142-02 20 th Avenue, 3 rd Floor, Flushing, NY 11351 (718) 559-0516 Web Site: www.psch.org E-mail: info@psch.org PSCH Policy CODE OF ETHICS AND CONDUCT No: PSCH - P08 - CC - 001 Effective: November 12, 2008 Issued By: PSCH Inc. 142-02 20th Avenue Flushing, NY 11351 Published By: Corporate Compliance 1.0 Purpose PSCH is dedicated to maintaining excellence and integrity in all aspects of its patient care and business operations. As part of our compliance and ethics program, PSCH has developed this Code of Ethics and Conduct ("Code"). This Code is a statement of our core business values. It is documented and communicated so that it can be read and understood by everyone involved with PSCH, including all employees, management, officers and the board of directors. It is available at all times as a reference and to help answer questions. The principles laid out in this Code guide our work, shape our workplace, and define PSCH as a company deeply committed to ethical business conduct and compliance with the laws and regulations that govern our business. This Code provides guiding standards for decisions and actions made by everyone associated with PSCH. Although the Code can neither cover every situation in the daily conduct of PSCH's activities, and it is not a substitute for common sense, individual judgment or personal integrity, it is the duty of each member of PSCH to follow, without exception, the principles set forth in the Code. If you do not understand something, please seek clarification. If an ethical dilemma, question or concern should arise, it is your responsibility to notify and seek guidance from your supervisor or PSCH's Chief Compliance Officer. 2.0 Scope This Code describes the standards of business conduct required of all PSCH employees, managers, directors, officers, contractors and representatives ("Personnel"). This Code serves to help us identify and focus on key areas of legal and ethical risk, provide guidance on appropriate behavior, and remind everyone of their responsibility to help foster a culture of honesty and accountability throughout the Company. Everyone at PSCH has a personal responsibility to ensure that his or her actions abide by the letter and spirit of this Code and the laws and regulations outlined in it. Everyone at PSCH is responsible for instilling and supporting a culture in which compliance with the Company's policies
and all applicable laws is at the core of all the Company's activities. All PSCH Personnel are expected to be aware of the legal requirements and restrictions applicable to their own positions and duties. We are all expected to: Know and follow the Code. Know and comply with the requirements and expectations that apply to our jobs. Take responsibility for our own conduct. Report suspected violations of the Code and other concerns to the Compliance Officer or otherwise as set forth in the Code. Cooperate with any investigations of an alleged violation of this Code. This Code and the policies outlined within it will apply equally to all PSCH Personnel, regardless of position or level of responsibility within the Company. The Code is intended to provide a means to: 1) Detect and prevent improper or illegal conduct 2) Provide a framework for the compliance and ethics program 3) Outline the ways in which the program will operate 3.0 Policy 1) Compliance with Laws, Rules and Regulations. PSCH will implement the programs necessary to promote and monitor awareness of and compliance with applicable laws and regulations. Failure to follow these laws and regulations is often unethical, illegal and in conflict with the Company's values and commitment to integrity. Personnel are encouraged to seek guidance, report genuine concerns and ask questions regarding compliance with the Code and the related policies and procedures. Violations will be dealt with decisively. Because of the complexity of some of the regulations which govern our operations, some violations will be honest mistakes. These will be corrected and follow up training will be provided to help avoid the same problem in the future. Other violations may be the result of reckless or intentional misconduct. These violations will be dealt with more severely. Some examples of laws with which the Company must comply include: Federal and New York Anti-Kickback statutes Federal and state Physician Self-Referral laws Federal, New York State and New York City Civil False Claims Acts Health Insurance Portability and Accountability Act ("HIPAA") Affordable Care Act Patient Data Privacy and Security laws Antitrust laws and Fair Business & Competition Practices Labor & Employment and Non-Discrimination laws Intellectual Property protection laws Whistleblower and Nonretaliation laws
2) Integrity and Ethics in all Business Practices. PSCH shall conduct its affairs in accordance with the highest ethical standards. PSCH Personnel will use integrity in all relationships, including those with the patients we serve, family members, vendors, our communities, and our colleagues. As providers of mental health care services we are subject to rules and regulations that are often complicated and not easy to understand. Regardless of what job you do, there are legal, regulatory and ethical standards that must be considered and upheld. You must strive to be aware of and understand the national, state and local laws-as well as the business requirements and practices-that affect your day-to-day duties, your department's operations and your area of responsibility. Disregard of the laws will not be tolerated, and violations of laws may subject you, as well as the Company, to civil and criminal penalties. Failure to comply with laws may also result in disciplinary action or termination of employment. It is, therefore, in your best interest to know and comply with PSCH's legal obligations. Please understand that you are required to report any violations or suspected violations of applicable law, regulations or corporate policy, including this Code. You are also encouraged to raise any questions or concerns you may have. It is only through open and free communication that problems can be identified and corrected before they cause serious damage to the Company, to our patients, and to Personnel. 3) Conflicts of Interest. A conflict of interest situation can arise when you take actions or have interests that may make it difficult to perform your Company work objectively and effectively. Although we cannot list every conceivable conflict of interest, following are some common examples that illustrate actual, apparent or potential conflicts of interest: Outside Employment with a Competitor. You may not compete with PSCH or consult with or be employed in any capacity by, a competitor of PSCH. Outside Employment with a Supplier. Without prior written approval from PSCH, you may not be employed by, serve as a director of, or represent a supplier of PSCH. Corporate Opportunities. You owe a duty to PSCH to advance its legitimate interests when the opportunity to do so arises. You may not take personally for yourself opportunities that are discovered through the use of Company property, information or position, or use Company property, information or position for personal gain. Certain Relationships. You may find yourself in a situation where your spouse, children, siblings, parents, in-laws or someone else with whom you have a close relationship is a referral source, supplier, customer, competitor or employee of PSCH. Such situations are not necessarily prohibited, but they call for extra sensitivity to security, confidentiality and conflicts of interest and should be disclosed to the Compliance Officer, who will help to establish appropriate protections in these situations. All Personnel shall support the Company's goals and avoid conflicts of interest. Personnel must faithfully conduct their duties in their assigned roles and tasks for the purpose, benefit and interest of PSCH and those it serves. Personnel have a duty to avoid activities, behaviors and decisions in
conflict with the interests of PSCH and may not use their positions and affiliation with PSCH for personal benefit, regardless of whether these are actual or appearances of conflicts. 4) Patient Care and Provider Credentials. PSCH shall strive to attain the highest standards for all aspects of consumer care. The care provided must be reasonable, necessary, appropriate to the situation, and provided only by properly qualified individuals. All Personnel and vendors must obtain and maintain all appropriate licensure or certifications required for their job responsibilities. Personnel shall not deny services to any individual we serve who meets the minimum admission criteria, if such service is within the normal and usual scope of the program's purposes, or if required by reason of an emergency. 5) Personnel Relations, Safety and the Environment. PSCH shall provide equal opportunity and shall respect the dignity of all Personnel and consumers. Below are specific mandates with respect to Personnel relations, safety and the work environment at PSCH: Diversity: The Company welcomes diversity in its workplace and is committed to equal employment without regard to race, color, religion, sex, national origin, age, medical condition or disability, sexual orientation, veteran status, or any other characteristic protected by law. Harassment: All Personnel are expected to treat others with respect and fairness. Workplace harassment is any unwelcome or unwanted attention or discriminatory conduct based on an individual's race, color, religion, sex, national origin, age, medical condition or disability, sexual orientation, veteran status, or any other illegal or inappropriate basis. It can also include verbal, nonverbal or physical abuse. Something that is considered harmless by one individual may be perceived as harassment by another. You are expected to conduct yourself in a manner appropriate to the workplace, to keep all work environments free of harassment and improper discrimination, and to conduct relationships with appropriate behavior and integrity. Workplace Safety: PSCH strives to provide all Personnel with a clean, safe, and healthy place to work. To achieve that goal, all Personnel must understand the shared responsibilities of abiding by all safety rules and practices, taking the necessary precautions to protect oneself and coworkers, and reporting immediately any unsafe conditions, practices or accidents. Alcohol and Drugs: Our work requires clear thinking. Being under the influence of alcohol and/or drugs or improperly using medication diminishes your ability to perform at your best. It is Company policy to prohibit the sale, use, possession or influence of alcohol or non-prescription controlled substances, including illegal drugs, on Company property. If you observe any drug or alcohol abuse, you should report it to your supervisor or the Compliance Officer. Environment: The Company is strongly committed to caring for the environment and is dedicated to meeting all regulatory performance requirements. The Company expects all Personnel to be alert to environmental issues and share in the
commitment to conserve natural resources, reduce waste, and conduct business in an environmentally responsible manner. 6) Financial Integrity: Billing and Pricing Laws. PSCH shall maintain a relationship of integrity with each payor source. There are many laws and regulations relating to billing for the mental health care services that we provide. The Federal and New York State and City False Claims Acts make it illegal to knowingly present a false or fraudulent claim to the government. The Company's False Claims Act Policy, as well as the Whistleblower and Nonretaliation Policy outline the specific and proper procedures to comply with requirements of these laws. Under the False Claims Acts and PSCH's policies, "knowingly" or "knowing" has a broad definition. If a claim or information relating to a claim that is submitted to the government is inaccurate, it can violate the False Claims Acts if PSCH or the Personnel involved in submitting the claim or information: i) have actual knowledge that the claim or information is inaccurate; ii) acts in deliberate ignorance of the truth or falsity of the accuracy of the claim or information; or iii) acts in reckless disregard of the truth or falsity of the claim or information. The Company's billing practices must be timely, accurate and honest as they relate to government agencies, including Medicare, Medicaid and government employee and military health benefits programs, as well as to private third-party payers. To ensure proper billing and pricing, we must also make certain that bills are prompt, and complete. A few principals to guide you when using PSCH funds or recording a Company transaction includes the following: Be cost-conscious when acquiring materials and services for the Company. Accurately price products and services. Do not split invoices to hide costs or avoid payment procedures. Make certain that bills are accurate, prompt and complete. Whenever you are responsible for a payment made by or on behalf of PSCH, be sure it is supported by appropriate documentation that describes its purpose. Never make or approve a payment on PSCH's behalf with the intention, understanding, or awareness that any part of the payment will be used for a purpose other than the one described by supporting documents. Take responsibility for the complete accuracy of all cost charges and records. Falsifying records is a serious offense that can result in criminal and financial penalties for the Company and the people involved. If you are involved in contract negotiations, make sure that contracts and proposals comply with all applicable laws, regulations and provisions of existing contracts, and that all statements, communications and representations to prospective customers concerning the company are truthful and accurate. Never use PSCH funds or assets for any unlawful, improper or personal use.
7) Anti-Kickback and Bribery Laws. Both the Federal government and the State of New York make it illegal to provide, offer or accept a kickback or bribe. A kickback or bribe may be defined as offering or receiving: any money, fee, commission, credit, gift, gratuity, any thing of value, or benefit of any kind that is provided, directly or indirectly, and that has as one of its purposes the improper referral, recommendation, obtaining of business or services that will be paid for by a federal, state or local health care program, or as a reward for favorable treatment in a health care business transaction. PSCH's policy on kickbacks and bribes is clear: they are illegal and are not allowed. There are a complex series of "safe harbors" or exceptions to the anti-kickback laws. If you have any questions at all concerning practices or activities at PSCH, please bring them immediately to the attention of the Compliance Officer or a supervisor. 8) Physician Self Referral Laws ("Stark Laws"). Patient referrals for certain health care services, such as laboratory services, in which the referring physician, or their relative, has an ownership interest or compensation arrangement, are prohibited under statutes commonly known as the "Stark" laws. There are several exceptions to the Stark prohibitions, but the appropriate course of action is to raise all issues in this regard with PSCH's Compliance Officer when you have any doubt whatsoever. 9) Confidentiality, Data Privacy & Security and the Health Insurance Portability and Accountability Act ("HIPAA"). PSCH shall maintain the appropriate levels of confidentiality for information and documents entrusted to it. PSCH and its Personnel possess and have access to a variety of sensitive and proprietary information, the confidentiality of which, they are obligated to protect. PSCH and its Personnel must follow the appropriate laws, regulations, policies and procedures to ensure that confidential information is properly maintained and to prevent inappropriate or unauthorized release of such information, except when disclosure is authorized or legally permitted or required. Confidential information includes all non-public information that might be of use to competitors, or harmful to the Company or its customers, if disclosed. Equally important is safeguarding the confidentiality of the protected healthcare information ("PHI") entrusted to us by providers and patients. We must comply with HIPAA's provisions relating to the privacy and security of PHI. The requirements for protecting this kind of information can be found in the Company's HIPAA Policies and Procedures. All questions concerning the handling or disclosure of PHI should be referred to the Compliance Officer. Anyone who does not have a business reason to access PHI should never seek to do so, and those who do have legitimate access should take steps to protect against the unauthorized release or use of private customer information. Outside parties who are given access to this information for legitimate, appropriate reasons are also responsible for protecting it, and they should be monitored for their compliance. The obligation to safeguard confidential information continues after employment or representation ends. 10) Use of Company Assets. PSCH's assets include its facilities, computers and information systems, inventory, proprietary information, office supplies, equipment, products, and funds.
Everyone is responsible for using good judgment to ensure that these assets are not misused or wasted. Theft, carelessness, and waste have a direct impact on our ability to provide excellent services. Everyone who uses our information systems is responsible for ensuring that these resources operate as they should. This means that everyone must use these information systems mainly for legitimate business purposes. PSCH prohibits the use of information systems for the purpose of: Engaging in communications that might be considered illegal, offensive, defamatory, harassing, obscene, vulgar, or otherwise disruptive to normal business activity. Visiting inappropriate websites. Improperly disseminating copyrighted or licensed materials or confidential and proprietary information. Installing hardware or software without advance authorization from PSCH management. Everyone is also expected to protect the security and confidentiality of our information systems by protecting user IDs, passwords, and building access codes. This kind of information should never be shared with others. Any communications you have at work (email, voicemail, etc.) are not necessarily private. Records of your communications may be made and used for a variety of reasons, and may be monitored to verify that Company policies are being followed. Please keep this in mind and follow the guidelines above to ensure compliance. 11) Records Management and Retention. Managing records and recorded information is critical to the Company's business, and we must take care to ensure that our records are managed properly. Personnel should adhere to the following rules: Maintain Records as Required by Law: Some laws have specific record-keeping requirements. Each department must manage and maintain all records as required by law. Guidance on what specific requirements must be followed will come from the Compliance Officer and your individual departments. Understand and Follow Company's Records Management Policy: The Company has a Records Management Policy which explains the process for retaining, storing, and disposing of hard copy and electronic documents and other records. Please consult the policy, your supervisor, or the Compliance Officer for additional guidance. Be Alert to the Need for Accuracy: Personnel should always maintain accurate records. Providing false or misleading records, or altering them, is wrong under any circumstance and may constitute serious violations of law. Retain Any Records Related to Litigation or an Investigation: If an investigation, audit or litigation is pending or even anticipated, relevant records including emails, voicemails and internal computer disk drives must be retained and preserved. You will be notified of these situations by your supervisor, the Compliance Officer or the Company's lawyers. Destruction of relevant records, even if inadvertent, could seriously hurt the Company. If you have any questions regarding whether a particular record may be relevant to an investigation or litigation, you should preserve the record in question and ask the Compliance Officer for advice.
12) Violations of this Code. The values and principles set forth in this Code are critically important to the Company and must be taken seriously by all of us. Accordingly, violations will lead to appropriate disciplinary action. Such disciplinary action may include reprimand, reimbursement of any loss or damage suffered by the Company or termination of employment. The Company will be consistent in its enforcement of the Code and in its investigations of reports of violations. Under certain circumstances, violation of this Code may also result in referral for civil action or criminal prosecution, or any other disciplinary action deemed appropriate by the Company. 13) Waivers of this Code. While most of the policies referenced in this Code must be strictly adhered to and no exceptions allowed, in rare cases exceptions may be appropriate. If your supervisor and the Company's President agree that an exception is appropriate, the approval of the Company's Compliance Officer must also be obtained. The Company's Compliance Officer shall be responsible for maintaining a record of all requests for exceptions to any of these policies and the disposition of such requests. 14) Duty to Report. Anyone who has knowledge that an applicable law, regulation, policy or ethical guideline has been, or may be, violated must promptly report such information to an appropriate person within the Company. The Company actively promotes honest and ethical behavior in all its business activities. The Company has an "open-door" policy and Personnel are encouraged to report potential violations to their supervisors, any member of management, the Compliance Officer, or through the Compliance Hotline. Personnel are encouraged to speak to their supervisors, Compliance Officer, any member of management, or other appropriate Personnel at any time if there is doubt about the best course of action in any situation. If you are not comfortable speaking with your supervisor, you may report violations or potential violations to the Compliance Officer or through the Compliance Hotline No Personnel will suffer any penalty, punishment or retaliation for making a good faith report of suspected misconduct or noncompliance, or will be subject to any adverse consequences as a result of making the report. 4.0 Contact Information Questions concerning this policy may be directed to the Corporate Compliance Officer, at 718-559-0522. PSCH has also established a telephone hotline number that Personnel may call to file anonymous reports as a response to improper, unethical or illegal activity. The hotline may be accessed by calling 1-866-713-2331
5.0 Revision History Date November, 2008 Description of Change Original policy February, 2012 Revised (Format changes; added Affordable Care Act on page 7) ACKNOWLEDGMENT OF RECEIPT OF CODE I certify that I have received a copy of the PSCH Inc. Code of Ethics and Conduct (the "Code'). I have reviewed the Code, and I understand the policies and guidelines it explains. I agree that I will follow those policies and guidelines to the best of my ability, and I will report any suspected misconduct, violation of this Code or the Company's policies and procedures using the methods outlined in this Code. Signature Printed Name Department Date