Policy Approval Form - RuralMED Management …...2020/03/09 · timesheet. ruralMED x Workers Compensation Policy ruralMED is committed to minimizing the risk of work‐related injury

Policy Name Summary Dept. New Reviewed Revised Retired Comment/ApprovalAnti‐Discrimination & Anti‐Harassment Policy

This policy is intended to ensure proper conduct to and amongst ruralMED staff in both the letter and spirit of the law in making certain that discrimination and harassment does not exist in its policies, regulations and operations.

ruralMED x

Classification of Employees Policy Policy outlines ruralMED's accordance with the Fair Labor Standards Act and the classification of exempt or non exempt employees.

ruralMED x

Employee Occurance / Injury or Illness Reporting Policy

Policy and Form for reporting events that causes or may cause injury, exposure or illness.

ruralMED x

Establishing Policy Policy to document the method for the establishment, review and maintenance of policies for ruralMED.

ruralMED x

Jury Duty Policy To provide income protection while an employee carries out his or her civic responsibility, ruralMED provides the jury duty pay to employees summoned to serve as jurors. Jury pay shall be equal to the employee’s regular rate of pay based on hours typically scheduled per day/week, less any pay received from the court. Full‐time and regular, part‐time employees are eligible to receive this benefit.

ruralMED x

Licensure, Certification and Registration Verification and Control Systems

ruralMED will employ only those individuals who have proper licensure, certification, or registration by the appropriate agency in those jobs requiring such status.

ruralMED x

Payroll distribution/Time Verification ruralMED Management Resources shall distribute pay to employees through direct deposit on a biweekly basis (26 per year). Pay days shall be every other Thursday according to our annual payroll calendar.

ruralMED x

Policy Approval Form

Personnel Files ruralMED Management Resources shall initiate and maintain a personnel files on all employees. The Human Resources Department shall initiate the personnel files at the time of hire. It shall be the responsibility of the Human Resources Department to originate and maintain personnel files according to that information which is required by federal, state or local regulations or information otherwise required by ruralMED to commence employment.

ruralMED x

Paid Time Off Policy Policy that outlines PTO accumulation and usuage for employees.

ruralMED x

Time Card Policy The purpose of this policy is to establish procedures for using the Kronos timekeeping system and to ensure accurate reporting of time worked as well as time off benefits. In order to properly compensate the employee, it is necessary for all time worked to be clearly documented and approved on the individual’s timesheet.

ruralMED x

Workers Compensation Policy ruralMED is committed to minimizing the risk of work‐related injury and illness. When work‐related injuries/illnesses do occur, the organization has a legal and moral obligation to provide compensation and assistance to staff members who have suffered an injury or illness arising out of in the course of their employment. Any employee bloodborne pathogen exposure shall be handled in a confidential manner. Employees who contact a bloodborne disease shall be covered under workers’ compensation if it is determined that they were infected at work.

ruralMED x

Employee Status Policy To explain the hours that constitude full‐time, part‐time and PRN ststus as an employee of ruralMED.

The Classification of Employees policy will outline this, and this policy is nolonger needed or relevant.

ruralMED x

Access By Workforce Compliance and privacy policy to mitigate unauthorized protected health information by employees.

ruralMED x

Designating Covered and Non‐Covered Entities

Compliance and Privacy policy to identify covered components under HIPAA

ruralMED x

General Policy‐Use and Disclosure Compliance and Privacy policy to explain the policy use and disclocure process of ruralMED

ruralMED x

Reporting Internal Investigations Compliance and Privacy to mitigate risk with non‐compliance fo the HIPAA Privacy Plan, to handle investigations, and to ensure no retailatory action will be taken against reporters.

ruralMED x

Privacy Training Compliance and privacy policy to train employees on privacy polcies and procedures.

ruralMED x

Workforce Sanctions Compliance and privacy policy to disciple employees who violate the HIPAA Compliance Plan

ruralMED x

ANTI-DISCRIMINATION & ANTI-HARASSMENT POLICY

Policy No.: Effective Date: Origin Date:

Category(s): Company Wide, Responsible Party: CEO

I. PURPOSE: This policy is intended to ensure proper conduct to and amongst ruralMED staff in both the letter and spirit of the law in making certain that discrimination and harassment does not exist in its policies, regulations and operations.

II. POLICY: A. Discrimination and harassment will not be tolerated. All employees are prohibited from engaging

in the discrimination or harassment of any employee or other person in the course of or in connection with their employment at ruralMED. The desired standard of employee behavior is one of cooperation and respect for each other, despite any differences.

B. In general, slurs, jokes, and other verbal or physical conduct relating to any of the following characteristics constitutes discrimination and harassment when they unreasonably interfere with the person’s work performance or create an intimidating work environment: age, race, color, creed, ethnicity, religion, national origin, marital status, sex, sexual orientation, disability, veteran or military status, or any other basis protected by federal, state or local law. Prohibited conduct may include, but is not limited to, the following:

a. Epithets, slurs or negative stereotypes, intimidating or hostile acts based upon protective classification, and/or written or graphic material that denigrates or shows hostility or aversion to persons of a protected class that is posted or circulated on ruralMED property.

b. Verbal harassment and unwelcome discussions relating to or motivated by a person’s protected characteristic or class.

c. Unwelcome requests or demands for sexual favors. This includes subtle or blatant expectations to engage in sexual relations and pressures for dates, especially when submission to such conduct is a condition of employment, or when submission or rejection of such conduct is used as a basis for employment decisions affecting the individual.

d. Verbal harassment or unwelcome kidding of a sexual nature, such as telling “dirty” jokes and comments about body parts, appearance, or clothing, where such comments go beyond mere courtesy.

e. Unwelcome or unwanted sexual advances, such as patting, pinching, brushing up against, hugging, cornering, kissing, fondling, sexual flirtations, or any other similar contact.

f. Creating a work environment that is intimidating, hostile, abusive, or offensive because of the display or circulation of offensive written materials, pictures, cartoons, or representations of any action or subject which is sexual in nature and which can be perceived as offensive, such as unwelcome conversations, suggestions, requests, demands, or physical contacts which are sexually oriented.

C. Discrimination or harassment may exist when co-workers, or even non-employees, such as vendors, engage in such conduct, when the conduct unreasonably interferes with an employee’s work performance or creates an intimidating, hostile, or offensive work environment.

D. Sexual harassment does not have to involve conduct of a sexual nature in order to constitute improper behavior. For example, abusive, offensive, or demeaning behavior that is directed to

members of one gender only (whether male or female) may be deemed a form of sexual harassment, even though the conduct was not motivated by sexual desire or gratification. In addition, harassment of a male by another male, or a female by another female also constitutes a form of sex discrimination. If there are questions about whether conduct is permissible under this policy, employees should consult their immediate supervisor (unless he or she is the person engaging in the conduct) or the Human Resources Department.

III. PROCEDURE: A. Everyone at ruralMED has a responsibility to promote equal employment opportunities, and we

expect everyone to share this commitment. If you believe you have been subjected to any form of discrimination, harassment, or offensive conduct, please take the following action immediately:

a. Step 1: Ask the offending party to stop, unless confronting the offending party would be uncomfortable or place you in danger; AND

b. Step 2: Report your complaint to your immediate supervisor. If your immediate supervisor is unavailable or if your immediate supervisor is the person you believe is responsible for the harassment, discrimination, or offensive conduct, or you believe it would be otherwise inappropriate to contact your immediate supervisor, you should immediately report the complaint to the Human Resources Department.

c. Please note that the complaint must be reported in accordance with Step 2, even if the offending party is asked to stop.

B. ruralMED will not retaliate against you for filing a complaint in good faith and does not permit retaliation by management, employees or co-workers. In addition, individuals who participate in this complaint process as potential witnesses (other than the alleged harasser) are assured of non-retaliation. You must report acts of retaliation just as you must report acts of discrimination or harassment.

C. Your complaint will be investigated in a confidential and professional manner, consistent with resolution of the complaint, by the Compliance Officer and/or the Human Resources Department. If at any time you are not satisfied with the handling or outcome of your complaint, of if you would be more comfortable bypassing the other steps, the complaint may be taken directly to ruralMED’s Chief Executive Officer, who may be contacted at 308-217-4212. If a complaint alleges that the Chief Executive Officer was a party to an incident of discrimination or harassment that is prohibited by this policy, the complaint should be referred to the Chairman of the ruralMED Board of Directors.

CLASSIFICATION OF EMPLOYEES POLICY

Policy No.: Effective Date: March 2020 Origin Date:

Category(s): Company Wide, Responsible Party: Human Resources

I. POLICY: A. ruralMED Management Resources abides by all regulations for qualifying an employee as an

exempt or nonexempt and payroll record-keeping in accordance with the Fair Labor Standards Act as amended from time to time.

B. ruralMED Management Resources offers benefits to certain employees. Eligibility for benefits is based on hours worked, length of employment and the benefit plan documents. ruralMED complies with all state and federal laws regulating employee benefit plans.

C. All employees will be informed of their status (exempt or nonexempt) and benefit eligibility requirements at the time of employment. Any change of status or eligibility will be recorded in the employee’s personnel file and communicated to the employee.

II. PROCEDURE FOR TRANFER OR CHANGE IN CLASSIFICATION: A. A transfer in the classification of employment may be available, depending upon needs of the

organization and ability to meet the requirements of state and federal laws. Recommendations for change in status are made by the department manager and must be approved in concert with Human Resources.

B. DEFINITIONS – FEDERAL CLASSIFICATION OF EMPLOYEES

C. Non-exempt Employees – Nonexempt employees are those who do not meet the requirements for exempt status as outlined by Federal Wage and Hour Requirement, or those who are not considered to be exempt employees by mutual agreement with ruralMED.

D. Exempt Employees – An exempt employee is considered to be “salaried” and must meet the requirements of the Fair Labor Standards Act (FLSA) and fall into one of the following categories based on the requirements set forth in the law (executive, administrative, professional, computer-related, outside sales or highly compensated). For help in making this determination use the FLSA Exemption Questionnaire. Employees are placed in this classification by mutual agreement with ruralMED legal counsel.

EMPLOYEE OCCURRENCE/INJURY OR ILLNESS REPORTING POLICY


Category(s): Company Wide Responsible Party: Human Resources

I. POLICY: ruralMED Management Resources is committed to providing a safe work environment. Prevention, education and continuous improvement are priorities.

II. PROCEDURE: A. Any event that causes or may cause injury, exposure or illness must be immediately documented

and reported to the Supervisor/Department Leader and Human Resources.

a. Employee and/or witness must complete a First Report of Alleged Injury or Illness Form. The report shall include a factual account of the details of the event. All areas MUST be completed in order to properly document and investigate. A copy of the report should be submitted to the Department Leader and HR.

b. The Department Leader shall complete a thorough investigation, with input from the employee and/or witness within 48 hours of the occurrence and determine if any changes to policy/procedure are needed.

B. Human Resources will review all employee occurrences and if/when appropriate submit a Nebraska Worker’s Compensation Court report to the ruralMED Workers’ Compensation Carrier and when to document on OSHA Form 300

C. Employee Injury or Illness reporting is not intended to be used for punitive reasons or as a means of documenting alleged misconduct on the part of employees or other staff.

D. Employee Alleged Injury or Illness reports are not to be included in a patient’s medical record or in an employees’ personnel file.

ruralMED First Report of Alleged Occupational Injury or Illness

Investigation/Documentation Form

1. Name of employee:

2. Position: Department:

3. Date of Incident: Time: AM PM

4. Place of incident:

5. Witness(es):

6. Did you authorize first-aid or doctor? Yes No When ________

7. Did injured leave work? Yes No When

8. Did injured return to work? Yes No When

9. Describe nature of and extent of injuries:

10. Describe Alleged Occupational Injury or Illness:

11. Physical sources that may have contributed (i.e. needle, concrete, etc) if applicable:____

12. Manager Notified? Yes No

13. Unsafe Behaviors that may have contributed

14. Describe actions or recommendations to take to avoid recurrence:

16. Signatures:

Prepared by: Employee Date

Reviewed by: Manager Date

HR Date

____________________ CEO Date

This form must be completed within 72 hours of incident and sent to the Human Resource Department

ruralMED Management Services

CATEGORY: Administration POLICY NUMBER: EFFECTIVE DATE: March 2020 REPLACES: LATEST REVISION: RESPONSIBLE PARTY: CEO TOPIC: ESTABLISHING POLICY PURPOSE: To document the method for the establishment, review and maintenance of policies for ruralMED Management Resources. SCOPE: All departments at ruralMED Management Resources. POLICY: ruralMED Management Resources will establish a consistent way of creating and reviewing policies that impact the way business is conducted throughout the organization. It will be the responsibility of all managers to maintain appropriate written policies that provide overall guidance for effective operations of the organization as a whole and each individual operating unit therein. No departmental policy shall be established that will be in conflict with an organization-wide policy. Where departmental and/or organizational policy conflicts with governing board policy, governing board policy shall govern. Where any policy conflicts with law, law shall govern. DEFINITIONS:

Policy: A policy is a statement of philosophy and principle. It is a statement of intention that stipulates in a general way the course of action for management to follow. Organization policies provide overall guidance for effective operations of the facility, its divisions, and its departments that are consistent with the facility mission and philosophy. Policies require the signature of the department manager, department director, Medical Director, CEO or governing board chairperson, as applicable.

Organization-wide policies - Interdepartmental policies that normally affect

most, if not all, areas of the organization. Organization-wide policies will fall into one of five major categories.

• Administrative Policies – Policies that cover a very broad spectrum of topics. They essentially cover all issues other than those addressed in the

ESTABLISHING POLICY – PAGE 2

other four categories.

• Fiscal Policies – Policies that address issues primarily related to financial operations.

• Human Resources Policies – Policies that deal with employee relations and all aspects of work life at ruralMED Management Resources.

• Information Technology Policies – Policies that deal with information technology processes throughout the facility.

• Patient Care Policies – Policies that address patient care topics facility wide.

Departmental Policies – Policies affecting personnel within one department. Governing Board Policies – Policies affecting governance of the organization.

Procedures – Procedures are detailed, specific plans of action. Procedures are always subordinate to and supportive of policy. Procedures require the signature of the department manager or designee only.

PROCEDURE: There are three (3) distinct categories of policies that are recognized:

1. Organization-wide policies.

2. Departmental policies - These policies are created and reviewed by individual departments within ruralMED. They are signed by the Department Director and Department Manager. Policies should follow the suggested format and numbering scheme addressed below.

3. Governing board policies - These policies are reserved for the governing board and are not addressed in this policy.

All organization-wide policies will be documented on the format prescribed below:

• Heading/Topic • Purpose • Scope • Policy • Definitions • Procedure • Signatures

a. Approval Signature (Director, Manager, and/or CEO, as applicable) b. Chair of Health System Board of Trustees, if applicable

The following policy number scheme is required for organization-wide policies and is encouraged for other policies as well.

EXAMPLE: Policy Number: HR-06 “HR identifies a Human Resources policy, and the “06” would indicate this is the 6th

policy in the Human Resources section.

ESTABLISHING POLICY – PAGE 3

Policies will be available electronically for all employees to view the most recent version. The manual of facility-wide policies will have an Index containing the name, date and number of each policy. Organization-wide policies will be reviewed periodically by the appropriate director according to operational or regulatory requirements such as Medicare, new legislation, etc., at least every two (2) years. The review of organization-wide policies will be a standing agenda item at Director Team meetings. The Director Team will be responsible for organization-wide policy development and review to ensure that policies don’t conflict with other organization-wide policies, governing board policies, federal, state, or other governing entity regulations. Policies should be in a standard format and readily accessible in either electronic or paper format to all employees. STEPS FOR ORGANIZATION-WIDE POLICY APPROVAL:

1. The draft policy will be forwarded electronically to the administrative assistant. 2. The draft policy will be reviewed by the Director Team at their regular meeting, for

conflicts with other policies, regulations, etc. 3. All comments will be submitted to the Director updating the policy, and a final

draft will be sent to the Director Team for approval. 4. The final draft will then be forwarded to the CEO for approval and signature; and,

if required to the board of trustees for approval. 5. The final policy will be available electronically to all employees. The latest version of all organization-wide policies will be communicated appropriately to all department managers. Department managers and supervisors/coordinators are responsible for communication of policies within their respective departments. Discontinued Policies: One hard copy of all discontinued policies will be maintained by the Administrative Assistant. These will be maintained according to federal or state requirements, whichever is more stringent.

Chief Executive Officer

Date

Policy/Admin/Est Policy A-01

ruralMED Management Resources

Jury Duty Policy

Policy No: Category: Company Wide Effective: March 2020 Responsible Party: HR Revision Date: POLICY:

To provide income protection while an employee carries out his or her civic responsibility, ruralMED provides jury duty pay to employees summoned to serve as jurors. Jury pay shall be equal to the employee’s regular rate of pay based on hours typically scheduled per day/week, less any pay received from the court.

Full-time and regular, part-time employees are eligible to receive this benefit.

PROCEDURE:

ruralMED recognizes that jury duty is a civic responsibility of our employees. You must provide a copy of the jury duty summons to Human Resources and your manager within one day of receiving the summons.

Occasionally, the summons to jury duty will occur at a time of the year when the employee or the employer might experience a significant impact on customers or staffing from the loss of the employee to jury duty. In these instances, the employer may write a letter to the court requesting the postponement of the employee's jury duty.

ruralMED provides paid leave when an employee must serve on a jury. You will be paid your normal salary or hourly compensation while you are on jury duty less the jury duty pay for that day. No overtime payments, if you are eligible for overtime pay, are made during the time that you serve on a jury. You must provide documentation to the Human Resources Department of your jury duty at the end of each pay period in which you are on jury duty.

In no case will your employment be affected if you perform jury duty. You will not be harassed, threatened, or cajoled into getting out of jury duty and your same job will be available upon your return.

If you report for jury duty and are dismissed, you will be expected to report for work for the remainder of each day on which this occurs. If you are told that you do not need to report to the court on any day of your jury duty stint, you are required to come to work.

Your benefits such as health care, dental, vision, and disability will be continued and the normal payments that you make will be subtracted from your pay on your return from the unpaid leave.

https://www.thebalancecareers.com/what-is-the-human-resource-department-1918141

https://www.thebalancecareers.com/leave-of-absence-what-a-leave-is-and-how-to-apply-1918176

https://www.thebalancecareers.com/what-is-overtime-1918206

https://www.thebalancecareers.com/health-insurance-benefits-foundation-1918146

https://www.thebalance.com/how-do-dental-credit-cards-work-4174062

https://www.thebalancecareers.com/what-s-in-a-comprehensive-employee-benefits-package-1917860

https://www.thebalancecareers.com/what-is-long-term-disability-insurance-1918178

LICENSURE, CERTIFICATION AND REGISTRATION VERIFICATION AND CONTROL SYSTEMS

Policy No.: Effective Date: 5/27/16 Revision Date: March 2020


I. POLICY: ruralMED will employ only those individuals who have proper licensure, certification, or registration by the appropriate agency in those jobs requiring such status.

II. PROCEDURE: A. At the Onset of Employment

a. All newly hired staff whose job requires licensure by the state or other proof of registry or certification will provide a photocopy of such document to Human Resources upon request.

b. Human Resources Department staff will verify the individual’s licensure, certification or registration with the primary source via website or telephone. Human Resources will generate an electronic copy of the license, certification, or registry directly from the licensing agency.

c. The license, certificate, or registration is documented on the new hire checklist and a copy is placed in the employee’s personnel file.

d. Failure to provide valid licensure, certification, or registration will relieve the organization of any employment obligations. The new hire will be considered unable to perform duties of the job requiring the document or the date of hire will be adjusted to reflect the date the document is received.

B. Periodic Renewal

a. It is the responsibility of the staff member to provide documentation of current licensure, certification, or registration at each date or time of renewal.

b. Human Resources will verify the renewed licensure, certification, or registration through the primary source.

C. Assuring Current Status

a. At the date of hire, documentation of licensure, certification, or registration is reviewed by Human Resources.

b. Monitoring of licensure, certification, and registration will be done by Human Resources in conjunction with the department leader.

c. Staff members will be notified by Human Resources of impending expiration before the first of the month in which the expiration will occur. The employee’s Department Leader will also be notified.

d. If documentation is not received by the day of expiration, the staff member’s status is considered to have changed. At this time, one (1) or more of the following actions may be taken:

i. Demotion to an available position closest to that normally held which does not require licensure; termination if no position is available

ii. Suspension without pay until such documentation is received

iii. Disciplinary action as deemed appropriate by the Department Leader

a. A telephone call from Human Resources to the state licensing agency may confirm the renewal of said license. The hardcopy of the license will be presented to Human Resources within a reasonable period of time.

b. In case of clerical or procedural error on the part of the licensing agency, documentation from that agency must be provided in lieu of the actual license.

PAYROLL DISTRIBUTION/TIME VERIFICATION


Category(s): Company Wide Responsible Party: Accounting

I. POLICY: ruralMED Management Resources shall distribute pay to employees through direct deposit on a biweekly basis (26 per year). Pay days shall be every other Thursday according to our annual payroll calendar.

A. ruralMED shall remain in compliance with federal wage and hour regulations in all facets of the payroll program.

B. The pay period shall begin and end as follows:

a. Beginning Sunday at 0001 and continuing for 14 consecutive days ending on Saturday at 2400 after the 14 day period. (The only exception to this policy would be the ER on-call schedule, which considers weekend call to end on Sunday at 1700.)

C. In the event there are three (3) payrolls in a month, neither employee or employer benefit deductions will not be taken out of the third payroll that month.

D. Payroll shall be processed on time records properly maintained by our policy. Verification of time worked shall be provided by supervisory staff and managers and shall be acknowledged by each employee.

E. Records of hours worked shall be maintained by use of the time and attendance application (Kronos Workforce Ready) for each pay period. Records of time worked shall be maintained for a period of time not less than three (3) years and shall not be removed or deleted without approval of the Executive Team or unless lawfully required or requested.

PERSONNEL FILES



I. POLICY: ruralMED Management Resources shall initiate and maintain a personnel files on all employees. The Human Resources Department shall initiate the personnel files at the time of hire. It shall be the responsibility of the Human Resources Department to originate and maintain personnel files according to that information which is required by federal, state or local regulations or information otherwise required by ruralMED to commence employment.

II. PROCEDURE: A. The personnel files shall contain, but is not limited to, the documents listed below. Other

information placed in the personnel files shall be included at the discretion of the Human Resources Department and in accordance with other related policies and laws.

a. Main HR File:

i. Application and/or Resume for Employment, previously completed by the employee.

ii. Documentation of reference requests or the documents themselves.

iii. Employment offer letters/contracts.

iv. Licensure/certification/registration documentation.

v. Direct Deposit form

vi. State and Federal W4 (completed)

vii. Performance Evaluations/Competencies

viii. Photocopies of driver’s license, automobile insurance (if appropriate), etc.

ix. New Employee Orientation Documentation/Code of Conduct/Standards of Behavior, Employee Handbook acknowledgment, confidentiality statement

x. Nebraska New Hire verification form

xi. Other documents or photocopies as deemed useful and necessary by Human Resources.

b. Supplemental Background File

i. Background check forms, policy and background check results (including OneSource, OIG, GSA, etc. checks), National and NE Sex Offender search results

c. Supplemental Benefits File

i. Benefit enrollment forms as required for FMLA paperwork/forms.

d. Supplemental I-9 File

i. I-9 form and copies of proof of citizenship documents (SS card, Driver’s License, Birth Certificate, Passport, etc.)

ii. E-verify confirmation

e. Employee health records shall be considered confidential and shall be maintained in a file separate from the employee’s personnel records. This includes but is not limited to immunization records, annual Healthstream verification and health/drug screens.

f. Workman’s Compensation information and claims she be kept in a separate file by year.

B. Retention of personnel files

a. ruralMED Management Resources shall retain current personnel files for the duration of employment. When the employment status is terminated, the file shall be retained in the “terminated” files on the premises for a period of time no less than three (3) years. When removed from the “terminated” file, they shall be removed to the ruralMED storage area where they shall remain indefinitely. Personnel files may not be destroyed or removed from storage without written authorization.

C. Access to personnel files

a. Employees - Employees shall be allowed to review the contents of their personnel file at a time convenient to the Human Resources Department. No document shall be removed from the file without the approval of the Human Resources Director. The employee may request, in writing, photocopies of documents contained in the personnel file. Such a written request must contain the reason for the request, specific documents requested, date of the request and the employee’s signature. The request shall be given to the Human Resources Department.

b. Supervisor/Department Manager – When it becomes necessary for review of certain documents in the personnel file, these individuals shall be allowed limited access to the employee’s personnel file. Such access shall be limited to that information necessary to the reason for the request, such review shall be done in the Human Resources Department with a Human Resource employee.

c. Outside Parties – Regulatory organizations shall have access to personnel files to conduct business upon notification of the CEO/Department Head, etc. No information or documents from any personnel file shall be released to any outside party without the written consent of the employee, unless required by law and requested in a lawful manner.

D. Confidentiality of personnel files a. ruralMED Management Resources shall assure the total confidentiality of personnel files

maintained in the Human Resources Department in locked cabinets. Strict adherence to rules of access as outlined in this policy shall be required. Deviation or alterations of these rules shall occur only at the direction of the Executive Team.

E. Ownership of Personnel Files

a. Ownership of all personnel files shall be that of ruralMED Management Resources. No personnel file shall be removed from the Human Resources Department without approval of the Executive Team unless otherwise stipulated by this policy.

ruralMED Management Resources Effective: 6/7/16

Revised: 2/22/17, 2/24/20 PAID TIME OFF POLICY: Employees shall accumulate Paid Time Off (PTO) based on worked hours and may use PTO as income for periods they are absent from work for vacation, sick time, holidays, personal or family illness, bereavement or other personal time off. All employees are required to contact their Department Leader/Supervisor immediately when they are delayed or will be absent from work, generally at least one hour prior to their scheduled shift. With the exception of sudden onset illness or emergency situations, all time off must be arranged well in advance and the employee’s supervisor must grant approval for the time requested. Employees are required to fill out a PTO Request form and submit to their supervisor for approval. PROCEDURE: 1. To be eligible to earn PTO, employees must be hired to work a minimum of 24 hours per week. 2. PTO hours shall be paid at the employee's regular rate of pay at the time it is taken.

a. PTO shall only be used to receive compensation in place of regularly scheduled work hours for time off for vacation, holiday, bereavement, personal or sick time. PTO may only be requested for time off on a regularly scheduled day, either due to the department being closed or the employee requesting the day off. b. Employees cannot use a day of PTO and also make up the day of work later in the week because they must stay within their scheduled/budgeted hours, unless asked to do so by management. c. Employees who are at or over their scheduled/budgeted hours cannot use PTO to go over scheduled/budgeted hours for the week. d. If employee does not have enough PTO hours to cover their approved time off, they may be required to take the time off unpaid.

d. Employees who are under their scheduled/budgeted hours for the week must use PTO to cover this time.

i. Exceptions to this policy may be granted with Supervisor and Department Head approval.

3. Accumulation of PTO hours shall be calculated on regular hours worked, according to the schedule below. PTO accrual begins immediately upon hire. 4. The maximum amount of PTO an employee may accumulate shall be the same as the Maximum Annual PTO as outlined below. Accumulated hours carryover year-to-year.

a. For new hires: PTO may be used as accumulated. Accumulated hours will be indicated on the employee's pay stub when they become available. ruralMED reserves the right to make exceptions to this rule as needed.

5. PTO must be requested utilizing the time and attendance system and documented on the timecard.

a. SCHEDULING PAID TIME OFF: Paid Time Off, except for illness or injury must be approved by your Department Leader/Supervisor according to the following schedule: 1-2 Days 5 Days in advance 3-5 Days 14 Days in Advance Over 5 Days 30 Days in Advance The Department Leader is responsible for ensuring adequate staffing levels; therefore may not always be able to approve the request for Paid Time Off. b. Consideration for granting specifically requested time shall be subject to the needs of the department in which the employee is working. At such times when two or more employees are requesting the same time off, providing that the department in which the employee works has no specific policy, the first employee to turn in a request shall be given first choice. c. Time off for family and medical leave will be subject to current State and Federal rules but will receive priority for time off. d. Employees who miss three consecutive shifts due to illness must complete a "Certification of Health Care Provider" and submit to the Human Resource Leader. e. PTO may be granted for portions of a day with Department Leader approval, such as going home early or time off due to low census, or personal reasons. g. Scheduled deductions will be withheld from gross pay. If gross pay is less than the scheduled deductions the employee is responsible for making arrangements to pay.

6. Every employee is encouraged take at least one continuous week (equivalent to one week of regular scheduled hours) of scheduled PTO each year. Due to the financial control within the various positions, senior leadership, department leaders and directors are required to take at least one continuous week of PTO each year. 7. The PTO balance shall be paid in full on the last paycheck. 8. Once a year, up to 24 hours of PTO may be cashed out by employees who meet the requirements. See PTO Cash Out Policy. 9. Accumulation Rates and Annual Maximums update on the pay period following the anniversary date of Continuous Years of Service (last hire date). Accumulation Years Rate Maximum Annual PTO 1 0.0847 176 2 0.0876 182 3 0.0905 188 4 0.0933 194 5 0.0962 200 6 0.0991 206 7 0.102 212 8 0.1049 218 9 0.1078 224

10 0.1106 230 11 0.1136 236 12 0.1164 242 13 0.1193 248 14 0.1222 254 15+ 0.1251 260

TIME CARD


Category(s): Company Wide Responsible Party: Human Resources

I. POLICY: The purpose of this policy is to establish procedures for using the Kronos timekeeping system and to ensure accurate reporting of time worked as well as time off benefits. In order to properly compensate the employee, it is necessary for all time worked to be clearly documented and approved on the individual’s timesheet.

II. PROCEDURE: A. Kronos Workforce Ready is the organization’s time and labor management system. All hourly,

non-exempt employees will utilize Kronos for timesheet management.

a. Access Kronos on desktops. (Contact your manager with questions.)

b. Physical computers with access to Kronos in vicinity. (Contact your manager with questions.)

c. For assistance with clock-in and clock-out procedures, employees should contact their Department Leader or Human Resources. Kronos guide is given to all employees during new hire process.

d. Holiday and other shift differentials will be calculated by Human Resources.

e. Stand-by time is to be entered manually by Department Leader

f. Overtime hours will be paid at one and one-half of the average hourly rate to non-exempt employees (as per the U.S. Department of Labor Wage and Hour Division regulations). Overtime is be calculated automatically when payroll is processed.

B. Each employee is responsible for clocking in and out for shifts and meal periods.

C. Timesheets must reflect only worked hours.

D. Employees are expected to clock in and out within 10 minutes of the scheduled start or end time to fulfill the scheduled work shift unless approved by their immediate supervisor.

E. Employees are expected to clock out for personal time other than paid breaks for which employees do not need to clock out. Employees are encouraged to take a 30-minute break during their shift. Meal breaks are unpaid and employees are expected to clock in and out for meals.

F. An employee may never clock in/out for another employee or allow another employee to clock him/her out.

G. The employee is responsible for ensuring that all time is documented in the time and attendance system, including manual corrections to be made by their supervisor, if needed. Any missing punches are the responsibility of the employee to submit in Kronos before the end of each pay period.

H. Employees are required to submit all timesheets to their Department Supervisors who will then review timesheets for accuracy at the end of each pay period, request necessary corrections, and submit their timesheets in Kronos no later than Noon on the Monday before a scheduled pay day.

I. In certain circumstances (holidays, etc.), the payroll processing window may be condensed.

When this occurs, employees and leaders may be asked to submit timecards earlier than the above-mentioned timeframes. Advance notice of the earlier deadline will be provided by Human Resources.

J. Errors or needed corrections due to improper input should be brought to the Department Supervisor and Human Resources immediately and may/will be paid on the next payroll.

K. Salaried, exempt employees will automatically receive compensation without clock in/out and will receive a constant rate of pay. PTO and Sick Pay usage must be documented on the employee timesheet.

L. Failure to comply with the provisions of this policy and/or falsification of timecard could result in disciplinary action up to, and including termination.

WORKERS COMPENSATION POLICY

Policy No.: 000000 Effective Date: Origin Date:


I. POLICY: ruralMED is committed to minimizing the risk of work-related injury and illness. When work-related injuries/illnesses do occur, the organization has a legal and moral obligation to provide compensation and assistance to staff members who have suffered an injury or illness arising out of in the course of their employment. Any employee bloodborne pathogen exposure shall be handled in a confidential manner. Employees who contact a bloodborne disease shall be covered under workers’ compensation if it is determined that they were infected at work.

II. PROCEDURE: A. First Aid Cases:

a. Injuries requiring minor medical attention or only first aid, generally are not “recordable” under OSHA, however a record of all injuries must be kept. Employees involved are required to fill out an “First Report of Alleged Injury or Illness” form and immediately notify both their immediate Supervisor/Manager and the Human Resources Department. Depending on the incident and the severity, the employee may be required to submit to immediate drug testing. The Human Resources Department will make this determination on a case by case basis.

B. Medical Provider Cases and Serious Medical Claims:

a. If the employee sees a medical provider and the injury is considered reportable, the “First Report of Alleged Injury or Illness” form, must be prepared in coordination with the Department Supervisor/Manager and copies forwarded immediately to the Human Resources Department. This report must be submitted immediately. In the case of serious injuries or fatalities, OSHA notification shall be the responsibility of the Human Resources Department in conjunction with the Employee Health Nurse. All employees with work-related injuries/illnesses requiring medical attention must submit to immediate drug testing.

i. Investigations and Questionable Claims

1. Every claim involving lost time shall be investigated immediately and shall include interviewing witnesses, the injured employee (as soon as health permits), examination of the injury scene and photographs, if appropriate. Any and all physical evidence (broken machine parts) shall be retained. Should there be any information uncovered that would cause a question as to the validity of the claim, this information shall be communicated immediately and fully to the Department Leader and Human Resources Department. This shall be by phone conversation or face to face and then followed by a letter, either attached to the Injury Report or sent later.

ii. Medical Care

1. For any injury, the employee shall receive prompt and appropriate medical treatment. If referred to a medical provider (including chiropractor or optometrist) , the employee shall notify the medical provider that this is a work-related injury.

iii. Treatment of Pre-Existing Conditions

1. Departments shall direct their staff accordingly and consideration should be given when assigning a prospective or current employee, with a known pre-existing injury which could be aggravated while doing the work assigned.

2. Documentation of prior injuries shall be placed in employee medical files. Documentation may be in the form of group insurance information or as a result of a claim examination or prior workers’ compensation claim.

iv. Contact with Injured Employees

1. It is very important to maintain close contact and open communications with an injured employee, but particularly if he/she is away from work more than a week. This shall include phone calls and home visits by the employee’s immediate supervisor and other members of management, as deemed necessary.

v. Rehabilitative Work

1. It is recommended that every effort be made to accommodate an employee who may return to work on a restricted activity basis. This may be accomplished by discussion with the manager, the treating medical provider and the employee. Rehabilitation is most effective when initiated as soon as medical conditions stabilize (usually within six weeks).

vi. Return to Work

1. Authorization for the employee to return to work must be in writing by the attending medical provider and presented to the immediate supervisor, department manager and Human Resources Department.

2. Even though the medical provider returns the employee to “full work” status, caution shall be exercised for all employees returning after a prolonged disability period.

3. If an employee does not report to work on the day he/she is designated, the supervisor shall attempt to reach the employee to see if the disability period was extended. If the disability period has not been extended, disciplinary action shall be taken in accordance with standard procedures for not reporting to work.

4. If there are any restrictions noted by the physician on the return to work authorization, advise the supervisor of such and determine if the employee can return to work with the restrictions noted.

vii. OSHA Reporting Responsibilities

1. An injury or illness is recordable, if it results in any of the following: death, days away from work, restricted work or transfer to another job, medical treatment beyond first aid, or loss of consciousness.

2. All employers are required to notify OSHA when an employee is killed on the job or suffers a work-related hospitalization, amputation, or loss of an eye. A fatality must be reported within 8 hours. An in-patient hospitalization, amputation, or eye loss must be reported within 24 hours.

3. Maintenance and required posting of the annual OSHA Log (Form 300) and supplemental report (Form 300A) shall be the responsibility of the Human Resources Department.

ruralMED First Report of Alleged Occupational Injury or Illness Investigation/Documentation Form

1. Name of employee: 2. Position: Department: 3. Date of Incident: Time: AM PM 4. Place of incident: 5. Witness(es): 6. Did you authorize first-aid or doctor? Yes No When ________ 7. Did injured leave work? Yes No When 8. Did injured return to work? Yes No When 9. Describe nature of and extent of injuries: _____________ 10. Describe Alleged Occupational Injury or Illness: _____________ 11. Physical sources that may have contributed (i.e. needle, concrete, etc) if applicable:____ __________________________ 12. Manager Notified? Yes No 13. Unsafe Behaviors that may have contributed ______________ 14. Describe actions or recommendations to take to avoid recurrence: ______________ 15. Signatures: Prepared by: Employee Date Reviewed by: Manager Date HR Date

____________________ CEO Date

This form must be completed within 72 hours of incident and sent to the Human Resource Department

Full-Time, Part-time, PRN Status

Policy No. Effective Date: 1/1/20 Origin Date: 11/19

Category(s): Human Resources

Responsible Party: Human Resources

I. PURPOSE: To explain the hours that constitute full-time, part-time and PRN status as an employee of ruralMED.

II. SCOPE: All employees.

III. POLICY: • Full-time status employees must work 32 hours per week. These employees will be eligible for all

ruralMED benefits. • Part-time status will be any employee working at least 24 hours but less than 32 hours per week. These

employees will accrue PTO. • PRN will be anything less than 24 per week. PRN employees will not accrue PTO or be eligible for any

benefits. • Eligibility for benefits other than PTO will be determined by the benefit plan documents and may not be

consistent with the requirements stated herein.

CONTRACTS POLICY (Policy number and effective date) 000000, 12/12/12

ACCESS BY WORKFORCE


Category(s): Compliance and Privacy

Responsible Party:

I. PURPOSE: To mitigate unauthorized protected health information by employees.

II. POLICY: A. The minimum necessary standard applies to access and use of protected health information by members

of the workforce. Each member of the workforce must avoid intentionally accessing or using protected health information except as authorized by policy. This means that workforce members may access and use the minimum necessary protected health information only –

a. for a permitted use or purpose, as described in this Plan;

b. within the scope of the individual’s authority, based on role and responsibility at RURALMED; and

c. as permitted by their assigned data classification.

B. RURALMED will implement physical, technical and administrative safeguards and technical access controls to limit inappropriate access to protected health information by members of its workforce. However, in recognition that safeguards and access controls can be only partially effective in the provider setting, final responsibility for compliance with this policy rests with each individual member of the workforce.

C. Authority: 45 C.F.R. 164.514(d).

III. DEFINITIONS: A. Access means to acquire, obtain, possess, open or view data, records or information.

B. Data classification means a grouping or category of protected health information.

C. Minimum necessary means the least information (both type of information and quantity) necessary to accomplish the intended purposes of the use, disclosure or request.

D. Protected health information means individually identifiable health information about a patient, regardless of whether the information is gathered, stored or transmitted in written, electronic, video or even oral form.

E. Use means to apply or utilize data, information or a record to perform a task or in connection with performing a task.

F. Workforce means people whom RURALMED directly controls when they perform work or services on behalf of RURALMED. Workforce includes officers, members of the governing body, employees, volunteers, trainees or others, if they function under direct control of RURALMED.

IV. RESPONSIBILITIES: A. Compliance Committee

B. Privacy Officer

C. Data Security Officer


DESIGNATING COVERED AND NON-COVERED ENTITIES



Responsible Party:

I. PURPOSE: To identify covered components under HIPAA

II. POLICY: RURALMED hereby designates which of its components are “covered components” under HIPAA and which are not. The Plan will include reasonable safeguards for all covered components. RURALMED may adopt safeguards for non-covered components as well.

III. DEFINITIONS: A. Covered component refers to those organizational components of RURALMED which conduct health care

provider or health care clearinghouse functions in a way that subjects them to direct regulation under HIPAA. Covered components also include those components which provide supporting services to covered components and would be classified as business associates if conducted by a separate entity.

IV. RESPONSIBILITIES: A. All ruralMED Employees

V. PROCEDURE: Covered Components

A. ruralMED hereby designates the following components as covered components, subject to this plan:

a. ruralMED 47-2365020

B. ruralMED hereby designates the following components as non-covered components, subject to this Plan:

a. None

C. The list of covered and non-covered components may be revised periodically to reflect changing operations and laws

D. ruralMED may choose to apply safeguards to non-covered components. Doing so will not have the effect of making them covered components.

VI. REFERENCES:

VII. COLLABORATED WITH:

VIII. DISTRIBUTION: A. All ruralMED Employees

IX. RESCISSIONS:


X. REVIEW AND REISSUE DATE:

XI. FOLLOW-UP RESPONSIBILITY:

XII. ATTACHMENTS: A. None


GENERAL POLICY-USE AND DISCLOSURE



Responsible Party:

I. PURPOSE: To explain the policy use and disclosure process of ruralMED

II. POLICY: RURALMED is committed to limiting the use and disclosure of protected health information to the right people, for the right purposes, with the right authority and always subject to reasonable safeguards. Meeting these objectives requires the understanding and cooperation of everyone subject to our HIPAA Compliance Plan. Accordingly, the following general policies govern use and disclosure of protected health information at RURALMED.

A. Each use or disclosure must be an authorized use or disclosure.

B. The use or disclosure must be consistent with RURALMED’s Notice of Privacy Practices.

C. The person using or disclosing the information must be authorized by policy to do so.

D. The person or entity to which protected health information is disclosed must be authorized to receive it and their identity and authority must be verified.

E. Protected health information used must conform to the minimum necessary standard for uses and disclosures to which that standard applies.

F. Uses and disclosures are subject to any voluntary restrictions which RURALMED may have accepted. Uses and disclosures are also subject to the individual's right to require that RURALMED not submit a claim or claim details to a health plan when pertaining to items or services which an individual has paid RURALMED in full when requested by the individual (mandatory restrictions). Disclosures may be subject to reasonable requests by individuals for confidential communications.

G. If a disclosure is subject to a patient’s right to an accounting, it must be logged and linked per policies and procedures adopted by RURALMED

H. Uses and disclosures not clearly provided for in policies of RURALMED must be considered and resolved by a designated decision-maker. The Privacy Officer is the designated decision-maker unless someone else is designated for a particular policy or situation.

I. All uses and disclosures should be made in accordance with safeguards adopted by RURALMED to further protect the privacy of protected health information.

J. Improper uses and disclosures should be immediately brought to RURALMED’s attention in order that we can consider whether effective mitigation or remedial steps are practical.

K. Everyone subject to this Plan is required to be familiar with the policies and procedures which affect them in their role at RURALMED and will be held accountable for their individual compliance.

III. DEFINITIONS: The following terms are used throughout this Section and have the following meanings:

A. Disclose means to release, transfer, divulge or grant access to protected health information to someone outside of the workforce.

B. Health care operations means the following activities when related to RURALMED’s covered functions:


a. Quality assessment activities, utilization management activities and activities designed to monitor or improve quality or reduce costs.

b. Peer review activities and activities to evaluate the competence or qualifications of health care professionals.

c. Conducting or arranging for audit functions, compliance functions, legal functions and medical reviews.

d. Business planning, management and general administrative activities of RURALMED.

e. Fundraising for RURALMED.

Note – This is a partial listing of health care operations activities. See the Privacy Officer for the expanded definitions or for help applying the definition to actual uses and disclosures.

C. Patient means the individual whose information is protected under HIPAA or State law, or the individual who was given rights under State law. The term includes personal representatives entitled to make health care decisions on behalf of the patient.

D. Payment means activities undertaken by a provider to obtain payment for health care. Examples include:

a. Preparing and submitting claims and attachments to support payment.

b. Obtaining certification of enrollment or coverage and obtaining pre-certification for treatment.

c. Inquiring about an individual’s coverage or benefits.

d. Pursuing collection through an attorney or collection agency.

e. Reporting limited information to a collection bureau.

f. Participating in utilization management, claims adjudication, risk sharing and coordination of benefits activities.

E. Protected health information means individually identifiable health information about an individual, regardless of whether it is gathered, stored or transmitted in written, electronic, or even oral form.

F. Treatment means:

G. Furnishing preventive, diagnostic, therapeutic, rehabilitative, maintenance or palliative care, and furnishing counseling, assessment or other procedures with respect to the physical or mental condition or functional status of an individual or that affects the structure or function of the body; and

H. Sale or dispensing of a drug, device, equipment or other item in accordance with a prescription.


V. PROCEDURE: A. None

VI. REFERENCES: A. None



IX. RESCISSIONS:



XI. FOLLOW-UP RESPONSIBILITY:

A. Compliance Officer and HIPAA Privacy Officer



REPORTING INTERNAL INVESTIGATIONS



Responsible Party:

I. PURPOSE: To mitigate risk with non-compliance of the HIPAA Privacy Plan, to handle investigations, and to ensure no retaliatory action will be taken against reporters.

II. POLICY: A. Mandatory Reports. Members of the workforce with first-hand knowledge of the facts are required to report

their knowledge or belief that:

a. There has been a violation of HIPAA or a breach of RURALMED’s HIPAA Compliance Plan.

b. There has been an improper use or disclosure of protected health information.

B. Permissive Report. Members of the workforce are encouraged to report their belief that:

a. RURALMED’s policies and procedures do not comply with HIPAA.

b. RURALMED’s HIPAA-related policies and procedures interfere with quality patient care.

c. An event described under "Mandatory Reports" (above) has occurred.

C. Protection. Members of the workforce who make a mandatory or permissive report shall be protected from retaliatory action.

D. Sanctions. Members of the workforce who fail to make a mandatory report are subject to discipline.Each use or disclosure must be an authorized use or disclosure.

III. DEFINITIONS: The following terms are used throughout this Section and have the following meanings:

A. First-hand knowledge means information gained as a result of direct observation or contact, or direct admission of the person engaged in the violation, but does not include information relayed by a third party.

B. Improper use or disclosure means an access, acquisition, use or disclosure of protected health information not authorized by a policy of RURALMED.

C. Protected health information means information that relates to the past, present or future physical or mental health, health care or condition of an individual or payment for health care, including identifying demographic information, which identifies an individual, regardless of whether the information is gathered, stored or transmitted in written, electronic, video or even oral form.

D. Retaliatory action means action by RURALMED, one of its department directors, area managers or supervisors, which is intended to, or foreseeably will, have the effect of intimidating, threatening, coercing, discriminating against or otherwise retaliating against an individual.


V. PROCEDURE: It is the policy of RURALMED that any member of the workforce who has first- hand knowledge of certain acts, events or omissions with serious potential consequences to RURALMED or its patients shall report such acts,


events or omissions in accordance with this policy. All mandatory and permissive reports shall be investigated to the extent necessary to determine their validity. No workforce member making a report pursuant to this policy shall be retaliated against by RURALMED for having made such report. Discipline for (i) engaging in acts that violate applicable laws and regulations, (ii) making knowing false reports or (iii) discipline of the individual for any other performance-related reason unconnected to reporting potential violations, is not retaliation.

A. Mandatory and permissive reports may be made in person or in writing to the department director or area manager, or the Privacy Officer verbally through the anonymous Compliance Reporting Line or in writing to the Privacy Officer at RURALMED. Any report received by a department director, area manager or supervisor shall be immediately turned over to the Privacy Officer.

B. Information regarding the obligation to report and the means of reporting shall be consistently communicated throughout RURALMED through orientation and training sessions and other means developed from time to time.

C. All members of the workforce making reports are encouraged to disclose their identity, recognizing that anonymity may hamper complete and timely investigation. Nonetheless, no report shall be refused or treated less seriously because the reporter wishes to remain anonymous. The option of anonymous reporting shall be communicated to all workforce members along with methods of reporting.

D. All mandatory and permissive reports, however received, shall be investigated according to the following procedure:

a. The Privacy Officer shall establish and develop a written record for each report.

b. No promises will be made to the workforce member making the report, or witnesses providing supporting information about the report, by the Privacy Officer or anyone else regarding his or her culpability or what steps may be taken by RURALMED in response to the report.

c. In accordance with the incident Response Plan, the Privacy Officer shall conduct an initial assessment of each report to determine whether the report has merit and warrants further investigation. A written record will be established for each report at the time of initial assessment.

d. The Privacy Officer shall determine, in consultation with legal counsel as appropriate, whether the alleged wrongdoing: (i) is a violation of State or federal law or administrative regulation; (ii) is a violation of policy, procedure or plan connected with the HIPAA Compliance Plan; (iii) is a violation of other administrative policy; (iv) poses a risk to the general public; or (v) otherwise puts RURALMED at risk of economic injury or injury to reputation.

e. If the Privacy Officer believes that the allegation, if true, constitutes a violation of statute or regulation, he or she shall report the matter immediately to legal counsel (if not already involved) for consideration and determination of appropriate action, including further investigation, corrective action, disciplinary action and/or government reporting.

f. Further investigation of the report will be conducted by the Privacy Officer (or under the direction of legal counsel at the request of the Privacy Officer) in accordance with the incident Response Plan.

g. The Privacy Officer investigates the concern and presents the facts to the appropriate manager, director, Vice President, Director of Human Resources, and CEO, they may recommend suspension of any questionable practices during the course of an investigation.

E. Following the investigation, the Privacy Officer shall document the findings of the investigation. The final report shall be signed by and placed in a permanent file maintained by the Privacy Officer.

F. No one involved in the process of receiving and investigating reports shall communicate any information about a report or investigation, including the fact that a report has been received or an investigation is ongoing, to anyone within RURALMED who is not involved in the investigation process or to anyone outside RURALMED without the prior approval of the Privacy Officer.

G. All records relating to reports of potential wrongdoing shall be retained and preserved in accordance with RURALMED’s policy governing record retention. All records shall also be treated as HIPAA Records and retained as such. The Privacy Officer shall make annual reports to the Board of Directors summarizing


reports filed, results of completed investigations and actions taken unless the Compliance Officer does so as part of compliance reporting generally.

H. Confidentiality of the reporter and the content of the report should be preserved to the extent permitted by law and by the circumstances. Information about reports, investigations or follow- up actions shall not be disclosed to anyone other than those individuals charged with responsibility for investigation and remedial action as well as legal counsel.

I. The role of the Privacy Officer may be assumed by RURALMED’s Compliance Officer under this policy if the Compliance Officer makes the determination that the investigations and reports should be treated under RURALMED’s general Compliance Program.




IX. RESCISSIONS:


XI. FOLLOW-UP RESPONSIBILITY: A. Compliance Officer and HIPAA Privacy Officer



PRIVACY TRAINING



Responsible Party:

I. PURPOSE: To train employees on privacy policies and procedures.

II. POLICY: A. RURALMED will conduct training for its workforce, Medical Staff and others who are subject to this Plan, as

follows:

B. All members of the workforce, regardless of job classification, will receive general training regarding the Privacy, Security and Breach Notification Rules promptly after workforce status commences or prior to the compliance date set by such rules.

C. RURALMED will provide targeted training to all members of the workforce specific to their assigned job functions promptly after workforce status commences, and again promptly after members of the workforce change job classifications and become subject to materially different or additional policies and procedures in their new role.

D. RURALMED will offer general and targeted training to members of the Medical Staff and their office staffs regarding access, use and disclosure of protected health information at RURALMED. If RURALMED and members of its Medical Staff enter into an organized health care arrangement, RURALMED will provide training on policies and procedures applicable to the organized health care arrangement.

E. RURALMED will offer retraining and additional training to members of the workforce at reasonable intervals.

F. RURALMED will retrain workforce on new or revised policies and procedures as necessary and appropriate for such workforce to carry out their assigned functions.

G. RURALMED will maintain documentation of general and targeted training as a HIPAA Record.

H. Authority: 45 C.F.R. § 164.530(b).

III. DEFINITIONS: A. Compliance date means the compliance date for the Privacy Rule under HIPAA, April 14, 2003.

B. Targeted training means training specific to the policies, procedures and responsibilities of a member of the workforce based on assigned role or function at RURALMED.


V. PROCEDURE: A. General Training. General training will cover, at a minimum, the following areas:

a. Basic HIPAA awareness.

b. Organizational commitment to compliance.

c. The level of access to protected health information permitted by the member’s data classification and job classification.


d. The identity and role of the Privacy Officer, security official, Compliance Officer, and supervisors to enforce policies and answer questions.

e. How to ask a question, raise a concern, report a breach or file a complaint and the member’s protection when doing so.

f. Basic workforce responsibilities.

B. Written Materials. At least the following will be distributed to all members of the workforce as part of general training:

a. RURALMED’s Notice of Privacy Practices.

b. General HIPAA awareness materials.

c. The Acceptance of Basic Workforce Responsibilities (which must be signed and returned during or at the end of the general training process, once the provisions have been explained).

C. Targeted Training. Targeted training will be primarily the responsibility of department directors, area managers and supervisors. Training content and methodology will be appropriate to the workforce member’s responsibilities. Targeted training will be provided for all affected workforce when policies are revised or new policies adopted.

D. Documentation. The Privacy Officer is responsible to see that complete and accurate training records containing the following information are established and maintained:

a. Training announcements and communications.

b. Content outlines, including timeframes.

c. Attendance records of the course name, date, times and names of individual attendees.

d. Copies of training materials, whether handed out at a training session, included in newsletters, posted on bulletin boards, or otherwise communicated to members of the workforce, with a description of how, when and where the materials were distributed and/or posted.

E. Reports. The Privacy Officer should report to the President/CEO and the Board of Trustees on at least an annual basis regarding training activities conducted and offered during the year and the general level of training of members of the workforce.

F. Training Effectiveness. The Privacy Officer is responsible to evaluate the effectiveness of training and training materials. Such evaluations may include, but not be limited to, workforce evaluations of the programs and materials.

G. Workforce Conditions. It is the responsibility of members of the workforce to attend and participate in training programs and utilize training materials in order to become and remain informed regarding RURALMED’s HIPAA Compliance Plan. Completion of required training is a condition to becoming or remaining a member of the workforce.

H. Short-Term Workforce. Temporary and short-term members of the workforce, such as students, residents and trainees or agency care staff, are expected to complete general and targeted training appropriate to their role and responsibility at RURALMED.





IX. RESCISSIONS:


XI. FOLLOW-UP RESPONSIBILITY: A. Compliance Officer and HIPAA Privacy Officer



WORKFORCE SANCTIONS



Responsible Party:

I. PURPOSE: To discipline employees who violate the HIPAA Compliance Plan

II. POLICY: A. Members of the workforce who violate RURALMED’s HIPAA Compliance Plan are subject to discipline.

B. Authority: 45 C.F.R. § 164.530(e).

III. DEFINITIONS: A. Discipline includes adverse job action up to and including termination or loss of volunteer, student, Medical

Staff, employee or other status at RURALMED.


V. PROCEDURE: A. HIPAA Privacy Officer will conduct a full investigation and after it is determined that a breach has occurred

HIPAA Privacy Officer will present the investigation to the CEO, Human Resources Department, respective Department leader and respective Vice President to determine discipline. Discipline for members of the workforce who are employed by RURALMED is administered according to the following:

a. Group 1 Offense is an inadvertent access or disclosure of Protected Health Information (PHI) in any format.

i. 1st Offense: Written Warning

ii. 2nd Offense: Three day suspension without pay

iii. 3rd Offense: Immediate Termination

b. Group 2 Offense is intentional access and willful disregard.

i. 1st Offense: Three day suspension without pay

ii. 2nd Offense: Immediate Termination

c. Group 3 Offense is purposeful, intent to harm.

i. 1st Offense: Immediate Termination

B. If an employed workforce member is also a member of the Medical Staff, he or she is also subject to discipline under Medical Staff procedures.

C. In addition to grounds for discipline contained elsewhere, the following are considered serious offenses under this HIPAA Compliance Plan and may result in immediate discipline, up to and including termination:

a. Sharing a password or identity with another person or obtaining information under false pretenses or false identity.

b. Accessing or disclosing protected health information contrary to RURALMED’s policies for personal gain or for other personal benefit or motive.


c. Disclosing protected health information when the workforce member knew or should have known that he or she had no authority to do so.

d. Failure to make a mandatory report.

e. Retaliating against a patient because the patient or someone on the patient’s behalf has filed a complaint with the Department of Health and Human Services, exercised rights described in RURALMED’s Notice of Privacy Practices, or engaged in other conduct protected by law.

f. Retaliating against a member of the workforce who has made a mandatory or permissive report or who has engaged in other conduct protected by law.

g. Failure to complete and document required training.

h. Failure to sign and return the “Acceptance of Basic Workforce Responsibilities” form.

i. Improper destruction of HIPAA-related records, information or data involved in a complaint or investigation.




IX. RESCISSIONS:

X. REVIEW AND REISSUE DATE: A. Privacy Policies must be reviewed annually

XI. FOLLOW-UP RESPONSIBILITY: B. Compliance Officer

C. HIPAA Privacy Officer


Documents

Policy Approval Form - RuralMED Management …...2020/03/09 · timesheet. ruralMED x Workers Compensation Policy ruralMED is committed to minimizing the risk of work‐related injury