compliance-banner.png

Code of Conduct

CONTENTS

Mission, values and ethics.


Your obligations under the Code of Conduct. 7

PART ONE
Our agency: principles of conduct.

  1. Quality of care and services delivered.
  2. Federal and State reimbursement requirements. 
    1. Claims submission, cost reporting and false claims acts.
    2. Admissions, ISPs, service necessity, documentation, coding and billing. 
  3. Records 
    1. Types of records. 
    2. Accuracy of records. 
    3. Expense records.
    4. Records retention.
  4. Confidential Information 
    1. Privacy of confidential information. 
    2. Security of confidential information. 
    3. Upon termination of your relationship with YAI. 
  5. Work environment. 
  6. Ineligible persons and entities. 
  7. Audits and investigations. 
  8. Conflicts of interest. 
  9. Outside employment and other activities. 
  10. Use of agency assets. 
  11. Fair dealing. 
    1. Kickbacks, bribes and rebates. 
    2. Agreements with contractors and vendors. 
    3. Business dealings between YAI Associates and YAI. 
  12. Political contributions and activities.

PART TWO
Seeking guidance and reporting concerns.

  1. When to seek guidance: responsibility to report.
  2. Where to go for guidance or to report a concern.
  3. Non-retaliation and non-intimidation.
  4. Corrective action and discipline.

Mission, values, and ethics

Download document (pdf)

Definition of terms used in this document:

  • YAI, the Agency The Young Adult Institute, Inc.
  • YAI Associates The Young Adult Institute’s employees, officers, trustees, independent contractors, vendors, and volunteers
  • Code The Young Adult Institute’s Code of Conduct
  • Personnel Practices Manual or PPM YAI Employee Handbook
  • CFR Consolidated Fiscal Report
  • OPWDD New York State Office for People with Developmental Disabilities

YAI’s mission is to provide the highest quality health care and human services to people with developmental and learning disabilities. The success of this mission requires that all YAI Associates adhere to the highest standards of ethical conduct. It also requires that YAI Associates fully comply with all legal requirements concerning the provision of health care and human services. Furthermore, YAI Associates must avoid even the appearance of dishonesty or wrongdoing in all interactions with the following entities:

  • The individuals we serve and their families
  • Other health care providers
  • Companies with which YAI does business
  • Government entities to which YAI reports
  • Public and private entities that reimburse YAI for its services.

These requirements apply to all aspects of our work. They ensure the ongoing success of the Agency and its operations.

This Code of Conduct expresses the basic principles that govern our operations, business activities, and relationships, both internal and external. The Code is based on the laws, regulations, and rules that apply to the work that we do.

Your obligations under the Code of Conduct.

The Code of Conduct is a formal statement of YAI’s commitment to the standards, rules, and requirements of ethical and legal conduct as they apply to YAI’s operations and business activities. These include the requirements of:

  • YAI’s Compliance Program
  • New York State’s Medicaid Program
  • All government health care programs

YAI’s Board of Trustees has approved and adopted this Code of Conduct. You have received it because you are a YAI Associate. Review the Code carefully upon receipt. It may have changed since you last read it. YAI holds every Associate accountable for understanding and complying with the Code. If you are a YAI Associate on a part-time basis, the Code of Conduct applies to you only when you are acting as a YAI Associate.

The Code of Conduct does not apply directly to the individuals we serve and their families. However, we encourage the individuals we serve and their families to review the Code and ensure that they understand it. The Code governs the services that YAI provides. Therefore, it may have a direct and substantive impact on the care that the individuals we serve and their families receive.

The Code of Conduct informs every YAI Associate of the Agency’s expectations regarding its internal and external operations and relationships. The Code sets forth the basic ethical principles that guide our operations and activities. It points you in the right direction. However, it does not address every circumstance you may encounter. You may find yourself in a situation that the Code of Conduct does not cover. You may even find yourself in a situation that appears to require that you violate the Code of Conduct. In such cases, do not guess. Seek direction and guidance from your immediate supervisor, management staff, or the Compliance Officer. Do this whenever you are unclear as to your responsibilities under the Code of Conduct.

The Code of Conduct does not contain a comprehensive list of all the policies and procedures to which YAI employees are subject. The Agency also maintains an employee handbook, the Personnel Practices Manual (PPM). There are additional policies and procedures you must observe as a YAI employee that govern specific Agency programs and operations, as well as policies governing the Compliance Program. The standards of the Code do not replace the standards contained in the PPM and all other YAI policies and procedures. They supplement them and provide added clarification.

If you don’t know how to respond appropriately to a particular situation, ask your immediate supervisor, management staff, or the Compliance Officer what to do. If this is not possible and you need to make a decision without help, ask yourself the following questions before you act:

  1. Will my action comply with the intent and purposes of the Code of Conduct, the PPM, and YAI’s policies and procedures?
  2. Is this action honest in every respect?
  3. Will I compromise either my reputation or the Agency’s if my supervisors, colleagues, or outside parties find out about this action?
  4. Could this action appear inappropriate to others even if it is legal, and complies with applicable rules and regulations?

If you can honestly answer “yes” to the first two questions and “no” to the last two, your response will be compliant in all probability. However, contact your supervisor or the Compliance Officer as soon as possible afterwards to explain both the situation and your response. No one wants to make mistakes. However, it is far better to disclose and attempt to rectify an honest error than to try to cover up the fact that you made it.

Thank you for taking the time to review the Code of Conduct carefully. If you have any questions about either the Code or YAI’s Compliance Program, please call YAI’s Central Office and ask the receptionist to connect you with the Compliance Officer.

You may also call the Compliance Hotline at 212.273.6100 ext 2427.

PART ONE

Our agency: principles of conduct.

I. Quality of care and services delivered.

YAI’s mission is to provide the highest quality health care and human services to people with disabilities and their families. To that end, YAI provides a comprehensive network of programs and services. We strive to be responsible, effective, and compassionate—always acting in the best interests of the individual we serve and their families. In order to foster effective delivery of the highest quality services, promptly report any actual or suspected quality of care issues to your immediate supervisor, management staff, or the Compliance Officer.

II. Federal and State reimbursement requirements.

YAI complies with all federal, state and local laws and regulations applicable to its operations and business activities. These include the requirements of New York State’s Medicaid program and all federal health care programs. The vast majority of YAI’s funding comes from these programs.

How reimbursement works.

To understand why compliance is so important, it is important to know how government reimbursement works. Like a vendor in the for-profit world, YAI offers a wide range of services to people with disabilities and their families. Government will pay YAI for providing these services. However, government only provides reimbursement when YAI delivers documented proof that the services were properly requested, delivered, and documented. If YAI provides services and does not document them properly, government will not pay for them.

Government reimbursement is the lifeblood of YAI’s operations. Accordingly, YAI has developed its policies and procedures, including the PPM, the Compliance Program, and this Code of Conduct, with the requirements of these government programs in mind. Together, we must all ensure that YAI adheres to all governmental requirements. Please promptly report any actual or suspected violations of government requirements to your immediate supervisor, management staff, or the Compliance Officer.

A. Claims submission, cost reporting and false claims acts.

As a provider of services under contracts with federal and state programs, YAI is subject to federal and state False Claims Acts. Medicare or Medicaid are among the government programs covered by the False Claims Acts. These laws explicitly prohibit the following behavior:

  • Submission of false claims for reimbursement from a government-sponsored program
  • Making false records or statements in order to gain reimbursement from a government-sponsored program
  • Making false records or statements in order to avoid an obligation to a government-sponsored program

YAI is dedicated to ensuring that the Agency’s reimbursement and cost reporting practices for its services and programs comply with all applicable government requirements. The Agency explicitly forbids its Associates from submitting any false, fraudulent, or fictitious claim for reimbursement. YAI is also committed to preventing the accidental submission of any claim that is false, inaccurate, or not supported by proper documentation.

If your job responsibilities involve the preparation or submission of the CFR you must ensure the accurate, properly categorized submission and reporting of costs related to YAI’s operations. YAI must submit the CFR to OPWDD for review and approval. If you are ever unsure how to report a cost on the CFR, don’t decide on your own. Seek guidance from your immediate supervisor, management staff, the Compliance Officer, or the Chief Financial Officer.

B. Admissions, individualized service plans, service necessity, documentation, coding, and billing.

You must adhere to the following compliance standards and requirements at all times in order to ensure that YAI does not submit false, fraudulent, or inaccurate claims for reimbursement:

Admissions criteria

YAI shall provide services to an individual only when the following conditions are met:

  • YAI has received an accurately documented need for such services
  • YAI has determined that the Agency has sufficient resources to provide adequate, appropriate care for the individual

Individualized service plans and ongoing services.

A long-term care record must contain an Individualized Service Plan (“ISP”). The ISP must completely and accurately set forth the following information:

  • Long term goals and outcomes
  • Short-term goals and outcomes
  • The need for services that further day-to-day functioning at the highest possible level of independence
  • The necessity of each planned service

An appropriate clinical supervisor must periodically review all ISPs. If your job responsibilities include access to an ISP, you must report to your supervisor any change in circumstances that may affect the necessity or appropriateness of the services provided.

Service necessity

YAI shall submit claims to the government only for services that are included in the ISP and documented in the medical record.

Documentation

YAI bills for services only when they are sufficiently justified and documented. YAI’s documentation must comply with all applicable federal and state laws, regulations and other requirements. This documentation also must comply with all internal YAI requirements, guidelines, policies, and procedures. YAI accounts for all changed circumstances or new information when justifying and documenting provided and billed services.

Coding

All claims for reimbursement must accurately reflect rendered and documented services. YAI strictly prohibits up-coding for increased reimbursement.

Billing

All billing must be accurate and truthful. YAI will submit claims for services only in accordance with the individual’s ISP. All claims submitted must contain the appropriate provider identification number. YAI strictly prohibits YAI Associates from engaging in improper billing practices. Improper billing practices include, but are not limited to, the following actions:

  • Submitting duplicate claims for services
  • Billing for services not provided
  • Billing for services not medically necessary
  • Bundling or unbundling claims inappropriately
  • Falsely certifying compliance with conditions of payment

III. Records

A. Types of records.

For the purposes of the Code of Conduct, YAI defines “records” as any information created or received in the course of YAI’s operations and business activities, regardless of physical format. The Code of Conduct applies to all such information, regardless of its physical format or location. Physical formats of records may include hard copy, electronic, disk, audio, and video. YAI may elect to keep records in other formats not specified here.

YAI creates, maintains, and transmits various types of records. These types include the following:

  • Medical records
  • Documentation of services provided
  • Bills and claims for reimbursement
  • Claims payment records
  • Financial statements and accounting books
  • Vouchers and expense reports
  • Timesheets and other payroll documents

YAI may also maintain other types of records not specified here. This Code of Conduct applies to all records regardless of type.

B. Accuracy of records.

YAI Associates must prepare and maintain all operational, financial, and health care service related records fully, accurately, and honestly. YAI’s records must fairly reflect the Agency’s business transactions, assets, and services provided. This requirement applies to both electronic and written transactions and correspondence. YAI strictly prohibits the falsification or inappropriate alteration of records in any context, for any reason. YAI also prohibits the following specific actions, regardless of justification:

  • Creating false entries in YAI’s records
  • Creating false entries in any public record
  • Omitting information in records or documentation that causes other information to be false or misleading as a result
  • Altering permanent entries in YAI’s records or public records
  • Approving payments or receipts that lack supporting documentation
  • Documenting services you did not provide personally
  • Documenting events in which you were not involved
  • Creating or participating in the creation of any records that mislead or conceal information

If you are unsure about the accuracy or completeness of information you are required to provide, do not guess. Use your best efforts to locate the correct information. Alternatively, discuss the situation with your immediate supervisor.

C. Expense records.

You must always charge expenses accurately, to the appropriate YAI account or accounts. You must charge expenses accurately and appropriately regardless of the financial or budget status of the related line item, program, project, or contract. If you have any questions about accurate and appropriate charging of expenses, please speak with your immediate supervisor or the YAI Controller.

D. Retention of records.

The proper maintenance and retention of records is integral to YAI’s operations. All YAI Associates must comply with the applicable legal and regulatory requirements that govern the maintenance, retention, disposal, and destruction of records. YAI Associates must also comply with YAI’s policies and procedures concerning records, as follows:

  • You must maintain all records for the duration of their specified retention periods
  • You may not destroy records pertaining to litigation, government investigations, or audits without the express written approval of the Compliance Officer
  • You may not copy or remove records from YAI’s custody for any reason except to further the Agency’s operations and business activities
  • You may not copy or remove records from YAI’s custody for personal purposes

IV. Confidential information

A. Privacy of confidential information.

YAI requires you to observe its Privacy Policy. YAI’s Privacy Policy covers all confidential information related to the following parties:

  • YAI
  • YAI Associates
  • Individuals served by YAI and their families

YAI defines the following information as confidential under its Privacy Policy:

  • Non-public health information about the individuals we serve that could be harmful to YAI, those individuals, or their family members if released.
  • Non-public, proprietary information and trade secrets about the operations, activities or business affairs of YAI and its business associates that could be useful to competitorsYAI may also define other types of information as confidential at the Agency’s discretion.

YAI’s Privacy Policy states that all YAI Associates must keep confidential information both private and secure. YAI releases confidential information only in accordance with Agency policies, procedures, and applicable law. The Agency releases confidential information to outside parties for the following reasons only:

  • To enable or facilitate treatment
  • To enable or facilitate YAI operations
  • To obtain reimbursement for services delivered
  • To comply with federal, state, and local laws

If YAI has not authorized you to release confidential information as an ongoing part of your job responsibilities, you must seek approval before doing so. Ask your immediate supervisor, the Compliance Officer, or the Privacy Officer for permission before sharing confidential information outside of the Agency. If you have questions concerning confidential information or the Privacy Policy, contact your immediate supervisor, the Compliance Officer or the Privacy Officer.

B. Security of confidential information.

In order to maintain the security of YAI confidential information, all YAI Associates must adhere to YAI’s Communications Technology Policy and other policies, procedures, and practices related to information security. These policies are as follows:

  • You may use information produced by or stored on YAI’s computer systems for YAI business purposes only. This restriction includes all physical copies or reproductions of YAI information. For example, printouts and backup copies of files may be used for YAI business purposes only.
  • You may use YAI computers, internet access, e-mail, and other office communications systems for YAI business purposes only.
  • You may not use YAI communications and IT tools to disrupt, offend, harass, or harm anyone.
  • Do not use YAI Communications and IT tools for personal purposes.
  • Do not share your YAI user name or password with anyone.
  • Any document produced or provided by a YAI Associate is the sole property of YAI. You may not destroy it. You may not use it for any purpose other than in connection with YAI operations or business activities.

If you have any questions concerning information security, contact your immediate supervisor, the Compliance Officer or the Security Officer.

C. Upon termination of your relationship with YAI.

If you terminate your relationship with YAI, adhere to the following requirements and practices to maintain the security and privacy of the Agency’s confidential information:

  • You may not take copies of any reports, documents or any other YAI property upon departure.
  • You may not use any confidential information from your association with YAI for your own personal benefit.
  • You may not use any confidential information for the benefit of any person or entity other than YAI.

Upon termination of your association with YAI, you must return all YAI property to YAI. YAI property specifically includes the following:

  • Copies of documents, notes and other records
  • Portable media storage devices, to the extent such use is permitted
  • Your YAI ID
  • Keys to YAI assets, such as facilities or vehicles
  • YAI credit cards

YAI may require you to return other property not listed here as well.

V. Work environment.

YAI’s success depends on everyone’s individual contributions—YAI Associates, the individuals we serve, and family members. Your ability to contribute to YAI depends on our maintaining a positive, safe, and professional work environment.

YAI therefore mandates its Associates to observe the following requirements pertaining to the work environment:

  • Treat other YAI Associates, the individuals we serve and their family members, and others with respect at all times
  • Base all YAI employment decisions solely on merit, performance, and qualifications. Employment decisions include the following:
    • Hiring
    • Retention
    • Compensation
    • Promotion
    • Training
    • Placement
    • Assignment
    • Benefits
    • Other operations and business activities.
  • Disregard all protected identifying characteristics when making employment decisions. Protected identifying characteristics include the following:
    • Race
    • Ancestry
    • Ethnicity
    • National origin
    • Sex
    • Color
    • Age
    • Marital status
    • Religion
    • Disability
    • Creed
    • Sexual orientation
  • YAI prohibits all forms of harassment in the workplace. YAI specifically prohibits harassment based on any protected identifying characteristics. Protected characteristics include:
    • Race
    • Ancestry
    • Ethnicity
    • National origin
    • Sex
    • Color
    • Age
    • Marital status
    • Religion
    • Disability
    • Creed
    • Sexual orientation
  • YAI prohibits all forms of sexual harassment. YAI specifically prohibits the following:
    • Unwelcome sexual advances
    • Requests for sexual favors
    • Other verbal or physical conduct of a sexual nature.
  • YAI encourages growth and job development through training, education, and on-the-job experience.
  • YAI Associates must foster an environment of business integrity, teamwork, trust, and respect.
  • YAI Associates must prioritize the safety and security of all YAI Associates, the individuals we serve and their family members while they are at YAI facilities, or engaged in YAI-sponsored activities.
  • YAI is a drug- and alcohol-free work environment.
  • YAI Associates must respect the dignity and personal privacy of other YAI Associates, the individuals we serve, and their family members at all times.

You are responsible for understanding, upholding and embodying these policies and principles. Promptly consult with your supervisor, management staff, the Compliance Officer, or the Human Resources Department if you have any questions about YAI policies or procedures. Report any known or suspected violation of these policies or principles to any of the above immediately.

VI. Ineligible persons and entities.

YAI does not do business with any individual or entity that is excluded from, or ineligible to participate in, any federal or state health care program. Specifically, YAI maintains the following policies concerning ineligible persons and entities:

  • YAI will not contract with an excluded or ineligible person or entity
  • YAI will not employ an excluded or ineligible person
  • YAI will not retain an excluded or ineligible person or entity
  • YAI will not permit an excluded person from serving as a Trustee
  • YAI will not bill any federal or state health care program for services rendered by an excluded or ineligible person or entity

Engaging in business with excluded or ineligible entities or persons can have serious consequences. If a regulatory agency finds evidence that this has occurred, YAI could be excluded from participation in government health care programs. YAI verifies the eligibility status of all YAI Associates as a part of its hiring and retention process. Afterwards, YAI routinely checks the eligibility status of all YAI Associates. If you become ineligible, or excluded from participation in a federal or state health care program, report this to the Compliance Officer immediately.If you know or suspect that any other person or entity with which YAI has a business relationship has become ineligible or excluded, also report this immediately to the Compliance Officer.

VII. Audits and investigations.

A federal or state government agency may request that YAI cooperate with an investigation or provide it with information. The Agency may send this request to YAI, a particular YAI department or program, or to a specific YAI Associate. The request may come in the form of a letter, subpoena, a personal visit, or phone call. Report any government request for information or cooperation to the Compliance Officer immediately. This ensures that the Agency can respond to it correctly.

YAI requires all YAI Associates to cooperate fully in all audits, inquiries, investigations or other reviews. This requirement applies to all internal and external proceedings. Full cooperation means prompt, complete, and truthful compliance with all requests for documents, information, and interviews. Inadequate cooperation may be grounds for disciplinary action, including termination. If you have any questions regarding proper cooperation and compliance with requests, contact your immediate supervisor, management staff, or the Compliance Officer.

VIII. Conflicts of interest.

A conflict of interest exists whenever an individual’s or an entity’s private interests conflict with YAI’s interests. A conflict of interest can be financial in nature. There may be other kinds of conflicts that make it hard to be objective or effective. You may not allow any conflict of interest to influence the decisions or actions you make concerning the services you provide for YAI. You must avoid any conflict of interest between YAI’s interests and those of any outside party, including yourself.

You must also avoid the appearance of any conflict between YAI’s interests and any personal or other outside interests. The appearance of a conflict of interest can be just as damaging as a true conflict of interest at times. YAI requires you to report any actual or potential conflict of interest promptly to your immediate supervisor, management staff, or the Compliance Officer.

Below is a list of potential conflicts of interest. This is not an exhaustive list. Other actual or perceived conflicts of interest may occur in addition to those listed below.

  • Engaging in a financial transaction involving a personal or financial interest that may affect YAI
  • Acquiring assets or other interests that you know YAI may want to acquire
  • Using your position at YAI to pursue an opportunity for personal gain
  • Using YAI property to pursue an opportunity for your personal gain
  • Using information belonging to YAI to pursue an opportunity for your personal gain
  • Using your position at YAI, YAI property, or information belonging to YAI to benefit an individual or entity other than YAI, other than in the ordinary course of the performance of your YAI duties

You may not compete with or usurp business from YAI. However, if you are a trustee, independent contractor, vendor, volunteer or part-time YAI officer or employee, you may perform services for a competitor, with the following restrictions:

  • Before you commence providing such services, you must give notice to YAI that you will be performing services for a competitor; and
  • You may not attempt to persuade YAI business partners, the individuals we serve, or their family members to seek services from YAI competitors, and
  • You may not attempt to persuade YAI business partners, the individuals we serve, or their family members to alter their business relationships with YAI.

You may not provide or arrange for the delivery of YAI services on a preferential basis. You may not give preference to anyone over an individual we currently serve when providing or arranging for YAI services. For example, you may not arrange for someone with whom you have a personal relationship to receive services ahead of current service recipients because of that relationship. In instances where a potential conflict may occur, you must seek the approval of your immediate supervisor, management staff, or the Compliance Officer before proceeding. Remember that the appearance of a conflict of interest may be as damaging to YAI as an actual conflict of interest, even if the treatment provided is the same as is delivered to everyone YAI serves.

IX. Outside employment and other activities.

The continued success of the Agency depends largely on the devotion and work ethic of individual YAI Associates to their job responsibilities. It is important that you focus your efforts exclusively on these responsibilities during your work hours. This means that you may not conduct outside activities during work hours, unless given advance approval by your immediate supervisor. Such activities can interfere with your regular duties and negatively affect your work.

YIt is important that you recognize that wherever you are, you represent YAI. Because of your status as a YAI Associate, your actions and statements reflect upon YAI, the individuals we serve and their families. This is true regardless of your intentions and regardless of whether you are acting as a YAI Associate. It is imperative that you represent the Agency in a positive light at all times, at work and outside of work.

X. Use of agency assets.

You may use YAI assets only for the benefit of YAI and, the individuals we serve. YAI assets include both physical and intellectual property. Examples of physical property are funds, equipment, inventory, and office supplies. Examples of intellectual property are business plans, concepts, information related to the individuals we serve, financial information, and computer property rights. YAI strictly prohibits you from using its assets for personal gain or benefit. YAI also prohibits you from using its assets for the gain or benefit of an individual or entity other than YAI, except in the routine course of YAI operations and business activities.

XI. Fair dealing.

You must deal with all outside parties (providers, contractors, competitors and the individuals we serve and their families) fairly and equitably. In the course of conducting YAI business, you may be confronted with ethical problems. Adherence to the following guidelines will help you to make appropriate, responsible, and ethical decisions.

A. Kickbacks, bribes, and rebates.

YAI complies with applicable federal and state anti-kickback laws and regulations. This means that you may not offer, give, solicit, or accept kickbacks, bribes, rebates or anything of value to or from anyone for any reason. This specifically includes offering, giving, soliciting, or accepting anything for referring, ordering, or recommending an individual for the furnishing of health care items or services. Specific examples of kickbacks, bribes, and rebates include the following:

  • entertainment
  • gifts
  • personal favors.
  • credits
  • free goods or services
  • forgiveness of a debt
  • sale or purchase of an item or service below fair market value
  • compensation for unnecessary services
  • compensation for legitimate services at a rate exceeding fair market value

If you are ever unsure whether something constitutes a kickback, bribe, or rebate, seek guidance from your supervisor, management staff, or the Compliance Officer before proceeding.

B. Agreements with contractors and vendors.

YAI’s Procurement and Bidding Policy governs the negotiation and execution of all agreements with outside parties. YAI prohibits kickbacks, bribes, and rebates as described above. YAI also prohibits the establishment of any financial relationship based on the volume or value of referrals for Medicare or Medicaid business.

YAI requires all agreements with its contractors and vendors to describe clearly and accurately the services performed and/or the items they are contracting to provide. The delivery and performance of services must meet minimum industry and regulatory standards. Compensation for service delivery (if any) must be in line with current industry standards. Compensation must also be in line with the fair market value of the services at the time of delivery.

All YAI agreements must specify the exact rate or full dollar amount payable for goods and services received under the agreement. YAI will not give or accept payment, goods, or services from a contractor or vendor outside of the specifications of the agreement covering the arrangement. YAI will not accept goods, services, or other consideration from a contractor or vendor as a full or partial substitute for contractually specified payments.

C. Business dealings between YAI Associates and YAI.

Any business arrangements between YAI and a business in which a YAI Associate or a YAI Associate family member has a substantial interest, financial or otherwise, must be fully disclosed to appropriate parties within and outside of YAI. YAI requires that these arrangements be negotiated at arm’s length. YAI requires that all compensation paid represent fair market value for the items or services provided.

A YAI Associate may not offer or provide anything of value to anyone in order to influence actions on behalf of YAI. Nor may a YAI Associate accept or solicit anything of value from or on behalf of YAI in order to influence his or her actions. These provisions are consistent with the sections of this Code of Conduct regarding conflicts of interest and kickbacks. Remember that the appearance of impropriety may be as serious as actual impropriety.

XII. Political contributions and activities.

YAI is a not-for-profit organization. As such, YAI may not engage in political campaign activities. There are also legal limits to the nature and amount of lobbying that YAI may conduct. You must observe the following guidelines when engaged in any political activity:

  • You may not use YAI funds and resources, including your YAI work time, for political contributions or activities.
  • You may not act as a representative of YAI in any political campaign or activity without advance authorization from the Compliance Officer.
  • When expressing personal political views you must state that you speak as an individual, not as a representative of YAI. This includes expressing support for or opposition to a candidate for public office
  • You must seek prior approval from the Compliance Officer before engaging in the lobbying of federal, state or local officials. The Compliance Officer will need to record the amount of time you spend lobbying, as well as the details of your activity. The Compliance Officer also may need to consult with legal counsel on the matter.

PART TWO

Seeking guidance and reporting concerns.

I. When to seek guidance: your responsibility to report.

You should seek guidance within the Agency whenever you are not sure what the appropriate legal or ethical course of action is in a given situation. Do not guess! Ask for guidance if you have a question or concern regarding a particular practice or activity. Always ask for help in the following situations:

  • You do not know how to interpret any of the following documents or rules -
    • The Code of Conduct
    • The PPM or Supervisors’ Interpretive Guidelines
    • A YAI policy or procedure
    • An applicable law or regulation
  • Applicable laws, regulations or rules are confusing or complex
  • You have limited experience with the matter at hand
  • You find yourself torn between two optionsv
  • YAI is a drug- and alcohol-free work environment.

You must report promptly any actual or suspected violation of the Code of Conduct, PPM, a YAI policy or procedure, or applicable law or regulation to your immediate supervisor, management staff, or the Compliance Officer. This includes actual or suspected violations by anyone you supervise. It also includes actual or suspected violations anyone outranking you. This includes Agency officers and trustees. You must also report violations that you know or suspect will occur in the future.

II. Where to go for guidance or to report a concern.

You may seek guidance from, or report violations to any of the following:

  • Your immediate supervisor
  • Other management staff
  • The Compliance Officer.

You may also seek guidance or report violations anonymously by calling the Compliance Hotline at 212.273.6100, ext 2427. YAI has posted the Compliance Officer’s contact information at all YAI program sites. You may also reach the Compliance Officer by calling YAI’s Central Office. The receptionist will connect you with the Compliance Officer on request.

III. Non-retaliation and non-intimidation.

YAI prohibits all forms of retaliation, intimidation, and harassment against an individual who makes a good-faith report of known or suspected non-compliance with the Code of Conduct, the Personnel Practices Manual, a YAI policy or procedure or an applicable law or regulation. YAI will not penalize any individual making such a report. YAI will take appropriate disciplinary action against anyone who penalizes or intimidates an individual for reporting such a concern in good faith. However, this policy of non-retaliation and non-intimidation does not preclude YAI from taking disciplinary action against anyone who behaves improperly or inappropriately.

You must cooperate fully and honestly with any investigation regarding a reported violation of this Code of Conduct, the PPM, a YAI policy or procedure, or an applicable law or regulation..

IV. Corrective action and discipline.

You must comply with the Code of Conduct, the PPM, YAI policies or procedures or applicable laws or regulations as a condition of your employment or retention. You must also report all actual or suspected violations of these rules to YAI management or the Compliance Officer as described above. Your annual performance evaluation will factor in the degree of your compliance with these obligations.

Any YAI Associate who violates, directs another to violate, or knowingly fails to report a violation of the Code of Conduct, the PPM, a YAI policy or procedure, or applicable law or regulation may be subject to appropriate disciplinary action. This action may range from a warning to suspension or discharge. YAI may also discipline any Associate for the following behavior:

  • Retaliating against, harassing, or intimidating anyone for reporting a concern or violation
  • Interfering or failing to cooperate with an internal or external investigation.

The specific disciplinary action imposed will depend on the nature of the incident and the surrounding circumstances.

Version Number

Summary of Changes

Effective Date

1.0

Initial Version

March 11, 2011

2.0

Updated to: Reorganize the Code of Conduct; eliminate and combine with the separate code of conduct provided to the Board of Trustees; include new cover art; include a statement from CEO Stephen Freeman; revise based on feedback from the Independent Review Organization’s and YAI’s experiences during the First Reporting Period of its Corporate Integrity Agreement.

June 19, 2012