in addition to purposes of treatment, payment, and operations.
- All employees, volunteers, interns, and contractors are required to comply with WWAMH’s Policies on Confidentiality & HIPAA Policies.
- Employees are urged to contact their immediate supervisor or the Director of Corporate Compliance and Quality Assurance if there are any questions concerning confidential information or WWAMH’s policies.
Guidelines for employees and contractors:
- Employees must treat all Agency records and information as confidential.
- Employees may not release confidential information without the proper authorization. Confidential information includes not only information about the people that we serve and their families, but also non-public information about the Agency that may be of use to the Agency’s competitors or harmful to the Agency or its clients if released.
- Employees must protect Agency information and avoid discussing or disclosing Agency information, purposefully or inadvertently (through casual conversation), to any unauthorized person inside or outside the Agency. Furthermore, staff may not share confidential Agency information with anyone, except where required for a legitimate business purpose.
- Agency information may not be removed from Agency property without permission from a supervisor or administrator with proper authority over the information. Employees are urged to ask their supervisor if they are not sure whether certain information is confidential.
Termination of Employment
- Employees may not use any confidential information gained from their employment with the Agency for their or another company’s benefit. Employees may not take copies of any reports, documents, or any other property belonging to the Agency when they leave employment at WWAMH.
- Upon termination of employment with WWAMH, employees must return all Agency property including, but not limited to, copies of documents, notes, and other records containing confidential information, all forms of computer media (i.e. laptops), ID badges, keys, cell phones and credit cards.
- Employees are responsible for properly using information stored and produced by all of WWAMH’s computer systems.
- Computers, Internet access, email, or other office communications systems are intended for business-related purposes only and not for uses that may be disruptive, offensive, harassing, or harmful to others.
- System user names or passwords are not to be shared with another person. Employees should not allow another to access the computer with their password.
- All employees and contractors are required to comply with WWAMH’s “IT Acceptable Use Policy” or “HIPAA Security Policies”. If there are any questions concerning information security, employees are urged to contact their immediate supervisor or the Director of Corporate Compliance and Quality Assurance.
- Conducting business with providers, contractors, suppliers, people we serve, and competitors may pose ethical problems. Employees and contractors are expected to deal fairly with providers, contractors, people we serve, and competitors.
- The Code of Conduct and the following guidelines are intended to help employees make appropriate, responsible and correct decisions in these and all matters.
Kickbacks and Rebate
- Kickbacks and rebates in cash, credit, or other forms are prohibited. They are not only unethical, but in many cases, illegal.
Gifts and Gratuities and Entertainment
- Employees may not solicit money, gifts, gratitude, or any other personal benefits or favors of any kind from providers, contractors, producers, accounts, or people we serve and their families.
- Employees must not offer or accept entertainment that is not a reasonable addition to a business relationship but is primarily intended to gain favor or to influence a business decision.
- Occasional non-cash gifts from providers, contractors, producers, accounts, that are limited to reasonable meal expenditures or entertainment or that are of nominal value, although not expressly prohibited, are discouraged.
- Occasional nominal non-cash gifts from people we serve and their families are acceptable but must be disclosed to the respective division director.
- Employees should report any potential conflicts of interest concerning themselves or their family members to the Director of Corporate Compliance and Quality Assurance.
Agreements with Contractors and Vendors
WWAMH must assure that any agreements with contractors and vendors clearly and accurately describe the services to be performed or items to be purchased. Performance standards, and the applicable compensation, if any, must be reasonable in amount, not be excessive in terms of industry practice and must equal the value of the services rendered.
Improper Use of Funds or Assets
Use of WWAMH’s funds or assets for any improper purpose is strictly prohibited. If an employee becomes aware of or has reason to believe that funds or assets are being improperly used, they must report this immediately to their supervisor or the Director of Corporate Compliance and Quality Assurance.
Federal and State Programs
WWAMH is committed to complying with the laws and regulations that govern the federal and state programs that it administers. Policies and procedures, the Compliance Program, and this Code of Conduct are developed to provide guidance for an employee’s day-to-day work. All employees must abide by the policies and procedures and the standards set by WWAMH.
There may be times that WWAMH is asked to cooperate with an investigation by a federal or state governmental agency, or to respond to a request for information. A request may be formally addressed to WWAMH or an individual within the Agency. Employees and contractors must report any requests for information or cooperation with an investigation to the Director of Corporate Compliance and Quality Assurance immediately.
Political Activities and Contributions
Because WWAMH is a non-profit organization, it is prohibited from engaging in any political campaign activities and a “substantial” amount of lobbying.
Guidelines for Employees and Contractors:
- WWAMH funds and resources, including an employee’s work time, may not be used for political contributions or activities.
- Employees may not act as a representative of WWAMH in any political campaign activity. In expressing their personal political views or support or opposition of a candidate for public office, it must be very clear that employees are expressing their personal view, support or opposition as an individual and not a representative of WWAMH
- Laws and regulations prohibit a “substantial” amount of lobbying. There are allowances for WWAMH to advocate its position on public issues. To assure that WWAMH does not violate any laws or regulations, or risk losing its tax-exempt status, employees must seek prior approval from the Director of Corporate Compliance and Quality Assurance before engaging in any lobbying activities. The Director of Corporate Compliance and Quality Assurance may need to consult with legal counsel on the matter and will need to record the amount of time spent in lobbying activities.
- WWAMH is committed to creating a safe and professional workplace where employees and others are treated with respect and without regard to their race, sex, age, religion, national origin, color, marital status, disability, or other protected characteristics. Business integrity, teamwork, trust, and respect are WWAMH’s most important values.
- Unlawful discrimination or harassment of any sort violates these values. All agents of the Agency (including employees, volunteers, interns, and independent contractors) must exhibit and promote respect, integrity, trust, and teamwork in the workplace and must comply with this policy prohibiting discrimination and harassment in all facets of the Agency’s work.
- Quality consumer care can only be delivered through the use of qualified, competent staff. WWAMH will contribute to an employees’, consultants’ or vendors’ competence by making available continuing job-related education and training (within the limits of its resources).
- Applicants and employees shall be afforded equal employment and advancement opportunities, pursuant to WWAMH’s policies.
- Work and safety rules were created to protect us all. Employees and agents are expected to comply with those rules.
- As defined further in its policies, WWAMH strives to maintain a working environment free from all forms of sexual harassment or intimidation. By way of example, unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature are serious violations of the standards of conduct and will not be condoned or permitted.
- WWAMH promotes a drug and alcohol free workplace in accordance with its policies.
- WWAMH will not permit any action of retaliation or reprisal to be taken against an employee or contractor who reports a violation of law, regulation, standard, procedure or policy.
- The physical environment in the workplace should always remain safe and clean not only for the employees, but also for those this Agency provides services to. This would include assuring compliance with the Agency’s Safety Plan, as well as other guidelines enacted by the Agency through policy and procedure and individual programmatic guidelines.
Guidelines for Employees and Contractors:
Please note that the following list is not all inclusive of the policies and procedures that the Agency upholds for the Employment Environment. Please refer to the Agency’s Policy and Procedure Manual for more information.
- All employees are required to support WWAMH’s commitment to a safe and professional work environment and to demonstrate appropriate behavior in the workplace.
- All employees are prohibited from joking about another employee’s race, sex, age, religion, national origin, color, marital status, disability, or other protected characteristics.
- All employees are prohibited from considering someone’s race, color, religion, sex, national origin, age, disability, or other protected characteristic in making decisions about hiring, placement, assignment of duties, training, promotion, termination, compensation, benefits and other work terms.
- Sexual harassment is prohibited. Sexual harassment includes any form of unwelcome sexual advance, request for sexual favors, or other verbal or physical conduct of a sexual or sex-based nature.
- Workplace violence and harassment is prohibited among agents of the Agency, between agents of the Agency and clients of Agency services, or between agents and non-agents of the Agency during work hours or on Agency property. Although it is understood that agents of the Agency may encounter such treatment for those individuals that the Agency provides services too, the actions of such individuals is not condoned and treated as such based on the individual circumstances. Agency agents are to receive guidance from their supervisors and applicable policies and procedures in such circumstances.
- Employees are responsible for understanding WWAMH’s policies prohibiting discrimination, harassment, including sexual harassment and workplace violence. Employees should consult with an appropriate supervisor, administrator or Human Resources if they have questions about their right to a workplace free from unlawful harassment, discrimination, or violence, or if they have questions about their duty to avoid such.
- As the Agency functions as a “Drug Free Workplace” environment, all Agency agents are responsible and expected to adhere to such defined policies, and promote such adherence from clients of Agency services. Violations of such policies by Agency agents will be handled on a case by case basis and discipline will be instituted up to and including termination. Violations by clients of service will be referred to the client’s program administration for appropriate follow up.
- All employees must exhibit and promote respect, integrity, trust, and teamwork in the workplace and must comply with this policy prohibiting discrimination and harassment in all facets of WWAMH’s work.
- Employees and contractors are expected to conform to the standards of their respective professions and exercise sound judgment in the performance of their duties. Any differences of opinion in professional judgment should be referred to appropriate management levels for resolution in accordance with standard grievance procedures.
Seeking Guidance and Reporting Violations
Employees, and contractors must report any actual or suspected violations of this Code of Conduct, any applicable law or regulation, or any WWAMH policy and procedure to their immediate supervisor or the Director of Corporate Compliance and Quality Assurance. A compliance hotline, (TBG Fraud and Abuse Hotline) is also available for confidential or anonymous reporting of such issues. The Compliance Hotline number is: (866) 219-1122.
When an actual or suspected violation of this Code of Conduct, any applicable law or regulation, or any Agency Corporate Compliance policy and procedure is reported to any agency employee, it must be promptly referred to the Director of Corporate Compliance and Quality Assurance. Steps will be taken to protect confidentiality and anonymity, when appropriate and warranted. WWAMH will not tolerate any form of retaliation against a person who makes a good-faith report in accordance with this Code of Conduct.
All employees, volunteers, interns, and contractors must cooperate fully and honestly in any investigation into a reported violation of this Code of Conduct, any applicable law or regulation, WWAMH’s Corporate Compliance policies, procedures or practices.
Corrective Action and/or Discipline
Any employee, volunteer, intern, or contractor who violates or knowingly fails to report any violation of this Code of Conduct, any applicable law or regulation, or Agency policy, procedure, or practice is subject to appropriate disciplinary action, up to and including termination.
Disciplinary action may range from a warning to suspension or discharge, depending upon the nature of the incident and the relevant surrounding circumstances.
- Attend required trainings, and read and understand WWAMH’s Corporate Compliance Plan, Corporate Compliance Policies and Procedures, Code of Conduct and Conflict of Interest Disclosure Statement.
- Follow WWAMH’s Code of Conduct and abide by all policies and procedures, guidelines, and Federal and State laws and regulations.
- Be alert to any situation that could violate WWAMH’s Code of Conduct, policies and procedures, guidelines, and/or federal and state laws and regulations.
- Promptly report any issues, concerns, violations or suspected violations to immediate supervisor, other management staff, Director of Human Resources, Director of Corporate Compliance and Quality Assurance, or the Chief Executive Officer.