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Compliance and Reporting of Suspected Violations of Law, Regulation or Policy

South Lincoln Medical Center

1. Policy:

1.1 All employees and agents of SLMC are required to comply with all Hospital compliance policies and standards and all federal and state laws and regulations applicable to the performance of their duties. All employees and agents are required to report conduct by another employee or agent of SLMC which a reasonable person should know is unlawful or violates any of SLMC's compliance standards or policies.
1.2 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 and agents 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 Chief Executive 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 or agents 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.

2. Duty to Report:

2.1 All employees and agents of SLMC shall have a duty to report any suspected wrongdoing or violation of applicable laws, regulations or SLMC's compliance standards or policies. Employees or agents who fail to fulfill this duty may be subject to disciplinary action or other consequences.

3. Methods of Reporting:

3.1 Suspected misconduct or violations of SLMC's compliance standards and policies may be reported by any of the following methods:
A.Directly contacting SLMC's Chief Executive Officer or Board of Trustees Chair; B.Contacting the Compliance Officer;
C.Reporting via the Compliance Hotline (1-888-298-9897);
D.Contacting the employee's or agent's supervisor or the manager or director of the employee's department. Supervisors, managers and directors who receive such reports shall forward them immediately to the Chief Executive Officer;
E.Submitting a written report using the Compliance Report Form, which may be obtained from the Compliance Officer or the Human Resources Manager.
3.2 Regardless of how a report is made, to be useful in the detection and prevention of misconduct, the report must contain specific information regarding the suspected misconduct, including when and how the conduct occurred or is occurring, the persons involved in the conduct, and the specific nature of the conduct. Employees and agents may report suspected violations anonymously. SLMC encourages persons making anonymous reports to maintain contact with the Chief Executive Officer, however, so that the Chief Executive Officer may obtain any additional information needed to properly investigate the report.

4. Confidentiality of Reports:

4.1 SLMC shall treat reports of suspected misconduct as confidential to the greatest extent possible, subject to SLMC's obligation to investigate the report and take appropriate action to correct any violations or misconduct. SLMC shall take reasonable steps to maintain confidentiality of the identity of any person providing information to SLMC. SLMC cannot, however, guarantee complete confidentiality of the identity of persons who make reports, due to SLMC's obligations to investigate and correct misconduct and its obligations to report certain misconduct to state and federal authorities.

5. Investigation:

5.1 The Chief Executive Officer and legal counsel, as necessary, shall determine whether the alleged wrongdoing is a violation of law, a violation of SLMC's compliance standards, policies, or procedures, poses a risk to patients or the public, puts SLMC at risk of economic injury, civil or criminal liability, or injury to SLMC's reputation, and shall determine what steps will be taken to investigate the report. The Chief Executive Officer may investigate the report or may delegate the responsibility for such investigation to an appropriate person within or outside SLMC.
5.2 If the Chief Executive Officer, after consultation with the department director in appropriate cases, believes that the integrity of SLMC's investigation is compromised because of the presence of any employee under investigation, such employee shall be removed from his or her current work activity, with or without pay at the sole discretion of the Chief Executive Officer, until the investigation is complete.

6. Corrective and Disciplinary Action:

6.1 After the investigation is completed, the Chief Executive Officer shall, in consultation with legal counsel as necessary, develop a plan for corrective action to remedy the violation. Such plan for corrective action shall include education of Hospital employees and/or contractors as appropriate and, if applicable, any appropriate disciplinary action against any employees engaged in the misconduct or wrongdoing. The Chief Executive Officer shall monitor the implementation of corrective action plans on a regular basis to assure that the plans are properly implemented and the misconduct or wrongdoing has been corrected.

7. No Retaliation; False Reports:

7.1 SLMC prohibits any form of retaliation against any employee, agent, or contractor for filing a good faith report under this Policy, for assisting in any investigation regarding compliance matters, or for making a good faith effort to stop violations of the Federal False Claims Act, 31 U.S.C. § 3729-3733, 3801-3812. Persons who engage in such retaliation shall be subject to discipline. However, if after investigating any report, SLMC determines that the action was not taken in good faith or that a person has provided false information regarding the report, disciplinary action may be taken against the individual who took the action or gave the false information.
7.2 No person shall be subject to disciplinary action solely on the basis that he or she mistakenly reported what he or she reasonably believed to be an act of wrongdoing or a violation of law or of SLMC's compliance standards or policies. A person will be subject to disciplinary action, however, if it is determined that the report of wrongdoing was knowingly or willfully fabricated by the person or was knowingly or willfully distorted, exaggerated, or minimized to either injure someone else or to protect himself or herself. A person "knowingly" provides false information for purposes of this policy 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.

8. Discipline of a Reporting Person:

8.1 A person whose report of misconduct contains admissions of personal wrongdoing is not guaranteed protection from disciplinary action simply because he or she made the report. In determining what, if any, disciplinary actions may be taken against a reporting person, the Chief Executive Officer may take into account a person's own admission of wrongdoing provided that the person's involvement was not previously known to SLMC, its discovery was not imminent, and that the admission was complete and truthful. The weight to be given to self-reporting will depend on all facts known at the time SLMC makes its discipline decisions and the applicable discipline procedures set forth in SLMC's compliance policies. NOTHING IN THIS POLICY IS INTENDED TO MODIFY THE AT-WILL RELATIONSHIP BETWEEN SLMC AND ITS EMPLOYEES, OR TO CREATE A CONTRACT OF EMPLOYMENT.