NORTHPOINTE BEHAVIORAL HEALTHCARE SYSTEMS



REVISIONS TO POLICY STATEMENT: YES NO OTHER REVISIONS: YES NO

APPLIES TO:

All Northpointe Behavioral Healthcare Systems services and staff, including employees, volunteers, interns, board members and other representatives of Northpointe.

POLICY:

Northpointe Behavioral Healthcare Systems has an ethical responsibility to its service recipients and the community it serves, as well as the staff employed by Northpointe. Therefore, it is the policy of Northpointe Behavioral Healthcare Systems that:

A. Ethical business practices will be utilized and enforced.

B. Ethical care practices will be utilized and enforced.

C. Northpointe will endeavor to accommodate employee requests to be excused from providing care or services due to cultural values, ethics or religious beliefs.

PURPOSE:

The provision of services to individuals experiencing problems related to mental health or intellectual/developmental disabilities is a public trust that requires integrity, compassion, dedication to truth, belief in the dignity, worth and the right to self-determination of all human beings, and respect for individual and group differences. Accordingly, Northpointe provides to all staff a framework for ethical care practices and ethical business practices.

DEFINITION:

Ethical Practices: Delivery of service by agency staff which would be interpreted by a reasonable person as necessary, suitable to condition and humane.

Ethical Conduct: Working in a manner that is honest, legal and respectful of others. Ethical conduct also describes

behavior that falls within the boundaries established by the organization’s mission, vision and values statements.

PROCEDURES:

A. Ethical Practice Agreement

1. All new employees are given a copy of the Code of Ethical Practices Policy and Procedure, Corporate Compliance Policy and Procedure and the “Ethics and Corporate Compliance in Healthcare” handbook to review during orientation.

1. All new employees are asked to sign an Ethical Practice Agreement form.

2. The Ethical Practice Agreement form is filed in the employee's personnel file.

3. Annually, at the time of an employee’s performance review, the employee will review Northpointe’s Code of Ethical Practices.

4. All staff are encouraged to contact a manager with any questions or for any clarification of this policy.

B. Ethical Business Practices

1. Northpointe's mission statement and strategic plan provides an ethical framework for business operations. All procurements will be conducted in a manner that encourages open and free competition.

2. Upon admission to services, full information is given to the individual on the source of Northpointe's reimbursement for his/her care and any limitations placed on duration of services.

3. Service recipients and their respective insurers/funding entities will only be billed for services provided by Northpointe staff or contractual staff.

4. Any marketing practices will focus on providing information about services that are available and reflect the level of licensure and/or accreditation.

5. Northpointe will clarify its relationship with other healthcare providers, educational institutions, and payers of services through contractual agreements, service agreements or some other formalized arrangement.

6. Northpointe will review relationships with other entities carefully, to avoid conflict of interest and to ensure that Northpointe's mission to its service recipients and the community is not harmed by any relationship.

7. Before entering into a contractual agreement with a provider or vendor, Northpointe reviews the relationship for potential for conflict of interest.

C. Ethical Care Practices

1. All individuals served by Northpointe will be treated with dignity and respect, and in accordance with state law and relevant accreditation, professional licensure standards and professional code of ethics.

2. All service recipient rights will be protected. All Northpointe staff will complete training on Recipient Rights at the time of hire. Any violation of these rights shall be reported to the Office of Recipient Rights.

3. All individuals of Northpointe services will receive an Individual Plan of Service (IPOS), based on person-centered planning principles, which serves as the working document. Ethical and cultural differences will be considered when developing the IPOS.

4. Northpointe staff will not engage in personal fund raising or use personal property with individuals.

5. Any witnessing of documents with service recipients will consider the individual’s condition and request and be completed only as appropriate to staff’s professional relationship with the individual.

6. Personal, cultural, and ethical values and beliefs of providers of Northpointe services will not negatively impact service recipient’s care and/or treatment.

7. All Northpointe staff will refrain from improper inducements for referrals.

8. All Northpointe staff will not, directly or indirectly, solicit, accept or agree to accept, any gift of money or goods, loans or services or other preferred arrangements for personal benefit under any circumstances which would tend to influence, or have the appearance of influencing, the manner in which they perform their duties. An employee will not grant or make available to any person a consideration, treatment, advantage or favor beyond that which is the general practice to grant or make available to the public at large.

9. Staff will strive to know their limitations and to stay within the bounds of these limitations in practice. Staff will follow any established best practice guidelines.

10. All staff will maintain appropriate boundaries with person served and stakeholders.

11. Staff will be diligent in the performance of duties, professional in provision of services and avoid any personal conflicts of interest.

12. Staff will obtain and maintain any license, certification and competencies required by Northpointe and state and federal regulations and laws for the performance of duties at Northpointe. Staff will abide by any professional code of ethics per law and/or license.

13. Staff will display personal behavior in both the workplace and community, including social media, which reflects respect for self and others, respect for Northpointe and its Board and respect for Northpointe’s service recipients.

D. Reporting Unethical Conduct

All Northpointe staff recognizes their obligation to report to an appropriate member of the management team any act of unethical conduct of any staff member, or any case of gross negligence or professional incompetence. Northpointe strongly urges prompt reporting of all incidents of unethical behavior of a staff to the Director of Human Resources, Northpointe’s Corporate Compliance Officer or any member of management. It is Northpointe’s expectation that investigations are initiated within five (5) working days from notification/knowledge of unethical conduct. Time frames may be extended when necessary. Any corrective action taken will be consistent with Northpointe’s Corrective Action policy.

E. Managing Staff Requests

1. In the event that a staff member has a conflict with an individual's cultural values, ethics or religious beliefs that may impact the individual's care, the staff will contact their immediate supervisor and request, in writing, a case transfer. The request will include the cultural, ethical or religious reasons, as well as the aspect of care or service he/she wishes to be excused. The supervisor will review the request to justify appropriateness and determine whether accommodation is possible. If accommodation is possible, the supervisor will notify the staff and others who need to be involved in the accommodation. If the accommodation is prevented because of an emergency situation, the staff is expected to perform assigned duties so as not to negatively affect delivery of care or services. If accommodation is not possible, the employee will be allowed to explore other job opportunities within Northpointe where accommodations might be possible. If a staff member does not agree to render appropriate care or services in an emergency situation because of personal beliefs, the staff will be placed on a leave of absence from their current position and the incident reviewed.

2. In the event that a personal/social relationship develops between any staff and a service recipient, to whom the staff is rendering services, the staff will contact their immediate supervisor and request a case transfer.

3. All staff have an administrative chain of command and formal grievance procedure should they need to utilize it. This is reviewed with staff during their orientation at Northpointe.

NON-RETALIATION CLAUSE:

The above policy also prohibits any act of retaliation against an employee who, in good faith, has filed a complaint pursuant to this policy or for otherwise assisting in the investigation of a complaint. Any supervisor, agent, or employee of the employer who is found to have taken actions determined to be retaliatory in nature against a complainant shall be subjected to immediate corrective action up to and including immediate discharge. Any person who believes they were retaliated against for exercising his or her rights under this policy should immediately file a complaint with Northpointe’s Human Resources Department or any supervisory personnel.

CROSS REFERENCE:

NBHS Policies:

✓ Reporting Abuse & Neglect

✓ Reporting Unusual Incidents

✓ Conflict of Interest

✓ Corrective Action

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