Protections for hospital and ambulatory surgical center employees forcertain disclosures--written policy required--procedures fordisclosure--anonymous reports.
197.285. 1. Hospitals and ambulatory surgical centers shallestablish and implement a written policy adopted by each hospital andambulatory surgical center relating to the protections for employees whodisclose information pursuant to subsection 2 of this section. This policyshall include a time frame for completion of investigations related tocomplaints, not to exceed thirty days, and a method for notifying thecomplainant of the disposition of the investigation. This policy shall besubmitted to the department of health and senior services to verifyimplementation. At a minimum, such policy shall include the followingprovisions:
(1) No supervisor or individual with authority to hire or fire in ahospital or ambulatory surgical center shall prohibit employees fromdisclosing information pursuant to subsection 2 of this section;
(2) No supervisor or individual with authority to hire or fire in ahospital or ambulatory surgical center shall use or threaten to use his orher supervisory authority to knowingly discriminate against, dismiss,penalize or in any way retaliate against or harass an employee because theemployee in good faith reported or disclosed any information pursuant tosubsection 2 of this section, or in any way attempt to dissuade, prevent orinterfere with an employee who wishes to report or disclose suchinformation;
(3) Establish a program to identify a compliance officer who is adesignated person responsible for administering the reporting andinvestigation process and an alternate person should the primary designeebe implicated in the report.
2. This section shall apply to information disclosed or reported ingood faith by an employee concerning:
(1) Alleged facility mismanagement or fraudulent activity;
(2) Alleged violations of applicable federal or state laws oradministrative rules concerning patient care, patient safety or facilitysafety; or
(3) The ability of employees to successfully perform their assignedduties.
All information disclosed, collected and maintained pursuant to thissubsection and pursuant to the written policy requirements of this sectionshall be accessible to the department of health and senior services at alltimes and shall be reviewed by the department of health and senior servicesat least annually. Complainants shall be notified of the department ofhealth and senior services' access to such information and of thecomplainant's right to notify the department of health and senior servicesof any information concerning alleged violations of applicable federal orstate laws or administrative rules concerning patient care, patient safetyor facility safety.
3. Prior to any disclosure to individuals or agencies other than thedepartment of health and senior services, employees wishing to make adisclosure pursuant to the provisions of this section shall first report tothe individual or individuals designated by the hospital or ambulatorysurgical center pursuant to subsection 1 of this section.
4. If the compliance officer, compliance committee or managementofficial discovers credible evidence of misconduct from any source and,after a reasonable inquiry, has reason to believe that the misconduct mayviolate criminal, civil or administrative law, then the hospital orambulatory surgical center shall report the existence of misconduct to theappropriate governmental authority within a reasonable period, but not morethan seven days after determining that there is credible evidence of aviolation.
5. Reports made to the department of health and senior services shallbe subject to the provisions of section 197.477, provided that therestrictions of section 197.477 shall not be construed to limit theemployee's ability to subpoena from the original source the informationreported to the department pursuant to this section.
6. Each written policy shall allow employees making a report who wishto remain anonymous to do so, and shall include safeguards to protect theconfidentiality of the employee making the report, the confidentiality ofpatients and the integrity of data, information and medical records.
7. Each hospital and ambulatory surgical center shall, withinforty-eight hours of the receipt of a report, notify the employee that hisor her report has been received and is being reviewed.
Protections for hospital and ambulatory surgical center employees forcertain disclosures--written policy required--procedures fordisclosure--anonymous reports.
197.285. 1. Hospitals and ambulatory surgical centers shallestablish and implement a written policy adopted by each hospital andambulatory surgical center relating to the protections for employees whodisclose information pursuant to subsection 2 of this section. This policyshall include a time frame for completion of investigations related tocomplaints, not to exceed thirty days, and a method for notifying thecomplainant of the disposition of the investigation. This policy shall besubmitted to the department of health and senior services to verifyimplementation. At a minimum, such policy shall include the followingprovisions:
(1) No supervisor or individual with authority to hire or fire in ahospital or ambulatory surgical center shall prohibit employees fromdisclosing information pursuant to subsection 2 of this section;
(2) No supervisor or individual with authority to hire or fire in ahospital or ambulatory surgical center shall use or threaten to use his orher supervisory authority to knowingly discriminate against, dismiss,penalize or in any way retaliate against or harass an employee because theemployee in good faith reported or disclosed any information pursuant tosubsection 2 of this section, or in any way attempt to dissuade, prevent orinterfere with an employee who wishes to report or disclose suchinformation;
(3) Establish a program to identify a compliance officer who is adesignated person responsible for administering the reporting andinvestigation process and an alternate person should the primary designeebe implicated in the report.
2. This section shall apply to information disclosed or reported ingood faith by an employee concerning:
(1) Alleged facility mismanagement or fraudulent activity;
(2) Alleged violations of applicable federal or state laws oradministrative rules concerning patient care, patient safety or facilitysafety; or
(3) The ability of employees to successfully perform their assignedduties.
All information disclosed, collected and maintained pursuant to thissubsection and pursuant to the written policy requirements of this sectionshall be accessible to the department of health and senior services at alltimes and shall be reviewed by the department of health and senior servicesat least annually. Complainants shall be notified of the department ofhealth and senior services' access to such information and of thecomplainant's right to notify the department of health and senior servicesof any information concerning alleged violations of applicable federal orstate laws or administrative rules concerning patient care, patient safetyor facility safety.
3. Prior to any disclosure to individuals or agencies other than thedepartment of health and senior services, employees wishing to make adisclosure pursuant to the provisions of this section shall first report tothe individual or individuals designated by the hospital or ambulatorysurgical center pursuant to subsection 1 of this section.
4. If the compliance officer, compliance committee or managementofficial discovers credible evidence of misconduct from any source and,after a reasonable inquiry, has reason to believe that the misconduct mayviolate criminal, civil or administrative law, then the hospital orambulatory surgical center shall report the existence of misconduct to theappropriate governmental authority within a reasonable period, but not morethan seven days after determining that there is credible evidence of aviolation.
5. Reports made to the department of health and senior services shallbe subject to the provisions of section 197.477, provided that therestrictions of section 197.477 shall not be construed to limit theemployee's ability to subpoena from the original source the informationreported to the department pursuant to this section.
6. Each written policy shall allow employees making a report who wishto remain anonymous to do so, and shall include safeguards to protect theconfidentiality of the employee making the report, the confidentiality ofpatients and the integrity of data, information and medical records.
7. Each hospital and ambulatory surgical center shall, withinforty-eight hours of the receipt of a report, notify the employee that hisor her report has been received and is being reviewed.
Protections for hospital and ambulatory surgical center employees forcertain disclosures--written policy required--procedures fordisclosure--anonymous reports.
197.285. 1. Hospitals and ambulatory surgical centers shallestablish and implement a written policy adopted by each hospital andambulatory surgical center relating to the protections for employees whodisclose information pursuant to subsection 2 of this section. This policyshall include a time frame for completion of investigations related tocomplaints, not to exceed thirty days, and a method for notifying thecomplainant of the disposition of the investigation. This policy shall besubmitted to the department of health and senior services to verifyimplementation. At a minimum, such policy shall include the followingprovisions:
(1) No supervisor or individual with authority to hire or fire in ahospital or ambulatory surgical center shall prohibit employees fromdisclosing information pursuant to subsection 2 of this section;
(2) No supervisor or individual with authority to hire or fire in ahospital or ambulatory surgical center shall use or threaten to use his orher supervisory authority to knowingly discriminate against, dismiss,penalize or in any way retaliate against or harass an employee because theemployee in good faith reported or disclosed any information pursuant tosubsection 2 of this section, or in any way attempt to dissuade, prevent orinterfere with an employee who wishes to report or disclose suchinformation;
(3) Establish a program to identify a compliance officer who is adesignated person responsible for administering the reporting andinvestigation process and an alternate person should the primary designeebe implicated in the report.
2. This section shall apply to information disclosed or reported ingood faith by an employee concerning:
(1) Alleged facility mismanagement or fraudulent activity;
(2) Alleged violations of applicable federal or state laws oradministrative rules concerning patient care, patient safety or facilitysafety; or
(3) The ability of employees to successfully perform their assignedduties.
All information disclosed, collected and maintained pursuant to thissubsection and pursuant to the written policy requirements of this sectionshall be accessible to the department of health and senior services at alltimes and shall be reviewed by the department of health and senior servicesat least annually. Complainants shall be notified of the department ofhealth and senior services' access to such information and of thecomplainant's right to notify the department of health and senior servicesof any information concerning alleged violations of applicable federal orstate laws or administrative rules concerning patient care, patient safetyor facility safety.
3. Prior to any disclosure to individuals or agencies other than thedepartment of health and senior services, employees wishing to make adisclosure pursuant to the provisions of this section shall first report tothe individual or individuals designated by the hospital or ambulatorysurgical center pursuant to subsection 1 of this section.
4. If the compliance officer, compliance committee or managementofficial discovers credible evidence of misconduct from any source and,after a reasonable inquiry, has reason to believe that the misconduct mayviolate criminal, civil or administrative law, then the hospital orambulatory surgical center shall report the existence of misconduct to theappropriate governmental authority within a reasonable period, but not morethan seven days after determining that there is credible evidence of aviolation.
5. Reports made to the department of health and senior services shallbe subject to the provisions of section 197.477, provided that therestrictions of section 197.477 shall not be construed to limit theemployee's ability to subpoena from the original source the informationreported to the department pursuant to this section.
6. Each written policy shall allow employees making a report who wishto remain anonymous to do so, and shall include safeguards to protect theconfidentiality of the employee making the report, the confidentiality ofpatients and the integrity of data, information and medical records.
7. Each hospital and ambulatory surgical center shall, withinforty-eight hours of the receipt of a report, notify the employee that hisor her report has been received and is being reviewed.
