CARF Standards for Written Ethical Codes of Conduct

The July-August 2013 newsletter of Behavioral Health Resources, LLC focuses on CARF standards for corporate compliance that includes written ethical codes of Scale-w-Ethics-Law-Book1conduct.

According to the Ethics Resource Center (ERC), “A code of conduct is intended to be a central guide and reference for users in support of day-to-day decision making.  It is meant to clarify an organization’s mission, values and principles, linking them with standards of professional conduct.  As a reference, it can be used to locate relevant documents, services and other resources related to ethics within the organization.”

Section 1.A (Leadership) of the CARF 2013 BH/CYS/OTP Standards Manuals includes written ethical codes of conduct in a minimum of 13 identified areas.   During accreditation surveys, recommendations are frequently received in 4 of the service delivery areas:

1.A.6.a(4)(b)   Exchange of gifts, money, and gratuities.  Conformance to this standard could be addressed by stating that no personnel or other persons associated with your organization will accept gifts of money or material value, favors, remuneration, or other consideration from any client, individual, or organization that does business with your organization.  It is important to state if gifts from clients of low monetary value are acceptable (i.e., whether purchased or handmade).  If so, the specific dollar amount (e.g., $20) should be indicated as well as who has the authority in the organization to approve the gift.

The ethical code could also indicate the guidelines for approving and accepting the gift (e.g., that decisions will be based on the therapeutic benefit to the client).  If a gift is received from a client or other stakeholder (e.g., client’s family, external vendor, or referral source), it could be stated that the gift is turned in to the supervisor and considered to be a donation to the program or organization.  Another consideration pertains to allowing pictures to be taken or exchanged.

1.A.6.a(4)(c)   Personal fund raising.  According to the Examples section in the CARF 2013 Standards Manuals, (e.g., BH, page 35), personal fund raising includes:  “personnel soliciting funds on behalf of a personal cause, Personal Fundraising - magazinesselling cookies for a daughter in girl scouts, selling candy or wrapping paper for a child’s school, having persons served sell items on behalf of the organization, and allowing persons served to raise funds by appeals to personnel and other persons served.”

Your organization needs to decide if and under what circumstances personal fund raising is allowed.   What materials are approved or authorized on the organization’s bulletin boards or for distribution (e.g., placed in employee lockers or individual mailboxes)?   Is it allowed to circulate various charity promotional items (such as magazine sales for various school projects) during work time, while on break, or on the organization’s premises?   Are employees allowed to solicit for personal fund raising during their bona fide break time?  If so, it could be stated that this is allowed provided that it is not done in the presence of clients and not in areas frequented by clients.  Who has the authority to approve personal fund raising or to make exceptions to your policy?

1.A.6.a(4)(d)   Personal property.  A statement that would adequately meet the standard is:  “All personnel shall respect and safeguard the personal property of clients, visitors, and other personnel as well as the property of [name of organization].  Employees will not use or allow the use of [name of organization] property or equipment for other than activities approved by the organization.  Theft and destruction of property may be addressed through treatment planning (clients), disciplinary action (personnel), and/or by contacting law enforcement, as appropriate.  The organization could also state that it is not responsible for personal property that is not safeguarded or is left unattended.

1.A.6.a(4)(f)   Witnessing of documents.  If not allowed in your organization, this statement would adequately meet the standard:  “Personnel shall not act as a witness to documents such as Power of Attorney, guardianship, advance directives, and/or agency contracts without the expressed written approval of the ______ [indicate the job position at your organization].  Personnel are authorized to countersign documents such as intake forms, authorizations (i.e., release of information form), treatment plans, etc. as directly related to their job duties.”

Notary Public signature and sealIf witnessing documents is acceptable by personnel who are certified as Notary Publics and this is a component of their job duties, a possible statement in the ethical code could be:  “Employees who are certified as Notary Publics may witness documents such as Power of Attorney, guardianship, advance directives, and/or agency contracts for clients, personnel, and other stakeholders in accordance with applicable state laws.  The person who witnesses a document should be neutral and have no financial or other interest involved.”  If witnessing of these types of documents is allowed by personnel certified as Notary Publics or other designation, your organization could benefit from developing a specific policy and procedure regarding this.

© 2013 Behavioral Health Resources, LLC. All rights reserved.

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