450-1-9-5.4 Core organizational standards

(c) Personnel Policies and Procedures

EOMHC-LLC does not discriminate in hiring on the basis of age, race, national origin, religion, ethnicity, gender, sexual preference, or degree of disability.

Employees who have contact with consumers should have First Aid and (annual) CPR certificates. These shall be documented in the personnel file, and on the privileging form for those clinical staff trained in First Aid and CPR. Each EOMHC site shall have at least one staff member with training in First Aid and CPR.

(2) The Application Process:

Applicants will fill out an application for employment form prior to interviewing for a position. Applicants must provide social security number, an up-to-date resume, a copy of diploma(s) of earned degrees from educational institution(s), a certified copy of transcript, copies of certificates of training and continuing education, current copies of licenses or certifications, and written permission to contact a minimum of three references.

References will be checked prior to hire. Backgrounds checks may be done. Any deliberate falsification of qualifications will disqualify the applicant for hire.

New hires must be oriented to the policies and procedures of EOMHC-LLC, and be clinically privileged prior to providing direct consumer services. The Clinical Director and Administrator will be responsible for orientation and privileging new hires. Privileging shall take place as soon as possible after hire, but no later than 30 days from hire.

Provisional Period: New staff will have a review of their job performance 90 days from hire. Thereafter, reviews of job performance will occur annually.

Independent Contractor AND Employee worker requirements:

  •  Independent Contract OR Employee/Volunteer Worker Agreement

  •  Employment Emergency Data Sheet

  •  Signed Contractor/Employee Orientation Packet Checklist

  •  Copy of Drivers License

  •  Copy of Social Security Card

  •  Copy of Resume or Application for Employment

  •  Signed Independent Contract/Employee Worker Disclosure

  •  Non-Disclosure Agreement

  •  Copy of Licensure or Supervision Agreement

  •  Transportation of Clients Agreement

  •  Copy of Academic Transcripts

  •  Copy of any CPR Certification or First Aid Certification

  •  Workman’s Compensation Exemption Status Form

  •  Copy of Professional Liability Insurance: $1,000,000/$3,000,000

  •  Signed W-9 OR W-4 Form

  •  I-9

  •  Clinical Privileging Data

  •  Confidentiality Questionnaire

  •  Code of Business Conduct

  •  Personnel Action Form

  •  Job Description

  •  Background Check Fee of $40 (fee waivable, background check is mandatory)

Prior to Hire

  •  OSBI Background Check:

  •  IG background check

  •  Licensure/Supervision Verification

Provisional Period of Hire

When you are hired, transfer to a different position, or are promoted, you are subject to a provisional period of hire. For all staff members, the provisional period lasts three calendar months for all professional positions.

The provisional period gives you time to learn and adjust to your new position and allows the departmental administrator time to evaluate your suitability for the position. This is accomplished by conducting a performance appraisal at the midpoint of the provisional period. If additional time is necessary to make an assessment of performance, the supervisor may request an extension of the provisional period. This request must be submitted to the Office of Human Resources prior to the conclusion of the provisional period. If the departmental administrator determines that you are not suited for the position, you may be dismissed at any time during the provisional period, subject to a review of all relevant circumstances by the Office of Human Resources. If you are dismissed during your initial provisional period, including any extension of it, you will not be eligible to use the Informal or Formal Complaint Procedure. EOMHC does not permit the waiver of the initial provisional period for any reason other than for potential hires that have had prior work performance evaluated at previous facilities, at which time the HR director may waive the initial provisional period upon hire or anytime in duration.

Provisional Contractors will receive 68% of Medicaid billing received from OHCA providing that supporting documentation, Treatment Plans, Assessments, etc., are in respective client records on a weekly basis prior to payroll deadlines. Contractors that have met all requirements of the provisional hire period and provide evidence and continual maintenance of the following attributes shall receive 73% of Medicaid billing received by OHCA.

Provisional Employees providing therapeutic services will receive 55% of Medicaid billing received from OHCA providing that supporting documentation, Treatment Plans, Assessments, etc., are in respective client records on a weekly basis prior to payroll deadlines. Employees that have met all requirements of the provisional hire period and provide evidence and continual maintenance of the following attributes shall receive 58% of Medicaid billing received by OHCA.

Minimal New Hire Attributes include:

  • • Have full license (not under supervision)

  • • Work independently as evidenced by:

  • o Check email twice a week. Mondays and Thursdays

  • o Properly write own treatment plans.

  • o Properly write own notes weekly.

  • o Turn in billing on time with no time overlapping/minimal errors.

  • o Keep a log or calendar book of appointments.

  • o Keep Charts in proper order and updated on a weekly schedule.

  • o Keep Admin updated: quarterly reviews, etc.

  • o Highly attentive to confidentiality re: consumer, co-worker and company data.

  • • Do not have any publicly identifiable associations with EOMHC outside the guidelines or written policies provided by EOMHC or express public behavioral demeanor which may be construed as atypical as a mental health professional.

  • • Attend and be attentive at all meetings.

  • • Have knowledge of and follow all rules policies/procedures, contractual obligations of EOMHC and laws, rules, and applicable codes regarding Chapters 1, 15, 17, 18 and 50 of OAC 450 of Oklahoma Department of Mental Health and Substance Abuse Services, as well as, rules laws and codes regarding your licensure.

  • • Follow the chain of command.

  • • Work only at EOMHC where EOMHC is the only affiliation you possess a professional relationship with that may directly or indirectly conflict with another facility or organization competitive with EOMHC. Waiver of this ruling may be provided upon review.

  • • Show good-will and etiquette on a continual basis to consumers, as well as fellow staff members.

Employment Classification

EOMHC adheres to all guidelines and determinations regarding ‘Employees or Contractors’ set forth by the State of Oklahoma that may be found in part on the workmans’ compensation questionnaire form that is required to be filled out, signed, and notarized prior to hire/employment.

All regular, full-time ‘employees’ will have the benefits of employment practices prescribed by the laws of the State of Oklahoma, and the Federal government, including federal and state withholding, PICA and Medicare withholding, and unemployment insurance and workman's compensation. All reporting procedures will be followed within the time frames prescribed by law.

Contractor/Employee Grievances:

If an employee has a grievance, he/she may file a written grievance with the Administrator. An appropriate third party will be brought in to investigate the merits of the grievance within five business days. If it is amenable to both parties, the services of a mediator may be engaged. If the Administrator deems it appropriate, the executive committee of the Board may serve to respond to the grievance. Grievances, investigation and mediation shall take place within 30 business days. Resolution must take place within 60 days.

Terminations:

Termination of contract/employment for cause may take place after review of an contractors/employees employment history, reviews, and an administrative interview. There shall be a witness to any termination for cause. Written reprimands may be added to the personnel file to document a contractors/employees failure to follow policy and procedure. Subsequent contractor/employee behavior will be documented following a written reprimand within 30 days. Reprimands and documentation of subsequent contractor/employee behavior may be considered when termination for cause is being considered. The well-being of the consumers, the contractor/employee, and the agency will be considered when making terminations for cause. Plans of correction may be developed which address these issues, whether or not a contractor/employee is terminated.

Resignations and other terminations of employment are to be planned with the well-being and continuity of treatment of the consumer in mind. A smooth transition will be aimed for in re¬assignment or referrals for the consumers involved.

Continuing Education of contractors/employees is considered to be a part of the growth and development of the agency as well as that of a contractor/employee. Continuing education shall be planned for all staff. Clinical staff will use the Continuing education plan form annually to ensure that their licenses and/or certifications are planned for adequately. This will help ensure that new developments in the field of Mental Health, co-occurring, and addictions and substance abuse will be included in the growth and development of the programs of EOMHC-LLCthis section

(2) Current and complete copies of EOMHC-LLC personnel policies and procedures shall be available to staff at each service location. All employees shall have access to these personnel policies and procedures, as well as other rules and regulations governing the conditions of their employment and shall be provided upon employee orientation and during all hours of operation.

Professional Code of Ethics:

EOMHC acknowledges the personal dignity of all persons served/applicants and will guarantee the protection of the rights of person served and his/her family members. All staff will conduct themselves in a highly ethical manner to ensure that all services are provided in an appropriate, meaningful manner without violating rights of persons served. High standards of integrity and ethics are hallmarks of this Agency. It is the Agency's goal to provide quality professional services to persons served. Employees are encouraged to avoid misconduct, which could reflect unfavorably upon the Agency, and to avoid activities in conflict with their peers, persons served or Administration.

A In order for integrity and ethics to be characteristics of this Agency, staff is expected to be:

  1. 1) Honest and trustworthy in all activities

  2. 2) Responsible and reliable in carrying out assignments

  3. 3) Dedicated in service to persons served and to the improvement of their quality of life and well being

  4. 4) Truthful and accurate in all communication

  5. 5) Cooperative and constructive in all duties undertaken

  6. 6) Fair and considerate in treatment of co-workers, persons served, and all other persons

  7. 7) Law abiding in all activities

  8. 8) Committed to accomplishing all tasks in a professional manner

B Unauthorized, illegal, unethical or otherwise irresponsible disclosure of sensitive and confidential of persons being served, employee or financial information is strictly prohibited.

C No employee of this Agency shall poke fun, ridicule or in any way denigrate any person served because of his/her illness. All persons receiving services from a “facility” as defined in the Mental Health Law 43AOS Section l-1-3 (h) shall retain all rights, benefits, and privileges guaranteed by the laws and Constitution of the State of Oklahoma and the United States of America, except those specifically lost through due law.

D Every person served shall have the right to humane psychological environment that protects him/her from harm or abuse, provides reasonable privacy, promotes personal dignity, and functioning.

APA Code of Ethics

The code of ethics is a system of standards which has, as its primary goal, the welfare and protection of the individuals and groups to whom EOMHC-LLC employees provide service.

Respect

Employees respect the rights of others, including the right for consumers to make informed autonomous choices. Employees will not unfairly discriminate.

Non-Malfeasance

Employees do not cause harm through the delivery of their services.

Integrity

Employees are fair and honest in their work. They are faithful to their word and contractual obligations. They do not exploit or mislead.

Responsibility

Employees take responsibility for upholding professional standards of practice. They clarify their professional roles and obligations. They consult with, refer to, or cooperate with other professionals, particularly to prevent or avoid unethical conduct.

Beneficence

Employees provide services, which are of benefit, particularly to fostering positive growth of independence and problem solving skills in the recipients of their service.

Adapted from APA Code of Ethics

Code of Business Conduct

It is the policy of EOMHC-LLC that all full and part-time employees, contractors, students, volunteers (collectively referred to as “staff”), 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 EOMHC-LLC’s administrative operations and clinical practices, and both staff and members of the governing authority will be held fully accountable to these standards. In addition to the specific guidelines contained in the policy, professionals are expected to follow the ethical standards required by their specific licensing and certification boards. The Code of Conduct Policy is to ensure that all employees’ actions reflect a competent, respectful, and professional approach when serving our consumers, their families and/or representatives, working with other providers of services, and interacting within the communities we serve. It is expected that staff and members of the governing authority will perform their duties in compliance with all federal, state, and local regulations in accordance with guidelines set forth in this policy. Violation of guidelines within the Code of Conduct Policy can lead to disciplinary actions, including termination of employment.

Professional Conduct:

Staff will respect the rights of our consumers by demonstrating full integration of the guidelines contained in the Rights and Responsibility Policy. This includes the right of the consumer to make autonomous decisions and fully participate in every aspect of the service delivery process. EOMHC-LLC employees will provide services in a manner that fully respects the confidentiality of consumers, by demonstrating a functional knowledge of confidentiality policies and guidelines. EOMHC-LLC employees will be fair and honest in their work. They will not exploit or mislead, and will be faithful to their contractual obligations and their word. To prevent and avoid unethical conduct, EOMHC-LLC employees will consult with, refer to, and cooperate with other professionals. EOMHC-LLC employees will clarify their professional roles and obligations and be accountable for upholding professional standards of practice.

Personal/Professional Conduct:

All prior personal relationships between staff and persons entering the organization’s programs shall be disclosed by the staff member and subject to review by the appropriate supervisor. Staff will limit relationships with persons served to their defined professional roles. Staff will not establish ongoing personal or business relationships with consumers receiving services. Staff will conduct themselves in a professional, ethical, and moral manner. Sexual relationships between staff and people served are never appropriate. Sexual relationships include, but are not limited to the following: engaging in any type of 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. Staff will not accept gifts of value from a consumer, family member, or stakeholder, and cannot accept personal favors or benefits that may reasonably be construed as influencing their conduct. Staff will dress in appropriate professional manner while representing EOMHC-LLC or while visiting consumers.

Business Practices:

EOMHC-LLC will utilize the Corporate Compliance Officer to ensure that it conducts business in an ethical manner and ensure that any business practices that are questionable are thoroughly investigated the ethical investigation procedures that follow in this policy. All financial, purchasing, personnel, facility development and information technology practices shall comply with local, state, and federal law and guidelines. All employees shall adhere to EOMHC-LLC’s Human Resource Policies and Procedures.

Marketing Practices:

EOMHC-LLC will conduct marketing practices in an honest and factual manner. Marketing materials and practices will in no way mislead the public or misrepresent EOMHC-LLCs abilities to provide services. EOMHC-LLC will not claim any service outcomes unless represented by valid and reliable outcome data and/or research studies. EOMHC-LLC will utilize clear and consistent methods of communicating information to consumers, family members, third-party entities, referral sources, funding sources, and community members, and will exhibit sensitivity to the educational and reading levels of all persons when distributing information. EOMHC-LLC will not utilize monetary rewards or gifts to any potential consumer of services in an attempt to entice them to enter programs.

Clinical Practices:

Staff will adhere to all professional codes of conduct and ethical standards for his/her specified professional discipline. As part of new employee orientation, staff will read the organization’s Code of Conduct and demonstrate knowledge of the guidelines.

Potential Conflicts of Interest:

No consumer will be hired or placed in an employee/employer relationship with EOMHC-LLC while an active participant in programming. Any programming that involves a work task, and remuneration for the task, will be therapeutic in nature and will be documented as such by programming guidelines based on theoretical constructs. EOMHC-LLC employees will not engage in outside professional mental health services that are incompatible or in conflict with job duties within the organization. Private practice may be done on the staffs own time and outside the organization, as long as such activities are not adverse to the interests and goals of EOMHC-LLC and have met the organization’s guidelines on conducting a private practice. Staff will not recruit consumers for their private practice within their professional roles as EOMHC-LLC staff members. If an employee leaves EOMHC-LLC and enters private practice, the consumer may choose to continue their therapy with the former employee. However, the therapy must be offered at the same cost with accessibility to therapy. No staff shall engage in any other employment or activity on the organization’s premises or to an extent that affects, or is likely to affect, his or her usefulness as an employee of the organization.

Quality of Care:

EOMHC-LLC will provide quality behavioral health care in a manner that is appropriate, determined to be necessary, efficient, and effective. Health care professionals will follow current ethical standards regarding communication with consumers and their representatives regarding services provided. EOMHC-LLC will inform consumers about alternatives and risks associated with the care they are seeking and obtain informed consent prior to any clinical interventions. EOMHC-LLC recognizes the right of consumers to make choices about their own care, including the right to do without recommended care or to refuse care.

Necessity of Care:

EOMHC-LLC shall submit claims for payment to governmental, private, or individual payers for those services or items that are clinically necessary and appropriate. When providing services, EOMHC-LLC employees shall only provide those services that are consistent with generally accepted standards for treatment and are determined by the professional to be clinically necessary and appropriate. Service providers may determine that services are clinically necessary or appropriate; however, the consumers funding source may not cover or approve those services. In such a case, the consumer may request the submission of a claim for the services to protect his/her rights with respect to those services or to determine the extent of coverage provided by the payer. Coding and documentation will be consistent with the standards and practices defined by the organization in its policy, procedures; and guidelines.

Coding, Billing, and Accounting:

EOMHC-LLC employees involved in coding, billing, documentation and accounting for consumer care services for the purpose of governmental, private or individual payers will comply with all applicable state and federal regulations and organizational policies and procedures. EOMHC-LLC will only bill for services rendered and shall seek the amount to which it is entitled. Supporting clinical documentation will be prepared for all services rendered. If the appropriate and required documentation has not been provided, then the service has not been rendered. 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. Consumers shall be consistently and uniformly charged. Government payers shall not be charged in excess of the provider’s usual charges. Billing and collections will be recorded in the appropriated accounts. An accurate and timely billing structure and medical records system will ensure that EOMHC-LLC effectively implements and complies with required policies and procedures.

Cost Reports:

EOMHC-LLC 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. All cost reports will be submitted and prepared with all costs properly classified, allocated to the correct cost centers, and supported by verifiable and auditable cost data. All cost report preparation or submission errors and mistakes will be corrected in a timely manner and, if necessary, clarify procedures and educate employees to prevent or minimize recurrence of those errors.

Personal and Confidential Information:

EOMHC-LLC will protect personal and confidential information concerning the organization’s system, employees, and consumers. EOMHC-LLC personnel shall not disclose confidential consumer information unless at the consumer’s request and/or when authorized by law. Appropriate use of consumer information for research purposes must be obtained with the full informed consent of participants in the research. Confidential information will only be discussed with or disclosed to persons and entities outside the organization through the request of the consumer. Persons outside the organization include the family, business, or social acquaintances of the consumer. Consumers can request, and are entitled to receive copies or summaries of their records with the exception of minors and consumers being treated for alcohol and drug abuse, or any consumer, if it is judged appropriate by the provider charged with their care. EOMHC-LLC personnel will be familiar with all organizational policy and procedures regarding confidentiality.

Creation and Retention or Consumer and Institutional Records:

Records are the property of the organization. Personnel responsible for the preparation and retention of records shall ensure that those records are accurately prepared and maintained in a manner and location as prescribed by law and organizational policy. Employees will not knowingly create records that contain any false, fraudulent, fictitious, deceptive, or misleading information. Employees 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 record the actual date that the additional entry was made. Employees will not sign someone e1se’s signature or initials on a record. Records shall be maintained according to specific organizational policy and procedure. Employees shall not destroy or remove any record from the organization’s premises. The organization will maintain record retention and record destruction policies and procedures consistent with federal and state requirements regarding the appropriate time periods for maintenance and location of records. Premature destruction of records could be misinterpreted as an effort to destroy evidence or hide information.

Government Investigation:

EOMHC-LLC employees and contractors shall cooperate fully with governmental investigations and audits. EOMHC-LLC will respond in an orderly fashion to the government’s request for information through employee interviews and documentation review. The organization will respond to the government’s request for information in a manner that enables the organization to protect both the organization and consumer's interests, while cooperating fully with the investigation.

When a representative from a federal or state agency contacts an EOMHC-LLC employee or contractor 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 or Operations Officer is not available, the individual will contact the Site Director. EOMHC-LLC employees will ask to see the government representative’s identification and business card, if the government representative presents in person. Otherwise, the employee should ask for the person’s name, office, address, phone number, and Identification number and then Contact the person’s office to confirm his/her identity.

Prevention of Improper Referrals or Payments:

EOMHC-LLC employees will not accept, for themselves or for the organization, anything of value in exchange for referrals of business or the referral of consumers. Employees must not offer or receive any item or service of value as an inducement for the referral of business or consumers. 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 particular behavioral health care provider. The organization shall establish procedures for the review of all pricing and discounting decisions to ensure that appropriate factors have been considered and that the basis for such arrangements is documented. Development or initiation of joint ventures, partnerships, and corporations within the organization must be reviewed and approved by the organization’s management to ensure compliance with organizational policy and federal regulations.

Antitrust Regulations:

EOMHC-LLC will comply with all applicable federal and state antitrust laws. Employees should not agree or attempt to agree with a competitor to artificially set prices or salaries, divide markets, restrict output, or block new competitors from the market, share pricing information that is not normally available to the public, deny staff privileges to qualified practitioners, or agree to or participate with competitors in a boycott of government programs, insurance companies, or particular drugs or products.

Avoiding Conflicts of Interest

All EOMHC-LLC employees shall conduct clinical and personal business in a manner that avoids potential or actual conflicts of interests. Employees 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. Employees 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:

  • • 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, payers, carriers, and fiscal intermediaries.

  • • Using EOMHC-LLC facilities or resources for other than organization sanctioned activities.

  • • Using EOMHC-LLC’s name to promote or sell products or personal services.

  • • Contracting for goods or services with family members of the organization directly involved in the purchasing decision.

External Relations:

EOMHC-LLC employees shall adhere to fair business practices and accurately and honestly represent themselves and the organization’s services. EOMHC-LLC employees will be honest and truthful in all marketing and advertising practices pertaining to the business practices of the organizations service delivery system.

Vendors who contract to provide goods and services to the organization will be selected on the basis of quality, cost effectiveness and appropriateness for the identified task or need, in accordance with organization policy.

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