1.Purpose and Commitment

Teen and Family Services ("the Practice," "we," "us," or "our") is committed to maintaining the highest standards of ethical conduct, patient safety, regulatory compliance, and integrity. We encourage open communication and the good-faith reporting of actual or suspected violations of law, regulations, professional standards, or Practice policies.

This Whistleblower & Non-Retaliation Policy establishes clear procedures for reporting concerns and strictly prohibits any form of retaliation against individuals who make good-faith reports or participate in investigations. The Practice will not tolerate retaliation in any form.

2.Scope: Who Is Covered

This Policy applies to:

• Employees: All current and former employees, including full-time, part-time, temporary, and contract staff;
• Non-Employees: Independent contractors, interns, volunteers, students, business associates, vendors, and other individuals performing services for or on behalf of the Practice;
• Clients / Patients: Individuals receiving therapy, counseling, or related services; and
• Others: Any person who, in good faith, reports a violation of law related to the Practice's operations or care.

3.Protected Activities: What May Be Reported

Individuals are encouraged and, in some cases, legally required to report in good faith any actual or suspected:

• Violations of federal or Texas law, regulations, or rules, including but not limited to HIPAA, the Texas Health and Safety Code, the Texas Occupations Code, and Texas Family Code reporting requirements;
• Patient safety concerns, substandard care, or risk of harm to clients;
• Fraud, waste, or abuse, including billing or coding irregularities, insurance fraud, or False Claims Act violations;
• Breaches of client confidentiality or unauthorized use or disclosure of Protected Health Information (PHI);
• Abuse, neglect, or exploitation of clients, including mandated reporting of child, elder, or disabled person abuse under Texas law;
• Unethical or unprofessional conduct by staff or providers;
• Workplace safety or workplace violence concerns;
• Any other violation of Practice policies, licensing board rules, or professional ethical standards.

4.Texas Legal Protections

4.1 Texas Health and Safety Code § 161.134 — Employees

If the Practice operates as, or is affiliated with, a hospital, mental health facility, or treatment facility under Texas law, it is prohibited from suspending, terminating, disciplining, or otherwise discriminating against an employee for reporting in good faith a violation of law to:

• The employee's supervisor;
• An administrator of the facility;
• A state regulatory agency; or
• A law enforcement agency.

A report may be made verbally or in writing.

4.2 Texas Health and Safety Code § 161.135 — Non-Employees

The same facilities may not retaliate against a person who is not an employee for reporting a violation of law. Non-employees who suffer retaliation may sue for injunctive relief, damages, or both, with a similar presumption and remedies.

4.3 Required Posting

Covered facilities must prominently and conspicuously post in a public area readily available to patients, residents, employees, and visitors a statement, in English and a second language appropriate to the community served, that employees, staff, and non-employees are protected from discrimination or retaliation for reporting a violation of law. The Practice will maintain such posting where required.

5.How to Make a Report

Reports may be made through any of the following channels. You are not required to follow a particular order:

1. Internal Supervisor or Manager: Report directly to your immediate supervisor or any manager.
2. Privacy Officer / Compliance Officer: [Name / Title], [Phone], [Email]
3. Anonymous Reporting: [Hotline number / Online portal / Email]. Anonymous reports will be investigated to the extent possible based on the information provided.
4. External Agencies. You may report directly to any of the following:
   • Texas Health and Human Services Commission (HHSC) or the Texas Department of State Health Services
   • Texas Behavioral Health Executive Council, for LPC, LMFT, LCSW, and Psychologist complaints
   • U.S. Department of Health and Human Services, Office for Civil Rights, for HIPAA matters
   • Texas Attorney General
   • Local law enforcement, for criminal matters
   • Medicare/Medicaid Fraud Control Unit or the HHS Office of Inspector General, for fraud

6.Good-Faith Requirement

Protection under this Policy and under Texas law applies to reports made in good faith. A report is made in good faith when the reporting person has a reasonable factual or legal basis for believing the information is true and that a violation has occurred or is occurring.

7.Strict Prohibition on Retaliation

The Practice strictly prohibits any form of retaliation against any person who, in good faith:

• Reports a concern under this Policy or applicable law;
• Participates in or cooperates with an investigation;
• Refuses to engage in conduct that the person reasonably believes is illegal or would expose a client to substantial risk of harm; or
• Exercises any right protected by Texas or federal law.

Prohibited retaliatory actions include, but are not limited to:

• Termination, suspension, demotion, or reduction in hours or pay;
• Discipline, written warnings, or negative performance evaluations that are not based on legitimate performance issues;
• Harassment, intimidation, isolation, or changes in job duties designed to punish;
• Threats or coercion; and
• Any other adverse action that would deter a reasonable person from reporting.

8.Investigation Process

All reports will be promptly and thoroughly investigated in a fair and impartial manner. Investigations will be conducted by the Privacy Officer, Compliance Officer, or designee, or by external counsel or investigators when appropriate. To the extent possible, the confidentiality of the reporting person and the subject of the report will be maintained, consistent with the need to conduct a thorough investigation and comply with legal obligations.

Individuals involved in an investigation are expected to cooperate fully and truthfully. Retaliation against anyone who participates in an investigation is strictly prohibited.

9.Corrective Action

If an investigation substantiates a violation, the Practice will take appropriate corrective and disciplinary action, which may include coaching, additional training, policy changes, suspension, termination of employment or contract, reporting to licensing boards or law enforcement, and other measures necessary to address the issue and prevent recurrence.

10.Additional Federal Protections

In addition to Texas law, federal protections may apply, including but not limited to:

• HIPAA Privacy Rule: Workforce members and business associates are protected from retaliation for good-faith whistleblowing disclosures of PHI under specific circumstances (45 C.F.R. § 164.502(j)).
• False Claims Act / Affordable Care Act: Protections for reporting healthcare fraud involving federal programs.
• Other federal statutes: OSHA, FLSA, and other laws that prohibit retaliation for protected activity.

11.No Waiver of Rights

Nothing in this Policy is intended to waive or limit any rights an individual may have under Texas or federal law, including the right to file a complaint with a government agency, to participate in an investigation, or to pursue legal remedies. This Policy does not create an employment contract or alter the at-will nature of employment in Texas.

12.Questions and Policy Administration

Questions about this Policy should be directed to the Privacy Officer / Compliance Officer:

13.Acknowledgment

All employees and applicable contractors are required to acknowledge receipt and understanding of this Policy. Failure to comply with this Policy may result in disciplinary action up to and including termination of employment or contract.