Agency Code of Conduct

I. POLICY

It is the policy of Waypost Counseling that all full and part-time employees, contractors, students, volunteers (collectively referred to as "personnel"), and members of the governing authority are expected to perform their designated functions in a manner that reflects the highest standards of ethical behavior. The ethical standards contained in this policy shape the culture and norms of Waypost Counseling's administrative operations and clinical practices, and both personnel and members of the governing authority will be held fully accountable to these standards. In addition to the specific guidelines in the policy, professionals are expected to follow the ethical standards required by their licensing or certification boards or other job descriptions. The Code of Conduct Policy is to ensure that the actions of all personnel reflect a competent, respectful, and professional approach when serving consumers, their families, and/or representatives, working with other providers, and interacting in the communities we serve. It is expected that personnel and members of the governing authority will perform their duties in compliance with all federal, state, and local regulations, as well as the guidelines set forth in this policy. Violations of the Code of Conduct Policy guidelines can lead to disciplinary actions, including termination of employment.

II. PROCEDURES

Professional Conduct:
1. Personnel will respect clients' rights by fully integrating the guidelines in the Rights and Responsibilities Policy. This includes the consumer's right to make autonomous decisions and to participate fully in every aspect of the service delivery process.
2. Personnel will provide services in a manner that fully respects the confidentiality of consumers, demonstrating functional knowledge of confidentiality policies and guidelines.
3. Personnel will be fair and honest in their work. They will not exploit, mislead, or violate clients' rights. 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.
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 clients 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, in accordance with the organization's values.
5. Sexual relationships between personnel and clients are never appropriate. Sexual relationships include, but are not limited to the following: engaging in any 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 consumers, family members, or stakeholders. It 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 property owner's permission.
8. Personnel will not solicit clients 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 personnel's children.
9. Waypost Counseling does not engage in any fundraising.
10. Personnel involved in clinical care will not serve as a witness to any document for that client, including, but not limited to, a power of attorney, advance directives, or guardianship.
11. When peer support specialists deliver services, additional guidelines are developed to support the unique role of these service providers.
12. Peer support specialists should fulfill their roles and responsibilities within the behavioral constraints set by the organization's policies and procedures.
13. Peer support specialists should refrain from developing relationships beyond those 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 clients (electronic and other).
14. Peer support specialists should openly share their recovery stories with clients and use those experiences to help clients achieve their own recovery.
15. Peer support specialists should be able to articulate what constitutes taking too much responsibility for the client's 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 into dual relationships or commitments that conflict with clients' interests.
18. All personnel shall respect and safeguard the personal property of clients, visitors, and other personnel, as well as the property of
  Waypost Counseling.
19. Employees will not use or allow others to use Waypost Counseling's property or equipment for any purpose other than activities approved by the organization.
20. Theft and property destruction may be addressed through treatment planning (clients), disciplinary action (personnel), and/or contacting law enforcement, as appropriate.
21. Waypost Counseling is not responsible for personal property that is not safeguarded or left unattended.
Business Practices
1. Waypost Counseling will utilize the Corporate Compliance Officer (or designated staff) to ensure that it ethically conducts business and that any questionable business practices are thoroughly investigated in accordance with 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 field operations.
3. All personnel shall adhere to Waypost Counseling's Workforce Development and Management Policies and Procedures.
Marketing Practices
1. Waypost Counseling will conduct its marketing practices honestly and factually. Marketing materials and practices will not mislead the public or misrepresent Waypost Counseling's services, providers, contracts, or capabilities.
2. Waypost Counseling will not claim any service outcomes unless represented by reliable data collection methods and valid research results.
3. Waypost Counseling will use clear, consistent methods to communicate information to consumers, family members, third-party entities, referral sources, funding sources, and community members. It will be sensitive to educational and cultural considerations when distributing information.
4. Waypost Counseling will not utilize monetary rewards or gifts to any potential consumer of services to entice them to enter programs.
Clinical Practices
1. Personnel will adhere to all professional codes of conduct and ethical standards for the specified professional discipline, as well as any other professional certification or job description.
2. Professional boundaries must be used in all business-related activities of the organization.
3. As part of orientation, personnel and other stakeholders will read the Ethical Codes of Conduct and demonstrate knowledge of the guidelines by providing proper administrative documentation, following policies and procedures, participating in training or continuing education to meet organization and professional requirements, and conforming to the clinical standards.
Quality of Care
1. Waypost Counseling will properly provide quality behavioral health care, determined to be necessary, efficient, and effective.
2. Healthcare professionals will follow current ethical standards for communicating with consumers (and their representatives) about services provided.
3. Waypost Counseling will inform consumers about alternatives and risks associated with the care they are seeking and obtain informed consent prior to any clinical interventions.
4. Waypost Counseling recognizes consumers' right to make choices about their own care, including the right to go without recommended care or to refuse care.
Necessity of Care
1. Waypost Counseling 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, Waypost Counseling personnel shall only provide those services that are consistent with generally accepted standards of treatment and that the professional determines 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 that a claim be submitted 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 organization's standards and practices as defined in its policies, procedures, and guidelines.
Coding, Billing, and Accounting
1. Waypost Counseling 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, as well as organizational policies and procedures. Training will be provided as needed.
2. Waypost Counseling will only bill for services rendered and shall seek the amount to which it is contracted.
3. Supporting clinical documentation will be prepared for all services rendered. If the required documentation has not been provided, 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 in accordance with 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 appropriate accounts, and proper review will occur.
8. An accurate and timely billing structure and medical records system will ensure that Waypost Counseling effectively implements and complies with required policies and procedures.
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 prepared and submitted, with all costs properly classified, allocated to the correct cost centers, and supported by verifiable, auditable cost data.
3. All cost report preparation or submission errors and mistakes will be corrected in a timely manner and, if necessary, clarified procedures and educated personnel to prevent or minimize their recurrence.
Personal and Confidential Information
1. Waypost Counseling will protect personal and confidential information concerning the organization's system, personnel, and consumers.
2. Waypost Counseling 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 the research purpose and use.
3. Confidential information will be discussed with or disclosed to persons and entities outside the organization only at the consumer's request. Third-party disclosures are not allowed. People outside the organization include the consumer's family, business, or social acquaintances.
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.
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. The staff responsible for preparing records shall ensure they are accurately prepared, maintained in accordance with the law and policy, and stored 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 are 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.
Government Investigation
1. Waypost Counseling personnel shall cooperate fully with appropriately authorized governmental investigations and audits.
2. Waypost Counseling will respond in an orderly fashion to the government's request for information through interviews and documentation review.
3. Waypost Counseling will respond to the government's request for information in a manner that enables the organization to protect both its interests and those of the consumer while cooperating fully with the investigation.
4. When a representative from a federal or state agency contacts Waypost Counseling 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. Waypost Counseling 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.
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 consumers.
2. Personnel will not offer, for themselves or for the organization, anything of value in exchange for referrals of business or 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 reviewing all pricing and discounting decisions to ensure that appropriate factors have been considered and that the basis for such arrangements is documented.
5. The development or formation 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.
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.
Potential Conflicts of Interest
1. Clients will not be hired or allowed to engage in a business relationship with Waypost Counseling. At the same time, they are active participants in the program.
2. Waypost Counseling personnel will not engage in outside Behavioral Health Services that are incompatible or in conflict with job duties or the organization's values, to the extent that such services impact 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 conducted on the personnel's own time, outside the organization. It shall meet the ethical and professional standards of practice.
4. Private practice activities must not conflict with Waypost Counseling's interests, goals, and values. Disclosure is to be made and documented in the personnel file.
5. Personnel will not recruit clients for their private practice while in their professional roles at Waypost Counseling.
6. If personnel end the relationship with Waypost Counseling and enter another practice, the consumer must be informed of their right to choose whether and 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 clients must be made aware of their rights to be referred to another provider or decline services.
Avoiding Conflicts of Interest
1. All personnel shall conduct clinical and personal business in a manner that avoids potential or actual conflicts of interest.
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 of it. 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, payors, 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 Waypost Counseling's name to promote oneself 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.
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 related to 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 conformity to the organization's policies, procedures, and standards of operation.
4. Waypost Counseling 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. Waypost Counseling will document participation in advocacy and corporate citizenship by utilizing meeting logs, meeting notes, or other publications.
5. Waypost Counseling 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 Waypost Counseling hopes to reduce and eliminate the stigma often associated with Behavioral Health or other supportive services.
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. Waypost Counseling will make reasonable accommodations to the known physical, mental, or cultural implications of otherwise qualified individuals with disabilities.
3. Waypost Counseling does not tolerate harassment or discrimination by anyone based on the diverse characteristics or cultural backgrounds of those who work for the organization, in accordance with the organization's affirmative action policy.
4. Any form of sexual harassment, workplace violence, and inappropriate professional responsibility is prohibited.
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 for filing in their personnel file.
3. To ensure awareness of ethical practices, review, and continued education will be conducted annually for personnel and other stakeholders.
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 clients, 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 know of. However, they are not required to investigate reported violations or to follow up on the results. A designated compliance staff member will complete that process.
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, an investigation will be initiated 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 Waypost Counseling in a potentially liable situation that needs legal consultation?
4. Code of Conduct investigations and timelines will follow the guidelines outlined in the Waypost Counseling Corporate Compliance Policy and Procedure.
General Ethical Guidelines and Considerations
1. The Code of Conduct is shared with clients during orientation. It is posted throughout public areas in all owned, leased, or rented facilities.
2. Waypost Counseling values ethical practices within the organization. Any personnel who report waste, fraud, abuse, or other questionable practices will not be subject to reprisal by the organization's management. To ensure 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 the 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 a client or other personnel.
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 for filing in their personnel file. To ensure the quality and consistency of information is disseminated from 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 Waypost Counseling's media policy shall be grounds for disciplinary action up to and including termination of employment.
Use of Social Media
Waypost Counseling respects employees' right to use social media forums for self-publishing and self-expression during 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 social media or other Internet technologies 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 Waypost Counseling.
4. If you choose to identify yourself as a Waypost Counseling employee, please understand that some readers may view you as a spokesperson for Waypost Counseling.
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 people engaged in Waypost Counseling business or at company-sponsored events.
7. You are to contact management immediately if the media or press contacts you about any post related to Waypost Counseling's business.
8. Violations of any of the guidelines listed in this policy will be subject to corrective counseling. They 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.
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 may be.
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 participate in a public or private speaking engagement, panel discussion, professional presentation, or other event, they should immediately direct the inquiring party to speak with an Executive Director.
4. Failure to comply with Waypost Counseling's media policy shall be grounds for disciplinary action up to and including termination of employment.
Contractual Relationships
1. The agency may contract an individual to perform specific tasks at an hourly rate or on a project basis. 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 with Waypost Counseling is that of an independent contractor, and no benefits, whether fringe or other types, will be provided under the contractual agreement.
5. The staff of Waypost Counseling 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.
Witnessing Documents
1. Employees who are certified as Notary Publics may witness documents such as Powers of Attorney, guardianship documents, 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.