Community Mental Health &
Substance Abuse Services
of St. Joseph County
Human Resources
Code of Ethics
Application:
Policy
and
Operating
Procedure
16.03
Subject:
All Departments
Effective
1/27/98
Reviewed
1/25/10
Revised
3/18/08, 4/23/11
12/02/11, 10/17/13
6/30/14
PURPOSE
To provide guidelines for staff interaction with past or present consumers; the community and
coworkers in a professional, helpful and respectful manner consistent with Community Mental
Health & Substance Services of St. Joseph County’s (CMHSAS-SJC) mission and values.
DEFINITIONS
Retaliation
Conduct or communication, taken in response to an employee complaint or report of alleged
fraud or abuse, violation of consumer privacy or recipient rights, or of any of the work rules of
the organization that result in the adverse change in the work status of an employee.
Retribution
Conduct or communication, taken in response to an employee complaint or report of alleged
fraud or abuse, violation of consumer privacy or recipient rights, or of any of the work rules of
the organization that result in a hostile work environment or dispensing of informal punishment.
Nondiscrimination
CMHSAS-SJC shall not discriminate against any employee or applicant for employment with
respect to his/her hire, tenure or conditions of employment because of:
1.
age
2.
color
3.
marital status
4.
gender
5.
national origin
6.
physical appearance (i.e., weight and height)
7.
race
8.
religion
9.
disability
Page 1 of 6
Approved
Operating Procedure
Subject:
16.3 Human Resources/
Code of Ethics
POLICY
All employees will be expected to uphold Employee Code of Ethics to the best of his/her ability.
It is not possible to anticipate all specific circumstances. The new hire will be asked by their
supervisor during orientation if there is any part of the Code of Ethics which is unclear or
unacceptable to him/her. Any staff with a question about the appropriateness of an activity should
first consult the Code of Ethics and then, if further questions remain, consult their supervisor.
PROCEDURE
I.
All CMHSAS-SJC employees will have access to this policy and any changes made to it.
Employees will sign a form provided by CMHSAS-SJC, indicating their receipt and review
of the Code of Ethics and review of this policy. This policy will be reviewed and updated as
needed to ensure compliance with the ethical standards and criteria in the Mental
Health/Substance Abuse industry and with Michigan laws.
To assist staff in understanding expectations of conduct consistent with this policy, the
Employee Code of Ethics will be provided to each new employee/volunteer at the time of
hire, generally enclosed with their Employment Letter stating the parameters of the
position. It is also included in the Employee Handbook.
During orientation he/she will be asked to sign a statement indicating that they have
received the Employee Code of Ethics and understand the expectations of the Agency.
This form will be kept in the employee’s personnel file.
II.
ETHICAL PRINCIPLES
The CMHSAS-SJC ethical code of conduct is established on six basic principles, which
employees are expected to maintain:
1. Honesty – we will be truthful in all our endeavors, to be honest and forthright with
one another and with our consumers, service providers and community partners.
2. Respect – we will treat one another with dignity and fairness, appreciating the
diversity within our community and the uniqueness of each individual. Staff will use
language that communicates respect.
3. Trust – we will build confidence through teamwork and open, candid communication
at all levels of the organization.
4. Responsibility – we will speak up and allow others to speak without fear of retribution
and report concerns within the organization, including any violation of law,
regulation, ethical standard, and CMHSAS-SJC policy.
5. Citizenship – we will obey the laws of the land, work to make our community more
productive, and act with pride and confidence as a representative of CMHSAS-SJC.
6. Competency – we will have and maintain the required competencies and credentials
for carrying out job responsibilities (refer to 16.8 Human Resources/Credentialing
Requirements policy).
III.
REPORTING OF VIOLATIONS
Page 2 of 6
Operating Procedure
Subject:
16.3 Human Resources/
Code of Ethics
Employees are expected to report violations or suspected violations of this or any policy
or the Code of Ethics to their supervisor, Corporate Compliance Officer, Recipient Rights
Officer or the Human Resources Coordinator for investigation. Employees who report
violations, participate in hearings, investigations, legislative inquiries, or court actions are
protected and there is to be no retaliation or retribution to the employee. If the individual
also believes the alleged unethical conduct violates state or federal law, he or she may file
a complaint with the proper authorities (i.e., law enforcement, Recipient Rights, DHS,
violator’s certifying professional board/organization, etc.)
See 16.17 Human
Resources/Ethics Complaint.
IV.
AGENCY RESPONSE TO A REPORT OF SUSPECTED VIOLATION
A. All reports of suspected ethics violations will be investigated. The procedures for the
suspected violation will be determined by the type of violation. Recipient Rights issues
will be investigated by the Office of Recipient Rights (as per Recipient Rights policies
and/or procedures in sections 24, 25 & 26). Regulatory Management (i.e., Medicaid
Fraud and Abuse) issues will be investigated by the Corporate Compliance Officer (as
Corporate Compliance policies and procedures in section 10). The HR Coordinator will
investigate other suspected code of conduct violations. In instances where the HR
Coordinator feels there would be a conflict of interest, or the scope of the investigation is
beyond his/her experience or expertise, the HR Coordinator will consult with the
Executive Director or the Corporate Compliance Officer on whether an outside party may
be needed to assist or complete the investigation.
B. At a minimum, such investigation will involve a review of written documentation and
supervisory interviews with the complainant, alleged violator and witness. The
investigation and report will be completed according the guidelines with the applicable
Recipient Rights or Corporate Compliance policies and procedures. In cases where there
are not timelines established, the investigation and report will be completed within 30
calendar days of the reported violation.
C. If the investigation finds that an ethics violation did occur, the agency may report such
violation to the violator’s certifying professional board or organization. Such a report
will be made if the employee’s misconduct is considered severe or if there is a pattern of
repeated violations.
D. The agency will, within the limits of state and federal law, cooperate with any
investigation that may be conducted by the police, other local state or federal agency or
certifying board or organization.
ATTACHMENTS:
Employee Code of Ethics
Employee Code of Ethics Acknowledgement
Page 3 of 6
COMMUNITY MENTAL HEALTH & SUBSTANCE ABUSE SERVICES
OF ST. JOSEPH COUNTY
RESPONSIBILITY TO COLLEAGUES
EMPLOYEE CODE OF ETHICS
I AFFIRM THAT:

I shall respect the rights and views of all of my fellow professionals and treat them
with fairness, courtesy and good faith.
RESPONSIBILITY TO CUSTOMERS
I AFFIRM THAT:

I shall not discriminate against or refuse professional services to anyone on the basis
of race, color, age, sex, marital status, physical or mental illness/disability, sexual
orientation, religion or national affiliation.

I do not use my professional relationship with current or former customers to further
my own interests including any personal funding raising, exchange of gifts, money, or
gratuity.

I shall be aware of my potential influence on students and co-workers and will not
exploit their trust.

I shall not engage in or condone any form of harassment or discrimination.

I shall respect the confidences of my co-workers.

When I replace a colleague or am replaced, I shall act with consideration for the
interest, character and reputation of the other professional.

If I see the customer of a colleague during a temporary absence or emergency, I shall
serve those customers with the same devotion and consideration as that afforded any
customer. If possible, I will have prior consultation with the colleague.

I shall continue therapeutic relationships only so long as it is reasonably clear that
customers are benefiting from the relationship.

I will maintain professional boundaries, avoid any conflict of interests and work in the
best interest of my current or former customers and help them help themselves


I will not engage in any personal relationship with current or former customers unless
I discuss it first with my supervisor as to its appropriateness.
If I have the responsibility for employing and evaluating the performance of other
staff, I shall do so in a responsible, fair, considerate and equitable manner.

If I know or suspect that a colleague has violated ethical standards, I shall report the
unethical activity to my supervisor, the Corporate Compliance Officer, Recipient
Rights Officer or the Human Resources/Payroll Specialist.

I commit to the “No Wrong Door” policy in assisting customers to obtain any services
they may need.

I will cooperate with the Office of Recipient Rights to protect current or former
customers’ rights.
RESPONSIBILITY TO AGENCY
I AFFIRM THAT:
CONFIDENTIALITY
I AFFIRM THAT:

I shall respect the privacy of customers and hold in confidence all information
obtained in the course of professional service. Therefore, I will not disclose
customer confidences to anyone except: (1) as mandated by law; (2) to prevent a
clear and immediate danger to a person or persons; (3) where I am a defendant in a
civil, criminal, or disciplinary action arising from the therapy (in which case
customer confidences may only be disclosed in the course of action); (4) if there is a
release previously obtained in writing, and then such information may only be
revealed in accordance with the terms of the release.


I shall work in a professional manner and uphold confidentiality towards colleagues,
job applicants and any sensitive issues arising within the agency. I acknowledge that
information may be released only under the Freedom of Information Act.
I, upon my termination, shall maintain customer and co-worker confidentiality and I
shall hold confidential information about sensitive issues within Community Mental
Health & Substance Abuse Services of St. Joseph County.
Page 4 of 6

I shall respect and use the property and resources of the agency only for the purposes
for which they were intended.

I shall fulfill any and all commitments made by me to the agency.

I shall adhere to agency policies, procedures and management decisions and will take
the initiative toward improvement of such policies, procedures and decisions when it
will better serve the best interest of my customers.

I shall support the integrity and reputation of the agency and its employees.

I will not use Social Media to cause harm or potential harm to this agency, its partners
or this community.

I shall respect the workplace as being drug free and will come to work free from the
influence of drugs, alcohol or any other substance.

In any situation where deemed necessary, I will regard the witnessing of signature to
be accurate and accountable and will not have any financial or other interest in
documents I witness for a customer.
STANDARDS OF CONDUCT

I shall comply with the agency’s Corporate Compliance Plan as to the requirements
of Medicare, Medicaid and all other federal health care programs

I will accurately record service provided and will report any potential or suspected
fraud, waste or abuse.

I will ensure that marketing materials (e.g. publications, descriptions of services)
reflect only the services available and accurate information about level of certification
and accreditation. Services, programs and outcomes will be accurately described in
an understandable manner.

I will abide by all federal and state statutes, regulations and/or administrative rules
applicable to any licenses and/or positions they hold, including, but not limited to, the
Michigan Department of Community Health’s administrative rules pertaining to
social workers, counselors and therapists.
PROFESSIONAL COMPETENCY
I AFFIRM THAT:

I shall accurately represent my education, training, experience, and competencies as
they relate to my profession.

I have a total commitment to provide the highest quality of service with the highest
standards of integrity..

I have a continuing commitment to assess my own personal strengths, my limitations,
my biases and my effectiveness.

I shall strive to become and remain proficient in the practice and performance of my
job duties.

I will witness (e.g., sign and date) documents according to standards and legal
requirements.

I will not attempt to diagnose, treat or advise on problems outside the recognized
bounds of my competence.

I shall seek appropriate professional assistance for my own personal problems or
conflicts that will impair my work performance and my judgment.
DISTRIBUTION:
Employee; Personnel File (acknowledgment of receipt)
BOARD APPROVED: July 25, 1989
FORMAT REVISED: May 11, 1995
BOARD APPROVED REVISIONS: 1/27/98; 7/29/03; 1/29/08; 4/26/11; 12/19/11; 3/14
I will acknowledge in writing the receipt of this Code of Ethics and that I understand the
expectations of the Agency.
Page 5 of 6
EMPLOYEE
CODE OF CONDUCT
COMMUNITY MENTAL HEALTH & SUBSTANCE ABUSE SERVICES
OF ST. JOSEPH COUNTY
EMPLOYEE CODE OF ETHICS ACKNOWLEDGEMENT
I have received and read the Employee Code of Ethics (REVISED July 2014) and
understand that employees of Community Mental Health & Substance Abuse Services of
St. Joseph County are expected to abide by and are held accountable to the Employee
Code of Ethics.
__________________________________
Signature of Employee
__________________________________
Printed name of employee
Page 6 of 6
___________________________
Date