DEPARTMENT: Human Resources / POLICY DESCRIPTION: Limitations on Employment
PAGE:1 of 6 / REPLACES POLICY DATED:9/15/98, 11/12/98, 3/16/99, 4/16/99, 6/30/99, 1/1/01, 4/1/01, 9/1/02, 2/1/05, 7/7/05, 11/1/05. 7/1/06, 8/1/08
EFFECTIVE DATE: November 1, 2008 / REFERENCE NUMBER: HR.OP.019 (formerly HR.209)
SCOPE: Employees in all facilities affiliated with the Company including, but not limited to, hospitals, ambulatory surgery centers, home health agencies, physician practices and all Corporate Departments, Divisions, and Groups.
PURPOSE: To define the legal or ethical limitations that may exist in establishing an employment relationship with an individual and the responsibility of the hiring manager to recognize these issues in the hiring process.
POLICY:
  1. Hiring of Former Fiscal Intermediary Personnel
  2. To ensure compliance with 42 CFR 420.203 and the disclosure of hiring former employees of fiscal intermediaries, Human Resources will notify the Secretary of Health and Human Services of the hiring of persons who had been employed in a managerial, accounting, auditing or similar capacity by a fiscal intermediary during the previous 12 months.
  3. Human Resources will send the letter of notification within 30 days of the first day of employment.
2.Prohibition Against Employment of Ineligible Persons
  1. For purposes of this policy, an “Ineligible Person” shall be any individual or entity who:
i. is currently excluded, suspended, debarred or otherwise ineligible to participate in the Federal health care programs;
ii. has been convicted of a criminal offense related to the provision of health care items or services and has not been reinstated in the Federal health care programs after a period of exclusion, suspension, debarment, or ineligibility; or
  1. is currently excluded on a state exclusion list.
  2. No Company-affiliated facility, including hospitals, ambulatory surgery centers, home health agencies, and physician practices will make an offer of employment to an applicant who is listed as an Ineligible Person.
  3. All applicants are required to answer the following question on the application for employment: Are you currently excluded, suspended, debarred or otherwise ineligible to participate in the Federal health care programs, or have you been convicted of a criminal offense related to the provision of health care items or services but not yet been excluded, debarred, or otherwise declared ineligible?
  4. Each employee of a Company-affiliated facility must disclose immediately any debarment, exclusion or other event that makes him or her an Ineligible Person.
  5. All Company-affiliated facilities, including hospitals, ambulatory surgery centers, home health agencies, and physician practices must immediately terminate any current employee who is listed as an Ineligible Person.
3.Employment of Minors
Normally, candidates for employment must have reached their eighteenth birthday. However, persons who have reached their sixteenth birthday may be considered for employment within the limits of state and federal law.
4.Employment of Relatives and employees with common domicile
  1. Employment of immediate family members and employees with common domicile at Company-affiliated facilities may cause the perception of inequitable hiring practices and/or conflicts of interest by fellow employees or others. Therefore, prior written approval must be obtained from a manager one level above the hiring manager and may only be approved after determining that such employment will not create the appearance of a conflict of interest or have other adverse consequences to business operations. Immediate family is defined as spouse, parent, parent-in-law, brother, sister, child, step-child and grandparent; common domicile is the same legal residence.
  2. Members of an immediate family or employees with common domicile shall not supervise one another directly.
  3. Members of an immediate family or employees with common domicile shall not supervise one another indirectly without prior written approval from a senior manager at least one level above the hiring manager.
  4. If marriage, promotion or other action creates a supervisory relationship among related employees or employees with common domicile, one of the related employees or employees with common domicile must either resign or transfer in order to resolve the situation within one calendar month.
  5. No Company affiliated facility shall employ a relative or an individual with common domicile of its Human Resources Director or any member of Senior Management without written approval of a senior manager at least one level above the hiring manager.
5. Use of Contract Personnel
  1. Contracts with independent contractors should be reviewed in advance by the Legal Department. Generally, if an individual is subject to the Company’s control or direction only regarding end results (and not as to the details by which those results are accomplished), the individual may be classified as an independent contractor.
  2. The agreement should include the Federal Tax ID number and the proof of workers compensation insurance certificate.
DEFINITION
SanctionCheck.comis the Compliance Concepts, Inc. (CCI) website that enables Company-affiliated facilities to verify exclusions using an individual name or a batch file of multiple individuals that is processed against the OIG Sanction Report and the GSA List at the same time. Instructions for individual and batch search using SanctionCheck.com are on the website at
PROCEDURE:
1. Hiring of Former Fiscal Intermediary Personnel
  1. Human Resources will prepare a letter similar to the attached example and forward it to the Department of Health and Human Services.
  2. Human Resources will forward a copy of the letter to the Vice President of Reimbursement for maintenance of consolidated Company information to be included in Form HCFA-1513, “Ownership and Control Interest Disclosure Statement” for hospitals to use during re-certification visits. A copy will also be placed in the employee’s personnel file.
2. Prohibition Against Employment of Ineligible Persons
a.Prior to hiring or re-hiring an employee, Human Resources must ensure that the individual being considered for employment has been checked against the General Service Administration’s List of Parties Excluded from Federal Programs (the “GSA List”) and the HHS/OIG List of Excluded Individuals/Entities (the “OIG Sanction Report”).
b.The GSA List and the OIG Sanction Report are on the Internet in searchable formats at, respectively:
  • and
  • Alternatively, both lists may be searched simultaneously at: This is the recommended method of conducting ineligible persons searches.
  1. Facilities located in states which maintain a state exclusion list must also search the applicable state exclusion list to ensure thatno colleague, affiliate, physician, privileged practitioner, or independent or dependent practitioner or contractor is an ineligible person. A list of states with exclusion lists is available on Atlas at:
  2. Human Resources or the vendor providing background investigations will compare the name and address of each potential candidate for employment to the GSA List and the OIG Sanction Report. Should an individual appear on either the GSA List or the OIG Sanction Report, the Company may not employ that individual. Corporate Information Technology & Services (IT&S) will compare the Company’s employee database against the GSA List and the OIG Sanction Report on a quarterly basis. IT&S will provide the report of the comparison, which lists potential matches, to the Corporate Human Resources’ VP, Employee Relations.
  1. The VP, Employee Relations must inform the Human Resources (HR) Director at the facility which employs the potentially Ineligible Person. The HR Director, or designee, is responsible for confirming the match, and if the employee is an Ineligible Person on the GSA List and/or the OIG Sanction Report the HR Director must terminate the employment relationship with that individual. The VP, Employee Relations will report the match and the action taken by the facility to the VP, Reimbursement and Director, CIA Implementation.
  2. Each employee must immediately disclose to his or her supervisor any debarment, exclusion or other event that makes the employee an Ineligible Person. The supervisor must report such disclosures to the HR Director, and the HR Director must terminate the employment relationship with that individual.
  3. The HR Director must notify the facility’s Division Reimbursement Manager to address potential cost reporting issues and report the disclosure or match and subsequent actions, including the final disposition, to the facility Ethics and Compliance Officer (ECO). The ECO will report each such incidence on the facility’s next ECO Quarterly Report.
  4. If the ineligible person is a Corporate payroll employee, the VP, Employee Relations, will work with the Corporate Reimbursement department to address cost reporting issues, and report the match or disclosure and subsequent actions, including the final disposition, to the Director, CIA Implementation.
  5. Documentation:
  6. Whenever a search of the GSA List, the OIG Sanction Report, or state exclusion list, if applicable is conducted by the background investigation vendor or a facility undertakes to confirm a possible match, the search results must be documented and copies of the search information should be maintained in the employee’s file or in a master exclusion verification file filed by year and alphabetized for applicants not employed.
  1. Documentation required for searches performed on SanctionCheck.com:
a)Documentation required when batch file results from SanctionCheck.com indicate a possible OIG or GSA List match:
  • An individual name certificate must be printed whenever a search results in a "Yes" (possible match) for an individual for either the OIG or GSA.
  • An individual certificate summary must be printed for all “Positive Matches Only” (both OIG and GSA possible matches).
b)Documentation required regardless of SanctionCheck.com search results:
  • The “All Names Submitted” file must be downloaded when the Batch Results page displays.
  • The list used to develop a batch search must be printed and saved.
iii.Electronic storage is also an acceptable storage option provided the documents are readily available on demand. A procedure for backing up documents in the event of system malfunction should be established to ensure accessibility.
iv.All documents pertaining to an incidence in which a listed employee is confirmed to be an Ineligible Person must be maintained by the facility or corporate department taking the action for a minimum of five (5) years.
  1. All Company-affiliated facilities must comply with the Records Management Policy, EC.014.
3. Hiring of Relatives
  1. Before extending an offer of employment to the relative or to an individual with common domicile of an existing employee, the manager should consult with Human Resources to ensure proper written approval is obtained and that there will be no appearance of or actual conflict of interest.
  2. In situations where Human Resources believes a perceived or actual conflict will exist,Human Resources should consult with the local ECO before a final decision is made.
  1. Independent Contractors and Employees of Staffing Agencies or Contracted Service Entities
All contract labor vendors for clinical and administrative staffing are to be contracted and managed by All About Staffing. Employees of contract services (e.g., lawn services, other contract workers, dietary) students and volunteers will continue to be managed by affiliated facilities.
On a quarterly basis, All About Staffing will compare its independent contractors, employees
of staffing agencies or contracted service entities, as appropriate, to the GSA and OIG lists to
confirm a potential match.
The CEO of each company-affiliated facility or designee is responsible for a process to conduct
a quarterly search of the GSA and OIG lists to confirm a potential match of any contract labor
provider not otherwise managed by All About Staffing.
REFERENCES:

42 CFR 420.203

48 CFR Subpart 9.4, Federal Acquisition Regulation, 9.4 – Debarment, Suspension, and Ineligibility
Form HCFA-1513, Ownership and Control Interest Disclosure Statement
Records Management Policy, EC.014
Prohibition Against Contracting with Any Ineligible Person Policy, MM.001

9/2008

DEPARTMENT: Human Resources / POLICY DESCRIPTION: Limitations on Employment
PAGE:1 of 6 / REPLACES POLICY DATED:9/15/98, 11/12/98, 3/16/99, 4/16/99, 6/30/99, 1/1/01, 4/1/01, 9/1/02, 2/1/05, 7/7/05, 11/1/05. 7/1/06, 8/1/08
EFFECTIVE DATE: November 1, 2008 / REFERENCE NUMBER: HR.OP.019 (formerly HR.209)

Standard letter for notification of H.H.S. of

employment of former fiscal intermediary employee:

[Date]

The Honorable ______

Secretary of the United States Department of Health and Human Services

200 Independence Avenue SW

Washington, DC 20201

Dear Secretary ______:

As required by 42 CFR 420.203, providers must disclose “the hiring of certain former employees of fiscal intermediaries.”

We wish to disclose our employment of the following individual:

Name:

Effective date:

Former employer:

If we may offer additional information concerning this matter, please notify us.

Sincerely,

cc: Vice President, Reimbursement

Personnel File

9/2008