Limitations on Employment Policy by 140RIE7X

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									 DEPARTMENT: Human Resources                    POLICY DESCRIPTION: Limitations on
                                                Employment
 PAGE: 1 of 6                                   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
 EFFECTIVE DATE: January 24, 2009               REFERENCE NUMBER: HR.OP.019 (formerly
                                                HR.209)

 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. 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.

 2. Prohibition Against Employment of Ineligible Persons
    a. For purposes of this policy, an “Ineligible Person” shall be any individual or entity who:
       i. is currently excluded, suspended, debarred or otherwise ineligible to participate in the
            Federal health care programs;
       ii. has been convicted of a criminal offense related to the provision of health care items or
            services and has not been reinstated in the Federal health care programs after a period
            of exclusion, suspension, debarment, or ineligibility; 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.


11/2008
 DEPARTMENT: Human Resources                     POLICY DESCRIPTION: Limitations on
                                                 Employment
 PAGE: 2 of 6                                    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
 EFFECTIVE DATE: January 24, 2009                REFERENCE NUMBER: HR.OP.019 (formerly
                                                 HR.209)

     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.

 3. 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.

 4. 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.

 5. 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.


11/2008
 DEPARTMENT: Human Resources                    POLICY DESCRIPTION: Limitations on
                                                Employment
 PAGE: 3 of 6                                   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
 EFFECTIVE DATE: January 24, 2009               REFERENCE NUMBER: HR.OP.019 (formerly
                                                HR.209)

     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://www.sanctioncheck.com.

 PROCEDURE:

 1. Hiring of Former Fiscal Intermediary Personnel
    a. Human Resources will prepare a letter similar to the attached example and forward it to the
       Department of Health and Human Services.
    b. Human Resources will forward a copy of the letter to the Vice President of Reimbursement
       for maintenance of consolidated Company information to be included in Form HCFA-
       1513, “Ownership and Control Interest Disclosure Statement” for hospitals to use during
       re-certification visits. A copy will also be placed in the employee’s personnel file.

 2. Prohibition Against Employment of Ineligible Persons
    a. Prior to hiring or re-hiring an employee, Human Resources must ensure that the individual
       being considered for employment has been checked against the General Service
       Administration’s List of Parties Excluded from Federal Programs (the “GSA List”) and the
       HHS/OIG List of Excluded Individuals/Entities (the “OIG Sanction Report”).
    b. 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://www.sanctioncheck.com. This is the recommended method of conducting
            ineligible persons searches.
    c. Facilities located in states which maintain a state exclusion list must also search the
       applicable state exclusion list to ensure that no colleague, affiliate, physician, privileged
       practitioner, or independent or dependent practitioner or contractor is an ineligible person.
       A list of states with exclusion lists is available on Atlas at:


11/2008
 DEPARTMENT: Human Resources                       POLICY DESCRIPTION: Limitations on
                                                   Employment
 PAGE: 4 of 6                                      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
 EFFECTIVE DATE: January 24, 2009                  REFERENCE NUMBER: HR.OP.019 (formerly
                                                   HR.209)

          http://atlas2.medcity.net/portal/contentuid/0fb0a8abdb3f7b3073d5e3a6ac01a1a0/Stat
          eExclusionList.doc).
    d.    Human Resources 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. Corporate Information Technology
          & Services (IT&S) will compare the Company’s employee database against the GSA List
          and the OIG Sanction Report on a quarterly basis. IT&S will provide the report of the
          comparison, which lists potential matches, to the Corporate Human Resources’ VP,
          Employee Relations.
    e.    The VP, Employee Relations must inform the Human Resources (HR) Director at the
          facility which employs the potentially Ineligible Person. The HR Director, or designee, is
          responsible for confirming the match, and if the employee is an Ineligible Person on the
          GSA List and/or the OIG Sanction Report the HR Director must terminate the
          employment relationship with that individual. The VP, Employee Relations will report
          the match and the action taken by the facility to the VP, Reimbursement and Director,
          Internal Compliance Reporting
    f.    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.
    g.    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).
    h.    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.
    i.    Documentation:
                i. Whenever a search of the GSA List, the OIG Sanction Report, or state exclusion
                   list, if applicable 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 the employee’s 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:



11/2008
 DEPARTMENT: Human Resources                     POLICY DESCRIPTION: Limitations on
                                                 Employment
 PAGE: 5 of 6                                    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
 EFFECTIVE DATE: January 24, 2009                REFERENCE NUMBER: HR.OP.019 (formerly
                                                 HR.209)

                 a) Documentation required when batch file results from SanctionCheck.com
                     indicate a possible OIG or GSA List match:
                      An individual name certificate must be printed whenever a search results
                         in a "Yes" (possible match) for an individual for either the OIG or GSA.
                      An individual certificate summary must be printed for all “Positive
                         Matches Only” (both OIG and GSA possible 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 documents pertaining to an incidence in which a listed employee is confirmed
                 to be an Ineligible Person must be maintained by the facility or corporate
                 department taking the action for a minimum of 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 believes 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 quarterly
    ineligible persons screening).



11/2008
 DEPARTMENT: Human Resources                     POLICY DESCRIPTION: Limitations on
                                                 Employment
 PAGE: 6 of 6                                    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
 EFFECTIVE DATE: January 24, 2009                REFERENCE NUMBER: HR.OP.019 (formerly
                                                  HR.209)

     On a quarterly basis, All About Staffing will compare its independent contractors, employees
     of staffing agencies or contracted service entities, as appropriate, to the GSA and OIG lists to
     confirm a potential match.

     The CEO of each company-affiliated facility or designee is responsible for a process to
         conduct
     a quarterly 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:

 42 CFR 420.203
 48 CFR Subpart 9.4, Federal Acquisition Regulation, 9.4 – Debarment, Suspension, and
 Ineligibility
 Form HCFA-1513, Ownership and Control Interest Disclosure Statement
 Records Management Policy, EC.014
 Background Investigations Policy, HR.OP.002
 Prohibition Against Contracting with Any Ineligible Person Policy, MM.001




11/2008
                           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:

          Name:

          Effective date:

          Former employer:

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


Sincerely,




cc: Vice President, Reimbursement
    Personnel File




10/2008
                                                                             Attachment to HR.OP.019

								
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