WELCOME TO

Employee Handbook

January 2018

Welcome!

We welcome you to the Robert Wood Johnson University (RWJUH) family. Our mission is to provide the highest quality patient care, , research and community outreach in a supportive environment that enhances the well-being of everyone we serve. As New Jersey’s premier Academic Medical Center, which includes both New Brunswick and Somerset campuses, we provide an expansive range of healthcare services. As a sophisticated academic medical center, we treat the most severely ill patients from around the state and even the country.

The excellence that we achieve is a result of the dedicated efforts of each member of the Robert Wood Johnson University Hospital staff. It is our growth as individuals and caregivers that contribute to the overall growth of our Hospital. Quality patient care depends upon the attitudes of the people who work here. No matter what your may be, your ability and demeanor are crucial factors in assuring the well-being of our patients.

This handbook is written to acquaint you with RWJUH policies. If you have any questions regarding your specific position expectations, be sure to speak with your . The Human Resources staff is always available to assist you throughout your at RWJUH.

Again, we welcome you to New Jersey’s premier Academic Medical Center. We hope that you will view this new opportunity as one of the most rewarding of your .

OUR COMMITTMENT

RWJUH is committed to recruit & retain the most qualified individuals for employment without regard to age, race, creed, marital status, sex, religion, national origin, sexual orientation, disability (with or without reasonable accommodation), genetic information, military or veteran status or other characteristics protected by federal, state and local law. This shall also apply to actions including, but not limited to, compensation, benefits, transfers, promotions and demotions, leave of absences, , education and recreational programs. In accordance with our policy of for all, the Hospital is committed to seeing to it that all employees are given the opportunities to attain their employment goals.

DIVERSITY AND INCLUSION

RWJUH is committed to providing an environment that encourages the talents and recognizes the uniqueness of each employee and patient. We believe a diverse workforce will help RWJUH interact effectively with a culturally diverse community in achieving our primary mission of providing the highest quality patient care. We operate on the fundamental belief that individual and cultural differences are a reality, and that such differences will produce better ideas, quality service and a genuine competitive advantage.

Believing that diversity and inclusion are important organizational values, RWJUH has an Office of Diversity, which supports these values and serves as a resource to our employees on issues related to cultural and other differences.

1 DIVERSITY AND INCLUSION VISION STATEMENT

Diversity at RWJUH is representative of our patients, employees, physicians and the community we serve. In our pursuit of excellence, we are committed to and celebrate the uniqueness of all individuals through acceptance, inclusion, education and respect. At RWJUH, we believe that every individual contributes to the fabric of our organization.

EQUAL EMPLOYMENT OPPORTUNITY AND

RWJUH is strongly committed to the principles of Equal Employment Opportunity and Affirmative Action. The hospital demonstrates this commitment through a policy of providing equal employment opportunities and by not discriminating against any employee or applicant based on race, color, religion, creed, age, marital status, gender or gender identity, citizenship status, national origin, sexual orientation or expression, ethnicity, military/veteran status or disability which can be reasonably accommodated without undue hardship, or any other classification protected by law.

All selection decisions are made consistent with the Equal Employment Opportunity principle and the hospital’s current Affirmative Action Plan goals. The hospital’s policy of non- discrimination applies to recruiting, hiring, training, transferring, promoting, assignments, compensation and all other personnel decisions.

All complaints of discriminatory treatment in violation of this policy should be made to your supervisor or the Human Resources Department, so that an investigation may be undertaken. Appropriate disciplinary or other action will be taken to address any wrongdoing that may be found upon the conclusion of the investigation as it relates to the discrimination policy.

HARASSMENT FREE POLICY

It is the policy of the Hospital to maintain a working environment which prohibits illegal, unwanted and/or , or other forms of harassment among its employees based on any protected status. The intent is to provide a system for the harassed employee to seek assistance, thereby allowing the Hospital, as the employer, to take immediate and appropriate corrective action against such misconduct. Employees are directed to contact their supervisor promptly, or Human Resources if the incident occurred at a supervisory or managerial level. However, under no circumstances do you need to report this to your supervisor. The Human Resources Department is responsible for overseeing, and in some cases, conducting a confidential investigation.

ORIENTATION AND IN-SERVICE PROGRAMS

New employees receive a general orientation as well as an individual orientation to their departments (as needed). In addition, ongoing in-service and education programs are available as deemed appropriate. If you have questions about your job or Hospital policy, speak with your supervisor. If the supervisor is unable to answer your questions or further explanations are needed, you should contact the Human Resources Department.

2 YOU AND THE HOSPITAL’S IMAGE

The Hospital’s image in the community is very much affected by the appearance and conduct of every employee. Please remember that patients and visitors are our guests and should be treated with courtesy and friendliness as described in the Patient Bill of Rights and Employee Code of Conduct. So that patients will not be disturbed, all unnecessary noise or loud talking must be avoided. When visiting a family member or friend hospitalized here, employees must observe all visitor regulations; otherwise employees should not be on the premises during hours when they are not scheduled to work.

EMPLOYEE CLASSIFICATION

Employees of RWJUH are classified as follows:

1. Regular full-time – regularly scheduled to work 80 hours per biweekly pay period. 2. Regular part-time – work a regular , consisting of 32 or more hours per biweekly pay period. 3. Per diem – do not have a regular schedule, or work on an as needed basis. 4. Temporary – hired for a specific assignment or project, which usually will not exceed one year.

EMPLOYEE IDENTIFICATION

All employees of RWJUH are issued an employee identification badge by the Safety and Security (Public Safety) Department. The badge must be worn and displayed at all times while on duty. Some employees will be issued a name tag in addition to an identification badge. It is important that patients and visitors be able to easily identify the name and position of every staff member they meet.

LICENSURE

An employee who works in a position requiring state or other registration/certification must present a valid, license to his/her department head for verification. The Hospital also verifies all licenses with the primary source.

EMPLOYEE RECORD CHANGES

Confidential up-to-date records on each employee are maintained in the Human Resources Department. All employees are required to update any changes in their name, address, telephone number, marital status, family composition, etc. preferably by accessing employee self-service on Lawson System. Other changes should also be reported to the Human Resources Department.

PERSONAL APPEARANCE AND UNIFORMS

3 You may be required to wear a uniform. Some positions also require protective clothing. Your supervisor will advise you of departmental uniform regulations. You will be expected to practice good personal hygiene. If you are not required to wear a uniform, suitable and appropriate business attire determined by your supervisor must be worn. Our expectation is simply neat, clean and professional. Clothing such as jeans, non-work related tee shirts and thong type sandals will not be acceptable dress for any department.

PAYROLL AND PAY DAY

The work week is defined as seven (7) consecutive days commencing on Sunday and ending the following Saturday. For employees of the New Brunswick campus only, night shifts, in their entirety, are credited to whichever day holds the majority of the hours.

Employees are paid on a biweekly basis which is every other Thursday. It covers the previous 14 day period, ending on Saturday. For your protection, no one other than yourself may pick up your paycheck without written authorization.

In addition to those deductions required by law, such as Social Security, Federal and State , you may authorize, in writing, additional deductions for the Credit Union, and other approved benefit programs.

Direct deposit of your paycheck to any bank that participates in the Automatic Clearing House (ACH) can be arranged. Contact Payroll for details.

The Hospital is required by law to comply with all court orders for garnishments. Under normal circumstances, and where possible, the Hospital will make reasonable efforts to notify you in advance when such actions are ordered.

TIME WORKED RECORDS

If you are a non-exempt (hourly) employee, it is required that you use the automated time and attendance system to record your time. Your supervisor will tell you where to swipe in using your Hospital ID badge. Misrepresenting hours worked is grounds for . Exempt staff below the level of Department Director is required to swipe for attendance, i.e., one time per day.

Non-exempt employees who clock in late six minutes will have a lateness deduction rounded to 10 minutes. Please note that this deduction is for payroll purposes only. Any clock-in time after the start of your shift is considered late. Appropriate disciplinary action will be taken for those with repeated lateness. Any early punch in or late punch out without specific authorization will be paid using the same rounding rule as noted above. However, this action may be subject to disciplinary action as well. Hourly employees leaving the building during the work day are required to clock out for their period of absence.

OVERTIME

4 If you are eligible for , it will be paid at the rate of time and one-half for any time worked over 40 hours per week. is included in all calculations for overtime.

In order to promote the health, safety and welfare of patients, hourly employees with direct patient care responsibilities may decline, without adverse employment action, non-emergency overtime requests that would result in their working in excess of forty (40) hours in a work week. Employees will be required to work “emergency overtime” in cases of “unforeseen emergent circumstances,” which does not include pre-scheduled staffing deficiencies. This policy is in accordance with the New Jersey Law on Mandatory Overtime Restrictions for Health Care Facilities.

SHIFT DIFFERENTIAL

Employees who normally work the evening (3:00 p.m. – 11:30 p.m.) and night (11:00 p.m. – 7:30 a.m.) shifts are eligible for shift differential. Employees assigned to work the night shift shall receive a shift differential of fifteen percent (15%) of the minimum of their pay grade. Those who normally work the evening shift shall receive twelve percent (12%) of the minimum of their pay grade. Shift differential for eligible exempt employees will be determined as a percentage of the minimum of the employee’s pay grade.

An employee who works at least half of his/her scheduled workday after 7:00 p.m. shall receive the evening shift differential for all hours worked on such day. Employees assigned to work on one of those shifts may contact their for more information. Shift differential for eligible exempt employees will be determined as a percentage of the minimum of the employee’s pay grade.

An employee who works at least half of his/her scheduled workday prior to 7:00 am shall receive the night shift differential for all hours worked on such day. An employee who works less than half his/her scheduled workday before 7:00 a.m. or after 7:00 p.m. shall receive the applicable shift differential for only such hours actively worked before 7:00 a.m. or after 7:00 p.m.

ON CALL

In order to provide uninterrupted patient care services, certain departments may have to be available on weekends, holidays and nights. If you are a non-exempt employee designated as “on call” your supervisor will explain your responsibilities and the method of payment.

PERFORMANCE REVIEWS AND ANNUAL INCREASES

Your job performance is formally reviewed and evaluated by your supervisor at least once a year. You are requested to sign the performance review form to acknowledge that the review has been conducted. Employees are given the opportunity to include their comments and responses.

5 All employees may receive an annual, general pay increase in an amount approved by the Hospital’s Board of Trustees.

CONTINUOUS SERVICE

For regular employees, Hospital continuous service starts with the employee’s last hire date. “Continuous service” means the period of time that the regular employee has been on the payroll since the last hire date. However, it excludes certain types of leaves of absence, layoffs and other periods of continuous absence from employment.

Per diem staff who change to regular status will be considered as newly hired on the date that such status change occurs. Also, full-time staff who transfers to per diem will be considered newly hired on the date of such status change.

TRANSFERS, PROMOTIONS AND VACANCIES

Promotions are made on the basis of merit and qualifications. Whenever feasible, the Hospital endeavors to fill job openings through internal promotion or transfer. First consideration will always be given to persons who qualify for the position. As a general rule, available positions will be posted on-line and on certain bulletin boards. If you are interested in transferring to another job, and meet the qualifications, you should submit a transfer form on-line. Your supervisor should be notified of your interest in securing another position prior to interviewing with the new department. To accommodate the needs of the releasing department, transfers and promotions may be delayed by up to four weeks based on Hospital need.

Applicants for transfer must be employed for at least 6 months, and will be considered on the basis of qualifications, attendance record, length of service, reason for request, and requirements of the department involved. An employee can transfer one time per year. Employees transferred by their request will be granted a trial period not to exceed 30 calendar days during which they can transfer back to the former job if it is still available. An employee transferred for any reason serves an introductory period on the same basis as a new employee.

ATTENDANCE

If you are unable to report for work when scheduled, be sure to give your supervisor as much notice as possible. The minimum notice required is at least three hours before the start of your assigned shift, unless otherwise specified in department policies.

You should not call the switchboard or leave messages with others, but should speak directly to your supervisor or the person designated by the supervisor. Failure to give such notice on two consecutively scheduled working days will be considered a voluntary . Failure to call within the required time frame is grounds for disciplinary action.

6 Because full services for patients must be maintained, you are expected to make every effort to be here even when traveling or other conditions are difficult. An employee unable to reach the Hospital because of severe weather, or an emergency situation declared by the Hospital, etc., will not be permitted to substitute with accrued paid time off or sick time when an emergency or unusual circumstance has been declared. Employees who anticipate that their arrival to work will be delayed must call their supervisor and provide an estimated time of arrival. Pay status for those who are late when an emergency situation has been declared, will be determined by the Senior Vice President, Operations or designee.

GRIEVANCE PROCEDURE

A grievance is defined as a complaint that a Hospital supervisor and/or management has violated, or has misinterpreted its written policies. Full and part-time employees have the right, without fear of reprisal, to file formal grievances if they feel they were not treated in an appropriate manner. If you wish, the Human Resources Department will assist you in filing a grievance. If you have a complaint or a problem, or want to appeal a disciplinary action, you should discuss it with your supervisor. If the complaint stems from a particular incident, you are required to make your supervisor aware of the incident within five working days of the occurrence. (As outlined in the grievance procedure, working days exclude Saturdays, Sundays as well as Holidays.) Your supervisor should answer you within three working days. In most cases, a problem can be settled at the supervisory level. If, after discussing the problem with your supervisor, you feel it is still not resolved to your satisfaction, you may initiate the written grievance procedure. This process is available to regular full and regular part-time employees who have satisfactorily completed their three (3) month introductory period.

Step 1:

The employee presents the grievance in writing to the appropriate Vice President/Director within three (3) working days after the discussion with his/her supervisor, but in no event later than ten (10) days after the occurrence. It is expected that the Vice President/Director will respond in writing within ten (10) working days.

Step 2:

If the Vice President/Director's answer does not satisfy the employee; he/she may notify the Senior Vice President, Human Resources in writing within ten (10) working days* after receipt of the answer and the matter shall be referred to the appropriate Senior Vice President.

At this time, the employee may request to meet with the Senior Vice President to discuss the grievance or may request that the issue be addressed without a hearing. The employee may, at his/her option, only bring a fellow employee to this meeting to assist in presenting the grievance. In either case, the employee shall receive a written answer within ten (10) working days* of the hearing or receipt of the grievance, whichever is later.

7 Or at the grievant’ s discretion, the grievant may select the alternative to have their grievance heard by a five (5) member panel of which three (3) will be from a similar position and two (2) from management. The grievant will select two (2) of the individuals in the similar role and the Hospital will select the third (3rd) person in a similar role and the two (2) individuals from management. A hearing would be held with the decision made by a simple majority vote. All decisions will be rendered within fifteen (15) days and will be considered as fully binding and the decision at this last step of the grievance process is final. All participants involved in the will sign a confidentiality agreement to ensure that all information from the proceedings is confidential.

The decision at this last step of the grievance process is final.

SEPARATION OF EMPLOYMENT

In the event of a , regular employees will receive severance pay, equal to their annual vacation entitlement, but not less than two weeks, in lieu of notice. This will be in addition to full pay for any accumulated paid time off accrued but not taken.

Those who have been employed for at least six months will also receive accrued paid time off, less time used and any pro-rated amount of the 96 hours not used during the paid time off cycle. To receive these benefits, employees must give written notice equal to their annual vacation allowance, or two weeks, whichever is greater and work the entire . Employees may not use paid time off or sick time to fulfill the notice requirement. Anyone terminated during the first 90 days of employment will receive pay for hours worked. Introductory employees are not entitled to two weeks’ notice or two weeks’ pay in lieu of advance notice.

Persons who are discharged for cause forfeit all terminal benefits. Terminal benefits include accrued paid time off earned but not taken. Sick accruals are not a terminal benefit nor are former SMC ESB balances.

Pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) an employee, under certain circumstances, has the right to continue benefit coverage in effect at the time of termination. Consequently, within the time prescribed by law, the employee will be notified in writing of any benefit continuation rights.

DISCLAIMER

It is our obligation under the law to inform you that employment with the Hospital is subject to termination with or without notice or with or without cause at the option of either the employee or the Hospital. This is not a contract of employment. Any of the terms and benefits can be changed by the Hospital. If you have any questions about benefits or terms and conditions of employment, contact the Human Resources Department.

8 DISCIPLINARY ACTION

The Hospital has the right to discharge, suspend, or discipline any employee for cause, including, but not limited to, the following:

- Misrepresentation of time worked - Failure to perform assigned duties competently - Improper treatment of patients - Discourtesy to patients, visitors, or fellow employees - Insubordination - Misrepresentation on employment application or benefit claim forms - Theft or unauthorized use of Hospital property - Possession of alcoholic beverages or intoxicants on premises or under the influence of any alcohol or drug - Unauthorized use, possession or distribution of controlled substances - Willful or negligent destruction of property - Failure to report for duty without notice (except when inability to give notice can be established to the satisfaction of the Hospital) - Possession of a weapon - Physical or mental inability to perform with or without reasonable accommodation - Clocking the time record of another employee or allowing your time record to be punched by another employee - Misrepresentation or false entries on any Hospital document or form including the time card - Dishonesty - Violations of parking regulations - Failure to report an on-the-job injury - Excessive absenteeism or tardiness - Failure to report interrupted lunch - Failure to report all time worked - Failure to wear employee identification badge and, if required, appropriate uniform - Giving false reasons for obtaining a - Breach of confidential information or misuse of computer access or information - Violations of the Patient’s Bill of Rights - Absence from department without proper authorization - Sleeping while on duty, sleeping in an unauthorized area, or other malingering - Violation of safety and OSHA regulations - Violation of any Hospital policy, rule or regulation - Violation of HIPAA - Failure to update professional licenses

9 The preceding does not cover all possible situations and the employee may be subject to disciplinary action or termination for any just cause.

Typically disciplinary action takes the form of any of the following (which may be expedited based on the severity of the situation):

Verbal Counseling - Note is made of the warning and placed in the employee’s permanent file. Written Counseling - Copy placed in permanent file and copy given to employee. Final Written Warning or - For serious or repetitive violation of Hospital rules, any employee may be suspended without pay for one or more days, normally not to exceed ten working days. Discharge - Employees discharged due to an inability to do their job to the satisfaction of the Hospital. Employees discharged for misconduct may be dismissed without advance notice and forfeit all terminal benefits.

An employee who is disciplined or discharged and feels that the action is inappropriate, can use the Grievance Procedure.

Upon termination, an employee must return all Hospital property, including identification badge, keys, name tag, uniforms, library materials and parking card.

BENEFITS

As a regular employee of Robert Wood Johnson University Hospital, you are eligible for a number of benefits ranging from various insurance protections and employee discounts to a defined contribution plan. This part of the handbook briefly summarizes existing benefits. In the event of any discrepancy, the terms and conditions of the applicable insurance policies, plan documents and such changes in policy as may be approved by the Board of Directors of Robert Wood Johnson University Hospital shall govern rather than the provisions of this handbook.

BENEFITS OVERVIEW

Regular full-time employees may participate in the employer sponsored benefit plans. These plans consist of two parts: (1) A foundation of “core” benefits provided to all regular full- time employees. These benefits are:

o Retirement and Sheltered Savings Plans o and accidental death and dismemberment o Employee Assistance Program o Tuition Reimbursement o Employee Discounts o Attendance Incentive o Paid Time Off (PTO)

10 (2) To complete the benefits package, employees may choose additional benefits tailored to their individual needs. Some of these options may be paid for with before-tax-dollars.

o Medical insurance including Prescription Drug coverage o Comprehensive dental plan including orthodontia o Long term disability insurance – For employees scheduled to work 72 hours or more per pay period. o Flexible Spending accounts which allow an employee to “contribute pre-tax dollars to pay for additional medical and/or dependent care expenses.

Employees may have a contribution for medical insurance based on level selected. This will be done through payroll deduction. Spouses are eligible to participate in coverage, but if they have medical benefits offered to them through their employer, the coverage through their employer will be considered primary, and coverage through the Hospital will be secondary.

Regular part-time employees who are regularly scheduled to work at least 32 hours in a biweekly pay period are eligible for fringe benefits on a prorated basis, according to the employee’s scheduled hours in a pay period. Employees may enroll themselves and/or their dependents in the Hospital insurance plans on a cost sharing basis where the Hospital pays a portion of the cost determined by the number of work hours regularly scheduled.

Benefits available are:

o Life insurance o Comprehensive medical insurance including Rx o Dental insurance plans o Retirement plan (for those who work at least 1,000 hours per year) o FSA (health & dependent care)

Other voluntary benefits, such as credit union, are also available.

INSURANCE

If the employee chooses not to enroll at the time of hire he/she may have to wait for the next open enrollment period, which normally occurs in the late Fall. Announcement of the enrollment period are communicated in a variety of ways that may include direct mailings and in-house bulletins. Employees who change from per diem to regular status will be considered “new hires” at the time of that status change for the purpose of benefit eligibility and will be eligible the first of the month following sixty (60) days.

All insurance is subject to the terms, conditions and provisions of the applicable contracts and policies of insurance. Coverage is not automatic and employees are responsible for completing the enrollment process. Detailed information is given in specific booklets and/or contracts which are issued upon enrollment.

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Life Insurance and Accidental Death and Dismemberment Insurance – The Hospital pays the premium for life insurance for regular full-time employees. Coverage amounts depend on your job classification, and in most cases, is equal to your base annual . The amount for which you are insured will be paid to your beneficiary in the event of your death from any cause. The policy also includes accidental death and dismemberment as well as a living benefit for terminal conditions.

Eligible employees terminating their employment have the option of converting their group life insurance to private insurance with no physical examination required. The amount to be covered is limited by the coverage then in effect and the premium is determined by the employee’s age at the time of conversion.

Regular part-time employees may participate in the life insurance plan on a cost sharing basis.

In addition, regular employees may elect to purchase voluntary benefits.

Medical Insurance – There are options available to regular full-time employees. These are explained in the benefit enrollment packet distributed to all eligible new employees.

The insurance plans available on a cost sharing basis to regular part-time employees who regularly work at least 32 hours per pay period are managed care options selected by the Hospital.

Dental Insurance – Regular full-time employees may choose dental coverage as part of their benefits package. Regular part-time employees who regularly work at least 32 hours per pay period may opt for dental coverage on a cost sharing basis. The plans provide substantial savings for dental care for employees and their dependents.

RETIREMENT PLAN

Beginning the first of the year after two years of service, employees who are at least 21 years of age and work 1,000 hours or more a year are eligible to receive Hospital Non-Elective Contributions, which will be the foundation of your retirement savings. Only those employees who also contribute a specific percentage of their earnings into their retirement plan can qualify to receive Hospital matching Contributions. Employees are immediately vested at 100 percent under the retirement plan. All new employees are automatically enrolled in the retirement plan with a three (3) percent contribution rate. Contribution and investment election changes may be made by logging into the retirement plan website or by contacting the retirement plan administrator.

Normal retirement under the retirement plan is at age 65. However, employees may elect earlier retirement, subject to Hospital approval and the rules of the plan. Although an employee may work beyond age 65, the employee should visit the Human Resources Department to discuss the impact of continued employment upon Social Security benefits. In accordance with the Age Discrimination in Employment Act, if an employee chooses to work

12 beyond age 65, contributions will continue. Those wishing to retire must so state in writing. Upon request, the Human Resources Department will assist you in contacting the pension and insurance carriers for a determination of benefits.

LONG TERM DISABILITY (LTD)

Long term disability is available to regular employees who are scheduled to work 72 hours or more per pay period. This plan provides financial protection in case the covered employee becomes disabled and unable to work for an extended period of time. For full information, see the benefit enrollment packet or contact the Human Resources Department.

REIMBURSEMENT ACCOUNTS

Reimbursement accounts may be set up by regular full and part time employees. The accounts provide an opportunity to set aside before tax dollars, through payroll deductions, for qualified healthcare or dependent care expenses. For full information, refer to the benefit enrollment packet.

TUITION ASSISTANCE PROGRAM

All regular full-time employees who have completed their introductory period are eligible for tuition assistance up to a specified maximum per calendar year for Hospital or job related education. Courses may be taken at any accredited school, college, or vocational institution. Certain costs related to exams and approved seminars may be covered under the tuition assistance program. There are additional tuition assistance incentives for employees who pursue a Bachelor of Science of Nursing degree. Regular part-time employees scheduled to work at least 32 hours per pay period are eligible on a prorated basis. Tuition assistance is pro-rated based on the status of employment.

To qualify for assistance, the employee must make written application; maintain a passing grade of “C” or better and present proof of enrollment and attendance. For a conference or seminar, proof of attendance and other related documentation must be submitted.

Detailed instructions regarding the employee tuition assistance program can be found on the intranet and are included with the tuition assistance application. Regular full and part time employees must maintain active employment status while the course is in progress to receive tuition assistance monies.

Employees who have been terminated or have submitted their resignation prior to the completion of their course/program/seminar will forfeit eligibility for tuition assistance. Additional information related to the program details and application process is available in Human Resources.

EMPLOYEE ASSISTANCE PROGRAM

13 The Employee Assistance Program (EAP) is a confidential interventional and referral service offered at no cost to employees and their immediate family members. The EAP addresses problems that can affect an employee’s wellbeing such as family, emotional, financial, substance abuse or alcohol related problems.

o You may refer yourself to the program. No one will be told of your participation. o A concerned supervisor may refer you if you are having work/performance problems. o Care EAP at 877-686-4327 or MHN 800-535-4985 (online at members.mhn.com, company code somerset). HOLIDAYS

All regular full-time employees who have completed 90 calendar days of employment are permitted to use paid time off in each calendar year for the following holidays:

New Year’s Day Martin Luther King’s Day (3rd Monday in January) Memorial Day (last Monday in May) Independence Day Labor Day Thanksgiving Day Christmas Day

NOTE: Employees may substitute recognized religious holidays for those listed above, subject to at least 30 days advance notice and prior approval by their supervisors based upon the needs of the Hospital.

Regular employees who have completed their introductory period are also entitled to use paid time off to take a day off with pay in recognition of their birthday. This day normally is scheduled within 30 days after the employee’s actual birthday.

Non-exempt employees who are required to work on a designated holiday will receive 1½ times their regular hourly rate.

An employee must work the last scheduled shift prior to the holiday, and the first scheduled shift subsequent to the holiday, or the employee will lose paid time off. If scheduled to work the holiday, the employee must work his/her shift on the holiday, unless prevented from doing so by a verified illness.

Employees working shifts in excess of 8 hours will take paid time off in increments according to the number of hours they are regularly scheduled to work.

PAID TIME OFF

14 All regular full-time and part-time employees working at least 32 hours in a pay period are eligible for paid time off (PTO). The number of days allowed varies according to length of service and job classification and will be pro-rated according to the number of position hours the employee holds. Increased PTO accrual allowances based on length of service or promotion become effective with the first full pay period once you become eligible.

PTO requests must be submitted according to department policy, usually not later than March 31st. All PTO must be approved in advance by the department head or designee.

Upon request, the Payroll Department will prepare an advance PTO check for the last payday before vacation commences. In order to receive this pay in advance you must complete a PTO Notice Form, which is available from your supervisor, at least three (3) weeks prior to the payday on which you will receive the check. Advance pay for less than (40) hours is not available.

Accrual of PTO hours is deemed to commence on your first day worked and will be determined by your job classification and length of service. After 90 days of service, you will be eligible to take PTO hours that have accrued. No PTO can be taken until it is accrued and appears on your pay stub.

PTO may be accrued up to a maximum balance, which varies based on length of service and job classification. Once the maximum balance is attained, accruals automatically cease and will not continue until the employee’s “bank” is reduced below the maximum. Accrual time forfeited during this period cannot be re-credited.

REST PERIODS

Employees shall be entitled to a paid 15 minute rest periods for each four hours worked. Rest periods may not be accumulated. The department head is responsible for scheduling rest periods.

All employees working 6.5 hours or more are entitled to a thirty (30) minute unpaid meal period, which is arranged for by the supervisor. If an employee takes a meal break away from hospital premise, they will need to record their meal break by swiping out when leaving hospital property and swiping in when returning from the meal break. Working through a meal break needs to be pre-approved by the manager/supervisor if foreseeable; if unforeseeable the manager/supervisor will be informed of the circumstances requiring the employee to work through their meal break. During meal breaks, if the employee is:

 asked to work through all or part of the break or if asked to return early from break to work, the supervisor will be informed so that the employee is paid appropriately  asked to carry a pager/beeper/cell phone and is responsible for responding to the pager/beeper/cell phone while on the break, the employee will be paid.

EMPLOYEE HEALTH SERVICE

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Through the Employee Health Service, the Hospital provides pre-employment physicals, post illness/injury return to work examinations, health screenings, annual physicals and work related injury care. Employees who become ill while at work may be referred to this service or to other service providers.

EMPLOYEE DISCOUNTS

Regular employees who are scheduled to work 32 hours or more in a biweekly pay period, and who have completed six months of continuous employment, are eligible for discounts on inpatient and outpatient services at the hospital. Discounts will be applicable on any balance after your appropriate insurance has been utilized.

Regular full-time and part-time employees are allowed a 100% discount on specified inpatient and outpatient Hospital services. Eligible dependents of regular full-time and part-time employees also receive a 100% discount. (Dependents are those who receive their full support from the employee and who qualify as a dependent of the employee for income tax purposes. Proof of dependency may be required.)

Robert Wood Johnson University Hospital will make available, as a benefit to all employees, discount cards from various associations or merchants in the area. Discount opportunities can be found on the Hospital Intranet.

MEETINGS AND SEMINARS

Attendance at meetings and educational seminars approved by the Hospital will be reimbursed according to Hospital policy. Requests to attend must be approved in advance by the Department Head and Vice President. Employees must complete a travel request and voucher form for approved reimbursable expenses.

CREDIT UNIONS

The County Educators Federal Credit Union, Financial Resources Federal Credit Union, and the Healthcare Employee Federal Credit Union (HEFCU) affords membership to all employees and their immediate family members. The credit union is a full service financial institution that provides a variety of financial services including checking, savings, club accounts, loans, mortgages, ATM privileges, online banking, electronic bill pay, shared branching and 24 hour bank by phone services. Savings deposits and loan re-payments can be made through payroll deductions. You may contact the Human Resources Department for further details and enrollment information or reach out directly to the following credit unions directly:  County Educators Federal Credit Union- 908-526-4264; www.countyedfcu.org  Financial Resources Federal Credit Union-1-800-933-3280; www.myfinancialresources.org  Healthcare Employee Federal Credit Union- 1-800-624-3312

16 JOB RELATED INSURANCE

Unemployment Insurance – The Hospital pays part of the cost of insurance, however, employees are responsible for a portion of the cost as determined by law. Benefits are determined on the basis of the reason for your separation from your job and by your earnings over a specified period immediately prior to termination of employment.

Temporary Disability Insurance (TDI) – This benefit provides for payments to employees who become disabled through non-work related injury or illness. Application for benefits under TDI must be made within 30 days of the last day worked. Although not required by law, the Hospital pays the full premium for this benefit for all eligible employees. Benefits begin on the eighth day of illness. After 28 days, benefits are retroactive to cover the first seven days.

Payments are subject to applicable state and federal laws. If you have sick time accrued and become eligible for Temporary Disability Insurance (TDI), the Hospital will, on request, pay you sick time benefits equivalent to the difference between TDI and your regular pay. Use of sick time will be reduced on a pro-rated basis which will extend your sick benefits over a longer period of time. If you choose to supplement your disability benefits by using your sick time, you must notify the Employee Health Department in writing. You may utilize your sick time only upon advanced notice of your leave request.

Malpractice Insurance – Employees are covered under the Hospital’s group malpractice insurance policy only when performing work in their capacity as employees of this Hospital.

Workers’ Compensation Insurance – Employees who are injured or become ill due to their work assignment are eligible for workers’ compensation benefits, which are paid for by the Hospital. To be eligible for these benefits, an employee must immediately report any work related injury to his/her immediate supervisor and immediate follow up with Employee Health. To help prevent work related injuries, please immediately report any hazards you may detect. Employees at the New Brunswick campus can report via telephone by dialing number 2425.

Workers’ Compensation payments do not start until the eighth calendar day of the absence, but are retroactive to the first day of illness or injury.

Employees whose injury prevents them from performing their regular work assignments, but who in the opinion of Employee Health or the treating physician can perform other available duties essential to the Hospital, may be temporarily placed Modified Duty assignment. If they are not assigned tasks within their own department then the Employee Health Department will assign that employee to other areas of the Hospital that need assistance. This is a temporary assignment with time limitation of six months.

Compensation payments are handled through third party administrator, and the carrier or the Hospital has the right to request an examination by a physician of their choice. Workers’ compensation benefits generally pay for all incurred medical and indemnity expenses. Any

17 questions pertaining to workers’ compensation payment should be directed to the Employee Health Department.

In the event that you are out on leave related to a work injury and your physician indicates that you are capable of returning to work, but with restrictions which will not permit you to perform the essential duties of your job, you may be placed in an alternate position for which you may be qualified for up to six months.

SICK TIME

Sick leave provides time away from work so that an employee can regain their health. To qualify for accrued sick time payment, you must notify your supervisor at least 2 hours prior to the commencement of your shift, or as determined by department policy. Your supervisor will advise you of reporting requirements. When on , you must keep your supervisor aware of your condition so the department can schedule around your absence. The supervisor may require at any time, a physician’s statement verifying your illness/condition.

After an absence of three days or more, or for a communicable disease of any duration, employees must present a physician’s statement to the Employee Health Department. This statement should contain the nature of the illness, type of medication being taken, physical limitations, if any, and clearance to return to work. Employee Health Department will take appropriate action in determining if the employee may resume work. Proof of illness for absences of less than three days may be required at the discretion of your supervisor or Employee Health Services.

Employees becoming ill on the job could be referred to the Employee Health Department for treatment and disposition. During weekends, or after normal working hours, the employee could be referred to the Emergency Department. Emergency Department physicians’ fees for non-work-related visits are the employee’s responsibility.

PAID SICK LEAVE

All regular employees are eligible for paid sick time. All employees accrue sick time according to their position status, to a maximum accrual of 96 hours per year for full-time staff.

Sick time may accumulate from year to year to a maximum of 480 hours (60 days). Employees should not abuse their sick time benefits, but save them for those times when income protection is actually needed. Sick time is solely for the use in the event of personal illness. Abuse of sick time may result in disciplinary action.

In most cases, use of accrued sick time commences automatically when you are out ill. However, if it appears that your illness will extend beyond three days, you should contact the Employee Health Department and they will send you the appropriate disability forms to complete. These forms must be filled out within 30 days of the last day worked or you may jeopardize your eligibility for disability insurance.

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When an employee with accrued sick time is also collecting temporary disability insurance benefits (TDI), use of earned sick time is pro-rated so that the combination of Hospital paid sick time and temporary disability benefits will equal the employee’s weekly pay. Under law, you cannot be paid more than your regular weekly pay. In order not to jeopardize your insurance coverage, contact Employee Health Department if you expect your illness to extend beyond 30 days.

UNPAID SICK LEAVE

In the case of lengthy illness, or when all Hospital sick time has been used, an individual determination of the employee’s status will be made. An unpaid leave will be granted to eligible employees for their own health condition, to provide care to a seriously ill family member and for those with newly born or adopted children, emergencies, personal reasons and military service. Eligibility in accordance with Federal and State regulations is based upon one year of employment and a prescribed minimum number of hours worked during the prior year.

ATTENDANCE INCENTIVE

As an incentive to maintaining good attendance, employees with at least 240 hours (30 days) of accrued sick time may sell back hours over 240 hours of accrued sick time. This entitlement is based upon your accumulated sick hours at the end of the first pay period in October of each year. Prior to December of each year, employees may exercise this option. Not more than 192 hours (24 days) can be sold back in any given year. The incentive or “buy back” eligibility is as follows:

 Employees must have at least 240 hours accrued in their sick bank.

 Employees hired on or before December 31, 1994 may sell back one earned sick day for one day's pay. (1:1 basis)

 Employees hired on or after January 1, 1995 may sell back two days of earned sick days for one day's pay. (2:1 basis)

 Employees hired on or after January 1, 2000 may sell back four days of earned sick days for one day’s pay. (4:1 basis)

 Employees who terminate, or transition to a position ineligible to accrue sick time, prior to the distribution of attendance incentive payments, shall not be entitled to receive any payment for accumulated, unused sick time.

Employees in the classifications of department director and above are not eligible for the attendance incentive.

19  Paychecks issued under this plan will be distributed no later than the employee’s last regular payday before Christmas. This incentive pay is subject to all withholding and tax regulations.

LEAVES OF ABSENCE

Employees who have completed one (1) year of service or having specific requests are eligible for leaves of absence. Employees may be eligible for medical leaves of absences as set forth below.

Requests for leaves of absence (except for bereavement and emergencies) must be made in writing at least two weeks in advance. The request must contain the reasons for the leave and the estimated date of return. Emergency leaves will be considered on an individual basis.

Employees may be granted more than one unpaid leave of absence in any calendar year. However, these unpaid leaves may not exceed a total of 90 days unless otherwise stipulated.

Failure to report to work within two working days following the expiration of a leave of absence will be considered a voluntary resignation unless a written request for extension has been received and approved by your vice president/director.

Depending upon the type of leave taken, the Hospital may not be able to guarantee an employee’s return to their current position. For further clarification read the following sections on specific leaves of absence. If an employee’s return to their original position cannot be accommodated, the first available similar position may be offered. Specific , scheduling and shift assignments cannot be guaranteed. Refusal to accept placement upon return from a leave of absence will be considered a voluntary resignation.

Situations involving employees on medical leaves of absence, who request to extend their approved leave, will be governed by other leaves of absence.

During an unpaid leave of absence, there is no accumulation of sick time, or paid time off. After 30 days, insurance benefits may be continued only if the employee assumes the full cost. However, for those on FMLA leaves, insurance benefits will continue for 12 weeks on the same terms and conditions that apply to active employees.

Employees on leaves of absence will receive all general increases which may occur during that period. Merit increases may be affected by leaves greater than 30 calendar days.

Any employee working for another employer during a leave of absence will be considered to have resigned his/her position at the Hospital. An employee who gives a false reason for obtaining a leave of absence shall be subject to disciplinary action up to or including discharge.

Military Leave will be granted consistent with Federal and State law. Questions related to military leave should be directed to the Human Resources Department.

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PAID LEAVES OF ABSENCE

Leave with pay is permitted for bereavement, jury duty and military training.

Bereavement – Employees will receive paid leave, up to three (3) days in the event of the death of a parent, current parents-in-law, step parents, grandparents, spouse, child, stepchild, brother or sister. Paid bereavement leave up to three (3) days will be granted to part-timers only if needed to attend the funeral services and limited to those days they are scheduled to work. These three (3) days must be taken consecutively, within a reasonable time of the date of death or day of the funeral and may not be split or postponed. Evidence of death may be required in some instances.

Jury Duty – Hospital employees are required by New Jersey law to serve on juries and must inform their department head immediately upon notification. The Hospital may grant a paid leave not to exceed four (4) weeks. If called to serve, you will be paid the difference between your jury stipend and regular pay provided the employee has completed their probationary period. In order to receive this pay, you will be required to present proof regarding the time spent on jury duty and the stipend received.

UNPAID LEAVES OF ABSENCE

Unpaid leaves of absence will be permitted to eligible employees for their own health condition, to provide care to seriously ill family members, for those with newly born or adopted children, an emergency, personal reasons and military service. Eligibility in accordance with Federal and State Family Leave regulations are based upon one year of employment, a prescribed number of hours worked during the prior year, or having a specific request. Leaves of absences may be granted to employees with disabilities who have less than one (1) year of service as an accommodation.

Emergency and Personal – A leave without pay may be granted at the discretion of the department head for up to thirty (30) calendar days for an emergency or for personal reasons. An employee may, by written request, apply for an additional extension in thirty (30) day increments.

Family Leave Act – The law requires employers to grant leaves to employees for the birth or adoption of a child, their own illness, or to care for a family member who is ill. In these instances employees are entitled to twelve (12) weeks of paid or unpaid leave during a twelve (12) month period. In some situations more than one twelve (12) week leave may be permissible. Leaves may be taken consecutively, intermittently, or on a reduced work week basis. During leaves that qualify as Family and Medical Leaves, all insurance benefits will remain in effect during that twelve (12) week period and the employee’s current position will be maintained. Leaves that extend beyond the twelve (12) week period offer no further continuation of these benefits or entitlements.

21 NJ SAFE Act - As foreseeable, employees are required to give written notice to the Leave of Absence Coordinator by completing a leave of absence request form as far in advance as is reasonable and practical under the circumstances. We will request documentation supporting the need for leave. Employees can satisfy this requirement by providing a copy of any applicable restraining order; a letter from the prosecutor; documentation of the conviction of the assailant; medical documentation of the victim; a certification from a certified Domestic Violence Specialist or Rape Crisis Center employee; or a certification or other documentation from a social worker, clergy member, shelter worker or other professional who assisted the victim.

FIRE PREVENTION

The most effective fire protection possible is through fire prevention. The following are recommended fire prevention methods that all employees should be familiar with:

o Smoking is prohibited in all Hospital buildings. o Maintain an orderly and neat work area. Report the accumulation of trash and other combustible materials immediately. o Check electrical appliances prior to their use. Electrical equipment found to have frayed cords, defective prongs, or defective outlets are to be reported at once. o Safe handling of flammable liquids. Proper storage of these items in approved containers is necessary at all times. o Awareness of your responsibility during an emergency situation is important.

HOSPITAL SAFETY

The Hospital Safety and Security Department (Public Safety) is committed to providing a safe and secure environment for patients, visitors and employees. All employees are relied upon to assist with the overall security effort. The appropriate safeguarding of one’s personal belongings and encouraging patients, visitors and fellow employees to utilize the same safeguards is necessary at all times. Employees should not bring valuables, large amounts of cash or credit cards to work. The reporting of suspicious activity, the safeguarding of Hospital equipment, and using available precautions will further assist in maintaining a secure environment. For security assistance, contact the Security Dispatch Office at your specific campus. The Security Department offers an escort program for all employees to the designated parking areas. This service is available, upon request, at all times. Employees are not to be on the premises unless they are scheduled for duty, have an official reason for being here, visiting a patient, or have a medical situation which requires the need for hospital services.

SERVICE AWARDS

Service awards are presented to all employees who have completed five years of continuous service. Additional service awards are presented at subsequent five year intervals. To receive an award, the employee must have attained the appropriate anniversary date prior June 30th of

22 the celebration year, and be on the payroll at the time of the presentation ceremonies. Employees who have completed the appropriate years of service, but who terminate their employment prior to the awards ceremony, are not eligible to receive service awards.

CONFIDENTIAL INFORMATION – PATIENTS

Please keep in mind that under the patient’s “Bill of Rights”, information concerning patients is strictly confidential. Such information should never be discussed with anyone not directly connected with the patient’s care. Further, conversation should be limited to where full confidentiality can be assured. The breach of patient confidentiality is a serious infraction and carries with it a penalty of discharge from employment.

HIPAA

The Portability & Accountability Act of 1996 (HIPAA) addresses the privacy of patient health information. While the act provides regulations to protect patient privacy, it is not meant to be a barrier to providing quality patient care. Heath Care Providers must continue to communicate important patient information to facilitate patient care and to communicate, when necessary, information with those individuals involved in the care of the patient-family members, friends and others.

At times, providers will have to use their professional judgment when determining what patient information can be shared with whom. Professional judgment involves focusing on: o What is the best interest of the patient; o Awareness of organization’s policies and procedures; o Organizational values; and o Professional education and experience.

For more information about HIPAA, please contact your supervisor or the Hospital’s Privacy Officer. HIPAA policies are also available on the Hospital Intranet. All employees will be required to attend mandatory HIPAA training sessions commencing at general Hospital Orientation.

CONFIDENTIAL INFORMATION – EMPLOYEES

Personal information about our employees is confidential. Information such as address, telephone number, etc., contained in your Human Resources file and personal health records will not be released without your written authorization or as required by law. Frequently the Hospital receives inquiries from credit agencies, department stores, banks, etc., requesting personal information about our employees. The Human Resources Department will not verify your employment over the telephone. For any information, the person calling is requested to write to the Human Resources Department and present the employee’s signed consent.

PARKING

23 At the New Brunswick campus a nominal charge is required for the use of parking through payroll deduction. There is no fee for employees regularly scheduled for the Somerset campus. Although parking facilities are limited, every effort will be made to provide parking for employees on Hospital premises. Only those vehicles registered with the Safety & Security. Department and displaying the appropriate Hospital parking decal will be permitted to use the Hospital parking facilities. Parking regulations will be strictly enforced. The Hospital does not accept any responsibility for theft or damages to vehicles parked on Hospital premises.

TELEPHONE & CELL PHONE USE

The Hospital telephone and fax lines must be kept free for business and emergency use. We ask that incoming personal calls be of an emergency nature only. Supervisors will determine if the call is of an emergency nature and should be put through to the employee. It is important that employees keep their family members aware of which department they are assigned to so they can be reached in an emergency.

Personal cell phones and other electronic devices are not to be used by employees while on duty unless specifically required for performance of their duties. If there is an emergency, the employee’s family and friends should be instructed on how to place a call to the employees work unit/supervisor.

Personal calls, both received and called out, using cell phones should be limited to break or meal times. On occasions when personal cell phones are used during work hours they are not permitted in patient care areas, elevators or other locations where patients and visitors are present.

The use of headsets and other hands-free equipment does not change the restrictions set forth above. All personal cell phones are to be turned off or switched to a non-audible signal for the receiving of calls.

Cell phones with cameras (still photos or videos), PDA’s or other devices with camera features are prohibited on Hospital premises at all times. Phones with this capability are to be turned off while on the premises.

BULLETIN BOARDS/COMMUNICATION BOARDS

Bulletin boards displaying information important to employees are located throughout the Hospital. Employees have the responsibility to stay informed by periodically consulting these bulletin boards.

SOLICITATION

1. In order to protect patients and employees from unauthorized visitors, solicitors of literature, services and products, bill collectors, and others, the following policy will be strictly enforced.

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2. All outside visitors and solicitors are required to present themselves at the Information Desk before proceeding to any part of the Hospital. Any person, who is not in the employ of the Hospital, is not permitted to solicit for any purpose or by any means whatsoever, anywhere on the Hospital premises without the expressed written approval of the Hospital Administration.

3. No employee may solicit any other employee in patient care areas or in the halls and corridors adjacent to the immediate patient care areas for any purpose whatsoever, regardless of whether the solicitation occurs during working or non- . Patient care areas include patients’ rooms, operating rooms, emergency rooms and places where patients normally receive treatment, such as in Radiology and therapy areas. Solicitation includes raffles, pools, and collections for any purpose, the sale of tickets or merchandise, or solicitation for any other purpose.

4. The restriction on employee solicitation during working time does not apply during break periods, mealtimes, or other specified periods during the workday when employees are properly not engaged in performing work assignments provided such solicitation does not occur in patient care areas, elevators, or in halls and corridors adjacent to immediate patient care areas.

5. Employees are to immediately report any violations of these solicitation rules to a department head or any member of Administration.

LOST AND FOUND

The Hospital cannot assume responsibility for any personal articles lost while you are at work. Sensible precautions should be taken to keep personal property safe. Wherever possible, the Hospital will provide lockers for employees’ personal property. If you find an article, please turn it over to the Safety and Security (Public Safety) Department where it may be claimed after proper identification.

PACKAGE AND LOCKER INSPECTION

For the safety and protection of employees and patients, the Hospital reserves the right to open and inspect Hospital lockers and/or packages being taken onto or off Hospital premises. Employees are asked to cooperate with this inspection. An employee removing personal articles from the Hospital premises must obtain from his/her supervisor a “property pass” for presentation to the security office when the employee leaves.

TIPPING AND GRATUITIES

No employee of the Hospital is to accept tips or gratuities under any circumstances from any patient, visitor or vendor. If the person is insistent, suggest making a gift to the Hospital itself. Politely refer donors to the administration offices.

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VOLUNTEERING

It is commendable that some employees want to give their free time to our patients; however, and hour laws place certain restrictions upon employees serving as volunteers. The most important restriction is that an employee may not work as a volunteer in the job for which he/she is hired. For example, a secretary may not volunteer service as a secretary in another department during off duty hours. Employees interested in volunteer work should direct their inquiries to the Volunteer Office.

SOCIAL EVENTS

Each year the Hospital invites all employees to social events such as a Holiday Party. Consult the bulletin boards for announcements. The Employee’s Activity Committee also arranges other events, such as trips and outings. Employees must receive approval from their supervisors to attend social events on regular work days.

EMPLOYEE SATISFACTION/ REWARD AND RECOGNITION

An awards program, which consists of the Employee of the Month and Star recipients, honors and recognizes those employees who demonstrate excellence on a daily basis, by performing their job in a way that enhances the caring image of our Hospital. Employees may be nominated for these honors by their supervisors, peers, patients, physicians or visitors. Nomination forms are conveniently located throughout the Hospital, on the Hospital Intranet (under the Employee Satisfaction link) and in the Human Resources Department. All nominations should be submitted in care of the Human Resources Department. Employees who are selected as Employees of the Month or Medal of Honor winners will wear “Gold ID Badges” for the duration of their employment. Employees who would like to offer suggestions or comments may do so using the Employee Satisfaction Intranet link.

CHANGES IN POLICY

This handbook has been prepared and distributed to all employees for informational purposes in order that employees may better understand the benefits of their employment and certain rules and regulations generally applicable to all employees. Information in this handbook is descriptive of policies, rules and regulations currently in force, and is subject to change unilaterally and without advance notice by action of the Administration of Robert Wood Johnson University Hospital. Such changes may modify, supersede or eliminate policies, rules and regulations as described in this handbook. Employment with the Hospital is subject to termination with or without cause, and with or without notice at the option of either the employee or the Hospital. Further, only the President of the Hospital has the authority to enter into any agreement for employment for any specified period of time.

SCIENTIFIC MISCONDUCT

26 Robert Wood Johnson University Hospital (RWJUH) is responsible for reviewing, investigating, and reporting allegations or evidence of misconduct in science by employees. Misconduct involves fabrication, falsification, plagiarism, or other practices that seriously deviate from those that are common in the scientific community for proposing, conducting and reporting research. A formal mechanism has been established to ensure compliance with this federal regulation.

Robert Wood Johnson University Hospital does not discriminate on the basis of race, color, religion, creed, age, marital status, sex, national origin or disability in access to employment or services.

FEDERAL DEFICIT REDUCTION ACT

It is the policy of Robert Wood Johnson University Hospital to provide health care services in a manner that complies with applicable federal and state laws and that meets the highest standards of business and professional ethics. To further this policy, and in compliance with Section 6032 of the Federal Deficit Reduction Act of 2005, Robert Wood Johnson University Hospital provides the following information about its policies and procedures and the role of certain federal and state laws in preventing and detecting fraud, waste, and abuse in federal health care programs.

Federal False Claims Act, 31 U.S.C. §§ 3729-3733

The Federal False Claims Act imposes liability on any person who:

(1) Knowingly files a false or fraudulent claim for payment to Medicare, Medicaid, or any other federally funded health care program;

(2) knowingly uses a false record or statement to obtain payment on a false or fraudulent claim from Medicare, Medicaid, or any other federally funded health care program; or

(3) knowing and improper retention of an overpayment

(4) does any of the above to obtain federally funded health care program money regardless of whether the claim was submitted directly to the government; or

(5) conspires to violate any requirement of the Federal False Claims Act.

“Knowingly” means (1) having actual knowledge that the information on the claim is false; (2) acting in deliberate ignorance of whether the claim is true or false; or (3) acting in reckless disregard of whether the claim is true or false.

A person or entity found liable under the Federal False Claims Act is generally subject to civil money penalties of between $5,500 and $10,000 per claim plus three times the amount of damages that the government sustained because of the illegal act plus the government cost in

27 recovering penalties and damages. In health care cases, the amount of damages sustained is the amount paid for each claim that is filed that is determined to be false.

Anyone may bring a qui tam action under the Federal False Claims Act in the name of the United States. The case is initiated by filing the complaint and all available material evidence under seal with a federal court. The complaint remains under seal for at least 60 days and will not be served on the defendant. During this time, the government investigates the complaint. The government may also request additional investigation time beyond 60 days. After expiration of the review and investigation period, the government may elect to pursue the case in its own name or decide not to pursue the case. If the government decides not to pursue the case, the person who filed the action has the right to continue with the case on his or her own.

If the government proceeds with the case, the person who filed the action will generally receive between 15% and 25% of any recovery, depending on the contribution of that person to the prosecution of the case. If the government does not proceed with the case, the person who filed the action will be entitled to between 25% and 30% of any recovery, plus reasonable expenses and attorneys’ fees and costs.

Federal Program Fraud Civil Remedies Act, 31 U.S.C. §§3801-3812

The Federal Program Fraud Civil Remedies Act (“PFCRA”) creates administrative remedies for making false claims and false statements. These penalties are separate from and in addition to any liability that may be imposed under the False Claims Act.

The PFCRA imposes liability on people or entities that file a claim that they know or have reason to know:

(1) is false, fictitious, or fraudulent;

(2) includes or is supported by a written statement that contains false, fictitious, or fraudulent information;

(3) includes or is supported by a written statement that omits a material fact, which causes the statement to be false, fictitious, or fraudulent, and the person or entity submitting the statement has a duty to include the omitted fact; or

(4) is for payment for property or services not included as claimed.

A violation of this section of the PFCRA is punishable by a $5,000 civil penalty for each wrongfully filed claim, plus an assessment of twice the amount of any unlawful claim that has been paid.

In addition, a person or entity violates the PFCRA by submitting a written statement that the person or entity knows or should know (1) asserts a material fact that is false, fictitious, or fraudulent; or (2) omits a material fact that they had a duty to include, the omission caused the

28 statement to be false, fictitious, or fraudulent, and the statement contained a certification of accuracy.

A violation of this section of the PFCRA carries a civil penalty of up to $5,000 in addition to any other remedy allowed under other laws.

“New Jersey False Claims Act, N.J.S.A. 2A:32C-1 to 2A:32C-17

This law was enacted on January 13, 2008 and took effect on March 13, 2008. It authorizes the New Jersey Attorney General and to file false claims lawsuits similar to what is authorized under the Federal False Claims Act. It also says that violations of the New Jersey False Claims Act also create liability under the New Jersey Medical Assistance and Health Services Act, discussed below.”

New Jersey Medical Assistance and Health Services Act, N.J.S.A. §§ 30:4D-1, et seq.

The New Jersey Medical Assistance and Health Services Act (“NJMAHSA”) makes it a misdemeanor for:

(1) any person to willfully obtain benefits to which he or she is not entitled and any provider to willfully receive payments to which the provider is not entitled, and;

(2) a person, entity, or provider to:

A. knowingly and willfully make or cause to be made a false statement or representation of a material fact in any cost study, claim form, or document necessary to apply for or receive a benefit or payment under the NJMAHSA, or;

B. knowingly and willfully make or cause to be made a false statement of material fact for use in determining rights to such benefit or payment, or;

C. conceal or fail to disclose the occurrence of an event that affects the initial or continued right to any such benefit or payment with an intent to fraudulently secure benefits or payments not authorized under the NJMAHSA, or;

D. knowingly and willfully converts benefits or payments to a use other than for which they were received.

A conviction carries a penalty of up to $10,000 for the first and each subsequent offense and/or imprisonment for up to three years.

29 In addition, any person, entity, or provider who solicits, offers, or receives any kickback, rebate, or bribe in connection with the furnishing of items or services for which payment may be made or whose cost may be reported in order to obtain or in connection with the receipt of benefits/payments under the NJMAHSA, will be liable for a penalty of up to $10,000 and/or up to three years imprisonment.

Whoever knowingly and willfully makes, causes to be made, or induces or seeks to induce the making of a false statement of material fact with respect to conditions or operations of a facility so that the facility may qualify as a hospital, skilled nursing facility, intermediate care facility, or health agency will be guilty of a high misdemeanor and will be liable for a penalty of up to $3,000 and/or up to one year in prison. Any person, entity or provider who violates any of the above provisions will also be liable for civil penalties of (1) interest at the maximum legal rate on the benefits or payments, (2) an amount of up to three times the amount of the benefits, and (3) an amount equal to the civil money penalties provided for under the Federal False Claims Act, currently between $5,500 and $11,000 per improper claim for benefits or payment.

Any person, entity or provider who, without intent to violate the NJMAHSA, obtains benefits or payments in excess of the entitled amount, may be liable for a civil penalty of the payment of interest on the excess benefits or payments at the maximum legal rate.

A provider or person participating in a benefit program or acting as agent, employee or independent contractor of a provider may be suspended, debarred or disqualified for good cause.

New Jersey Health Care Claims Fraud Act, N.J.S.A. §§ 2C:21-4.2, 4.3; 2C:51-5

The New Jersey Health Care Claims Fraud Act (“NJHCCFA”) makes it (1) a second-degree crime for any “practitioner” to knowingly commit health care claims fraud in the course of providing professional services, and (2) a third-degree crime for any “practitioner” to recklessly commit health care claims fraud in the course of providing professional services.

The NJHCCFA further makes it (1) a third-degree crime for non-practitioners to knowingly commit health care claims fraud, (2) a second-degree crime for non-practitioners to knowingly commit five or more acts of health care claims fraud if the aggregate pecuniary benefit obtained or sought is $1,000 or more, and (3) a fourth-degree crime for non- practitioners to recklessly commit health care claims fraud.

A person convicted under this statute may also be subject to a fine of up to five times the pecuniary benefit obtained or sought, as well as, in the case of an offending practitioner, suspension or forfeiture of his or her professional license.

“Practitioner” means a person licensed, registered, or certified by any state agency to practice a or occupation in New Jersey or another jurisdiction. “Recklessly” means consciously disregarding a substantial and unjustifiable risk that the fraud exists or will result from the person’s conduct. The risk must be such that its disregard

30 involves a gross deviation from the standard of conduct that a reasonable person would observe in the actor’s situation.

Protections Against Retaliation

Individuals within an organization who observe activities or behavior that may violate the law in some manner and who report their observations either to management or to governmental agencies are provided protections under certain laws.

For example, the Federal False Claims Act includes protections for people who file qui tam lawsuits as described above. The Federal False Claims Act states that any employee who is discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of employment because of lawful actions taken in furtherance of a qui tam action is entitled to recover damages, as well as all relief necessary to make the employee whole, including two times the amount of back pay owed to the employee. The employee can also be awarded litigation costs and reasonable attorneys’ fees.

(1) “The Federal False Claims Act also provides that employees, agents and contractors engaged in other efforts to stop a violation of the Federal False Claims Act may recover damages for retaliation against them that occurs because of those efforts.”

(2) “The New Jersey False Claims Act has protections similar to those provided by the Federal False Claims Act.”

Likewise, the New Jersey Conscientious Employee Protection Act (“CEPA”), N.J.S.A. §§ 34:19-1, et seq., prohibits an employer from retaliating against an employee because the employee:

(1) discloses or threatens to disclose an activity that the employee reasonably believes violates the law, is fraudulent or criminal, or (for employees who are certified or licensed health care professionals) constitutes improper quality of patient care;

(2) provides information to or testifies before a public body conducting an investigation, hearing, or inquiry into any violation of law, or (for employees who are certified or licensed health care professionals) into the quality of patient care; or;

(3) objects to or refuses to participate in an activity that the employee reasonably believes to be a violation of law, fraudulent, criminal, incompatible with a clear mandate of public policy, or (for employees who are certified or licensed health care professionals) improper quality of patient care.

Available remedies may include an injunction restraining a continuing violation, reinstatement of the employee including full fringe benefits and seniority rights,

31 compensation for lost , benefits, and other remunerations, punitive damages, a civil fine, and payment by the employer of reasonable litigation costs and attorneys’ fees.

ROLE OF FALSE CLAIMS LAWS

The false claims laws discussed above are an important part of preventing and detecting fraud, waste, and abuse in federal and state health care programs because they provide governmental agencies the authority to seek out, investigate, and prosecute fraudulent activities. Enforcement activities take place in the criminal, civil, and administrative arenas. This provides a broad spectrum of remedies to combat these problems. Anti-retaliation protections for individuals who make good faith reports of waste, fraud, and abuse encourage reporting and provide broader opportunities to prosecute violators. Statutory provisions, such as anti- retaliation provisions of the Federal False Claims Act, create reasonable incentives for this purpose. Employment protections create a level of security employees need in order to help in prosecuting these cases.

PROCEDURES FOR DETECTING AND PREVENTING FRAUD, WASTE, AND ABUSE

Any employee who knows of or reasonably suspects an incident of fraud, waste, or abuse regarding Medicare, Medicaid, or any other federal or state health care program, or a violation of any of the laws outlined in this policy, by any Hospital employee, supervisor, contractor, or agent is required as a condition of employment to immediately report such incident to their immediate supervisor, any member of senior management, or the Hospital’s Corporate Compliance Officer at 732-937-8778 or the RWJ Corporate Compliance HelpLine at 1-800- 238-4139. Likewise, any employee of a contractor, vendor, or agent of the Hospital who has concerns about the work he or she does for the Hospital or work done by the Hospital should report these concerns to the Hospital’s Corporate Compliance Officer.

The Hospital will not tolerate any intimidating or retaliatory act against an individual who in good faith reports practices reasonably believed to be a violation of this policy.

The Hospital will make this policy available to all Hospital employees, including management, as well as all Hospital contractors and agents. Furthermore, the Hospital will maintain its internal systems and controls to monitor its coding and billing practices on an ongoing basis to ensure compliance with the laws outlined in this policy.

The principles and guidelines articulated in this policy are further embodied in the Hospital’s Corporate Compliance Code of Conduct and related policies, specifically those sections addressing:

 Quality of Care and Services  Workplace Behavior and Equal Opportunity  Business Ethics and Compliance with Laws and Regulations  Coding and Billing  Employee Issues and Concerns

32  Conflicts of Interest

Questions regarding the Code of Conduct should be addressed to the Corporate Compliance Officer.

Thank you for your time in reading this Handbook!

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