Code of Conduct Training Information

MISSION AND VALUES

PURPOSE OF OUR CODE OF CONDUCT

LEADERSHIP RESPONSIBILITIES

OUR FUNDAMENTAL COMMITMENT TO STAKEHOLDERS

RELATIONSHIPS WITH OUR BEHAVIORAL HEALTH CARE PARTNERS

REGULATORY COMPLIANCE


THE CORPORATE ETHICS AND COMPLIANCE PROGRAM
Program Structure
Resources for Guidance and Reporting of Violations
Personal Obligation to Report
Internal Investigation of Violations
Corrective Action
Discipline
Internal Audit and other monitoring
Acknowledgment Process

ACKNOWLEDGMENT

(All references to “MHACGC” or the “organization” in this Code of Conduct refer to MHACGC – Mental Health Association of Columbia-Greene Counties, Inc..)


MHACGC Mission and Values Statement

To provide for citizen action to work for the conservation and advancement of mental health, the prevention of mental illness, the rehabilitation of persons with mental illness, the restoration of mental health and to provide education to the community pertaining to the above.

To establish, own, operate and maintain community residences and out-patient facilities as well as provide rehabilitation, support and case management and peer support services for adults diagnosed with a mental illness and for children with serious emotional/behavioral/social problems.

We are committed to providing quality, relevant, and accessible services to children, families, and adults who are affected by emotional disturbance and mental illness. We believe that those we serve all have potential and deserve our respect. We believe that those we work with have the ability, to varying degrees, to recover, and that it is our job to help them with this process. We are here to assist people in the process of change, not to “change them”. We believe that society in general is better off when it is able to embrace and accept people with disabilities. This is why we provide community education and legislative advocacy. This is also why we use ‘people first language’ (e.g. “people with mental illness” not “the mentally ill”). This philosophy is key to our work and it is important that all staff work with this in mind.

Purpose of Our Code of Conduct

Our Code of Conduct provides guidance to all MHACGC staff members and assists us in carrying out our daily activities within appropriate ethical and legal standards. These obligations apply to our relationships with participants, affiliated physicians, third-party Payors, independent contractors, vendors, consultants, and one another.

The Code is a critical component of our overall Ethics and Compliance Program. We have developed the Code to ensure that we meet our ethical standards and comply with applicable laws and regulations. The policies set forth in this Code are mandatory and must be followed.

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Leadership Responsibilities

While all MHACGC staff are obligated to follow our Code, we expect our leaders to set the example, to be in every respect a model. They must ensure that staff have sufficient information to comply with law, regulation, and policy; as well as the resources to resolve ethical dilemmas. They must help to create a culture within MHACGC which promotes the highest standards of ethics and compliance. This culture must encourage everyone in the organization to raise concerns when they arise.

Our Fundamental Commitment to Stakeholders

We affirm the following commitments to MHACGC stakeholders:

To our participants:We are committed to providing quality, relevant and accessible services.

To our MHACGC employees and sub-contractors: We are committed to a work setting which treats all employees and sub-contractors with fairness, dignity, and respect, and affords them an opportunity to grow, to develop professionally, and to work in a team environment in which all ideas are considered.

To our third-party Payors: We are committed to dealing with our third-party Payors in a way that demonstrates our commitment to contractual obligations and reflects our shared concern for quality behavioral healthcare and bringing efficiency and cost effectiveness to healthcare. We encourage our private third-party Payors to adopt their own set of comparable ethical principles to explicitly recognize their obligations to participants as well as the need for fairness in dealing with providers.

To our regulators: We are committed to an environment in which compliance with rules, regulations, and sound business practices is woven into the corporate culture. We accept the responsibility to aggressively self-govern and monitor adherence to the requirements of law and to our Code of Conduct.

To the communities we serve: We are committed to understanding the particular needs of the communities we serve and providing these communities quality, cost-effective behavioral healthcare. We realize as an organization that we have a responsibility to help those in need.

To our volunteers: The concept of voluntary assistance to the needs of participants and their families is an integral part of the fabric of behavioral healthcare. We are committed to ensuring that our volunteers feel a sense of meaningfulness from their volunteer work and receive recognition for their volunteer efforts.

Relationships with Our Behavioral Healthcare Partners

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Participant Care and Rights

Our mission is to provide quality services to all of our participants. We treat all people with respect and dignity and provide care that is both necessary and appropriate. We make no distinction in the admission, transfer or discharge of individuals or in the care we provide based on race, gender, color, religion, sexual orientation, or national origin. The provision of services is based on identified behavioral healthcare needs.

Upon admission to treatment programs, each participant is provided with a written statement of Consumer Rights. This statement includes the rights of the individual to make decisions regarding mental health care and conforms to all applicable state and Federal laws regarding his or her mental health treatment.

We assure participants’ involvement in all aspects of their care and obtain informed consent for treatment. As applicable, each participant or their representative is provided with a clear explanation of care, which may include, diagnosis, treatment plan, right to refuse or accept care, care decision dilemmas, advance directive options, estimates of treatment costs, and an explanation of the risks and benefits associated with available treatment options where applicable. Individuals have the right to request transfers to other facilities. In such cases, the person will be given an explanation of the benefits, risks, and alternatives.

Participants and their representatives will be accorded appropriate confidentiality, privacy, security and protective services, and an opportunity for resolution of complaints.

Participants are treated in a manner that preserves their dignity, autonomy, self-esteem, civil rights, and involvement in their own care. MHACGCstaff will receive training about Consumer Rights in order to clearly understand their role in supporting them.

Compassion and care are part of our commitment to the communities we serve. We strive to provide mental health education, and the awareness of mental health issues, as part of our efforts to improve the quality of life of our participants and our communities.

Participant Information

We collect information about the participants’ psychiatric condition, history, medication, and family illnesses to provide the best possible care. We realize the sensitive nature of this information and are committed to maintaining its confidentiality. We do not release or discuss client specific information with others unless it is necessary to serve the individual and a release is signed, or it is required by law. Participant Information is shared only for the purposes of treatment, payment or healthcare operations as defined by the Health Insurance Portability Act of 1996 (HIPAA).

MHACGC colleagues must never disclose confidential information that violates the privacy rights of our participants. No MHACGC staff, affiliated physician, or other care provider has a right to any participant information other than thatnecessary to perform his or her job.

Participants can expect that their privacy will be protected and that participant specific information will be released only to persons authorized by law or by the consumer’s written consent. In an emergency situation, when requested by an institution or physician treating the individual, consent is not required, but the name of the institution and the person requesting the information must be verified.This should be done as a call back process. Instances such as these will be documented in the participant’s program chart.

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Referral Sources

We do not accept payments for referrals that we make. No MHACGC staff or any other person acting on behalf of the organization is permitted to solicit or receive anything of value, directly or indirectly, in exchange for the referral of consumers. Similarly, when making referrals to another provider, we do not take into account the volume or value of referrals that the provider has made (or may make) to us.

Third-Party Payors

Coding and Billing for Services
We will take great care to assure that all billings to government and to private insurance Payors reflect truth and accuracy and conform to all pertinent Federal and State laws and regulations. We prohibit any agent of MHACGC from knowingly or recklessly presenting or causing to be presented claims for payment or approval which are false, fictitious, or fraudulent.

We will operate oversight systems designed to verify that claims are submitted only for services actually provided and that services are billed as provided. These systems will emphasize the critical nature of complete and accurate documentation of services provided. As part of our documentation effort, we will maintain current and accurate records.

Any subcontractors engaged to perform billing or coding services must have the necessary skills, quality assurance processes, systems, and appropriate procedures to ensure that all billings for government and commercial insurance programs are accurate and complete. MHACGC prefers to contract with such entities that have adopted their own ethics and compliance programs. Third-party billing entities, contractors, and preferred vendors that we consider must be approved consistent with the corporate policy on this subject.

Cost Reports

Our business involves reimbursement under government programs which require the submission of certain reports of our costs of operation. We will comply with Federal and State laws relating to all cost reports. These laws and regulations define what costs are allowable and outline the appropriate methodologies to claim reimbursement for the cost of services provided to program beneficiaries. Given their complexity, all issues related to the completion and settlement of cost reports must be communicated through or coordinated with our Fiscal Department.

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Regulatory Compliance

These services generally may be provided only pursuant to appropriate Federal, state, and local laws and regulations. Such laws and regulations may include subjects such as certificates of need, licenses, accreditation, access to treatment, consent to treatment, record-keeping, access to records and confidentiality, Consumer Rights, and Medicaid regulations. The organization is subject to numerous other laws in addition to these regulations.

In order to ensure that we fully meet all regulatory obligations, MHACGC staff must be informed about stated areas of potential compliance concern. The Department of Health and Human Services, and particularly its Inspector General, have routinely notified healthcare providers of areas in which these government representatives believe that insufficient attention is being accorded to government regulations. We should be diligent in the face of such guidance about reviewing these elements of our system to ensure their correctness.

MHACGC will provide its staff with the information and education they need to comply fully with all applicable laws and regulations.

We will comply with applicable laws and regulations. All staff members, must be knowledgeable about and ensure compliance with all laws and regulations; and should immediately report violations or suspected violations to a Supervisor, Division Director or the Compliance Officer.

MHACGC will be forthright in dealing with any billing inquiries. Requests for information will be answered with complete, factual, and accurate information. We will cooperate with, and be courteous to, all government inspectors and provide them with the information to which they are entitled during an inspection. Staff should contact his or her supervisor and the Compliance Officer if an inspector comes to the facility or inquires by telephone. Documents or charts should only be released with appropriate management approval.

During a government inspection, staff must never conceal, destroy, or alter any documents, lie, or make misleading statements to the government representative. There should not be an attempt to cause another colleague to fail to provide accurate information or obstruct, mislead, or delay the communication of information or records relating to a possible violation of law. Staff should contact management and the Compliance Officer in these situations.

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Business Information and Information Systems

Accuracy, Retention, and Disposal of Documents and Records

All MHACGC staff are responsible for the integrity and accuracy of our organization’s documents and records, not only to comply with regulatory and legal requirements but also to ensure that records are available to defend our business practices and actions. No one may alter or falsify information on any record or document.

Medical and business documents and records are retained in accordance with the law and our record retention policy. Case records and business documents include paper documents such as letters and memos, computer-based information such as e-mail or computer files on disk or tape, and any other medium that contains information about the organization or its business activities. It is important to retain and destroy records appropriately according to our policy. You must not tamper with records, nor remove or destroy them prior to the specified date.

Confidential Information

Employees are bound by the standards of confidentiality set forth by the Agency and the New York State Office of Mental Health. Every consumer has the right to expect that all information about his/her treatment will be kept absolutely confidential. This includes the very fact that the individual is a recipient of the Agency’s services. Specifically, it must be understood by all employees that the following actions are prohibited:

1. Using a consumer’s name in any conversation outside the treatment setting.
2. Discussing one consumer’s problems with another consumer.
3. Describing a consumer’s situation in such a manner that the consumer can be identified outside the treatment setting.
4. Giving out any information, written, oral, by telephone, or by copying files about a participant, without following standard practices re: consent.
5. Removing any records or papers containing confidential information from the office without permission from a Supervisor, Division Director, Corporate Compliance Officer or Director.

All consumer records are to be locked in file cabinets located in the program office. The Agency prohibits the inappropriate use, dissemination or solicitation of confidential/privileged information related to and arising from business conducted by the Agency. The employee’s Supervisor, who may take disciplinary action, shall review any violation of this policy immediately.

Electronic Media

All communications systems, electronic mail, Internet, Internet access, or voice mail are the property of the organization and are to be primarily used for business purposes. Highly limited reasonable personal use of the MHACGC communications systems is permitted; however, you should assume that these communications are not private. Participant or confidential information should not be sent through email or the Internet until such time that its confidentiality can be assured.

MHACGC reserves the right to periodically access, monitor, and disclose the contents of e-mail, and voice mail messages. Access and disclosure of individual employee messages may only be done with the approval of the Corporate Compliance Officer.

Colleagues may not use internal communication channels or access to the Internet at work to post, store, transmit, download, or distribute any threatening; knowingly, reckless, or maliciously false; or obscene materials including anything constituting or encouraging a criminal offense, giving rise to civil liability, or otherwise violating any laws. Additionally, these channels of communication may not be used to send chain letters, personal broadcast messages, or copyrighted documents that are not authorized for reproduction; nor are they to be used to conduct a job search or open misaddressed mail.

Colleagues who abuse our communications systems or use them excessively for non-business purposes may lose these privileges and be subject to disciplinary action.

Financial Reporting and Records

We have established and maintained a high standard of accuracy and completeness in the documentation and reporting of all financial records. These records serve as a basis for managing our business and are important in meeting our obligations to participants, staff, suppliers, and others. They are also necessary for compliance with tax and financial reporting requirements.

All financial information must reflect actual transactions and conform to generally accepted accounting principles. No undisclosed or unrecorded funds assets may be established. MHACGC maintains a system of internal controls to provide reasonable assurances that all transactions are executed in accordance with management’s authorization and are recorded in a proper manner so as to maintain accountability of the organization’s assets.

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Workplace Conduct and Employment Practices

Conflict of Interest

A conflict of interest may occur if your outside activities or personal interests influence or appear to influence your ability to make objective decisions in the course of your job responsibilities. A conflict of interest may also exist if the demands of any outside activities hinder or distract you from the performance of your job or cause you to use MHACGC resources for other than MHACGC purposes. It is your obligation to ensure that you remain free of conflicts of interest in the performance of your responsibilities at MHACGC. If you have any questions about whether an outside activity might constitute a conflict of interest, you must obtain the approval of your supervisor before pursuing the activity. You may not without permission from the Compliance Officer accept, solicit, or offer anything of value from anyone doing business with MHACGC, including any client, referring physician, vendor, contractor or other third party, if the gift or gratuity relates to, or results from your affiliation with MHACGC.

Controlled Substances

Some of our staff routinely have access to prescription drugs, controlled substances, and other medical supplies. Many of these substances are governed and monitored by specific regulatory organizations and must be administered by physician order only. It is extremely important that these items be handled properly and only by authorized individuals to minimize risks to us and to participants. If you become aware of the diversion of drugs from the organization, you should report the incident immediately.

Diversity and Equal Employment Opportunity

Our staff provide us with a complement of talents which contribute greatly to our success. We are committed to providing an equal opportunity work environment where everyone is treated with fairness, dignity, and respect. We will comply with all laws, regulations, and policies related to non-discrimination in all of our personnel actions. Such actions include hiring, staff reductions, transfers, terminations, evaluations, recruiting, compensation, corrective action, discipline, and promotions.

No one shall discriminate against any individual with a disability with respect to any offer, or term or condition, of employment. We will make reasonable accommodations to the known physical and mental limitations of otherwise qualified individuals with disabilities.

Harassment and Workplace Violence

Each MHACGC colleague has the right to work in an environment free of harassment. We will not tolerate harassment by anyone based on the diverse characteristics or cultural backgrounds of those who work with us. Degrading or humiliating jokes, slurs, intimidation, or other harassing conduct is not acceptable in our workplace.

Any form of sexual harassment is strictly prohibited. This prohibition includes unwelcome sexual advances or requests for sexual favors in conjunction with employment decisions. Moreover, verbal or physical conduct of a sexual nature that interferes with an individual’s work performance or creates an intimidating, hostile, or offensive work environment has no place at MHACGC.

Harassment also includes incidents of workplace violence. Workplace violence includes robbery and other commercial crimes, stalking cases, violence directed at the employer, terrorism, and hate crimes committed by current or former colleagues. As part of our commitment to a safe workplace for our colleagues, we prohibit colleagues from possessing firearms, other weapons, explosive devices, or other dangerous materials on MHACGC premises. Colleagues who observe or experience any form of harassment or violence should report the incident to their supervisor or to the Human Resources Department.

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Health and Safety

All MHACGC facilities must comply with all government regulations and rules and with MHACGC policies or required facility practices that promote the protection of workplace health and safety. Our policies have been developed to protect you from potential workplace hazards. You should become familiar with and understand how these policies apply to our specific job responsibilities and seek advice from your supervisor or the site Safety Officer whenever you have a question or concern. It is important for you to advise your supervisor and the OSHA Coordinator for the site of any serious workplace injury or any situation presenting a danger of injury so that timely corrective action may be taken to resolve the issue. All situations of this type will be reported to the Human Resources Coordinator immediately.

License and Certification Renewals

Colleagues and individuals retained as independent contractors in positions which require professional licenses, certifications, or other credentials are responsible for maintaining the current status of their credentials and shall comply at all times with Federal and state requirements applicable to their respective disciplines. To assure compliance, MHACGC will require evidence of the individual having a current license or credential status.

MHACGC will not allow any colleague or independent contractor to work without valid, current licenses or credentials.

Personal Use of MHACGC Resources

It is the responsibility of each MHACGC staff to preserve our organization’s assets including time, materials, supplies, equipment, and information. Organizational assets are to be maintained for business related purposes. As a general rule, the personal use of any MHACGC asset is prohibited. The occasional use of items, such as copying facilities or telephones, where the cost to MHACGC is insignificant, is permissible. Any community or charitable use of organization resources must be approved in advance by your supervisor. Any use of organization resources for personal financial gain unrelated to MHACGC’s business is prohibited.

Relationships among MHACGC Employees

In the normal day-to-day functions of an organization like MHACGC, there are issues that arise which relate to how people in the organization deal with one another. It is impossible to foresee all of these, and many do not require explicit treatment in a document like this. A few routinely arise, however. One involves gift giving among employees for certain occasions. While we wish to avoid any strict rules, no one should ever feel compelled to give a gift to anyone, and any gifts offered or received should be appropriate to the circumstances. A lavish gift to anyone in a supervisory role would clearly violate organization policy. Another situation, which routinely arises, is a fund-raising or similar effort, in which no one should ever be made to feel compelled to participate.

Relationships with Subcontractors, Suppliers, and Educational Institutions

We must manage our subcontractor and supplier relationships in a fair and reasonable manner, consistent with all applicable laws and good business practices. We promote competitive procurement to the maximum extent practicable. Our selection of subcontractors, suppliers, and vendors will be made on the basis of objective criteria including quality, technical excellence, price, delivery, adherence to schedules, service, and maintenance of adequate sources of supply. Our purchasing decisions will be made on the supplier’s ability to meet our needs, and not on personal relationships and friendships. We will always employ the highest ethical standards and meet OMH guidelines in business practices in source selection, negotiation, determination of contract awards, and the administration of all purchasing activities. We will not communicate to a third-party confidential information given to us by our suppliers unless directed in writing to do so by the supplier. We will not disclose contract pricing and information to any outside parties.

All MHACGC programs having relationships with an educational institution must have a written agreement which defines both parties’ roles and the agency’s retention of the responsibility for the quality of participant care.

Research

MHACGC is willing to participate in research projects which may benefit its participants. We expect high ethical standards to be followed. We do not tolerate intentional research misconduct. Research misconduct includes making up or changing results or copying results from other studies without performing the research.

All participants asked to participate in a research project are given a full explanation of alternative services that might prove beneficial to them. They are also fully informed of potential discomforts and are given a full explanation of the risks, expected benefits, and alternatives. The participants are fully informed of the procedures to be followed, especially those that are experimental in nature. Refusal to participate in a research study will not compromise their access to services.

All personnel applying for or performing research of any type are responsible for maintaining the highest ethical standards in any written or oral communications regarding their research projects as well as following appropriate research guidelines. As in all accounting and financial record keeping, our policy is to submit only true, accurate, and complete costs related to research grants. All research projects must be approved by the Corporate Compliance Officer.

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Substance Abuse and Mental Acuity

To protect the interests of staff and participants, we are committed to an alcohol and drug-free work environment. All employees and sub-contractors must report for work free of the influence of alcohol and illegal drugs. Reporting to work under the influence of any illegal drug or alcohol, having an illegal drug in your system, or using, possessing, or selling illegal drugs while on MHACGC work time or property may result in immediate termination. We may use drug testing as a means of enforcing this policy.

It is also recognized that individuals may be taking prescription drugs, which could impair judgment or other skills required in job performance. If you have questions about the effect of such medication on your performance, consult with your supervisor.

Employees who are arrested and convicted for off the job drug/alcohol activity, may be considered in violation of this policy. In determining what action to take, MHACGC will consider the nature of the charges, the employee’s present job assignment, the employee’s record with the Agency, the impact of the employee’s conviction on MHACGC’s ability to maintain efficient and productive operations and any other factor which MHACGC deems relevant under the circumstances.

Marketing Practices

We may use marketing and advertising activities to educate the public, provide information to the community, increase awareness of our services, and to recruit employees. We will present only truthful, fully informative, and non-deceptive information in these materials and announcements. All marketing materials including brochures will reflect services available. No payment of gift will be offered to any participant or potential participant as an inducement to receive MHACGC services.

Environmental Compliance

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It is our policy to comply with all environmental laws and regulations as they relate to our organization’s operations. We will comply with all environmental laws and operate each of our facilities with the necessary permits, approvals, and controls. We will diligently employ the proper procedures with respect to handling and disposal of hazardous and biohazardous waste, including but not limited to medical waste.

In helping MHACGC comply with these laws and regulations, we will adhere to all requirements for the proper handling of hazardous materials. You should immediately alert your supervisor to any situation regarding the discharge of a hazardous substance, and improper disposal of medical waste.

Political Activities and Contributions

The organization’s political participation is limited by law. MHACGC funds or resources are not to be used to contribute to political campaigns or for gifts or payments to any political party or any of their affiliated organizations. Organizational resources include financial and non-financial donations such as using work time and telephones to solicit for a political cause or candidate or the loaning of MHACGC property for use in the political campaign. The conduct of any political action committee is to be consistent with relevant laws and regulations.

It is important to separate personal and corporate political activities in order to comply with the appropriate rules and regulations relating to lobbying or attempting to influence government officials. You may, of course, participate in the political process on your own time and at your own expense. While you are doing so, it is important not to give the impression that you are speaking on behalf of or representing MHACGC in these activities. No political advertising is allowed on Agency property. You cannot seek to be reimbursed by MHACGC for any personal contributions for such purposes.

At times, MHACGC may ask colleagues to make personal contact with government officials or to write letters to present our position on specific issues. In addition, it is a part of the role of some MHACGC management to interface on a regular basis with government officials. If you are making these communications on behalf of the organization, be certain that you are familiar with any regulatory constraints and observe them. Guidance is always available from Administration as necessary.

The Corporate Ethics and Compliance Program

Program Structure

The Corporate Ethics and Compliance Program is intended to demonstrate in the clearest possible terms the absolute commitment of the organization to the highest standards of ethics and compliance. That commitment permeates all levels of the organization. The Executive Director reports to the Board of Directors for the purposes of oversight. Other oversight includes a Corporate Compliance Committee consisting of a Corporate Compliance Officer, senior management, and possibly any others as needed. All of these individuals or groups are prepared to support you in meeting the standards set forth in this Code.

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Resources for Guidance and Reporting Violations

To obtain guidance on an ethics or compliance issue or to report a suspected violation, you may choose from several options. We encourage the resolution of issues at a program level whenever possible. It is an expected good practice, when you are comfortable with it and think it appropriate under the circumstances, to raise concerns first with your supervisor. If this is uncomfortable or inappropriate, another option is to discuss the situation with the Division Director. You are always free to contact the Corporate Compliance Officer as well. In order for action to be taken, all formal complaints must be in writing. A copy of all complaints will be forwarded to the Corporate Compliance Officer, unless such complaint involves the Compliance Officer, in which case the Executive Director will be notified.

Anonymous reporting is possible via use of an anonymous “Drop Box” The drop box is available at the Staff Lounge at MHACGC’s main office at 713 Union St., Hudson, NY. Anonymous reporting can also occur via sending an anonymous letter to the Corporate Compliance Officer via U.S. mail at 713 Union St., Hudson, NY 12534. Correspondence should be addressed to the Mental Health Association of Columbia-Greene Counties, to the attention of the Corporate Compliance Officer.

MHACGC will make every effort to maintain, within the limits of the law, the confidentiality of the identity of any individual who reports possible misconduct. There will be no retribution or discipline for anyone who reports a possible violation in good faith. Any employee who deliberately makes a false accusation with the purpose of harming or retaliating against another employee, and/or abuses the system of anonymous reporting will be subject to discipline.
Personal Obligation to Report

We are committed to ethical and legal conduct that is compliant with all relevant laws and regulations and to correcting wrongdoing wherever it may occur in the organization. Each employee has an individual responsibility for reporting any activity by any employee, physician, subcontractor, or vendor that appears to violate applicable laws, rules, regulations, or this Code.

Internal Investigations of Reports

We are committed to investigate all reported concerns promptly and confidentially to the extent possible. The Corporate Compliance Officer will coordinate any findings from the investigations and immediately recommend corrective action or changes that need to be made. We expect all employees to cooperate with investigation efforts.

Corrective Action

Where an internal investigation substantiates a reported violation, it is the policy of the organization to initiate corrective action, including, as appropriate making prompt restitution of any overpayment amounts, notifying the appropriate governmental agency, instituting whatever disciplinary action is necessary, and implementing systemic changes to prevent a similar violation from recurring in the future at any MHACGC facility. Legal counsel will be involved in these decisions, as needed.

Discipline

All violators of the Code will be subject to disciplinary action. The precise discipline utilized will depend on the nature, severity, and frequency of the violation and may result in any of the following disciplinary actions:

* Verbal warning
* Written warning
* Suspension
* Termination
* Restitution.

Internal Audit and Other Monitoring

MHACGC is committed to the aggressive monitoring of compliance with its policies. Much of this monitoring effort is provided by the Corporate Compliance Officer who routinely conducts internal audits of issues that have regulatory or compliance implications. The organization also routinely seeks other means of ensuring and demonstrating compliance with laws, regulations, and MHACGC policy.

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Acknowledgment Process

MHACGC requires all employees and sub-contractors to sign an acknowledgment confirming they have received the Code and understand it represents mandatory policies of MHACGC. New employees and sub-contractors will be required to sign this acknowledgment as a condition of employment.

Adherence to and support of MHACGC’s Code of Conduct and participation in related activities and training will be considered in decisions regarding hiring, promotion, and compensation for all candidates and employees.