Code Of Conduct

Mission -Rockland Hospital Guild, Inc. (RHG) is a not-for-profit agency providing housing and support services to individuals living with a serious and persistent mental illness, so that they may transition to a productive and permanent setting in the community. We are licensed by the New York State Office of Mental Health to provide these services.  RHG is committed to providing the highest quality residential care and services to our recipients, and to conduct business with integrity and in compliance with all  applicable federal and state laws and regulations.

Intent -This Code of Conduct is a guide for employees/interns, Board members, and consultants of RHG, and is a resource for performing your duties and responsibilities consistent with appropriate ethical, professional, and legal standards. These obligations apply to relationships with program participants and their family members, providers/colleagues, members of the community, fellow employees, consultants, vendors, Board Members, and contractors. This Code is the foundation of our Corporate Compliance Program. It has been developed to ensure that ethical and professional standards are met, and to comply with applicable funding requirements, laws, and regulations. While this Code is intended to be comprehensive and easily understood, it may not fully cover a particular subject. In many cases, a subject may be complex and additional guidance may be necessary to provide sufficient direction. Employees are encouraged to seek out guidance from a supervisor or the compliance officer. This Code of Conduct is mandatory and must be followed.

Ethics -It is RHG policy to abide by all laws and regulations applicable to its business and to conduct business with the highest degree of integrity and ethical standards. To this end all employees and consultants must comply with all  laws, regulations, and policy that govern their work, and act in the best interest of the individuals we serve, and the greater community. Employees must report any alleged violations of this Code and assist our compliance and management team in investigating alleged and suspected violations.While all RHG employees are obligated to follow our Code of Conduct, we expect our leaders and managers to set the example and to be a model.  They should help to create a culture within RHG that promotes the highest standards of ethical conduct and compliance. This culture must encourage everyone in the organization to identify and raise concerns when they arise. Employees who are members of professional disciplines (Nurses, Social Workers, Mental Health Counselors, MD’s, etc.) must adhere to their professional code of ethics, ethical guidelines, and standards of practice. Employees must provide services only within the scope of their professional training, competence, and expertise.

Conflict of Interest-All RHG employees, Board members, consultants, and contractors shall avoid situations where their personal interests could conflict, or appear to conflict, with their responsibilities, obligations, or duties to RHG. No employee shall use their position and affiliation with RHG for personal benefit, apart from the normal compensations provided through employment. All employees are required to follow the RHG’s Conflict of

Interest Policy, and to contact the Corporate Compliance Officer with any questions or conflicts regarding personal interests. All employees are required to disclose any financial interest that they, or any immediate family member may have in any establishment that does business with RHG, to the Compliance Officer or their Supervisor. All employees are required to complete the Conflict of Interest Disclosure Statement annually.

Outside Activities and Employment- Employees must not conduct non–RHG related or personal activities during their work hours. Any such activities may negatively impact the quality of your work and ability to provide care to our residents. Outside employment must not conflict with your responsibilities to RHG, with your work hours, or duties to the individuals we serve.  Decisions of admission, discharge, and service provision for our recipients should not be based on any outside employment.

Use of Agency Resources- Agency funds, equipment, supplies, business information, and other RHG assets are to be used only on the recipients we serve, for providing services to those we serve, and in the course of business. Employees are strictly prohibited from using RHG funds and assets for their own personal use or gain, and from giving RHG assets to any other entity except in an approved transaction or in the ordinary course of business.

 Confidentiality  -Identifying and Confidential Information - All employees shall maintain the confidentiality of information and documents of individuals we serve in accordance with Health Insurance Portability and Accountability (HIPAA) and related statutes. Medical, clinical, or business information shall be released only to persons authorized by law or by the client’s written consent.

RHG employees, affiliated treatment providers, or other care providers shall be provided with the minimum amount of information necessary to provide care (HIPAA ‘minimum necessary rule’).

During the course of employment an employee may have knowledge of confidential and protected information about a recipient of services. Except as otherwise required by law, identifying and confidential information on individuals we serve shall not be released without an appropriately signed “Authorization to Disclose Confidential Information”. 

Employees shall follow all federal and state regulations, including but not limited to the HIPAA Privacy and Security rules and shall follow RHG’s Privacy Policy. Any breach of federal and state regulations may result in disciplinary action up to and including termination of employment.

Disclosure of Business and Personnel Information - Except as otherwise required by law (e.g. the Freedom of Information Act), protected personnel information and business information about the operations of RHG acquired by employees from any source shall be disclosed within RHG only, on a need-to-know basis, and solely for purposes related to the performance of job duties. Such information may be disclosed outside the agency only as permitted or required by law and RHG policy.

Responsibility to Individuals We Serve

Each RHG employee, volunteer, and contractor has an obligation to:

  • Treat individuals we serve and their family members with dignity and respect.
  • Not discriminate based on race, color, national origin, ancestry, religion, age, sexual orientation, gender, marital status, physical or mental handicap by an employee or volunteer in the provision of services, including admission to and discharge from services.
  • Not base service decisions on the resident’s funding source or benefits, or on billing for services.
  • Provide persons served and their families with all information concerning services and treatment when and to the extent required by applicable Federal and State laws and regulations, and by sound clinical practice.
  • Protect individually identifiable health information from unauthorized use or disclosure except as required or permitted by law.
  • Report suspected abuse and neglect as required by law.
  • Protect resident’s rights and furnish services in a manner that does not violate their legal rights as defined in Residents Rights (14 CRR-NY 595.10)
  • Not have relationships of a sexual or romantic nature of any kind with a person served. Relationships of a sexual nature with a consumer is always prohibited.
  • Always act fairly and in the best interests of the residents, the agency, and the community in general.
  • Not encourage a resident to engage in any illegal activity, or any activity that can harm the resident or any other individual.
  • Not impose personal beliefs on a resident. A resident may choose to pursue their own personal beliefs, including choice of religion, affiliation with or voting for a candidate, political party, or deciding whether or not to pursue a legal medical procedure
  • Unless an employee is directly involved in a defined money management program as part of the resident service plan, no CLUE personnel should be involved with resident funds.   All employees are  prohibited from borrowing or loaning money to residents, and from using any personal items belonging to the residents

Non-Payment Issues- Individuals in housing operated by the Rockland Hospital Guild shall not be denied restorative services while residing in Rockland Hospital Guild housing regardless of their financial situation. 

Should an instance arise where a resident is unable to meet any financial obligation, such as rent due to the Rockland Hospital Guild, a payment review committee shall convene.  Members of the committee are to include the Residence Counselor, Supervisor, and Financial Manager.  This committee will review the debt in question, determine forgiveness or a repayment plan of the arrears, and inform the consumer of the decision.  For those with two months or more in arrears, a failure or refusal on the part of the Resident to consider a repayment plan may result in the Resident receiving a 30-day notice of intent to terminate residency.

Business Practices-Financial Standards - All financial information must reflect actual transactions and conform to generally acceptable accounting principles. No undisclosed or unrecorded funds or assets may be established. Transactions must be authorized, recorded, and documented as provided by law and RHG policy.

Kickbacks  -  RHG employees, Board members, and contractors are prohibited from offering, soliciting, or accepting money or anything else of value from any RHG vendor or provider except:

An employee may share in a gift of goods or services from a vendor or provider if, and only if:

  • The gift consists of goods delivered to RHG premises;
  • Is used or consumed on the premises;
  • The gift is not intended for the personal use or benefit of specific individuals;
  • The gift does not violate federal and state laws and regulations that prohibit soliciting or accepting anything of value in exchange for influencing a purchase of goods or services or the referral of consumers for services.

We do not accept payments for referrals. No employee or any other person acting on behalf of RHG is permitted to solicit or receive anything of value, directly or indirectly, in exchange for the referral of potential recipients or vendors. Similarly, when making referrals to another provider, we do not take into account the volume or value of referrals that the provider has made (or may make) to us.

Procurement – Vendors of goods and services shall be selected based on objective criteria, including quality, technical excellence, price, delivery, and adherence to schedules, service, and maintenance of adequate sources of supply. Employees will follow the RHG Procurement of Goods/Services Procedure (Bid Policy) which adheres to the NY State OMH ‘Prudent Buyer Concept’.

Billing and Claims – RHG is committed to charging, billing, and submitting claims for reimbursement only when the services have been provided and documented in the manner required by laws, regulations, policies, and applicable standards of care. All employees must follow the applicable rules for submission of bills and claims for reimbursement, whether those claims are submitted to Medicaid for payment to RHG, or to RHG for payment. Any employee that knows or suspects that a bill or claim for reimbursement is incorrect is required to report the matter immediately to a supervisor or to the Compliance Officer.

Record Maintenance -  Each employee is responsible for the timeliness, integrity, and accuracy of RHG documents and records, to comply with regulatory, funding, and legal requirements, and in defense of our professional and ethical business practices. Employees may not alter or falsify information on any record or document. Program recipient and business documents and records are retained in accordance with applicable laws and our record retention policies. Program Participant and business documents include paper documents such as case records, letters and memos, computer-based information such as e-mail or computer files on hard drives, disks or tapes, and any other medium that contains information about the organization and/or its business activities. It is important to retain and destroy records according to policy. No Employee should tamper with records, nor move or destroy them prior to the specified timeline.

Medicaid Exclusions – In keeping with our commitment to conduct business with integrity and in compliance with all applicable federal and state regulations, all employees, interns, Board members, consultants, contractors, vendors, and treatment providers affiliated with our programs are checked for exclusion by the Medicaid program. This is done monthly by the RHG Administrative Assistant through a review of lists maintained by the NYS Office of the Medicaid Inspector General (OMIG) and Federal Office of the Inspector General (OIG).   These exclusion records are maintained as required by law.  Employees, vendors, and persons affiliated with RHG found to be on the exclusion list are checked for accuracy of the exclusion and terminated if they are in fact excluded from participation.  Employees have a duty to report any event that could potentially result in their being determined to be a person excluded from the Medicaid program.

Internal Auditing and Monitoring:

Auditing and monitoring the agency’s operations are key to ensuring compliance and adherence to policies and ethical business practices. Auditing and monitoring can also identify areas of potential risk and those areas where additional training and oversite is required. Practices will include, but are not limited to:

  • Periodic reviews of resident records by the CO to ensure that admission and continuing stay documentation required by state regulation is present and up to date.
  • Monthly reviews of Authorizations for Residential Services to ensure medical necessity, in accordance with Medicaid standards.
  • Periodic reviews of resident records and corresponding bills for compliance with RHG billing standards.
  • Periodic reviews of resident records to ensure documentation is completed in an appropriate time frame, including Assessments, Service Plans, and Progress Notes. Reviews to ensure services are relevant, necessary, provided as documented, and signed.
  • Monitoring of resident Personal Needs Allowance

In any instance where it is found that billing is not supported by documentation, billing will be withheld for that service. The Finance Director will void any claim, and instances where unsupported billing has occurred, monies will be returned, adhering to protocols and process for self-disclosure.

Duty to Report

All employees have a duty to report any suspected fraud, waste, or abuse of resources, and have a responsibility to report activity by any employee, contractor, or vendor that appears to violate applicable laws and regulations, including this Code of Conduct. Participating, encouraging, directing, and facilitating non-compliant behavior is prohibited and is subject to sanctions and/or disciplinary action as outlined in the Employee Handbook and Compliance Plan.

Anyone who submits a good faith report of suspected non-compliance is protected from retaliation by both law and RHG Policy. Reporting should be made to the Compliance Officer, Finance Director, or management staff.

Non-Intimidation and Non-Retaliation (Whistleblower Protections)

The RHG has a policy of non-intimidation and non-retaliation against individuals for good faith participation in the Compliance Program, and for reporting suspected violations of federal and state laws, and regulations. All staff, volunteers, consultants, and Board members can freely discuss, report to, and raise questions with the Compliance officer, Supervisors. and the Executive Director about any situation they feel may be in violation of Federal and NY State law, Rockland Hospital Guild policy and/or any regulatory requirements.

Employees, Board members, vendors or consultants who report any action or suspected action by Rockland Hospital Guild that is illegal, fraudulent, or in violation of any policy shall not be subject to intimidation, harassment, discrimination, or other retaliation, or adverse employment consequence.

Any violation of this non-intimidation policy should be immediately reported to the Compliance Officer, who will preserve the confidentiality of any reported information. Reports may be made in person, by phone, letter, email, or by leaving a message on the designated Compliance phone line. Any violations of this policy may result in disciplinary action up to and including termination.

Disciplinary Action

Any employee may be subject to disciplinary action, up to and including termination, if it is found that their actions (or inactions) constituted a violation of federal and state laws and regulations, or a failure to adhere to RHG’s compliance standards.  Compliance related discipline applies to all employees, and may include the following:

· a written reprimand

· suspension

· termination of employment or relationship with RHG

· restitution

· referral for criminal prosecution

· civil litigation

Workplace Conduct and Employment Practices

Conflict of Interest

A conflict of interest may occur if your outside activities or personal interests influence or appear to influence your ability to make objective decisions in the course of your job responsibilities. A conflict of interest may also exist if the demands of any outside activities hinder or distract you from the performance of your job or cause you to use RHG resources for other than RHG purposes. It is your obligation to ensure that you remain free of conflicts of interest in the performance of your responsibilities at RHG. If you have any questions about whether an outside activity might constitute a conflict of interest, you should discuss with your supervisor or the compliance officer before pursuing the activity. You may not without permission from the Compliance Officer, accept, solicit, or offer anything of value from anyone doing business with RHG, including any client, referring party, vendor, contractor or other third party, if the gift or gratuity relates to, or results from your affiliation with RHG.

Diversity and Equal Employment Opportunity

Our employees provide us with an array of talents and skills that contribute to our success. We are committed to providing an equal opportunity work environment where everyone is treated with fairness, dignity, and respect, regardless of gender, race, religion, color, national origin, ancestry, age, sexual orientation, marital status, veteran status, or physical or mental handicap . We will comply with all laws, regulations, and policies related to non-discrimination in all of our personnel actions. Such actions include hiring, staff reductions, terminations, evaluations, recruiting, compensation, corrective action, discipline, and promotions. No one shall discriminate against any individual with a disability with respect to any offer, or term, or condition of employment. We will make reasonable accommodations for the known physical and mental limitations of otherwise qualified individuals with disabilities.

Controlled Substances

Some of our staff routinely have access to prescription drugs, controlled substances, and other medical supplies. Many of these substances are governed and monitored by specific regulatory organizations and must be administered by physician order only. It is extremely important that these items be handled properly and only by authorized individuals, to minimize risks to us and to participants. If you become aware of the diversion of drugs from the workplace, you must report the incident immediately to your supervisor or the Compliance Officer.

Harassment and Workplace Violence

Each employee has the right to work in an environment free of harassment. RHG will not tolerate harassment by anyone based on the diverse characteristics or cultural backgrounds of those who work with us. Degrading or humiliating jokes, disparaging comments or slurs, intimidation, or other harassing conduct is not acceptable in our workplace.

Any form of sexual harassment is strictly prohibited. This prohibition includes unwelcome sexual advances or requests for sexual favors in conjunction with employment decisions. Moreover, verbal or physical conduct of a sexual nature that interferes with an individual’s work performance or creates an intimidating, hostile, or offensive work environment is strictly prohibited.

Harassment also includes incidents of workplace violence. Workplace violence includes robbery and other commercial crimes, stalking cases, violence directed at the employer, terrorism, and hate crimes committed by current or former colleagues. As part of our commitment to a safe workplace for our employees, we prohibit employees from possessing firearms, other weapons, explosive devices, or other dangerous materials on RHG premises.

Employees who observe or experience any form of harassment or violence should report the incident to their supervisor or to the Compliance Officer immediately.

Health and Safety

All RHG employees must comply with government regulations and rules, and with RHG policies or required agency practices that promote the protection of workplace health and safety. Our policies have been developed to protect you from potential workplace hazards. You should become familiar with and understand how these policies apply to our specific job responsibilities and seek advice from your supervisor or the Compliance Officer when you have a question or concern. It is important for you to advise your supervisor and the Administrative Assistant of any workplace injury or any situation presenting a danger of injury so that timely corrective action may be taken to resolve the issue. All situations of presenting a safety hazard should be reported to the Administrative Assistant and supervisor immediately.

Employee Activities

The following activities are expressly forbidden:

  • The use of alcoholic beverages, marijuana, or other drugs on the Rockland Hospital Guild's property, or

reporting for work under the influence of alcohol, marijuana,  or any other mind influencing substances

  • The use of profanity or abusive language while on duty
  • The possession of firearms or other weapons on the agency's property
  • Insubordination - the refusal by an employee to follow management's instructions concerning a reasonable job-

related matter

  • Assault on a fellow employee or resident
  • Theft or misuse of the Rockland Hospital Guild's, or of another employee's or residents’ property
  • The request or acceptance of gratuities and/or commission from vendors utilized by RHG              
  • Gambling on RHG's property
  • Possession, use, or sale of any illegal substance while on the Guild's premise
  • Leaving one's workplace for other than assigned duties without notification to, and approval from, management
  • Unauthorized submission of agency records, reports and papers to others who are not designated by the agency to receive such information  
  • Knowingly falsifying records and/or submitting, or causing to be submitted, false claims for payment by


  • Use of electronic recording devices while on duty at RHG. This includes audio recordings, video recordings, and taking photos without express authorization by the resident. No photos or recordings containing resident information can be shared on any social media site
  • Use of a personal vehicle to transport residents
  • Use of RHG computers for anything other than work related activities while on duty
  • Use of personal computers for personal or work-related business while on duty
  • Accepting gifts from a resident or family member in excess of $25.00

Political Activities and Contributions 

RHG’s political participation is limited by law. RHG funds or resources are not to be used to contribute to political campaigns or for gifts or payments to any political party or any of their affiliated organizations. Organizational resources include financial and non-financial donations such as using work time and telephones to solicit for a political cause or candidate or the loaning of RHG property for use in the political campaign. No employee shall directly or indirectly contribute RHG property, equipment, funds, resources or other tangible or intangible assets or the use thereof to political campaigns, candidates, political parties or any agent or affiliate thereof.  No political advertising is allowed on Agency property. On occasion RHG may ask colleagues to make personal contact with government officials or to write letters to present our position on specific issues. In addition, it is a part of the role of some RHG employees to interact with government officials. If you are designated to make these communications on behalf of the organization, be certain that you are familiar with any regulatory constraints and observe them.