Code of ethics

ETHICS

POLICY:

All Serenity Lane staff members* shall perform their duties in the context of this Code of Ethics and shall observe all relevant rules, laws and standards.

*This policy applies to all staff members. In the context of this policy, that includes employees, contractors, volunteers, as well as students (students include but are not limited to interns, residents or others doing practicum rotations from other agencies, and other outside institutions such as schools of medicine, counseling, nursing, psychology and the like).

DEFINITION:

A “Direct Contact" staff member is defined as a staff member who provides direct medical or therapeutic services to patients. These staff members are licensed and/or certified by an Oregon licensing or certification board.

I. Procedures:

1. All staff members will receive an orientation by the Human Resources Director, or designee, to this Code of Ethics and document their willingness to abide by these principles as a condition of employment.
2. The Compliance Committee of Serenity Lane shall review this Code of Ethics annually for continued relevancy and make revisions as indicated.
3. Admitted patients will receive an orientation to their rights, including their right to receive ethical care and to problem solving procedures should they perceive the need. This orientation shall be documented in the patient record.
4. This Code of Ethics is available to all stakeholders upon request.
5. Patients will be advised of the channels that are available to them for reporting ethical violations in the patient handbook and in the orientation session.

II. Confidential Information

The use of confidential information obtained from being employed by Serenity Lane must be limited to the proper conduct of Serenity Lane’s business. All information about our patients is confidential and must never be disclosed to outsiders, except with the patient's written authorization or as allowed under federal and/or state law. Neither Serenity Lane nor any member of the Board of Directors or the staff may use, or permit others to use, confidential information for the purpose of furthering a private interest or as a means of making a profit.

III. Responsibility to Patients

This principal refers to practices and procedures of individual and/or group counseling relationships.

1. The primary obligation of Serenity Lane’s staff members is to respect integrity of the professional relationship with the patient. In a group setting, staff members are also responsible for taking reasonable precautions to protect individuals from physical and/or psychological trauma resulting from interaction within the group.
2. The counseling relationship and information resulting from this relationship must be kept confidential and consistent with the obligations of all Serenity Lane staff. In a group counseling setting, the facilitator must set a norm of confidentiality regarding all group participants’ disclosures.
3. If a patient is already in a counseling relationship with another professional, staff members must attempt contact with that professional after obtaining a proper authorization to disclose protected health information for the exchange of relevant information regarding the patient in question. The contact, or the attempts to contact, shall be documented in the clinical record.
4. When the patient’s condition indicates that there is a clear and imminent danger to the patient or others, staff must follow Serenity Lane’s Duty to Warn and Mandatory Reporting policy and procedure.
5. The solicitation or acceptance of commissions, fees, or anything of monetary value on the part of a staff member from patients, suppliers, or any other source as compensation for services routinely rendered to patients is not permitted.
6. Records of the counseling relationship including interview notes, test data, correspondence, progress notes, and other documents are to be considered professional information for use in counseling and they are a part of the records of Serenity Lane.
7. Revelation to individuals or organizations of a patient’s protected health information shall occur with the written consent of the patient, unless the state or federal government allows or requires release of the information without the patient's written consent. Patients are given a copy of Serenity Lane's Notice of Privacy Practices which describes how clinical information about them may be used and disclosed with and without their written authorization.
8. Use of data derived from a counseling relationship for purposes of counselor training or research shall be confined to content that can be disguised to ensure full protection of the identity of the patient.
9. In recognition of the fact that the relationship between staff members and patients is one in which the utmost discretion, good judgment and ethical behavior is of paramount importance, certain restrictions as to the scope of that relationship need to be carefully and strictly outlined and adhered to by all staff. This needs to be done to ensure the relationship’s integrity and therapeutic soundness. Therefore, activities such as in-kind payment for services (i.e. a patient offering free meals at his or her restaurant to a counselor in exchange for counseling services), and financial transactions between staff members and patients such as lending/borrowing money, entering into loan agreements, formation of social relationships secondary to the ongoing therapeutic relationship, or the sponsoring (as in the practice of 12-Step groups and others) of active patients are all considered to be unethical and are not to be engaged in by the staff member or students. Giving or lending items to patients such as tobacco products is also prohibited for all staff. Similarly, if any staff member becomes aware of a colleague engaging in such activities, it is his or her responsibility to bring such issues and concerns to the President/CEO, or the CFO, or designee immediately. Serenity Lane’s Compliance Officer must also be notified.
10. Serenity Lane does not accept monetary or in-kind donations from current patients without permission from the President & CEO.

IV. Ethical Conflicts

1. If a staff member determines an inability to be of professional assistance to the patient, or perceives an ethical conflict, the staff member must bring this situation and its concerns to supervisor and Compliance Officer. Outside counsel may be sought to determine the most appropriate action to be taken.
2. Staff members who have relatives, close friends, and/or business acquaintances who become Serenity Lane patients will excuse themselves from taking an active part in the treatment of the individual while involved with Serenity Lane. This is necessary to ensure objectivity in the service to such individuals.

V. Responsibility to Colleagues

Serenity Lane staff members should treat colleagues with respect, courtesy, fairness and good faith.

1. Staff members should cooperate with colleagues to promote professional interests and concerns.
2. Staff members should respect ethical confidences shared by colleagues in the course of their professional relationships and transactions.
3. Staff members should create and maintain conditions of practice that facilitate ethical and competent professional performance by colleagues.
4. Any staff member having knowledge of unethical practices on the part of another colleague shall report such practices to Serenity Lane’s President/CEO, or the CFO, or designee. Serenity Lane’s Compliance Officer must also be notified.
5. Staff members who replace or are replaced by a colleague in a professional practice should act with consideration for the interest, character, and reputation of that colleague.
6. Staff members should extend to colleagues of other professions the same respect and cooperation that is extended to their staff colleagues.
7. Staff members may not use the workplace for proselytizing for religious, political, or economic purposes.
8. Staff members may not record the conversation of another staff member without his or her full knowledge and consent. Undisclosed electronic recordings of staff members’ risks violation of patient privacy and is disruptive to staff morale, can limit open communications, and is inconsistent with respectful treatment required of our staff. Secret conversations are strictly prohibited unless authorized in writing by legal counsel. No staff member may record, by any means, a conversation with another staff member unless all of the following criteria are met:
   • A legitimate purpose for the recording.
   • A recording device in plain view.
   • Written authorization from the person you wish to record.

VI. Responsibility to Serenity Lane

Serenity Lane staff should adhere to commitments made to Serenity Lane.

1. Staff members should work to improve Serenity Lane’s policies and procedures, as well as the efficiency and effectiveness of its services.
2. All staff members should act to prevent discrimination of any kind at Serenity Lane. When serving in the capacity of a supervisor, leadership should act to prevent and eliminate discrimination at Serenity Lane in work assignments and its employment policies and practices.
3. Staff members should use the resources of Serenity Lane with scrupulous regard, and only for the purpose for which they are intended.
4. Staff members should respect and safeguard the personal property of patients, family members and other stakeholders as well as Serenity Lane Property.
5. Staff members should adhere to Serenity Lane’s Compliance program.

VII. Business Transactions

All staff members should avoid representing Serenity Lane in any transaction with any person, firm, corporation, or organization with which the staff member, or any member of the staff member’s family, has any material connection or in which he or she owns a substantial interest. Any such conflict needs to be brought to the attention of his or her supervisor.

Staff members who serve as an officer or a board member of any other organization, corporation, association, government entity, etc. shall not represent Serenity Lane in any transactions with that same organization, corporation, association, or government entity in any contractual relationship without specific approval of the President/CEO, or the CFO, or designee.

All transactions with outside suppliers should be conducted at arm’s length and in the best interest of Serenity Lane. Decisions should be governed by a customer-business relationship and not by personal friendship.

1. Civic Activities:  Active participation by staff members in religious, community, professional or charitable organizations is encouraged. Approval is not required to participate in or accept appointment as a trustee, director, or officer of a non-profit organization unless there is some other potential conflict of interest between the organization and Serenity Lane.
2. Political Activities: A staff member may participate in political activities in his or her own time and in accordance with his or her individual desires and political preferences. However, it must always be clear that a staff member’s participation is done as an individual and not as a representative of Serenity Lane. Before a staff member becomes a candidate or appointee to a public office, the staff member must advise the President/CEO, or the CFO.
3. Proprietary Knowledge: No staff member will share knowledge, facts, reports, written documents regarding Serenity Lane methods, procedures, or operations etc., without the expressed consent of the President/CEO, or the CFO, or designee.
4. Personal Fundraising: No staff member shall utilize Serenity Lane’s resources for personal fundraising without approval of the President/CEO, or CFO, or designee.

Because the primary responsibility of Serenity Lane’s staff members is to provide clinical services to Serenity Lane patients in accordance with best practices in addiction and mental health treatment, Serenity Lane discourages such outside activities as facilitation of outside therapeutic groups, or any other activity that proves to be adversely affecting the staff member’s job performance at Serenity Lane. It is the obligation of every staff member when contemplating participating in such outside activities, to first bring these issues to the President/CEO, Compliance Officer, or the CFO for consideration and appropriate recommendations.

VIII. Marketing Ethics

The Serenity Lane Marketing Department, in addition to supporting and obeying laws and legal regulations pertaining to marketing and advertising, extend and broaden the application of high ethical standards. Specifically, they will not knowingly make marketing claims or create advertising that contains:

1. False or misleading statements or exaggerations.
2. Testimonials that do not reflect the real opinion of the individual(s) involved.
3. Price claims that are misleading.
4. Claims insufficiently supported or that distort the true meaning of practicable application of statements made by professional or scientific authority.
5. Statements, suggestions or graphics offensive to public decency or minority segments of the population.

They recognize there are areas that are subject to vastly different interpretations and judgment, nevertheless, they are determined not to use advertising that is in poor or questionable taste or that is deliberately insensitive.

These principles are based on the belief that sound and ethical practice is good business. Confidence and respect are indispensable to our success and our relationship with clients and the public at large is dependent upon good faith.

IX. Outside Conflicts of Interest

No outside activity must interfere or conflict with the interest of Serenity Lane. Acceptance of outside employment, election to directorships of other organizations, and participation in the affairs of outside organizations carries with it the possibility of a conflict of interest and shall be discussed with the President/CEO, or the CFO, or designee. Serenity Lane’s Compliance Officer must also be notified.

No staff member of Serenity Lane will be a director or officer of any other treatment facility or any other entity, which competes directly or indirectly with Serenity Lane without prior approval of the President/CEO, or the CFO, or designee. Serenity Lane’s Compliance Officer must also be notified.

Directors and Officers of Serenity Lane will be required to complete a Conflict-of-Interest Disclosure Form annually. The signed form will be kept in the signatory’s personnel file in Human Resources.

All staff members must report any known conflicts of interest to the President & CEO and Compliance Officer upon hire or discovery of a potential conflict. The Compliance Officer will collaborate with any staff member, as needed, to help determine a means to minimize the impact. The presence of a conflict is not necessarily wrong; it is when the conflict is either not disclosed, or not professionally managed that a situation of wrongdoing is created.

Specified types of outside activities that create a conflict of interest or other difficult situations include, but are not limited to:

1. Being employed or contracted by a business, or personally engaging in any activity that is competitive with Serenity Lane without specific approval of the President/CEO, or the CFO, or designee. Serenity Lane’s Compliance Officer must also be notified.
2. Using Serenity Lane equipment, supplies, files, letterhead, or facilities for purposes other than Serenity Lane related activities.
3. Personal conduct involving the use of mood-altering substances; gambling or other activities during or outside of work hours which may prove embarrassing or reflect adversely upon Serenity Lane or any staff member during the performance of his or her duties at Serenity Lane.
4. Statements or circumstances that may imply sponsorship or support by Serenity Lane of an outside employer or of a political, charitable, civic, religious, or similar organization when such is not the case.

X. Professional Competence and Integrity

Serenity Lane staff members must be dedicated to maintaining high standards of both professional competence and integrity and will do the following:

1. Staff members who are: convicted of felonies, convicted of misdemeanors, engage in conduct which could lead to conviction of felonies or misdemeanors related to their qualifications or functions, expelled from other professional organizations, or subject to suspension or revocation of their license or certification must report such activities or actions immediately to the President/CEO, CFO, or designee. Serenity Lane’s Compliance Officer must also be notified. Serenity Lane’s Compliance Officer is responsible for ensuring reporting to external subcontractors in compliance with network agreements (for example, Umpqua Health Alliance).
2. All former Serenity Lane patients who seek to become employed, contracted with, or enrolled in the CIT program must have at least 1 year since being discharged in good standing from Serenity Lane. Any variation requires approval from the President & CEO, or designee, and the Clinical and/or Mental Health Director respective to the program and/or department they supervise. Variations from the one-year requirement are exceptions, not the norm. This requirement does not exclude any patient or former patient from participation in Serenity Lane’s Alumni Program.
3. All former Serenity Lane patients who are accepted into the CIT program, become employed, or perform contract work for Serenity Lane should not have any former Direct Contact staff member as a direct supervisor for at least 2 years since discharge from Serenity Lane without approval from the Clinical and/or Mental Health Director respective to the program and/or department they supervise.
4. Staff members will seek appropriate professional assistance for their own personal problems or conflicts that are likely to impair their work performance or their clinical judgment.
5. Staff members will not engage in sexual relationships with current patients at any time.
6. Staff members or students who have direct contact with a particular patient or former patient of any Serenity Lane program shall not have, seek, or request a sexual relationship or sexual contact with that patient or former patient at any time.
7. Staff members who have not provided Direct Contact services to a patient or former patient of any Serenity Lane program should not have, seek, or request a sexual relationship or sexual contact with that patient or former patient for a period of at least two years following that patient’s receipt of Serenity Lane services.
8. All staff members shall not have or seek to have a personal, professional, or business relationship with any former patient for at least two years without consulting with the President & CEO, CFO and/or Compliance Officer.
9. Relationships between staff members and current or former patients or clients within Twelve Step recovery fellowships and other fellowships are sometimes unavoidable. In such cases, the relationships are to be maintained at a group level rather than a one-on-one level. These guidelines apply to the time a current or former patient participates in any Serenity Lane program and for the period established for personal relations as noted above.
10. Staff members will not engage in verbal, emotional or behavioral harassment of patients or colleagues.
11. Staff members will not attempt to diagnose, treat, or advise on problems outside recognized boundaries of their competence.
12. Under no circumstances, other than noted above, is a staff member ever to meet a patient, former patient, or patient family member, outside of Serenity Lane property unless participating in a Serenity Lane sanctioned activity. Additionally, no staff member may ever give a patient, or patient family member, their cell phone number, home phone number, email address or any other means of contacting them outside of Serenity Lane, including texting or social media resources (i.e. Facebook, Google Plus, Twitter, Tumblr, Snapchat, imgur, Pinterest, Instagram, YouTube, etc.) while the patient is active in treatment and/or within two-year period following the patient’s discharge from treatment. No staff member may give a patient or patient family member any other past or current staff’s personal contact information. Extenuating circumstances such as family member or associate known prior to beginning treatment may be an exception to this policy and counsel shall be sought from the President/CEO, or CFO, or designee regarding appropriateness of actions.
13. Staff members will attempt to prevent the distortion or misuse of their clinical findings.
14. Staff members will be aware that because of their ability to influence and alter the lives of others, they must exercise special care when making public their professional recommendations and opinions through testimony or other public statements.

XI. Responsibility to the Profession

Staff members respect the rights and responsibilities of professional colleagues; and participate in activities which advance the goal of the profession.

1. Staff members respect the rights and responsibilities of professional colleagues and participate in activities which advance the goal of the profession.
2. Staff members remain accountable to the standards of the profession when acting as members or employees of organizations.
3. All staff members that are involved with a professional organization, such as counseling and or medical, must understand and be in compliance with the ethical standards of that organization. Services must be provided within staff members’ scope of license or certification. The Medical Director, Director of Medical Operations, Mental Health Director, Clinical Director, or designee shall ensure providers are appropriately supervised according to their scope of practice.
4. Staff members must maintain their licenses and certifications/credentials in active and good standing order. If during employment at Serenity Lane, a provider’s license or credentials status changes and is not in good standing, they are required to report immediately to the Compliance Officer, Credentialing Coordinator, or President & CEO.
5. Staff members who have been excluded from Federal programs may not be employed or contracted with Serenity Lane. Serenity Lane screens employees and contracted employees at hire and, on a monthly basis thereafter, against Federal exclusion databases.
6. Staff members are encouraged to participate in activities that contribute to a better community and society.
7. Staff members are encouraged to assist with developing laws and regulations pertaining to their field that serve the public interest, and with sharing concerns about such laws and regulations that may not be in the public interest.
8. Staff members recognize the need for continuing education and are open to new procedures and changes in expectations and values over time.
9. Staff members recognize that personal problems and conflicts may interfere with professional effectiveness. Accordingly, they refrain from undertaking any activity in which their personal problems are likely to lead to inadequate performance or harm to a patient or colleague is the staff member’s or student’s obligation to bring any interference to the attention of his or her immediate supervisor so that a determination can be made as to whether they should suspend, terminate or limit the scope of their professional activity.

XII. Witnessing of documents

Unless approved by the President/CEO, or the CFO, or designee, no staff member shall act as witness to any document, for example, a will or advance directive, for a patient. See Notary Services Policy for more information.

XIII. Candor with Management, Auditors, and Counsel

Staff members are expected to maintain complete and open communication with management regarding Serenity Lane matters. Any staff member deliberately concealing information or misleading management, auditors, or counsel shall be sanctioned up to dismissal and referral to a prosecutor for possible criminal justice action.

XIV. Medicaid Fraud, Waste and Abuse (FWA)

All of Serenity Lane’s programs are supported by either State or Federal dollars. Staff members need to be aware of our Compliance Program, including our policies for: Reporting and Investigating Unethical Behavior: Medicaid Fraud Waste and Abuse (FWA).

Any person may openly or anonymously report any ethical concern or question, or any potential or actual legal or financial violation including fraud, waste, and misuse of resources, or accounting, auditing or record-keeping matters to the Compliance Officer. For reports that are not made anonymously, confidentiality will be maintained to the extent possible while permitting an appropriate investigation. Please review policy in full.

XV. Implementation of the Code of Ethics

Difficult questions of judgment may arise in connection with this Code of Ethics. If any doubt exists regarding the propriety of an action or activity, the staff member should seek advice and written approval from the President/CEO, or the CFO, or designee. All staff members are expected to promptly report the existence of any of their relationships, interests, or actions, which might violate or appear to violate this Code of Ethics.

XVI. Violations of the Code of Ethics

Any suspected violations of this Code of Ethics shall be referred to the President/CEO, or the CFO, or designee. Serenity Lane’s Compliance Officer must also be notified. Violations of any component of the Compliance Program, including but not limited to this Code of Ethics may be grounds for disciplinary action, up to and including dismissal and referral to a prosecutor for possible criminal justice action. In situations where infractions of the Code may have violated federal or state law, such infractions will be disclosed as appropriate and reported to enforcement agencies as required. Serenity Lane adheres to a no-reprisal approach for reporting violations or suspected violations. Violations or suspected ethical violations will be investigated and responded to within 30 days, apart from an ongoing or pending criminal investigation.

 

Revised: 9/2024