Disciplinary Action Guidelines

Compliance Policy #906A

The following is a guideline for disciplinary actions with respect to infractions and violations of the Hospital's Compliance Standards and Policies.   The infractions listed below are not exhaustive of all types of
conduct which may constitute grounds for disciplinary action, including termination of employment.   The disciplinary actions listed below are guidelines only.  Nothing in this policy or Compliance Policy #6 should be
construed as preventing, limiting or delaying the Hospital from taking other appropriate disciplinary action, including immediate termination, in any circumstances where the Hospital, in its sole discretion, deems such action
appropriate.

Any of the steps set forth in these guidelines may be skipped or eliminated, in the Hospital's discretion, depending on the seriousness of the offense and other circumstances of the specific case.  As a general rule, disciplinary
action shall be more severe for conduct which is a knowing, intentional or willful violation of the law or of Hospital standards or policies.  Where the guidelines below recommend termination, a lesser disciplinary action may be
imposed, in the Hospital's sole discretion, after consideration of all relevant facts, including, without limitation, the seriousness of the offense, whether the employee has committed previous violations; whether the employee
self-reported the conduct and/or cooperated in the investigation; and other mitigating or extenuating circumstances.
Nothing in this policy or Compliance Policy #6 is intended to alter the "at-will" nature of the employment relationship between the Hospital and its employees as set forth in the Hospital's employment policies, procedures and manuals.

Employee Action/Disciplinary Action Guidelines

1. Engaging in conduct as an employee of the Hospital specific to the workplace which violates any state or federal criminal statute./Termination.

2. Failure to report conduct by an employee or agent of the  Hospital specific to the workplace which a reasonable person should know is a criminal offense./Termination.

3. Failure to report another employee's or agent's violation of any duties under the Hospital's compliance standards or policies (other than criminal conduct)./Discipline may range from a written warning up to
suspension or termination of employment on the first offense.

4. Negligently providing incorrect information to the Hospital or to a government agency, consumer, third party payer, vendor or similar person or entity (footnote 1)./Discipline may range from a written warning up to
suspension or termination of employment on the first offense.
5. Knowingly (footnote 2) or willfully providing false information to the Hospital or to a government agency, consumer, third party payer, vendor or similar person or entity or falsifying any document or Hospital
record, including without limitation, any record required to obtain reimbursement for services provided by the Hospital or its employees or agents (footnote 3)./Termination.

6. Failure to comply with any provision of the Hospital's compliance standards or policies or state or federal statute or regulation (other than a knowing or willful violation or violation of a criminal statute)./Discipline may range from a written warning up to suspension or termination of employment on the first offense.

7. Knowingly or willfully violating any provision of the Hospital's compliance standards or policies or any state or federal statute or regulation (other than violation of a criminal statute)./Discipline may range from a written warning up to suspension or termination of employment on the first offense.

8. Failure to detect conduct by an employ or agent of the Hospital which a reasonable person should know is criminal or a violation of the Hospital's compliance standards and policies and reasonably could be expected to detect./Discipline may range from a written warning up to suspension or termination of employment on the first offense.

9. Intentional or reckless disregard or encouragement of  conduct by anemployee or agent of the Hospital which a reasonable person should know is criminal or a violation of the Hospital's compliance standards and policies and reasonably could be expected to detect./Termination.

10. Failure of a manager, director, or other supervisor to properly supervise employees under his or her direction, which failure results in a violation of law, regulations, or the Hospital's compliance standards or policies./Discipline may range from a written warning up to suspension or termination of employment on the first offense.

11. Intentional or reckless disregard or encouragement (by a director, manager or other supervisor) of conduct by employees or agents of the Hospital, which conduct constitutes a violation of law, regulations, or the Hospital's compliance standards or policies./Discipline may range from a written warning up to suspension or termination of employment on the first offense.

12. Failure to comply with the Hospital's record retention policies (other than intentional or willful destruction of records)./Discipline may range from a written warning up to suspension or termination of employment on
the first offense.

13. Intentional or willful destruction of Hospital records or of any evidence relevant to an investigation of a suspected violation of law or of the Hospital's compliance standards or policies./Termination.

14. Impeding or obstructing an investigation regarding a suspected violation of law or of the Hospital's compliance standards or policies./Termination.

15. Retaliation against any employee or agent who has made a bona fide report to the Hospital or to any regulatory or government agency with respect to violations of applicable laws, regulations or Hospital compliance
standards or policies./Termination.

16. Engaging in any other conduct or wrongdoing which has the potential to impair the Hospital's status as a reliable, honest and trustworthy health care provider./Discipline may range from a written warning up to
suspension or termination of employment on the first offense.


Footnotes:

1 Not applicable to the provision of false information during the application process, which shall be grounds for immediate termination.

2 An employee "knowingly" provides false information if he or she knows or reasonably should know that the information is false or intentionally or recklessly disregards whether or not the information is false.

3 See footnote 1.

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