Category: Compliance 

Date: January 23, 2002

Reviewed/Revised: April 2013

Purpose

To facilitate adherence to and enforcement of the EVMS Medical Group Compliance Plan.

Policy

It is the policy of EVMS Medical Group to encourage its employees to report any activity that they believe to be inconsistent with EVMS Medical Group policies or legal requirements and to investigate written complaints alleging acts of reprisal or intimidation due to disclosure of improper activities.

Procedure

The following procedures shall be followed to implement this policy:

I. Reporting Improper Activities

  1. Any person may file a confidential report on the Compliance Hotline, contact his/her supervisor, the Compliance Officer or representatives of the Compliance Program.
  2. Reports alleging improper activity shall be investigated and reported according to EVMS Medical Group procedures.

II. Protection Against Retaliation for Reporting Improper Activities

  1. Interference with the right to file a report.

    An EVMS Medical Group employee may not directly or indirectly use or attempt to use the official authority or influence of his or her position or office for the purpose of interfering with the right of a person to file a report as described in section I.A.

  2. Retaliation against filing a report
    1. The Compliance Officer or the designated Compliance representative shall investigate or oversee the investigation of reports from employees alleging such interferences or retaliation.
    2. If the report alleges that the Compliance Officer interfered or took retaliatory action, the report shall request Human Resources to appoint an investigating officer.
  3. Filing a report
    1. A report as described in II.B. 1. must be filed under existing EVMS grievance or complaint resolution procedures.
    2. Any report filed with the Compliance Officer must be filed within 180 days of the alleged act or threat of interference or retaliation.
    3. In order for a report of interference or retaliation or threatened retaliation to be accepted by the Compliance Officer, the complainant must have previously filed a report as described in Section I, above, with the appropriate EVMS or EVMS Medical Group official or must present a case alleging the prevention by intimidation from filing such a report.
  4. Investigation by the Compliance Officer or EVMS Human Resources
    1. The investigation is conducted as per the EVMS Human Resource guidelines.
    2. When no EVMS grievance or complaint resolution procedure is available to the complainant, the Compliance Officer will conduct the investigations.
    3. The Compliance Officer shall present findings to the EVMS Medical Group President within a reasonable time, or within such specific time limits as may be established by EVMS Medical Group or DHHS procedures.
    4. Before findings are reached, the Compliance Officer shall provide a copy of the complaint and any documents on which the Compliance Officer intends to rely in the reaching of the findings to the person accused of interference or retaliation. That person shall be provided the opportunity to respond to the complaint and to file a written statement which will become part of the record submitted to the EVMS Medical Group President.
  5. EVMS Medical Group President’s Decision

    The EVMS Medical Group President determines the appropriate disciplinary action, if any, which will be initiated against an EVMS Medical Group employee found to have interfered or retaliated as defined in Section II.A., above. For a member of the faculty, disciplinary actions are in accordance with procedures established by the Academic Senate.

  6. Appeal of the Decision

    Decisions of the EVMS Medical Group President based on findings of the Compliance Officer may be appealed to the EVMS President.
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