Response and Corrective Action

Compliance Policy #908

After an offense or violation of the Hospital's compliance standards or policies has been detected, the Hospital will take all reasonable steps to respond appropriately to the offense or violation and to prevent further similar offenses or violations including any necessary modifications to the Hospital's compliance program to prevent and detect violations of the law or of the Hospital's compliance standards or policies.

Responsibility: All Hospital Personnel


It is the Hospital's policy to take all reports of misconduct or wrongdoing seriously. Any such report, regardless of how or to whom the report was made, shall be forwarded to the Compliance Officer, who shall assure that the
 following steps, as applicable, are taken:

1. A written record of the report shall be made using a form approved by legal counsel.  The Compliance Officer shall take reasonable steps to obtain all information called for on the form.

2. No promises will be made to the person making the report regarding his or her liability, confidentiality of his or her identify or what steps the Hospital may take in response to the report.

3. The Compliance Officer, in consultation with the Chief Executive Officer and legal counsel, as necessary, shall determine whether the alleged wrongdoing is a violation of state or federal law (and if so, whether the violation is a criminal offense), a violation of the Hospital's compliance standards, poses a risk to patients or the public or otherwise puts the Hospital at risk of economic injury, civil or criminal liability or injury to the Hospital's reputation.

4. The Compliance Officer, in consultation with the Chief Executive Officer and legal counsel as necessary, shall determine, commensurate with the gravity of the allegation, what steps will be taken to investigate the report.  The
Compliance Officer may investigate the report or may delegate the responsibility for such investigation to an appropriate person within or outside the Hospital.

5. The investigation may include, as appropriate, review of documents, witness interviews, audits of Hospital practices, and other appropriate actions.  The person responsible for conducting the investigation shall keep a record of all activities undertaken in the course of the investigation. The final investigation report shall be provided to the Compliance Officer (if conducted by someone other than the Compliance Officer), and to the Chief ExecutiveOfficer, Compliance Committee and/or Board, as necessary and appropriate.

6. If the Compliance Officer, after consultation with the appropriate department director, believes that the integrity of the Hospital's investigation is compromised because of the presence of any employee under investigation, such employee shall be removed from his or her current work activity until the investigation is complete.

7. The Compliance Officer, or other person conducting the investigation, shall take appropriate steps to secure or prevent the destruction of documents or other evidence relevant to the investigation.

8. After the investigation is completed, the Compliance Officer shall, in consultation with legal counsel as necessary, determine whether a violation of state or federal law or the Hospital's compliance standards and polices has occurred.   The Compliance Officer shall, in consultation with legal counsel as necessary, and the Chief Executive Officer, Compliance Committee or other appropriate Hospital personnel, develop a plan for corrective action to remedy the violation.  Such plan for corrective action shall include education of Hospital employees and/or contractors as appropriate and, if applicable, any appropriate disciplinary action against any employees engaged in the misconduct or wrongdoing, in accordance with Compliance Policies #6, and 6A.

9. As part of the Compliance Office's regular reports to the Chief Executive Officer, Compliance Committee and Board of Directors, the Compliance Officer shall include a report summarizing all bona fide reports of  wrongdoing,including the results of any investigation and any subsequent disciplinary or remedial actions taken.

10. All records of reports of misconduct or wrongdoing, including initial reports, records of investigations, and corrective action plans, shall be prepared and maintained in such a manner as to preserve all applicable legal
privileges, including the attorney-client, work product and self-evaluative privileges, as appropriate.   All such records shall be retained for the period of time specified in the Hospital's record retention policies.

11. The Compliance Officer shall monitor the implementation of all corrective action plans on a regular basis to assure that the plans are properly implemented and the misconduct or wrongdoing has been corrected and has not reoccurred.

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