Community Mental Health &
Substance Abuse Services
of St. Joseph County
Operating
Procedure
Subject:
Human Resources
Ethics Complaint
Application:
16.17
All Departments
Effective
8/24/94
Reviewed
6/30/99, 4/26/01
1/5/05, 1/25/10
Revised
5/6/98, 5/24/05
3/18/08, 5/9/11
02/02/12, 10/17/13
Approved
PURPOSE: To regulate the reporting of a potential ethics violation and to assist in the proper investigation
and resolution of the matter.
POLICY:
Community Mental Health & Substance Abuse Services of St. Joseph County will adhere to the following
procedure to assure the purpose is met.
PROCEDURE:
I.
Report within the Agency
A.
If an employee believes he or she has been subjected to or witness to unethical conduct, as
defined by the agency, State or Federal regulations, or a widely recognized professional
organization (e.g., NASW, APA, AAMFT), he or she will report such conduct to his or her
immediate supervisor.
B.
If the alleged violator is the employee's immediate supervisor, then he or she will report such
conduct to that supervisor's immediate supervisor.
C.
The employee may, if he or she so chooses, make simultaneous report of suspected
unethical conduct to any or all of the following: supervisor of the employee, the Human
Resources Coordinator, the suspected violator, and witnesses. In instances where there may
be a conflict of interest at the supervisory level, it is expected that the employee will make
such disbursement of reporting. A conflict of interest may be defined as one of the following:
1. One's immediate supervisor is related to one or more of the involved parties by blood or
marriage, or is engaged in a romantic relationship with one of those parties.
2. The alleged violator, witness, or victim is in a supervisory position to one's own immediate
supervisor.
II.
Report Outside of the Agency
A.
If the subject of alleged unethical conduct believes that such conduct also violates State or
Federal law, he or she may file a complaint with the proper authorities.
B.
An employee who is subjected to or witness to alleged unethical conduct may, if he or she so
chooses, make a report to the suspected violator's certifying professional board or
organization, if there is one.
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Operating Procedure
16.17 Subject: Human Resources/Ethics
Complaint/
II.
Protection of Employee Reporting a Violation
Employees are expected to report violations or suspected violations and there is to be no retaliation or
retribution to the employee who reports a violation, participates in hearings, investigations, legislative
inquiries, or court action.
III.
Agency Response to a Report of a Suspected Violation
A.
IV.
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 (refer to the Recipient Rights policies).
Regulatory Management (i.e., Medicaid Fraud and Abuse) issues will be investigated by the
Corporate Compliance Officer according to the Risk Management policy. The HR
Coordinator will investigate other suspected code of conduct violations. In instances where
the investigating person believes there would be a conflict of interest, or the scope of the
investigation is beyond his/her experience or expertise, the Corporate Counsel or an outside
party may be asked 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.
C.
If investigation finds that an ethics violation did occur, disciplinary action will take place that
is consistent with the severity of the violation and the principles of progressive discipline. A
severe violation of ethical standards may result in immediate discharge from employment.
D.
If investigation finds that an ethics violation did occur, the agency may report such violation to
the violator's certifying professional board or organization. Such report will be made if the
employee's misconduct is considered severe, or if there is a pattern of repeated violations.
E.
The agency will, within the limits of State or Federal law, cooperate with any investigation that
may be conducted by the police, other State or Federal agency, or certifying board or
organization.
Examples
The following is a list of examples of unethical conduct arranged in descending order of approximate severity.
Infractions toward the top of the list can be expected to result in severe disciplinary action up to and including
immediate discharge from employment. Those toward the bottom of the list would most likely lead to
sanctions of lesser severity.
This list should not be considered comprehensive or exhaustive, and is instead provided as a general
guideline to the parameters of ethical conduct and the severity of misconduct. Similarly, actual disciplinary
action will depend upon a variety of factors, including the particular circumstances of the immediate offense,
the concept of progressive discipline, and the employee's status with the agency.
1.
A professional or direct care employee engaging in intimate relations with a current or former
client under his or her care, which may include dating or sexual encounter.
2.
Unauthorized release of confidential client information, which clearly lacks good faith and
best interest of the client, and is not supported by the most liberal interpretation of law.
3.
Physical or sexual assault, stalking, or extortion of a current or former client, or engaging in
threats to do so.
4.
Felonious assault of a fellow employee on work time, at an agency site, or at an agency
function.
5.
Embezzlement from the agency.
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Operating Procedure
16.17 Subject: Human Resources/Ethics
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6.
Falsification of personnel or employment records for the purpose of deception regarding
identity, experience, education, credentials, or background.
7.
Undermining the relationship or work between therapist and client.
8.
Creating, spreading, or supporting rumors that malign or degrade a fellow employee within
the agency.
9.
Making comments to other providers or agencies that malign or degrade the reputation or
professional status of a fellow employee, (this does not include reporting alleged misconduct
to the police or an employee's licensing board).
10.
Misdemeanor assault of a fellow employee on work time, at an agency site, or at an agency
function.
11.
Borrowing a possession of one's current or former client for personal use.
12.
Making rude, derogatory, or sexually suggestive comments to a current or former client.
13.
Making rude, derogatory, or sexually suggestive comments to a fellow employee.
14.
Accepting a gift of substantial material worth from a current or former client.
15.
The repeated submission of unfounded nuisance complaints against fellow employees.
REVIEW:
Annually by the Human Resources Coordinator and/or the Executive Director.
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