The Vice President of Human Resources together with the Compliance Officer will include compliance violations in the disciplinary guidelines. These guidelines will be applied and enforced consistently and will result in enforcement penalties, up to and including termination of employment/affiliation. The Compliance Officer along with the Vice President of Human Resources will be responsible for all compliance related disciplinary investigations. The Hospital reserves the right to exercise discretion in determining the disciplinary penalty for violating a compliance standard; the form of discipline will be case specific. The actual implementation of disciplinary actions will be in accordance with Human Resources policies and as applies to the members of the medical staff, the medical staff by-laws.
The disciplinary system shall provide that disciplinary actions, including a statement of the reasons why the disciplinary penalty was imposed, are documented in the personnel or credential file. The Compliance Officer will maintain a record of all disciplinary actions taken regarding compliance violations and will periodically review these to assure that discipline is administered in a fair and consistent manner to all Staff. The Compliance Officer will report to the Compliance Committee on a regular basis concerning the disciplinary aspects of the Plan.
CORPORATE COMPLIANCE PLAN 5/6/10
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