Background

GHVHS [Greater Hudson Valley Health System] has developed and implemented a compliance program that includes the encouraging of staff to report concerns, complaints and allegations of potential violations of law, regulations, policies, Code of Conduct (Code), and other wrongdoing. In addition, work of the Corporate Compliance Officer (CCO) may generate information that warrants closer examination or steps to resolve problems. Upon receipt of any reported violation of a law, regulation, the Code, policies, or other wrongdoing, there needs to be a process by which this information may be evaluated for accuracy, significance, and for determining appropriate courses of action. The CCO is empowered to engage in a preliminary investigation to determine whether the information alleged in the report alleges or contains allegations that might constitute an actionable offense. It is imperative that all allegations [of] wrongdoing in the workplace received by anyone be acted upon immediately.

Purpose

This policy sets forth the guidelines applicable to the conduct of such investigations. These guidelines must be followed by all staff members who receive reports of alleged misconduct or wrongful behavior, as well as staff members who assist in any investigation. The policy is further designed to give direction to the policy and procedures that should be followed.

Definitions

CCO – Corporate Compliance Officer

Whistleblower – An informant who exposes wrongdoing within an organization in the hope of stopping it. In the context of this policy the term also means one who reveals wrongdoing within an organization to higher authority within a company, the public, or to those in positions of authority outside the company.

Policy

1. All allegations and complaints relating to alleged misconduct or irregularities involving executive officers or directors of GHVHS shall be immediately reported to the Corporate Compliance Officer (CCO) who will notify the Board Compliance Committee, who in turn shall be responsible for ensuring appropriate investigation and resolution of the issue. The CCO and designated legal counsel shall conduct the investigation under their oversight.

2. The CCO shall coordinate all investigations of potential violations of fraud statutes and/or other criminal laws.

3. If an investigation confirms that wrongdoing or misconduct has occurred, prompt corrective action must be taken with respect to the person(s) involved. This may include possible termination of such person(s), as well as in the case of violations of law, referral or disclosure to appropriate law enforcement agencies. In addition, it is important to take appropriate steps to correct and remedy any causes for the misconduct, including failures of internal controls and management.

4. Any contact by staff members concerning compliance matters with executives and managers will be routed to the CCO for handling.

5. Most complaints, allegations, and concerns reported to the “Hotline” and received by the CCO will be handled under direction and coordination of the CCO. This includes reports of possible violations of the Code, policies, procedures, rules, and regulations. In the case where the allegation is a criminal violation of law, the referral must be made to Legal Counsel for determination as to whether there is sufficient evidence to support referral to a duly authorized law enforcement agency.