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CHILDREN’S HOSPITAL & MEDICAL CENTER CORPORATE COMPLIANCE PLAN - page 2 / 15

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who has been given authority to draft, manage and do all things necessary and expedient to develop and implement an effective compliance program. The Board of Directors has given the compliance officer the authority to establish committees to assist in the drafting and implementation of the Plan.

Compliance Officer The Board of Directors has appointed Beverly S. Greer, J.D., Vice-President Administrative and

Regulatory

Affairs,

Compliance

Officer

as its Compliance Officer. based on her commitment to

The Board of honesty, integrity,

Directors and high

has chosen the ethical standards

and on her knowledge and understanding Officer solely represents the Hospital and Directors.

of applicable laws and regulations. The Compliance not any officer, employee or member of the Board of

The Compliance Officer maintains administrative authority for implementation, monitoring and enforcement of the Plan. All questions and concerns regarding compliance with the Plan or legal and regulatory standards should be directed to the Compliance Officer. If an individual is uncertain whether their conduct or behavior is prohibited under law, they must contact their supervisor or the Compliance Officer for guidance prior to engaging or continuing in the conduct or behavior. The Compliance Officer has full discretion to investigate possible instances of non- compliance and to initiate corrective action when a non-compliant situation is identified. Staff is directed to cooperate fully and to assist the Compliance Officer in the exercise of her duties.

The Compliance Officer’s duties include but are not limited to the following:

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    Developing, overseeing and monitoring the implementation of the Plan,

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    Responding to Staff inquiries regarding matters related to the Plan,

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    Developing, coordinating and participating in compliance education and training,

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    Developing and supervising on-going compliance auditing and monitoring activities,

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    Developing a compliance concern reporting mechanism that encourages Staff to report compliance concerns without fear of retribution,

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    Receiving, investigating and reporting on compliance concerns and violations,

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    Recommending and overseeing implementation of corrective actions when necessary,

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    Functioning as the liaison with outside legal counsel,

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    Establishing committees to assist in drafting, implementing and maintaining the compliance program,

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    Chairing the Compliance Committee,

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    Revising the Plan in response to organizational need and changes in law and policy,

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    Reporting regularly to the President & Chief Executive Officer and the Audit and Compliance Committee of the Board of Directors regarding compliance activities.

Compliance Committee The Compliance Committee includes employees and managers of key operating units with the seniority and experience to implement necessary changes to policies and procedures as recommended by the Compliance Committee. The primary role of the Compliance Committee is to advise the Compliance Officer and to assist in the implementation of the Plan.

The responsibilities of the Compliance Committee are as follows:

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    Analyze the industry environment and applicable legal requirements,

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    Identify specific compliance risk areas,

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    Assess existing policies and procedures addressing compliance risk areas,

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    Develop standards of conduct and policies and procedures to promote compliance with

ethical and legal requirements,

CORPORATE COMPLIANCE PLAN 5/6/10

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