Category: Compliance 

Date: January 23, 2002

Reviewed/Revised: April 2013

Purpose

To document policies for disciplinary action established in accordance with the EVMS Human Resources Disciplinary Action Policy. These policies will apply equally to corporate officers, managers, employees, physicians, and other health care professionals.

Procedure

  1. Disciplinary action will be initiated against those who fail to comply with the foundation’s standards of conduct, policy and procedure, federal and state law and regulation, or those who engage in wrongdoing that has the potential to impair the foundation’s status as a reliable, honest, and trustworthy health care provider. Action will be taken by the appropriate authority with ability to provide discipline as needed. This may include the responsible manager, the administrator, the governing body, or the medical staff.
  2. Progressive disciplinary action will be taken against those who fail to comply with the foundation’s standards and policies and applicable law and regulation and will include, but not be limited to:
    1. Verbal warning, documented in Compliance files and sent to the employee via email with a copy to EVMS Human Resources;
    2. Written warning signed by the employee. The employee shall be given a copy of the written warning with a copy retained in the Compliance Office and a copy sent to Human Resources;
    3. Suspension with pay pending investigation;
      1. Investigation of misconduct, inappropriate, negligent, or reckless acts;
      2. Presentation of the results of investigation to administration, the governing body, the medical staff, legal counsel, or the Department of Health and Human Services Office of Inspector General, or other legal or regulatory bodies, as appropriate based on the nature and scope of infractions;
    4. Termination, financial sanctions, or suspension or revocation of privileges, as appropriate.
    5. Immediate termination. EVMS Human Resources and/or the Compliance Office may deem the nature and severity of the conduct such that it warrants immediate termination.
  3. Disciplinary action may be appropriate when an employee’s failure to detect a violation in his or her areas of responsibility can be identified as negligence or reckless conduct.
  4. Disciplinary action will be conducted in an appropriate and consistent manner. All staff shall be subject to the same disciplinary action for the commission of similar offenses, at all personnel levels in the foundation.
  5. On application for employment, EVMS Human Resources will conduct a prudent background check, including review of references, and a review of the OIG List of Excluded Individuals/Entities or the National Practitioner’s Data Bank, as appropriate, to determine if the applicant has been debarred from participation in government programs. The application will also require the applicant to disclose any criminal conviction as defined by 42 U.S.C. 1320a-7(I), or any exclusion action.
  6. EVMS Human Resources policy prohibits employment of any individual convicted of a criminal offense related to health care, or who is listed as debarred, excluded or otherwise ineligible for participation in federal health care programs, as defined by 42 U.S.C. 1320a-7b(f). If an individual being considered for employment is pending action for criminal charges, exclusion or debarment, they shall not serve in a position of direct responsibility for a federal health care program. Employees or prospective employees who have been officially reinstated into the Medicare and Medicaid programs by the Office of Inspector General may be considered for employment upon proof of such reinstatement.
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