Enforcement and Discipline

Compliance Policy #906

The Hospital's compliance standards will be consistently enforced through appropriate disciplinary mechanisms, including, as appropriate, discipline of individuals responsible for the failure to detect an offense.  The Hospital
will develop guidelines for disciplinary action, but the type of discipline imposed in each case will be determined based on the specific facts of the case.

Responsibility: All Hospital Personnel

PROCEDURE

Employee Conduct

All employees of the Hospital are required, as a condition of their employment by the Hospital, to comply with all Hospital compliance policies and standards and all federal and state laws and regulations applicable to the performance of their duties as employees of the Hospital.  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.  An employee acts "knowingly" if he or she knows or reasonably should know thathis or her conduct is prohibited or intentionally or recklessly disregards whether or not the conduct is prohibited. All employees are required to report conduct by another employee or agent of the Hospital which a reasonable person should know is criminal or violates any of the Hospital's compliance standards or policies.   Negligently, knowingly or willfully providing any false information to the Hospital or to any government agency, patient, third party payor or vendor is grounds for disciplinary action.

Employee Discipline

If it has been determined that an employee has violated any provision of the Hospital's compliance standards or policies or has engaged in conduct which violates state or federal law, the employee shall be subject to disciplinary action in accordance with this policy, and policy 6A.  The Compliance Officer shall be notified of all disciplinary actions involving compliance violations and shall be consulted prior to termination or suspension of an employee for compliance violation.  The Compliance Officer shall keep a record of all disciplinary actions for compliance violations and the specific grounds for those actions.  This policy shall apply with equal force to all levels of employees.   All employees will be educated about the disciplinary process in employee training programs.

Directors, Managers, Supervisors

Department directors, managers, members of senior management and other supervisors are responsible for complying with all applicable laws and Hospital compliance standards and policies and for assuring that employees under their supervision comply with the same.  A director, manager, member of senior management or other supervisor shall be subject to discipline for his or her failure to comply with applicable laws and policies pursuant to this policy in the same manner as any other employee.  In addition, a director, manager, member of senior management or other supervisor shall be subject to discipline if it is determined, in consultation with the Compliance Officer, that the director, manager, member of senior management or supervisor was negligent in the supervision of employees or agents under their control or direction;  knowingly or willfully failed to take reasonable measures to prevent the misconduct of employees under their control or direction; or
intentionally condoned or encouraged illegal or otherwise wrongful conduct. The performance evaluations of directors, managers, members of senior management and other supervisors shall include an evaluation of the ability of the director, manager, member of senior management or supervisor to detect and prevent compliance violations by employees or agents under his or her supervision, direction or control.

Agents and Independent Contractors

All agents and independent contractors shall be required, as a term of their contractual relationship with the Hospital, to comply with all state and federal laws and regulations applicable to their performance of duties for the Hospital and to comply with all applicable compliance standards and policies. Failure to comply with applicable laws and regulations and compliance standards and policies shall be grounds for termination of the contractual
relationship with the Hospital.

Criminal Offenses

Any person or entity who is charged with a criminal offense related to health care or proposed debarment or exclusion from a federal or state health care program shall promptly be  removed from direct responsibility for or
 involvement in any activities related to a state or federal health care program.  If resolution of the matter results in conviction, debarment or exclusion, the Hospital shall immediately terminate its employment or other contractual relationship with the individual or entity.

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