Limitations on Employment Policy

DEPARTMENT: Human Resources POLICY DESCRIPTION: Limitations on Employment PAGE: 1 of 7 REPLACES POLICY DATED: 9/15/98, 11/12/98, 3/16/99, 4/16/99, 6/30/99, 1/1/01, 4/1/01, 9/1/02, 2/1/05, 7/7/05, 11/1/05. 7/1/06, 8/1/08, 11/1/08, 1/24/09, 7/1/09, 11/1/09, 2/1/11 EFFECTIVE DATE: September 2, 2011 REFERENCE NUMBER: HR.OP.019 (formerly HR.209) APPROVED BY: Ethics and Compliance Policy Committee

SCOPE: Employees in all facilities affiliated with the Company including, but not limited to, hospitals, ambulatory surgery centers, home health agencies, physician practices and all Corporate Departments, Divisions, and Groups.

PURPOSE: To define the legal or ethical limitations that may exist in establishing an employment relationship with an individual and the responsibility of the hiring manager to recognize these issues in the hiring process.

POLICY:

1. Group/Division/Market Presidents, CFOs, COOs, CMOs, Affiliated Employer CEOs, CFOs, COOs, CNOs, Center Administrators and Corporate Payroll Employees in salary grade C34+ or O34+ are employed “at will” for an indefinite period by the employer and such employment may be terminated with or without cause or notice at the will of either the employee or the employer.

2. All other employees are employed for an indefinite period and the employer may terminate the employment relationship “for cause.” Cause is defined as a reason for disciplinary action that is not arbitrary, capricious, or illegal, that is based on facts that the employer reasonably believes to be true. Some examples of cause include, but are not limited to, (1) dissatisfaction with an employee for such reasons as lack of capacity or diligence, failure to conform to usual standards of conduct, or other culpable or inappropriate behavior, or (2) economic needs subject to the reasonable judgment of the employer.

3. Hiring of Former Fiscal Intermediary Personnel a. To ensure compliance with 42 CFR 420.203 and the disclosure of hiring former employees of fiscal intermediaries, Human Resources will notify the Secretary of Health and Human Services of the hiring of persons who had been employed in a managerial, accounting, auditing or similar capacity by a fiscal intermediary during the previous 12 months. b. Human Resources will send the letter of notification within 30 days of the first day of employment.

4. Prohibition Against Employment of Ineligible Persons

6/2011 DEPARTMENT: Human Resources POLICY DESCRIPTION: Limitations on Employment PAGE: 2 of 7 REPLACES POLICY DATED: 9/15/98, 11/12/98, 3/16/99, 4/16/99, 6/30/99, 1/1/01, 4/1/01, 9/1/02, 2/1/05, 7/7/05, 11/1/05. 7/1/06, 8/1/08, 11/1/08, 1/24/09, 7/1/09, 11/1/09, 2/1/11 EFFECTIVE DATE: September 2, 2011 REFERENCE NUMBER: HR.OP.019 (formerly HR.209) APPROVED BY: Ethics and Compliance Policy Committee

a. For purposes of this policy, an “Ineligible Person” shall be any individual or entity that: i. is currently excluded, suspended, debarred or otherwise ineligible to participate in Federal health care programs; ii. Has been convicted of a criminal offense related to the provision of health care items or services but has not yet been excluded, debarred, or otherwise declared ineligible; or iii. is currently excluded on a state exclusion list. b. No Company-affiliated facility, including hospitals, ambulatory surgery centers, home health agencies, and physician practices will make an offer of employment to an applicant who is listed as an Ineligible Person. c. All applicants are required to answer the following question on the application for employment: Are you currently excluded, suspended, debarred or otherwise ineligible to participate in the Federal health care programs, or have you been convicted of a criminal offense related to the provision of health care items or services but not yet been excluded, debarred, or otherwise declared ineligible?

d. Each employee of a Company-affiliated facility must disclose immediately any debarment, exclusion or other event that makes him or her an Ineligible Person. e. All Company-affiliated facilities, including hospitals, ambulatory surgery centers, home health agencies, and physician practices must immediately terminate any current employee who is listed as an Ineligible Person.

5. Employment of Minors Normally, candidates for employment must have reached their eighteenth birthday. However, persons who have reached their sixteenth birthday may be considered for employment within the limits of state and federal law.

6. Employment of Relatives and employees with common domicile a. Employment of immediate family members and employees with common domicile at Company-affiliated facilities may cause the perception of inequitable hiring practices and/or conflicts of interest by fellow employees or others. Therefore, prior written approval must be obtained from a manager one level above the hiring manager and may only be approved after determining that such employment will not create the appearance of a conflict of interest or have other adverse consequences to business operations. Immediate family is defined as spouse, parent, parent-in-law, brother, sister, child, step-child and grandparent; common domicile is the same legal residence. b. Members of an immediate family or employees with common domicile shall not supervise

one another directly. c. Members of an immediate family or employees with common domicile shall not supervise one another indirectly without prior written approval from a senior manager at least one level above the hiring manager. d. If marriage, promotion or other action creates a supervisory relationship among related employees or employees with common domicile, one of the related employees or employees with common domicile must either resign or transfer in order to resolve the situation within one calendar month. e. No Company affiliated facility shall employ a relative or an individual with common domicile of its Human Resources Director or any member of Senior Management without written approval of a senior manager at least one level above the hiring manager.

7. Use of Contract Personnel a. Contracts with independent contractors should be reviewed in advance by the Legal Department. Generally, if an individual is subject to the Company’s control or direction only regarding end results (and not as to the details by which those results are accomplished), the individual may be classified as an independent contractor. b. The agreement should include the Federal Tax ID number and the proof of workers compensation insurance certificate.

DEFINITION SanctionCheck.com is the Compliance Concepts, Inc. (CCI) website that enables Company- affiliated facilities to verify exclusions using an individual name or a batch file of multiple individuals that is processed against the OIG Sanction Report and the GSA List at the same time. Instructions for individual and batch search using SanctionCheck.com are on the website at http://app.sanctioncheck.com.

PROCEDURE:

1. Hiring of Former Fiscal Intermediary(FI)/Medicare Administrative Contractor (MAC) Personnel a. In the event a facility hires a former FI/MAC employee, the Human Resources Director

will prepare a letter similar to the attached example and forward it to the Department of Health and Human Services. b. The Human Resources Director will retain a copy of the letter to be available during a survey or certification visit. A copy will also be placed in the employee’s personnel file.

2. Prohibition Against Employment of Ineligible Persons a. Screening Prior to Employment. i. Prior to hiring or re-hiring an employee, the Human Resources Director or designee must ensure that the individual being considered for employment has been checked against the: (a) General Service Administration’s List of Parties Excluded from Federal Programs (the “GSA List”); (b) HHS/OIG List of Excluded Individuals/Entities (the “OIG Sanction Report”); and (c) Any applicable state exclusion list.

ii. The Human Resources Director or designee or the vendor providing background investigations will compare the name and address of each potential candidate for employment to the GSA List and the OIG Sanction Report. Should an individual appear on either the GSA List or the OIG Sanction Report, the Company may not employ that individual.

iii. The GSA List and the OIG Sanction Report are on the Internet in searchable formats at, respectively:  http://epls.arnet.gov ; and  http://exclusions.oig.hhs.gov.  Alternatively, both lists may be searched simultaneously at: http://app.sanctioncheck.com. This is the recommended method of conducting ineligible persons searches.

b. Screening Subsequent to Employment. i. Corporate Office-Based Screening. (a) On a monthly basis, Corporate Information Technology & Services (IT&S) will compare the Company’s employee database against the GSA List and the OIG Sanction Report and provide the report of the comparison, which lists potential matches, to the Corporate Human Resources’ VP, Employee

Relations. (b) The VP, Employee Relations is responsible for confirming the match by reviewing the GSA list on a semi-annual basis and the OIG list on a monthly basis. (c) If an employee is an Ineligible Person on either list, the VP, Employee Relations will notify the HR Director at the facility which employs the Ineligible Person. (d) The HR Director must terminate the employment relationship with that individual. (e) The VP, Employee Relations will report the match and the action taken by the facility to the VP, Reimbursement and Director, Internal Compliance Reporting ii. Facility-Based Screening. (a) Facilities located in states which maintain a state exclusion list must search the state exclusion list on a monthly basis to ensure that no employee is an ineligible person. (b) If an employee is an Ineligible Person on the state list, the HR Director must terminate the employment relationship with that individual. (c) A list of states with exclusion lists is available on Atlas. c. Each employee must immediately disclose to his or her supervisor any debarment, exclusion or other event that makes the employee an Ineligible Person. The supervisor must report such disclosures to the HR Director, and the HR Director must terminate the employment relationship with that individual. d. The HR Director must notify the facility’s Division Reimbursement Manager to address potential cost reporting issues and report the disclosure or match and subsequent actions, including the final disposition, to the facility Ethics and Compliance Officer (ECO). e. If the ineligible person is a Corporate payroll employee, the VP, Employee Relations, will work with the Corporate Reimbursement department to address cost reporting issues, and report the match or disclosure and subsequent actions, including the final disposition, to the Director, Internal Compliance Reporting. f. Documentation: i. Whenever a search of the GSA List, the OIG Sanction Report, or applicable state exclusion list is conducted by the background investigation vendor or a facility undertakes to confirm a possible match, the search results must be documented and copies of the search information should be maintained in an electronic file, separate file or in a master exclusion verification file filed by year and alphabetized

for applicants not employed. ii. Documentation required for searches performed on SanctionCheck.com: a) Documentation required when batch file results from SanctionCheck.com indicate a possible OIG or GSA List match:  A Batch Summary Report must be printed.  An individual certificate summary must be printed for all “Positive Matches Only” (both OIG and GSA positive matches). b) Documentation required regardless of SanctionCheck.com search results:  The “All Names Submitted” file must be downloaded when the Batch Results page displays.  The list used to develop a batch search must be printed and saved. iii. Electronic storage is also an acceptable storage option provided the documents are readily available on demand. A procedure for backing up documents in the event of system malfunction should be established to ensure accessibility. iv. All records regarding ineligible persons search results must be maintained according to the Company’s record retention schedules (i.e., five (5) years).

v. All Company-affiliated facilities must comply with the Records Management Policy, EC.014.

3. Hiring of Relatives a. Before extending an offer of employment to the relative or to an individual with common domicile of an existing employee, the manager should consult with Human Resources to ensure proper written approval is obtained and that there will be no appearance of or actual conflict of interest. b. In situations where Human Resources believe a perceived or actual conflict will exist, Human Resources should consult with the local ECO before a final decision is made. 4. Independent Contractors and Employees of Staffing Agencies or Contracted Service Entities All contract labor vendors for clinical and administrative staffing (i.e., “Subjects” as defined in policy HR.OP.002, excluding students and volunteers) are to be contracted and managed by All About Staffing. Contract labor which falls within the definition of “Other Contract Worker” as defined in policy HR.OP.002 will continue to be managed by affiliated facilities and are excluded from the requirements set forth below (i.e., are not subject to ineligible persons screening).

All About Staffing will compare its independent contractors, employees of staffing agencies or

contracted service entities, as appropriate, to the GSA and OIG lists and the state exclusion list, if applicable, to confirm a potential match by reviewing the GSA list on a semi-annual basis and the OIG list and state exclusion list, if applicable, on a monthly basis. The CEO of each company-affiliated facility or designee is responsible for a process to conduct a search of the GSA and OIG lists to confirm a potential match of any contract labor provider (“Subjects”) not otherwise managed by All About Staffing. REFERENCES: 1. 42 CFR 420.203 2. 48 CFR Subpart 9.4, Federal Acquisition Regulation, 9.4 – Debarment, Suspension, and Ineligibility 3. Records Management Policy, EC.014 4. Background Investigations Policy, HR.OP.002 5. Prohibition Against Contracting with Any Ineligible Person Policy, MM.001

6/2011 Standard letter for notification of H.H.S. of employment of former fiscal intermediary employee:

[Date]

The Honorable ______Secretary of the United States Department of Health and Human Services 200 Independence Avenue SW Washington, DC 20201

Dear Secretary ______:

As required by 42 CFR 420.203, providers must disclose “the hiring of certain former employees of fiscal intermediaries.”

We wish to disclose our employment of the following individual:

Effective date:

Former employer:

If we may offer additional information concerning this matter, please notify us.

Sincerely,

cc: Vice President, Reimbursement Personnel File

Attachment to HR.OP.019