Hill Crest Behavioral Health Services

*Employee Handbook

*This printout is to be used prior to the printing of the official Handbook. Effective
04/01/2011. Management reserves the right to make changes to this print-out with or

without prior notice.

[7 Copy

 

You are among a group of talented and dedicated professionals who uork
hard to provide quality care and service at the Facility. You ha\e been
carefully sc!ected for your position and we hope you ?nd your position a
rcoarding esperience. We are very pleased you have decided to join tts. and
we look forward to a pleasant and mutually bene?cial relationship.

This handbook highlights the goals- policies and benefits of the Facility.
Please familiarize yourself with this Handbook so that you may know what the
Facility expects from you and what you can expect from the Facility. The
policies stated in this llandbook are guidelines only and are subject to change
at the sole discretion of the Facility. From time to time. you may receive
updated information concerning changes in policy. We welcome any
suggestions or recommendations that would prove to be bene?cial to all
concerned.

The primary purpose of our mission is to provide quality service to those who
have been entrusted to our care. One of the most important functions of that
care is the protection of patients? personal and prOperty rights. Any private or
personal information regarding the facility. a patient. and/or family member.
must be kept con?dential. Current federal and state laws prohibit disclosure of
cenam information and it is recommended that you refer all queStions
conceming such matters to your department supervisor.

Although this Handbook contains much information about the Facility, its
operation and its policies= questions may arise which are not covered by the
Handbook. Please do not hesitate to bring your questions to your supervisor
or to some other management person. You will be provided with all the

assistance necessary to help you better understand our operational
procedures.

Once again. I'm glad you have joined our family and wish you success
with your employment at the Facility.

Director

Read Carefully~

This Handbook is designed to provide you with some information concerning
the Facility and your job. The Handbook is not a contract modifying the at-will
nature of your employment with the Facility. It is. instead. a set of
informational guidelines and its provisions may be modified. revoked or
changed at any time without notice. Employment by the Facility is not for a
de?nite term and may be terminated by you or the Facility at any time for any
reason. No employee or representative ofthe Facility has any authority to make
any oral or implied agreement which changes or contradicts the at-will nature
of your employment. The at-will nature of your employment can only be
modi?ed by an express mitten agreement signed by the CEO/Managing
Director of the Facility.

Ma;

~Employment~
Employment Policies

Equal Employment
Opportunity
Non-Discrimination

Policy

it is the policy of the Facility to
proxide equal opportunity in
employment to all employees and
applicants for employment. No
person will be discriminated against
in employment on the basis of his or
her race, religion, color, sex, age.
national origin. disability. pregnancy,
military status. or any other
characteristic protected by applicable
federal. state or local law.

This non?discrimination policy
applies to all temts and conditions of
employment. including but not
limited to hiring, placement-
promotion. termination, layo??,
recall. transfer. leaves of absence.
compensation and training. it is also
the policy of our Facility to admit
and treat all patients on a
non-discriminatory basis in
accordance with state and federal
la? The same requirements for
admissions. assignment and transfer
within the Facility are applied to all
patients. There is no distinction in
eligibility for. or in the manner of
proxiding. any patient service
proyided by the Facility. or by others
in or outside of the Facility. Stall
privileges and the referral of patients
?9 or from the Facility



are also granted in accordance with
state and federal law.

Reasonable .Jcc'ommoduttouts) for
Individuals with Disabilities

The Facility complies with the
American with Disabilities Act and
any applicable state laws providing
for equal employment opportunity
for quali?ed individuals with
disabilities. The Facility may also
provide a reasonable
accommodation for disabled
individuals in accordance with these
laws.

Procedure for Requesting an
Accommodation for 0 Disabled
Person

Quali?ed individuals with disabilities
may make requests for reasonable
accommodation to their Supervisor
or the Director of Human Resources.
Following the receipt of the request.
the Supervisor or Director shall meet
with the requesting individual to
discuss and identify the precise
limitations resulting from the
disability and the potential
accommodation that the Facility
might make to help overcome those
limitations. The Facility may consult
with a licensed health care
practitioner to assist in assessing the
individual?s limitations.

Productive Work Environment and
Harassment Policy

The facility's policy shall

provide a work environment that is
safe. conducive to good job
performance and free from
harassment andlor discrimination.
The Facility prohibits any form of
harassment, and speci?cally includes
harassment based upon disability.
age. race. sex, national origin-
religion or any other basis protected
by state or federal law. Improper
interference with the employees'
ability to perform their expected job
duties will not be tolerated. Such
conduct may result in corrective
action up to and including immediate
employment termination. A
supervisor who fails to take prompt
remedial action regarding instances
of harassment that has been brought

In hit.- nr 1101- n?nntinn mew racnli in

Sexual Harassment

While all forms of harassment are
prohibited, it is the Faeility's policy
to emphasize that sexual harassment
is unlawful and is specifically
prohibited. Each supervisor has a
responsibility to maintain the
workplace free of any form of sexual
harassment. No supervisor shall
threaten or insinuate. either explicitly
or implicitly, that an employee's
refusal to submit to sexual advances
will adversely affect the employee's
employment. evaluation, wages.
advancement. assigned duties. shifts.
or any other condition of
employment.

Other sexually harassing conduct in
the workplace. whether committed
by supervisors or non?supervisory
personnel. is also prohibited. Such
conduct includes. but is not limited
to:

a) Sexual flinations. touching.
advances. or propositions:

b) Verbal abuse ofa sexual
nature. including
inappropriate jokes:

c) Graphic or suggestive
comments about an
individual?s dress or body:

d) Sexually degrading words to
describe an individual; and

e) The display in the workplace
of sexually suggestive objects
or pictures, including nude
photographs.

Employee Complaint Procedure
Regarding Harassment

Any employee who believes that the
actions or words of a supervisor or
fellow employee constitute
unwelcome harassment has a
responsibility to report or
complain as soon as possible to
supervisor. If the employee
believes it would be inappropriate to
discuss the matter with hershis
supervisor, (slhe may bypass herr?his
supervisor and report it directly to the

head of the department. Human

Resources Director. same-$0

member of Senior Management. or

the CliO/Mmtaging Director.

All complaints of harassment shall be
imestigated and in an
impartial and con?dential manner by
the supervisor and?or Human
Resources Director. An employee's
complaint will be kept con?dential to
the maximum extent possible. The
employee will be advised of the
?ndings and conclusions from the
intestigatidn.

Any employ ee, supervisor. 0r
manager who is found, after
appropriate investigation. to have
engaged in the harassment of another
employee will be subject to prompt
correctiie action. up to and including
immediate employment termination.

Problem Solving Procedure

The Facility recognizes that in any
Organization employees may have
concerns or problems. It is the
policy of the Facility that all
employees are permitted to ask that
a concem(sl or problem(s) be
reviewed in a prompt and
professional manner. The Facility
shall ensure that employees receive
prompt and fair treatment. The
Facility shall not allow retaliation.
intimidation. coercion. or
discrimination against any
employee for ?ling a complaint.

I

My. within 30 days
?he incident or

problem given rise to your
contplaint(s). discuss the problems
with your immediate supervisor and
then document your speci?c
concents in uriting. In most
instances. a discussion with your
supervisor may solve the problem to
your satisfaction.

STEP 2

If the problem is not resolved at Step
l, an employee may arrange an
appointment to meet with the
department head/senior manager in
order to reach a satisfactory solution.

STEP 3

If, for any reason, an employee is
dissatis?ed with the decision of the
department head/senior manager. the
employee may ?le a written
complaint with the Director of
Human Resources following the
outcome of the meeting with the
department head/senior manager.

STEP 4

If an employee is dissatis?ed after
receiving the decision of the
Director of Human Resources. the
employee may ?le a written
complaint with the CEOIManaging
Director following the outcome of

the meeting with the Director ol
Human Resources.

0

Working Together (for non-union
employees only)

The Facility is dedicated to
maintaining an open door policy
between management and
employees, and considers its open
door policy essential for an effective
employer-employee relationship. The
Facility values its philosophy of trust.
fairness. mutual respect,
communication and teamwork. The
growth and personal achievement we
have experienced at the Facility is the
result of working together in a spirit
of cooperation and teamwork that has
enabled us to meet many dif?cult
challenges. The progress that has
been achieved re?ects this strong

mutual commitment between you and
the Facility.

Although you have the legal right to
join a labor union, you also have the
legal right not to join a labor union.
We prefer to work with our
employees infomially. personally.
and directly, rather than through third

party outsiders intervening between
us.

Recruiting and Hiring

It is the policy of the Facility to
hire individuals who are quali?ed
or trainable for the essential
functions of the applicable
position with or without a
reasonable accommodation. All
decisions regarding the
recruitment, selection and
placement of employees are made
on a nondiscriminatory basis. in
accordance with state and federal
law. Every effort will be made to
hire new employees for positions
which best utilize their abilities and
in which they will be able to achieve
both personal satisfaction and
opportunity for growth. In no event
shall a hiring of an employee be
considered as creating a contractual
relationship between the employee
and the Facility and. unless otherwise
provided in writing. such relationship
shall be de?ned as employment at
will. where either party may dissolve
the relationship at any All
vacant positions are

reported to the Human Resources
Department. The initial interview of
applicants for employment may be
conducted by the Human Resources
Department. lf Human Resources
determines that the applicant is
eligible for employment, an
interview shall be arranged between
the applicant and the hiring
head. If the law requires
that an employee be licensed or
registered, {slhe will be asked to
present evidence of current licensure
or registration at the time of the
interview. An employee must also
present proof of a renewed license or
registration to the depanment head
during the course of employment.

Employment Status

For purposes of position
management. resource allocation,
salary administration, eligibility
for overtime payments. and
employee eligibility for bene?ts.
the Facility classi?es its
employees as follows:

Regular Full- Time 

Employees who regularly work
thiny-two (32) hours or more each
week and are assigned as core stall
on the position
management plan. Such employees
are eligible for bene?ts as governed
by each bene?t plan.

Part- Time Employees

Employees who regularly work less
than thirty -two (32) hours each week
and are assigned as core staff on the
Facility"s position management plan.
Part-time employees must work a
minimum of twenty (20) hours per
week to be eligible for employee
bene?ts.

Temporary Employees

Employees, both full or part-time.
who may be hired to work for a
limited period of time not to exceed
6 to 8 months. These employees are
not eligible for employee bene?ts.
unless required by state or federal
law. The Facility may also engage
students andlor interns who may be
appointed by the Facility beyond
the customary 6 to 8 month
temporary assignment.

Studentsr'lnterns

These stall" may be regularly
scheduled to work either full-time
or pan-time hours.
Students/lntems ordinarily receive
no compensation for their services
and are not eligible for employee
bene?ts unless required by state or
federal law.

Per Diem Employees

Employees with irregular and
sporadic work schedules and/or are
on-call for work in various
unit/department locations based upon
the ?uctuating needs of the Facility.
Per diem



employees provide greater stalling
?exibility for the Facility and may
be offered a premium rate of pay as
determined by local market
conditions. For diem employees
may be eligible for leave of
absences. Per diem employees are
not eligible for employee bene?ts.

Citizenship and Immigration

All employees. upon being hired.
must complete the employment
eligibility veri?cation form (1-9).
Failure to complete the form or
provide acceptable documentation
will result in the withdrawal of any
offer of employment.

Introductory Period

The ?rst 90 calendar days after the
date of hire are considered an
introductory period. This period
gives supervisors an opportunity to
evaluate the ability with which
employees perform the their jobs. It
also gives the employee an
opportunity to decide if (s)he is
satis?ed with the job. At the end of
this period, the supervisor will
evaluate their employee?s
performance and may discuss the
evaluation with the employee. N0
advance notice is necessary for the
employee to resign or for the Facility
to terminate the employee?s
employment.



whether the employee is
considered to be in or out of the
introductory period. The Facility
will usually request that the
employee provide written notice
prior to resigning employment.
The introductory period is not
intended to compromise the at-will
nature of your employment.

When an employee transfers to a
different job. (s)he will complete a
new 90-day introductory period for
job performance. For purposes oi
bene?t calculation. the employee
will use her/his original date of hire
as long as there has not been a break
in service.

The 90?calendar day introductory
period may be extended one time at
the discretion of supervisors and
Human Resources Director.
Employees will be noti?ed as to the
length of the extension and will be
re-evaluated at the end of that
period.

Orientation

An orientation program is
conducted for all newly hired
employees. The primary purpose
of the orientation program is to
acquaint new employees with
Facility rules. policies and
procedures. and to assess
employee competency.
Additional subjects to be covered
in the scheduling of programs
shall be determined by the
Human ResourceRQ?r



Staff Development Department.
Supervisors have a vital part in
meeting the needs of new
employees through on-the-job or
unit-?department orientation. New
employees should feel free to ask

questions at any time during
orientation.

Working Hours

The Facility provides patient care
24 hours-a?day. 7 days a week. it
is. therefore. the obligation and
prerogative of the administration of
the Facility to establish work
schedules for all employees in
order to provide care for patients
around the clock.

Your schedule will be determined by
your department head or supervisor
according to department staf?ng
requirements. Your supervisor will
inform you as to your hours of work,
days oli'. lunch time, rest periods. etc.

Time Reporting

If you are a non-exempt employee,
you are required to record your work
each day. making sure to clock
for meal breaks. Exempt
employ ecs may be required to clock
in once per day.

Each employee has a time card or
record with herz?his name and payroll
number on it. This document is the
official payroll record front which
In) is computed. If you are an



exempt employ ee. you may be
required to record your absences on
a bi-weckly absence log.

Employees should not leave their
general work area except for tneal
periods and relief breaks hich may
be taken if the ?orkload permits. ll'a
non-exempt employee leaves the
Facility grounds for the meal period.
ts)he may he required to sign out
and in. if gone tnore than 30
minutes. the head must
speci?cally approte the time entry.
All non-exempt employees are
required to sign out no later than 6
or 7 minutes after their work shift
ends. Working additional hours
without prior supervisory approval
may be cause for corrective action.
Filling out another employee's time
record or falsifying one's own time
record is prohibited and may be
grounds for corrective action up to
and including immediate
employment termination. if you
make an error on your time card,
please notify your supervisor
immediately. If you lose your time
card you must repon to Human
Resources to secure a replacement.

Attendance and
Punctuatior

'l?he Facility encourages habits of
good attendance and punctuality on
the part of its employees.
Management recognizes that
circumstances

beyond an employee's control may
cause him to be absent from work
for all or pan of the day. However.
unauthorized absences or tardiness
will not be tolerated and may result
in corrective action up to and
including employment termination.

Any time that an employee is
unable to report for work: the
immediate supervisor. department
manager or nursing of?ce should be
noti?ed, in advance. to allow
suf?cient time for a replacement to
be secured, unless you are granted
an authorized medical leave. in
which case different noti?cation
procedures apply [see Leaves of
Absence policy].

Absence of 3 days or more because
of sickness may require a doctor's
certi?cate upon return to work.

Employees who are absent from
work for 3 consecutive days without
good cause and without giving
proper notice to the Facility shall be
considered as having voluntarily
resigned.

Rest Periods

Employees may be permitted [5
minutes for a rest break in both
moming and aliemoon. Times for
these rest breaks are scheduled in
each depanment with the approval
of your supervisor.

ea]:

Non-exempt employees. or
employees paid on an hourly basis.
are expected to take one half-hour for
a meal break each uork shift. (See
supervisor for exceptions). This time
is your con and you are free to use it
as you see lit. Please always take a
full half-hour for your meal period
unless ad\ised by your Sttper?tisor to
do otherwise. ?you are nonexempt
and required to work through your
meal break. you will be paid for the
worked time. You must ensure that
your supervisor has approved your
isorking through the meal period
prior to working the aura time. In
addition. it is your responsibility to
report this worked time on your time
record for that pay period.

Promotions and Transfers

The Facility may transfer
employees from one job to
another, either at their own
request or as a result of a
decision by management.
Reasons for transfer may
include. but shall not necessarily
be limited to. ?uctuations in
department workloads. the more
ef?cient utilization of personnel.
increased professional
opportunities. patient care needs.
personal situations. etc. An
employee will be eligible for a
transfer if (s)he meets the
minimum hiring requirements
for the position. and is capable-of
performing the cowl!"
functions of the job, with 0'
without a reasonable
accommodation. 'u?additton.

. .. my

   

an employee should be
performing in a satisfactory
manner in his or her current job
for a period of time. generally 6
months, prior to the request for a
transfer. Employees who have
received recent corrective action
and-?or a Performance
Improvement Plan will generally
not be referred for a transfer.
Empioyees who wish to transfer
from one department to another
should consult their department
head or supervisor. The
department head or supervisor
will contact the Human
Resources Department and a
referral to the hiring department
head will be arranged.

The Facility encourages all
employees to reach their full
potential and therefore encourages
opportunity for advancement within
the Facility. Whenever possible,
internal candidates shall be given
preference in ?lling vacancies.
however- the Facility shall select the
best candidate for the position. An
employee may be eligible for a
promotional opportunity if (slhe
meets the minimum hiring
speci?cations for the position. and-is
capable of performing the essential
functions of the job. with or without
a reasonable accommodation. In
addition. the Facility may consider
past performance. attendance-
compliance with Service Excellence
standards. etc. llsually. employ?es
\sill'be

required to complete at least 1 year 0!
employment in order to be
considered for promotional
opportunities or sooner at
management's discretion.

Corrective Action Process

The Facility expects all employees
to comply witlt the organization's
standards of behavior and
performance and to know that any
noncompliance with these standards
must be remedied. The Facility
prefers to attempt to correct
unacceptable behay ior or
unsatisfactory performance through
a progressive corrective process.
However. the Facility reserves the
right to by?pass any progressive
step(s) and impose the degree ol
corrective action. including
immediate employment termination
which it deems appropriate in the
sole discretion of the Facility. it is
also understood that there are certain
rules of conduct that are so
important that their violation usually
should lead to the offender's
immediate employment termination.
The corrective action process is not
intended to contradict the at?n?ill
nature of employment at the
Facility.

Performance Improvement
Plan

Any employee may be placed on a
Performance Improvement Plan
(PIP) when his?her performance has
deteriorated and the supervrsor

believes it is necessary to impress
upon the employee the need for
improvement. The HP may be
implemented at any time during an
employee?s employment at the
Facility. Failure to gain a
performance rating of satisfactory or
better during this time period may
result in transfer to another job more
suited to the employee's capabilities
or corrective action up to and
including immediate employment
termination.

Employment Termination and
Resignation

As mentioned elsewhere in this
handbook. all employment
relationships with the Facility are on
an at-will basis. Thus. although the
Facility hopes that its relationships
with employees are ful?lling and
mutually rewarding. the Facility
reserves the right to terminate the
employment relationship at any time.
with or withouteause.

As an at-will employee, you are free
to end your employment relationship
with the Facility at any time. with or
without cause. if you decide to end
your employment. you are asked to
give written notice of your intent to
resign. Although we have no preset
notice period. to minimize
disruption. we do request that you
discuss your resignation with your
supervisor to determine an
appropriate exit date. in many cases
no notice period will be necessary.
but in

some situations we might ask for a
notice period. but no more than 4
weeks. While working out your
notice period, payment for ELB
days will not be authorized. unless
required by state law.

Reduction in Workforce

Due to reduced patient census.
reorganization. or for some other
business reason. an employee may be
subject to temporary or permanent
layoff. An employee who is laid off
will receive accrued PTO pay. An
employee who has been given notice
of layolT will not be paid ELB during
the notice period. unless required by
state law.

Exit Procedure

When leaving the employment of the
Facility. an employee should contact
Human Resources to make
arrangements for an exit interview.
At that time. arrangements will be
made for the final paycheck.
termination of bene?ts and other
matters related to separation from
employment. Payment of the
employee's final paycheck will be
made in accordance \tilh state and
federal law.

Medical Procedures

After accepting employmizl-
new employees may be rm: 3]
to undergo a a
examination (or comp

. 't and
medicalhistoryr 

.. . 

.. . 

an alcohol and drug screen. Any
offer of employment that an
applicant receives from the
facility is contingent upon.
among other things. satisfactory
completion of this examination
and screening and a
determination by the Facility and
its examining physicians that the
applicant is capable ol
performing the essential functions
of the position that has been
offered. with or without a
reasonable accommodation. An
applicant under age 18 must have
written permission from a parent
or guardian to have the
pre-employment tests and
physical. All medical infonnation
will be held in a separate.
con?dential medical ftle.

As a condition of continued
employment. and as required by
applicable state and federal law.
employees may be required to
undergo periodic medical
evaminations. andr?or alcohol drug
screenings at times specified by the
Facility. In connection with these
examinations. employees may be
requested to provide the Facility with
access to their medical records.
Medical examinations and diagnostic
tests paid for by the Facility are the
propeny of the Facility and shall be
treated as con?dential. llouever.
records of such esaminations will be
asailable to public agencies or the
doctor. if required by law
or regulation.

 

if the results of the medical
culmination or drug screening
indicate that it ncu employee is not
suited for employment \tith tlte
Facility. then the employee may be
terminated

Con?icts of Interest

It is the policy of the Facility to
prohibit employees from engaging in
any aetryity. practice. or act \shich
con?icts \\ith the interests of the
Facility or its patients. Situations
uhich create an actual con?ict of
loyalty or interest or even the
appearance of such a conflict must be
avoided unless approved by the
CEOIManaging Director. It is not
feasible to specify all possibilities
that may give rise to a conflict ol
interest. It ?in be up to the individual
employee hen in doubt to err on the
side of reporting hisiher problem.
The following examples, however.

illustrate the types of potential
conflicts of interest:

involvement. directly or indirectly.
in outside commercial interests
which could influence the decisions
or actions of an employee and the
performance of hisfher job.

Acceptance by an employee or
member of his/her family of gills.
entertainment or favors which go
beyond common courtes?ies usually
associated with accepted business
practice and which could place the
employee under obligation to a

vendor or other persons seeking to
do business with the Facility.

Maintenance of an interest by an
employee or a relative of an
employee in a business with which
the Facility is about to have
dealings. it is incumbent upon the
employee to disclose such an interest
to his/her immediate supervisor so
that the Facility's business interests
can be assessed by someone who
clearly has no self-interest in the
matter.

Performance of work, even
pan-time, by an employee of the
Facility in any other commercial
enterprise that would be in conflict

with the position held at the
Facility.

Maintenance by an employee or a
member of his/her family of an
ownership interest. directly or
indirectly, in any vendor which
supplies goods or services to the
Facility.

Use of Facility employees.
material. equipment or other
Facility property for personal
purposes.

Using or revealing outside the
Facility any con?dential
information concerning the Facility.
or using for personal gain
con?dential or "insider" infonnation
obtained as a result of employment
with the Facility.

Any employee intentionally violating
this policy is subject to appropriate
corrective action

 

up to and including immediate
employment and. ti
appropriate. the facility may scelt to
recover any improperly gotten gains
tuid'or encourage prosecution for any
possible criminal ochnses.

Outside Employment

The Facility recognizes the right of
its employees to spend their
non-working time away from the job
as they please. It does. however.
require that activities away front the
job must not compromise the
Facility-'s interests or adversely
affect the employee's job
performance and ability to ful?ll all
responsibilities to the Facility.

Outside employment will not be
considered an excuse for poor job
performance. absenteeism.
tardiness. leaving early. refusal to
travel. or refusal to work overtime
or different hours. If outside
employment causes or contributes to
any of these situations. the outside
employment must be discontinued
and. if necessary. corrective action
may be implemented up to and
including immediate employment
termination.

Employment of Relatives

The Facility may employ a relatite
OT co-habitant or an employer
Provided the inditidual possesses
the usual lor
employment.

 

However, those persons will not be
gnen work assignments which
require one to supervise. evaluate. or

direct the work of the other.

In
addition.

those persons are not
permitted to hate access to the

Human Resources records of the
other.

~Pay Practices~

Salary

A program of wage and salary
administration is used by our
Facility to maintain a just and fair
relationship among the wages paid
for the many types of work
performed within the Facility. This
program is administered in
accordance with state and federal
law.

It is the Facility's desire to maintain
wage levels for its employees that are
competitive with those paid for
similar work by other similar
facilities in this area. The wage
program is reviewed periodically. ll
vou have any questions concerning
your pay rate. feel free to contact
your supervisor or the Human
Resources Department.

Performance Appraisals

A performance appraisal will
normally be completed during or at
the end of the ?rst three months 01
employment and. thereafter. on an
annual basis. The job performance 01
?Ch c"?Ployee shall be evaluated on

attainment of previously
?btectives and

 
   
  
  
 

goals. Factors considered in
appraising performance include. but
are not limited to: knowledge of the
job. quantity and quality of work.
promptness in completing
assignments. cooperation. initiatiye.
reliability. attendance. judgment.
acceptance of responsibility. and
meeting Service [Excellence
standards.

Typically. the person who directly
supervises an employee shall be
responsible for eyaluating his/her
perfonnance. You will have an
opportunity to see your evaluation
during the performance review and
you will sign your evaluation,
indicating that your evaluation has
been explained and discussed with
you. During this review you should
feel free to discuss your evaluation
and your job with your supervisor.

If you have not received a
performance review in accordance
with the above time frames. it is
your responsibility to notify your
supervisor and the Human
Resources department. This will
help the Facility to ensure that the
appraisal process is administered in
a timely manner. A performance
appraisal is not a contract or a
commitment to provide a salary
increase. a bonus. or continued
employment. It is a communication
process aimed at facilitating
optimum employee performance.
Your

appraisal is only one of several
factors that the Facility uses in
connection with compensation.
bonuses. promotion and retention
decisions.

Salary Reviews and
Increases

The salary of each employee will be
reviewed on a regular basis and if a
salary increase is granted. it will
normally be effective on the
employee's anniversary date or
another date chosen by the Facility.

Shift Di?eremial

Certain employees, because of the
requirement of their position. must
work varying shifts. For these
employees, the Facility may
provide shi? differentiaK 

Overtime

All non-exempt employees will be
paid overtime in accordance with
state and federal law. The Human
Resources Department interprets the
provisions of these laws and
classi?es all positions accordingly as
exempt or non-exempt. 
employees are eligible for overtime
pay for all hours worked over 40
hours in a work-week or on an 8/80
basis: exempt employees are not
eligible for overtime pay.

Call-Back Pay

From time to time, it is necessary
that employees be

called back to the Facility to perfonn
certain duties after their workday.
Callback pay will be paid when the
employee finishes his?her regular
shift. goes home. and is called back
for additional duties. it may not be
paid when the employee's regular
shift is continued without
interruption. Department heads and
exempt employees may not be
eligible for callback pay.

Pay Day

All employees are paid on alternate
Fridays. The computation of time for
a particular pay period will be up to
and including the preceding
Saturday. Employees are
encouraged to review their
paychecks for errors. if an employee
?nds a mistake, (s)he should report it
to her/his supervisor immediately.
Lost paychecks must be reported
immediately to the department head
or to Human Resources.
Authorization in writing must be
given to the department head or to
the Human Resources office in order
for a paycheck to be released to
another person.

~Bene?ts~

See your Human Resouces
Department for details.



_l

  

 

Leaves of A bsence

It is the policy ol'the Facility to grant
extended laws of absence under
certain circumstances. Request and
approvals for 21 Leave of Absence
(LOA) be in ?Tiling. Full-time
and part-time employees who have
successfully completed one year 01
service may request a leate of
absence. Employees are eligible for
leaves of absence as required by the
Family and Medical Leave Act
(FMLA) if they have completed at
least one year of service: have
worked at least l250 hours in the
previous 12 months: and \tork at a
facility with 50 or more employees or
as provided by state law.

Leaves of absence could fall under
one of the following categories:
Medical, Parental. Family Care.
Personal or Military. Employees not
eligible under the FMLA will not be
assured a position upon conclusion of
their leave. The Facility requires that
an employee contact Human
Resources for details for approval ol
a medical LOA. The third party
administrator will work with your
health care practitioner to review the
circumstances of your LOA.

Employees may pay employee-only
Premiums or full premiums for
healthcare bene?t continuance

depending on the type and length 0'
leave

  

chosen. The maximum period to
continue bene?ts is ttsually up to 6
months. Accrual bene?ts. such as
To and ELB. do not accrue during
unpaid LOAs or paid absences
beyond 30 days.

Special Absences

:l-Irlirmjt'

A military leave of absence will be
granted if an employee enlists. is
inducted, or is recalled to active duty
for a period of up to ?ve years.
Employees who serve in the
uniformed services. including the
voluntary or involuntary performance
of duty in active duty. training for
active duty. initial active duty for
training. inactive duty training.
full-time National Guard duty. and
periods of absence for ?tness for
duty examinations are entitled to
re-employment and all other
requirements applicable to state and
federal law.

Deaths or Funerals

In the event of a death in your
immediate family mother.
father. grandchildren. mother in-law.
l?atlter-in-lao, brother. sister. spouse.
or child). you may be granted a paid
leave of up to three consecutive
day s. In the event of a death in your
extended family ti.e.. brother in-law,
sister-in-latv. aunt. uncle. niece. or
nephew) you may be eligible for one
day of paid absence.

Jury Duty

lf you are called to serve as a juror.
notify your supervisor and submit a
copy of your summons to the
Human Resources Department as
soon as you receive it.

~Facility
Premises 
Work Areas~

Safety and Security

The Facility strives to provide a safe
and healthy work environment for all
employees. Employees are expected
to comply with all safety and health
requirements whether established by
management or by federal. state, or
local law. If you identify an unsafe
condition in the work area or with
the equipment, notify your
supervisor or department head
immediately. Also. if you are
injured while at work. you must
immediately report this injury to
your supervisor. the Loss Control
Coordinator. or Human Resources.

The Facility strives to maintain
security for our property. employees.
patients. and persons visiting its
premises. Security is the
responsibility of all employees.
identi?cation badges are issued to
all

personnel and must be worn at all
times while at Work. Employees
must obtain prior approval to remove
Facility property from the premises.
The Facility reserves the right to
conduct reasonable searches when
necessary to maintain security. The
Facility's search can include. but is
not limited to: patient care areas.
employee lockers- desks. ?les. or
any other area or article in the
Facility's premises. All of?ces.
desks. computers. tiles, lockers and
so forth are the property of the
Facility and are issued for the use at
employees only during their
employment with the Facility.
Employees hold no expectation of
privacy with regard to any
aci ity-provided equipment.
including. but not limited to
computer drives. e-mail. voice mail.
etc.

While the Facility will attempt to
protect employees and their property
on the Facility premises, employees
must exercise reasonable care for
their own protection and that of their
personal property. The Facility will
assume no responsibility for
employee losses resulting from
robbery or theft. including while the
employee is away from the premises
on Facility business.

Vendors and guests must sign in and
identify themselves at the main
reception area. Former and off?hour
employees must also Sign in and are
not permitted to loitcr and



socraltze during business hours

Workplace Violence

The Facility is committed to

providing a work environment

that is

free of violence. Any acts or
threatened acts of violence will not
be tolerated. All Facility employees

must share the responsibili

or

maintaining a safe work environment.
Any employee with knowledge

regarding potentiai
violence must immediately
such information to
supervisor or Human Res
Anyone engaging in such acts

workplace

report
hisiher
ources.
will be

subject to corrective action up to and
including immediate employment
termination, and may also be
personally liable for civil or criminal

offenses.

The Facility?s designated

Safety

Manager is responsible for and
oversees the entire security operation

ofthe Facility. The Safety 
in conjunction with the

anagen
Senior

Management. shall monitor policies

dealing with the security
workplace. Their duties

of 
inc ludc

establishing relationships with the

proper authorities. developing
to mitigate workplace violen
serving as the central loc
dissemination 01
Additionally. the Salety Man
involved in
meetings/committee. where
related to security are presen
discussion and resolution.

a plan
cc and
us for

information.

agcr is
safety
issues
ted for

The Safety Manager?s responsi-
bilities include securing our Facility.
patients. visitors. and personnel. in
addition. the Safety Manager
implements crime pret ention
programs that also include ensuring a
fair and impartial investigative
process. All security incidents are
investigated. and forwarded to Risk
Management. the Safety Manager
and. possibly the Patient Safety
Committee. for follow-up and
eventual disposition.

For purposes of this Employee
Handbook. violent behavior is
de?ned as (this is not an all
inclusive list of violent behaviors):

The actual or implied threat of hartn
to an individual, group of
individuals- or relatives of those
individuals.

. The possession on Facdity
property of weapons of any kind- unless
speci?cally authorized by Facdity, or the
brandishing of any object that could
reasonably be construed as a weapon

- Loud, angry or disruptive
behavior that is clearly not a pan of the
typical work environment.

. Callous or intentional
disregard for the pl'l'ySlcal safety or well
being of others

. Willftil destruction of FaCtlity
or employee property.
- Commission of a 

felony or misdemeanor on 

property
- Any other conduct that a

reasonable person would perceite as
constituting a threat of Violence

Again. the Facility asks that any
employee who is subject to.
witnesses or has knowledge at
actions that could be perceived as
violent acts. or has reason to believe
that such actions may occur. is
required to report it immediately to
his/her manager, the House
Supervisor, Human Resources
Director, or Senior Management
member.

Solicitation and
Distribution

In the interest of maintaining a
proper business environment and
preventing interference with work
and inconvenience to others,
employees may not distribute
literature or printed materials of any
kind, sell merchandise. solicit
?nancial contributions. or solicit for
any other cause during working time
or in-patient care areas at any time.
Employees who are not on working
time may not solicit employees who
are on working time for any cause or
distribute literature of any kind to
them. The following de?nitions
apply to solicitation and/or
distribution at the Facility:

Solicitation refers to
approaching others with a request or plea
for a monetary contribution. urging
paniCIpation in a cause. selling
merchandise, or collecting money or
other things of value

for non-Facrlitt related
ilCll HUGS

. Distribution refers to provtding or
circulating literature. brochures. or other written
or printed materials connected with a solicuation
effort. This includes directly handing materials
to individuals. as well as leaving quantities oi
materials at Facility for individuals to pick up

- Working time is when either the
employee who is solicning or the employee
being solicited is on working time. Working
time does not include scheduled breaks, meal
periods or the times before or after work.

- Patient care area includes all areas in
which patients receive care. such as patient
rooms. treatment rooms. testing areas,
laboratories. diagnostic areas, offices, group.
rooms, pool. creative arts area, patient lounges.
examining rooms as well as all other areas in
which patients are receiving treatment or are
likely to be disturbed or their care disrupted.
such as corridors and patient sitting rooms.

Non-employees are prohibited from
soliciting antL?or distributing
materials on the Facility's premises
at any time.

Smoking

Smoking is prohibited in'ali
interior areas of the building.
Smoking is permitted externally-
only in designated areas.

~Employee
Standards of
Conduct~

Service Excellence

The Facility shall recognize kcy
Service Excellence standards that are
designed to provide the optimum in
service to our customers. These
Service Excellence standards are
available for all employees at the
Facility. Each employee is required
to make a commitment to
demonstrate these critical behayiors
and incorporate them during daily
interactions with customers.

The Facility seeks to employ
professionals who are equally-
committed to demonstrating
behaviors that reflect our Service
Excellence standards. in addition, the
Facility supports ongoing
communication of our Service
Excellence expectations in all areas
of our business day-to-day
patient interactions. new employee
orientation, annual employee

Behavior of Employees

Cenain rules and regulations
regarding employee behenior are
necessary for the ef?cient
operation of the Facility and for the
bene?t and protcction of the rights
and safety of all. Conduct that
interferes with Facility operations.
brings discredit on the Facility. or
is oll?ensite to patients or fellow
employees will not be tolerated.

The Facility has established policies
and procedures that address our
corrective action process. The
decision to impose corrective action,
and the particular level of corrective
action to be imposed, are exclusively
determined by the Facility. Some or
all of the corrective action steps may
be skipped or otherwise modi?ed on
a case-by-case basis. The Facility"s
policy regarding corrective action
shall not alter the at-will nature ot
employment.

The following are examples ol?
certain types of behavior and

2) Fighting or striking another
person while on Facility premises or
during work hours. except in
self-defense against an unprovoked
assault.

3) Non-compliance with any
established Facility policy or work
rttles.

4) Theft or inappropriate removal
from Facility premises property that
belongs to or is in the possession of
a Facility employee, patient or
visitor.

5) Possessing. consuming. or
being under the influence ot
alcohol, illegal, illicit or controlled
substances, or intoxicants while on
duty or on Facility premises.

6) Illegally selling or
distributing unauthorized
substances at the Facility.

7) Falsifying records. including false
or misleading information on job
application, resume, work reports,
of?cial documents, patient records.
etc.

8) Falsifying or destroying any

l0) Possession of \teapons. ?rearms
or any other hazardous or dangerous
devices on Facility property.

ll) Unauthorized reading or
disclosure of patient health
information.

12) Absence of two or more calendar
days without being approved by the
Facility: frequent or excessive
tardiness or absence as de?ned by the
Facility: failure to observe
department call-in procedure: or
failure to notify the supervisor on
each separate day of unexpected
absence. whether or not consecutive.

Any other misconduct which
affects the quality of patient care
service.

14) lnsubordination. including
refusal to do assigned work or refusal
to pcrfomt work in the manner
described by a supervisor without
properjusti?cation.

l5} Sleeping during work
hours.

evaluations and competchy
'ndardsof 

assessments. the I-acilrty action up ?0 and including

Conduct. hmploy ee out the immediate employment termination

program presentations-It tong}; fails please note that this is not intended

. I A -

year- etc.). An) emp to be an all-rncluswe list):

i0 adhere to these Service Excellence

is subject to correctne

mmcdiale

conduct that could lead to corrective l6) Gambling 0n work hours. on

timekeeping record. recording time
the premises. or during work hours.

on another employee's time record.
accessing time report for another
employee. allon ing another
employee to record time on one's
own time card.

l7) lnanention to duties or
unsatisfactory job perfonnance.
standards .

. . . . 
action up to and Including
employment termination.

18) Violation of any Facility
safety and health rules or
standards.

1) Verbal or physical abuselthreats.
intimidating. swearing. or coercing Facility propertv or supplies. or the
behavior directed toward (DI the property of an employee patient. or
presence of) a patient. visitor or visitor -

Facility employee.

9) Willful destruction or damage to

19) Negligence or 

treatment in the

care of patients.

20) Violating Facility standard
socialization with
pattent(s) during or following

regarding
treatment.

Violating the Facilities
smoking practices.

22) Failure to abide by set
standards for lunch or break
periods. andr?or working
unauthorized overtime.

matter investigated. If after
conducting an investigation the
supenisor andfor liR determines
that the employee has successlitlly
resolved the previous issuets). a
written notice shall be placed in the
employee?s HR tile indicating
employee's progress. Nevertheless
all Employ ee Reports- including the
written notice regarding the
employee?s positive progress, will
remain pan of the employee's HR
?le.

Any employee concerned about
unauthorized disclosure of PHI must
report this information to his/her
supervisor or the Facility's privacy
and security of?cer. In addition.
employees concerned about
unauthorized disclosure of may
access the Facility's Problem Solving
Procedure. The Facility shall not
allow retaliation. intimidatiOn.
coercion, or discrimination against
any employee for ?ling a complaint.
including those assisting in an
investigation of such matters.

that each employee will use his or
her best judgment in selecting
appropriate attire. The Facility
requires that employees avoid radical
depanures from conventional dress
and grooming. Employees are
expected to present a professional
image at all times. As a general rule=
if an employee is uncertain if an
article of clothing will be acceptable.
most likely it will not be suitable. In
other words. if you are in doubt.
don't wear it. You may contact your
supervisor or Human Resources
department for the Facility-'5 dress

23) Failure to notify Facility. in a
timely manner. of any sanctions or
criminal convictions received by the
employee during their employment.
The particular sanction or criminal
conviction may also lead to
corrective action or immediate

code guidelines.
Con?dentiality

In addition to disclosures of PHI.
employees have an obligation to
maintain business-related and
information, which

All patient health information (Pl-ll)
is to be maintained con?dentially

and the release of such sensitive Employees are expected to keep

themselves neat. clean and well

employment termination.

24) Any other serious event that
Facility deems as a major infraction

of employee conduct or work rules.

in addition to the above examples of
serious workplace infractions. the
Facility may utilize the corrective
action process for other employee
issues. Employees are encouraged
to refer to the Facility's policy.
which may be obtained from the
Human Resources Department.

When an employee believes that a
pruious corrective action issuetsl
has been corrected. the) may
make a written request to their
or HR to hate the

patient information must comply
with all state and federal laws as
well as our Faciliry's policyts).
Proper procedures for the disclosure
of PHI can be very complex and any
employee who is uncenain of how to
handle such matters must contact
hisi'hcr supervisor or the Facility-?5
privacy and security of?cer prior to
disclosure of any Pill. Employees
have a duty to respect patients'
privacy and con?dentiality by acting
responsibly in using and/or
disclosing Any employee who
fails to comply with the Fadlity?s
policy regarding disclosure of
confidential or private information.
may be subject to corrective action
up to and including immediate
employment termination.

employee
includes, but is not limited to all
written. verbal and electronic
infomiation. Employees must not
disclose any con?dential or
proprietary information except as
required by law or as authorized by
your supervisor. if you are uncertain
of whether or not information is
considered con?dential or
proprietary. do not be afraid to ask
your supervisor a question prior to

disclosing such con?dential
information.
Personal Appearance

The Facility requires appropriate
dress and grooming at all times
while working. An employee's
dress and grooming should be
apprOpriate to the work situation,
Wearecoufrdent

groomed at all times. The appearance
of an employee is also an important
part of public relations. Employees
are expected to monitor their
personal appearance to ensure that it
does not adversely impact upon
patient care. To patients and visitors
alike. our employees are the Facility.

Employees are expected to use good
taste in selecting the clothes they
wear on the job avoiding extreme
styles. Employees are not permitted
to wear clothing which contains
information iincluding solicitation.
slang slogans. potentially olTensive
comments. etc.) tthich may be
disruptive to patient care or the ?ark
environment. Use cosmetics
moderately and avoid 
fragrances which

 
 

may be offensive to other people.
Hair should be clean. combed- and
neatly trimmed or arranoed.
Sideburns. mustaches and beards
should be nearly trimmed.
Employees are expected to be
consenative in the selection and
amount ol'jewelry they wear.

Employees failing to adhere to this
policy may be subject to corrective
action up to and including
immediate employment termination.

Employee Sanction(s)

All staff are required to report
sanctions. convictions, suspensions.
censures or revocation (sanction)
action taken against them by any
federal. state. local, or other
professional The sanction
may include but are not limited to
infractions against professional
licensure. certi?cation. registration,
criminal history cOnvictions, history
of child abuse, managed care
organizations, Medicare. Medicaid,
or any other Facility payor or
provider. ctc. Employees shall
report sanction and/or felony
convictions that have occurred
during the past 7 years. A conviction
record may not necessarily be a bar
to employment other factors shall
be taken into consideration by the
Facility. In the event a current
employee of the Facility has action
taken against himfher during 
employment.

  

(s)he is required to report the
incident(s) within 72 hours of its
occurrence to the Director oi
I Iurnan Resources.

Property Damage

If an employee willfully damages
Facility property or the property
of a co-?orker, (s)he may be
subject to corrective action. up to
and including immediate
employment termination.

Personal Finances

In the event that garnishment or
similar proceedings are instituted
against an employee. the Facility will
deduct the required amount from the
employee's paycheck. The amount
deducted from an employee's
disposable earnings will not exceed
that permitted by law. No employee
will be subject to termination solely
on the basis that his/her earnings
have been subjected to a single wage
garnishment. Multiple garnishments.
excluding garnishrnents for child
support. may lead to corrective
action up to and including
employment termination.

Personal Telephone Calls
and Mail

The Facility"s telephone and mail
svstems are available during
working hours for effective
communication with employees.
patients. visitors- and other business
assocrates.

The Facilily's telephone and other
systems should not be used for
personal telephone calls or personal
mail except in cases of emergency.
Instruct relatives and friends not to
contact you by telephone at the
Facility while on duty unless it is an
emergency. Incoming personal calls
will be transferred to your
department only in cases of
emergency.

Electronic Media

Access to electronic media 
telephone system, pagers, e-mail,
Internet. local area network (LAN).
frame relay network. wide area
network (WAN), etc.) has been
provided to staff members for the
benefit of the organization and the
customers it serves. Every staff
member has a responsibility to
maintain and enhance the Facility's
public image, and to use electronic
media in a productive manner.
These electronic media tools are
Facility assets just like the desks and
computers and are to be used at all
times only for legitimate business
purpo5es.

Electronic media. speci?cally
e-mail. fax. and voice mail otlers no
guarantee of employee privacy.
The Facility has the right to inspect
the content of any information.
including e?mail messages sent or
received. Electronic media otl?ers no
guarantee of employee
confidentiality. Employees should
exercise signi?cant caution when

managing sensitive infonnalion. It
is a violation of this policy to
communicate identifiable patient
information using Internet,
including external e-mail messages.

Violations of any guidelines listed in
the Facility?s Electronic Media
policy may result in corrective action
up to and including immediate
employment termination. Employees
are asked to sign and acknowledge
that they have reviewed and agree to
comply with the Electronic Media
policy.

Alcohol and Drugs

The Facility recognizes that illegal
drug use and alcohol abuse can
adversely affect the performance of
employees in the workplace.
Therefore, the Facility is committed
to providing a drug-free workplace.
To achieve a healthy. safe, and
productive work environment, the
Facility has adopted the position that
prospective and current employees
must be free from the effects of or
evidence of illegal drug use. and/or
abusive alcohol consumption or
other intoxicants. The Facility's drug
and alcohol program includes testing

in the following situations (this is not

an all-inclusive list): 

employment, for reasonable

suspicion. and following a serious

on-the?job accident. In the event that

a prospectit or

  

current employee tests posithe. the
employee may request
rc-tcst done

expense

to hate 
at his or her mm
This second test must be
comparable or bener than the initial
alcohol und-?or drug test and must be
approy ed in ad\ ance by the Facility.

it is the Facility"s policy that the
unlawful manufacture. distribution.
sale. possession- use or presence in
the body it?- an)? amount detectable by
3 drug test of a controlled
substancesillegal drug by any
employee is prohibited. The policy
funher prohibits the bringing in.
consuming of. or being under the
in?uence of alcohol by any employee
while on duty or conducting Facility
business off-premises. unleSs in
conjunction nith authorized Facility-
events. No prescription use is
allowed on the Facility"s premises by
any employee other than by the
employee for whom the drug is
prescribed by a licensed medical
pracutioner. and is to be used only by
the employee in the manner and
quantity prescribed. Additionally. the
employee is to notify his/her
supervisor andlor Human Resources
if lie-"she is taking a prescribed
medication \\thh may influence
his-'her ability to perform liis?lter job
functions and/or compromise his-her
safctv or that of anmher individual.
Violation of this policy may in
correctite action up to and including
immediate employ ment.

The Facility has an Fmployee
Assistance Program that provides
con?dential counseling and referral
services to eligible employees
Additionally. bene?t eligible
employees may haye other bene?ts
for treatment programs that are
explained in the Bene?t Plan
Description. It is the employee's
responsibility to seek assistance
through available programs prior to
any violation of Facility policy.
Employees ?ho seek assistance or
enter a rehabilitation program after
violating the Facility-'5 policy
regarding illegal drug use may still be
subject to corrective action. including
immediate employment termination.

For the protection of Facility
employees and patients. and to help
prevent the possession. sale, and use
of illegai drugs on the Facility's
premises. itt keeping with the spirit
and intent of the Facility-"s Substance
Abuse policy. the Facility reserves
the right to conduct reasonable
searches when it suspects that there
has been a violation ofthe Substance
Abuse policy. The Facility"s search
can include. but is not limited to:
patient care areas. employee lockers.
desks. ?les. or any other area or
article on the Faeility"s premises.

Corporate
Compliance
Program

The Corporate Compliance
Program establishes standards
regarding the acility?s compliance
with applicable laos gmerning
relationships among hospitals.
other institutional health prmiders.
physicians. employees. etc.

The Facility has designated a local
omplianee Of?cer who has been
appointed by the CEOfManaging
Director. The Compliance
Committee (consisting of Corporate
Of?cers) shall ultimately be
responsible for supervising the work
of the Compliance Ollicers and
maintaining the standards of conduct
subject to the ultimate authority 0!
the Ul-lS Board of Directors. Any
individual may contact their local
omplianec Of?cer or the Corporate
Compliance post of?ce box andlor
toll free 800 number which provides
staff a con?dential way to raise
concerns. The Corporate Compliance
contact information is:

Universal llealth Services- Inc.
PO. Box 61823 King of Prussia. PA
19406-8823 1-800-352-3449

For more details regarding the
Corporate Compliance program.
please refer to the Corporate
Compliance brochure. Copies are
available at your local Human
Resources of?ce or by" contacting the
post of?ce hos. or 800 number listed
abo\e.

.0

Please note that the Facility also has
an internal Problem Solung

'Procedure for employee complaints

ohtch may not mated to fraud.
abuse. etc.

Human Resources Records

A Human Resources ?le is
maintained for each employee of the
Facility. In order to ensure you
receive all benefits to which you may
be entitled under all conditions ol
employment. it is important that your
records be kept current at all times. If
there is a change in your marital
status, number of dependents.
address, telephone number. or legal
name, please notify the Human
Resources Department in writing.
This information will be incorporated
into your Human Resources ?le.

Sta? Requests for Exclusions
from an Aspect of Patient Care

Facility recognizes that an employee
may request an accommodation to
not participate in certain aspects of
patient care procedures or treatments
for cultural. religious. or ethical
reasons. Honey-er. the Faeility's
primary responsibility is to the
patient and. therefore. the Facility
\till ensure that a patient?s care uill
not be negatixely affected. The
shall reue? any stall

member's request for exclusion from

an aspect of patient care and the
employee shall be noti?ed of 
Facility's decision as soon 35
possible.

 

 

.

. 



 

HILL CREST BELLA VIORAL HE4L TH SER VICES

 

 

 

 

 

 

 

 

 

 

 

 

Emma? 1.. 

ORGANIZATION: HUMAN RESOURCES POLICY: HRJ 1.034A
SUBJECT: Social Media Policy PAGE: I of 5
EFFECTIVE DATE: SUPERSEDES: APPROVED BY:
10/2011 Revised Date: Section No.
Revision No.
Chief Executive Of?cer
1. Scope:

Ail Hill Crest Behavioral Health Services employees

Purp' ose:

II.

in.

The Facility recognizes the importance of the Internet and social media sites in its
business and its employees? personal lives. The Facility supports the rights ofits
employees to interact knowiedgeably and socially on the web through blogging and
interaction in social media. However, if activities on social media sites impact Facility,
its employees, services, customers, relationships or reputation, Facility has a legitimate

business interest in monitoring and responding to those activities.

The Facility is concerned with ensuring that use of social media does not compromise
patient con?dentiality as well as the Facility's brand identity, integrity, and reputation
while minimizing actual or potential legal risks.

This policy addresses appropriate use of social media to convey Facility information,
whether such media is used in or outside the workplace, and general use of social
media by all executive of?cers, board members, and employees while at work.

This policy is also cross-referenced with Electronic Media Communication System.

De?nitions

 

?Social Media? is de?ned broadly to include?online platforms that facilitate activities
such as professional or social networking, posting commentary or opinions, and sharing
audio, video, or other content, including but not limited to: Twitter,

Facebook, Fouquuare, MySpace, Wiki, Digg, Del.icio.us, Blogs, Blogspot, YouTube,
Jaiku, Plurk, Google and Yahoo Groups, Bebo, Eons, Linkedln, Flickr, iTunes, Podcast
Alley, Podcast.com, Podcast Directory, Podseek, StumpleUpon, Miss, Reddit, Yelp,
ePinions, internet forums, online pro?les, blogs, message boards and chat rooms, and

others like them.
FY

pictures,

 

Hill Crest Ref: 1 I
av oral Health Services HR 

  
 
 

RESOURCES

. Page 3of 5
subject: Socral Media Policy

. Employees may never post any information that is con?dential or speci?c to patients, coworkers,

:13 where the employee works, UHS, or other companies or peeple doing business with the
ac: .

.The Facility discourages employees from linking to Facility's external or internal website or
social media web pages from personal social media web pages. Employees also should consider
Facility's code of professional conduct and social media and related electronic communication
policies before discussing work-related activities on their personal social media web pages.

The Facility strives to maintain a professional work environment and considers harassment in all
forms to be a serious offense in violation of Facility's Productive Work Environment pelicy.
Employees who use social media to harass, threaten, defame, libel, embarrass, disrespect, or offend
co-workers or Facility?s customers, business partners, vendors and suppliers, af?liates and
subsidiaries, or competitors, will be subject to corrective action up to and including immediate
employment termination.

Employees cannot use social media to disparage or embarrass the Facility or its management,
practices, products, or services, or otherwise cause harm to the Facility.

N.

I Employees who engage in illegal activity via social media over Facility's electronic
communications systems, whether at work or elsewhere through telecommuting may be subject to
corrective action up to and including immediate employment termination. Additionally, such
employees may be subject to appropriate legal action by Facility or governmental entities.

. Employees understand that the Facility reserves the right to require the employee to remove
content on any Social Media that violates this or any other policy of Facility.

Employees are expected to speak respectfully about the Company and its products, employees,
customers, partners, and competitors.

Employee Responsibilities When Using Social Media for Work Related Reasons:

An Employee of the Facility is prohibited from creating a Facility-sponsored Social Media site
without the prior written authorization from the President of Behavioral Health, Vice President of
Division Business Development, or designee.

. Facility employees should not attempt to create public interest in Facility, its parent or other
af?liated companies, or the services they provide.

Employees are not to encourage testimonials from the public or send messages to others that
night be considered to be ?Spam? or unwanted solicitations.

i, COPY

Harem: Behavioral Heal?, We
A HRII.034A

 

   
   

RESOURCES Page 4 of 5

5ubject: Social Media Policy

. Media contacts about the Facility or UHS and its current or potential products, employees,
partners, customers, and competitors must be referred to the Facility CEO/Managing Director,

General Counsel, or designee. If your online activity generates contacts from third parties, you are
n_o_t authorized to speak on the Facility?s or behalf.

- The Facility does not permit employees to post online information regarding the Facility, current
and potential products, employees, partners, customers, and competitors, etc.

Facility-sponsored Social Media Sites:

The Facility is prohibited from creating a Facility-Sponsored Social Media site without the prior
written authorization from the President of Behavioral Health, Vice President of Division Business
Development, or designee.

Con?dentiality and Proprietary Information:

I Regardless of whether an Employee uses social media for personal or business related reasons,

1- employees may never share information that is con?dential and proprietary about the Facility without
express written consent in advance from the Facility CEO/Managing Director or designee.
Con?dential and proprietary information includes information about the Facility employees

. (including their status and whereabouts), patients, trademarks, revenues and ?nances, company
strategy. and any other information that might be considered a trade secret or that has not been
publicly released by the Facility or UHS.

- The Facility protects its copyrights, trademarks, patents, trade secrets, customer lists, and other
sensitive, proprietary, and con?dential material. Under no circumstances may the Facility?s or 
logo and trademarks be used without the express permission in writing, in advance, from the Facility
CEO/Managing Director, President of UHS, or designee.

J. These are given as examples only and do not cover the range, of what the Facility considers
con?dential and proprietary. If you have any question about whether information can be released
publicly, or doubts of any kind, Speak with your manager or Human Resources before releasing
information that could potentially harm the Facility, or its current and potential products, employees,
partners, and customers. This obligation is not simply based on this policy. Disclosing confidential
information may be a violation of federal, state or local law in addition to being the basis for

termination of employment.

Security and Monitoring of Social Media Websites: 3

As the Facility owns and Operates its electronic communication systems, the Facility reserves the

right to monitor employee use of social media websites (including password-protected websites) over its

. systems, whether accessed at work or elsewhere through telecommuting, to ensure that electronic (W

communications systems are being used in compliance with federal, state, and local laws, this policy, and
other Facility rules. Facility communications systems and devices should be used for business?related
purposes. Employees should not expect any privacy when using Facility communication systems

 

 

Hill Crest Behavioral Health Services HR 11,034 A

7-

  
 
   
 

RESOURCES
we?; Social Media Policy

Page 5 of 5
51!

and devices for social media purposes- For more information about security and monitoring of
electronic communications systems, see Facility's electronic communications policy.

Training and Acknowledgement of Facility's Social Media Policy:

. When hired, employees review and receive Facility's Social Media Policy as part of their
orientation with the Facility.

At orientation and at any subsequent training seminars, employees should sign an
acknowledgement form that they have reviewed and received training on and will comply with
Facility's Social Media policy.

Violations of Facility's Social Media Policy:

Although it is not the desire of Facility to infringe on its employees? off-duty conduct, Facility
reserves the .right to take action for off-duty behavior if such behavior directly impacts the workplace
or the legitimate interests ofthe Facility or UHS.

lf not otherwise provided in this policy, employees who violate Facility's Social Media Policy are
subject to corrective action up to and including immediate employment termination. Employee
violations of Facility's Social Media policy also can constitute violations of other relevant Facility

., policies. Employees who use social media for defamatory or other illegal purposes may be subject to

legal action by Facility or governmental entities. .

Facility requests and strongly urges employees to report violations of Facility's Social Media
policy, including security breaches, misappropriation or theft of proprietary business information,
and trademark infringement. Employees can report actual or perceived violations to supervisors,
other managers, or to the human resources department. They also can report violations by using
Facility?s corporate compliance hotline, which is listed on Facility's internal homepage.

The company email system must maintain the same con?dentiality as other media. Staff should
limit the email distribution to those on a need to know. Emails concerning issues between two staff
should not be forwarded or copied to other staff. Do not forward emails to other staff without the

consent of the person from whom it was received.

Employee Acknowledgement

By signing below, I acknowledge that have read the Social Media Policy and I agree to abide by it.

 

 

Employee

Date

COPY

 

my 
rest Behavioral Health Services HR 

EXHIBIT 

SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT

.Fair Credit Reporting Act (FCRA) is. designed to promote accuracy, fairness, and privacy of
?maaon 1n the ?les of every consumer reporting agency" (CRA). Most CRAs are credit bureaus that
and sell infonnatlon about you such as if you pay your bills on time or have ?led bankruptcy to
.xcde-tors, employers, landlords, and other businesses. You can find the complete text of the FCRA 15
U.S.C- 168.1-16dlu, at the Federal Trade Commission's web site The 
gives you specr?c as outlined below. You may have additional rights under state law. You may
contact a state or local consumer protection agency or a state attorney general to learn those tights.

0 You must be told if information in your ?le has been used against you. Anyone who
uses information from a CRA to take action against you - such as denying an application
for credit, insurance, or employment - must tell you, and give you the name, address, and
phone number of the CRA that provided the consumer report.

You can find out what is in your ?le. At your request, a CRA must give you the
information in your ?le, and a list of everyone who has requested it recently. There is no
charge for the report if a person has taken action against you because of information
supplied by the CRA, if you request the report within sixty (60) days of receiving notice of
action. You also are entitled to one free report every twelve months upon request if you
certify that (1) you are unemployed and plan to seek employment within sixty (60) days, (2)
you are on welfare, or (3) your report is inaccurate due to fraud. Otherwise, a CRA may

charge you up to eight dollars.

a?on with the CRA. If you tell a CRA that your ?le
contains inaccurate information, the CRA must investigate the items (usually within thirty
(30) days) by presenting to its information source all relevant evidence you submit, unless
your dispute is frivolous. The source must review your evrdence and report its ?ndmg to
the CRA. (The source also must advise national CRAs - to It has provrded the data
.. of any error.) The CRA must give you a written report of the investigation, and a copy
of your report, if the investigation results in any change. If the mvestigation does
not resolve the dispute, you may add a brief statement to your ?le. The CRA must
normally include a summary of your statement in future reports. If an item is deleted or a
dispute statement is ?led, you may 38k that anyone who has recently received your report
be noti?ed of the change.
9 Inaccurate information must be corrected or deleted. A CRA must remove or correct

inaccurate or unveri?ed information from its .?les, usually within thirty (30) days a?er you

dispute it. However, the CRA is not required to remove accurate data from you ?le

unless it is outdated (as described below) or cannot be veri?ed. If your dispute results in
any change to your report, the CRA cannot remsert mto your ?le a disputed item unless the
information source veri?es its accuracy and completeness. In addition, the CRA must give 
you a written notice telling you it has reinstated the item. The notice must include the
name, address and phone number of the information source,

. ?va 1

You can dispute inaccurate inform

. can dispute inaccurate items with the source of the

gush as a creditor who reports to a CRA that You dis Ormation. If you tell anyone

pute an item, they may not then
cc of your dispute. In addition,

once you ve noti?ed the source of the error in writing, it may not continue to report th


information if it is, in fact, an error.

Outdated information may not be re

- . . ported. In most cases, a 
negative information that is more than se RA may report

ven years old; ten years for bankruptcies.

0 Access to your ?le is limited. A CRA may provide information about you only to people

with a need recognized by the FCRA -- usually to consider an application with a creditor,
msurer, employer, landlord, or other business.

6 Your consent is required for reports that are provided to employers, or reports that
contain medical information. A CRA may not give out. information about you to your
employer, or prospective employer, without your written consent. A CRA may not report
medical information about you to creditors, insurers, or employers without your
permission.

6 You may choose to exclude your name from CRA lists for unsolicited credit and
insurance offers. Creditors and insurers may use ?le information as the basis for sendmg
you unsolicited offers of credit or insurance. Such offers must include a toll-free phone
number for you to call if you want your name and address removed from future lists. If
you call, you must be kept off the lists for two years. If you request, complete, and return
the CRA form provided for this purpose, you must be taken off the lists mde?mtely.

You may seek damages from violatbrs. If a CRA, a user or (in some cases) a provider of
CRA data, violates the FCRA, you may sue them in state or federal court.

Federal Register/Vol. 62, No. 126/
Tuesday, July 1, l997/Rules and Regulations

COPY

thibit 



EXHIBIT 
INTENT TO OBTAIN AN INVESTIGATTVE CONSUMER REPORT

Section 606 'of the federal Fair Credit Reporting Act (FCRA) requires that we
info?n you that, the course of our backgr

. . ound investigation related to your application for
employment or promotion, this Company mtends to obtain an investigative consumer report about
you.

. . As part of this investigation, information may be obtained through personal
intervrews your neighbors, friends, associates, or others with whom you are acquainted
regarding your character, general reputation, personal characteristics, and mode of living.

You have the right to request additional disclosures of the nature and scope of the
investigation. Upon written request made by you within a reasonable time after this disclosure,
we will deliver a written statement providing you with a complete disclosure of the nature and
scope of the requested information.

In addition, as required by Section 609 of the FCRA, we have inchided a smnmary
of consumer rights.

COPY 1

Exhibit 



. I I 
Follows mStrucnons oiunn -

. 3A Compliance Requirements

   

?wmml?

employer (except "church groups")
who maintains agroup health insurance plan.
and who employs 20 or more lull- and/or
pastime employees during 50% of the
business days in the preceding calendar year.

Notification of Rights

1.The employer or the plan administrator
must notriy every employee and every
covered spouse at all of their rights under
COBRA when they ?rst become covered
under the group health plan. Separate
noticesmust be sent it separate residences
are maintained. This applies to all current
andiuture employeesandcovered spouses.

2. Each time a Qualifying Event occurs, the
employer must notify, within 14 days, each
Quali?ed Bene?ciary of his/irercontinuation
rights, bene?ts and premium rates for the
plan(s) in which they're eligible.

For either kind of notification, good faith
compliance has been de?ned as First-Class
Mail, addressed to both the employee and

use and sent to the last known home
address. it covered dependents .live at a
separate address. separate notifications must
be sent.

Election Rights

Dual Event muses loss of
We.? living rmustailow continued
under the group health plan for up
to 18 months in the case?oi termrnabon of
ment or reduction in hours, or up to
36 months for a dependent Qualifying Event

A second Qualifying Event for a dependent
occurring during the 18-month coverage

of the ?rst Qualiiying Event expands
?ngsiginal period to 36 months

What is a Qualifying Event?
at the iotlowing events which would
gas: a loss of coverage by a Quali?ed
Bene?ciary under the plan:
for gross
a

1.Termlnation (other the
uct oithee ees

tor any reason (layoff. resignation,
retirement. etc);
2. Reduction of hours worked by employee;
3. Death of the employee;
4. Divorce or legal separation:
5. Dependent child ceasing to 
requirements;

 

eet eligibility

 

6.0ependent coverage is lost becau
. se the
active employee (or COBRA continuant)
becomes entitled to Medicare.

7. Retiree or retiree's spouse or child loses
matings onte year before or after
mencemen ofproceedings under

Title 1 1 (bankruptcy). United States Code.

Who is a Quali?ed Bene?ciary?

Any employee, spouse or dependent child
who was covered on the day before the
Qualriyrng Event and who would otherwise
lose coverage under the plan because of the
Qualriyrng Event. This de?nition also includes
a child born to or placed tor adoption with a
covered employee during the period of COBRA
coverage.

Election Tlmeframe

Quali?ed Bene?ciaries are allowed to buy
continuation coverage retroactive to the bene?t
termination date. They are entitled to make
this election within 60 days ofthe date of the
noti?cation of their rights or the date that
benefits would laminate. whichever is later.
If they decline. they may change their minds
and elect - it they are still within the 60-day

election period.
Choices of Coverage

Each Qualified Bene?ciary must be allowed
to make an independent election. For example.
it the plan contains medical and dental
coverage, the employee maydecline coverage,
the spouse may elect medical only. and the
child may elect medical and dental.

Dependents

You must allow "branching" of coverage. If a
continuant elects iarnily coverage, or her
dependentls) are allowed to continue benefits
if/when they would otherwise cease to be
eligible undermecontractasdependenis during
the 18- or 36-month continuation penod.
Quali?ed Beneficiaries otherthan the covered
employee may continue coverage for up to
36 months from the date of the covered
employee's Medicare entitlement. it the
covered employee becomes entitled to
Medicare and. within 18 months thereafter,
has a Qualifying Event.

You must allow continuantsto add dependents
tithe dependents meetthe special enrollment
rules under the Health Insurance Portability
and Accountability Act (HIPAA) or if the
corrtinuants acquire any new dependents after

 

their Qualifying Event ?if such a ti ht is
to similarly-situated active 

Ongoing Administration

You must allow continuanis to change
bene?ts annually lithe option is available to
active employees (to, double benefits plans/
HMO dual option plans). Open Enrollment
penods mustbe allowed for continuants on
the same basrs as for active employees.

Continuants must be offered a conversion
attire end of the 18- or 36-month
period. rfone is available to active employees.

You must allow existing COBRA continuants
to continue coverage as long as they meet
the eligibility requirements, even lfyour group
size falls below 20 full-time and/or part-time
employees.

Payments

The employer or plan administiator must
allow continuants to pay their ?rst premium
within 45 days oithe date they elect coverage.
itcoveragels elected within the 60~day election
period. You may not require any premium
. 
You must allow a grace period of not less
than 30 daysforthe payrnentofall subsequent
premiums.

Disability Extension

A Quali?ed Bene?ciary?s continuation period
must be extended to 29 months from 18
months if the Social Security Administration
determines that the Quali?ed Bene?ciary was
totally disabled under Title ll or XVI of the
Social SecurityActonthe dayofthe Qualifying
Event, or within the ?rst 60 days of COBRA
coverage, and the Quali?ed Bene?ciary sends

before the end of the initial 18-month period
and within 60 days of the date of the notice.

Other Coverages

You must allow continuant s) to continue
COBRA coverage despite eir becoming
covered under a new group health plan if the
new plan contains an exclusion or limitation
with respect to any pre-existing condition of
that continuant.

See Your Attorney

The complexity of the law - and the tact that
judicial decisions affecting compliance can
happen at any time - precludes a complete
descri den of legal requirements. Please
consu your attorney.

CQPY

 

[respecting

?7 Your Privacy

THIS NOTICE DESCRIBES HOW MEDICAL
INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN
GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.

PROTECTED HEALTH
INFORMATION

Information about your health is private.
And it should remain private. That is why
this healthcare institution is required

by federal and state law to protect and
maintain the privacy of your health
information. We call it ?Protected Health
Information" (PHI).

The basis for federal privacy protection
is the Health Insurance Portability and
Accountability Act (HIPAA) and its
regulations, known as the "Privacy Rule"
and ?Security Rule" and other federal and

state privacy laws.

WHO WILL FOLLOW THIS NOTICE
This Notice describes the information
privacy practices followed by our hospital
employees, volunteers, and related

personnel.

The practices described in this Notice may
also be followed by health care providers,
who are members of our Medical Staff, if
they have opted to abide by its contents.
Many of our doctors follow the practices
contained within this Notice.

Each participant who joins in this joint
Notice of Privacy Practices serves as

their own agent for all aspects of HIPAA 
Compliance. other than the delivery of this
Joint Notice. For physician specific issues or
questions, lease feel free to contact your
physician irectly.

Hospital employees. volunteers, and related
personnel, including those members of the
Medical Staff who have opted to abide by
its contents. must follow this Notice with
respect to:

0 How We Use Your PHI

0 Disclosing Your PHI to Others

0 Your Privacy Rights

0 Our Privacy Duties
0 Hospital Contacts for More Information or,
if necessary, a Complaint

USING OR DISCLOSING
YOUR PHI:

FOR TREATMENT

During the course of your treatment, we

use and disclose your PHI. For example.
if we test your blood in our laboratory, 3
tkhnic-an mil share the report With yOur
doctor or, we use your PHI to follow
orders for an away, surgical
types of treatment



 

FOR PAYMENT

After providing treatment, we will ask your
insurer to pay us. Some of your PHI may be
entered into our computers in order to send
a claim to your insurer. This may include

a description of your health problem,

the treatment we provided and your
membership number in your employer?s
health plan.

Or, your insurer may want to review your
medical record to determine whether your
care was necessary. Also, we may disclose
to a collection agency some of your PHI for
collecting a bill that you have not paid.

FOR HEALTHCARE OPERATIONS

Your medical record and PHI could be used
in periodic assessments by physicians about
the hospital's quality of care. Or we might
use the PHI from real patients in education
sessions with medical students training in
our hospital. Other uses of your PHI may
include business planning for our hospital or
the resolution of a complaint.

SPECIAL USES
Your relationship to us as a patient might
require using or disclosing your PHI in

order to

0 Remind you of an appointment for
treatment

0 Tell you about treatment alternatives
and options

0 Tell you about our other health benefits
and services

YOUR AUTHORIZATION MAY

BE REQUIRED

In many cases, we may use or disclose your
PHI, as summarized above, for treatment,
payment or healthcare operations or as
required or permitted by law. In other
cases, we must ask for your written
authorization with specific instructions

and limits on our use or disclosure of your
PHI. This includes, for example, uses or
disclosures of notes, uses or
disclosures for marketing purposes, or for
any disclosure which is a sale of your PHI.
You may revoke your authorization if you
change your mind later.

CERTAIN USES AND DISCLOSURES OF
YOUR PHI REQUIRED OR PERMITTED
BY LAW

As a hospital or healthcare facility, we must
abide by many laws and regulations that
either require us or permit us to use or
disclose your PHI.

REQUIRED OR PERMITTED USES AND

DISCLOSURES

0 Your information may be included in a
patient directory that is available only to
those individuals whom you have
identified as contacts during your hospital
stay. You will receive a unique patient
code that can be provided to these
contacts

0 If you do not verbally object, we may
share some of your PHI with a family
member or friend involved in your care,

CCPY

   
 
 
 
  
  
  
    
  
   

0 We may use your PHI in an emergency
when you are not able to express yourself.

0 We may use or disclose your PHI for
research if we receive certain assurances

which protect your privacy.

WE MAY ALSO USE OR DISCLOSE

YOUR PHI

0 When required by law, for example when
ordered by a court.

0 For public health activities including
reporting a communicable disease or
adverse drug reaction to the Food and
Drug Administration.

0 To report neglect, abuse or domestic
violence.

0 To government regulators or agents to
determine compliance with applicable
rules and regulations.

0 In judicial or administrative proceedings
as in response to a valid subpoena.

0 To a coroner for purposes of identifying a
deceased person or determining cause of
death, or to a funeral director for making
funeral arrangements.

0 For purposes of research when a research
oversight committee, called an
institutional review board, has determined
that there is a minimal risk to the privacy

of your PHI.

0 For creating special types of health
information that eliminate all legally
required identifying information or
information that would directly identify
the subject of the information.

0 In accordance with the legal requirements
of a Workers' Compensation program.

0 When properly requested by law
enforcement officials, for instance in
reporting gun shot wounds, reporting a
suspicious death or for other legal
requirements.

0 If we reasonably believe that use or
disclosure will avert a health hazard or to
respond to a threat to public safety
including an imminent crime against
another person.

0 For national security purposes including
to the Secret Service or if you are Armed
Forces personnel and it is deemed
necessary by appropriate military
command authorities.

0 In connection certain types of organ
donor programs.

YOUR PRIVACY RIGHTS AND

HOW TO EXERCISE THEM
Under the federally required privacy
program, patients have specific rights.

YOUR RIGHT TO REQUEST LIMITED USE
OR DISCLOSURE

You have the right to request that we do not
use or disclose your PHI in a particular way.
We must abide by your request to restrict
disclosures to your health plan (insurer) if

1!


.: ?lim?hopurPOEOf
f3" or health care
5,:st .3 not required by law; and


.1 pr? pawns solely to a healthcare
0, ?Wm that you. or someone else
j" in: thefulhealth plan (insurerother situations. we are not required
to abide by your request. If we do agree

to your request. we must abide by the
agreement.

YOUR RIGHT TO CONFIDENTIAL
COMMUNICATION

have the right to receive con?dential
communications of PHI from the hospital

at a location that you provide. Your request
must be in writing, provide us with the
other address and explain if the request will
interfere with your method of payment.

YOUR RIGHT TO REVOKE YOUR


You may revoke, in writing. the authorization
you granted us for use or disclosure of your
PHI. However, if we have relied on your
consent or au?'iorization. we may use or
disclose your PHI up to the time you revoke
your consent.

YOUR RIGHT TO INSPECT AND COPY
You have the right to inspect and copy your
PHI (or to an electronic copy if the PHI is in
an electronic medical record), if requested
in writing. We may refuse to give you access
to your PHI if we think it may cause you 
harm, but we must explain why and provrde
you with someone to contact for a review of
our refusal.

YOUR RIGHT TO AMEND YOUR PHI

If you disagree with your PHI within our
records, you have the right to request,

in writing. that we amend your PHI when
it is a record that we created or have
maintained for us. We may refuse to make
the amendment and you have a right to
disagree in writing. If we still disagree. we
may prepare a counter-statement. Your
statement and our counter-statement must
be made part of our record about you.

YOUR RIGHT TO KNOW WHO ELSE
SEES YOUR PHI 
You have the right to request an accounting
of certain disclosures we have made of your
PHI over the past six years. but not before

14. 2003. We are not required to
account for all disclosures, including those

involving treatment. payment and health
care operations as described above. There
is no charge for an annual accounting,
but there maybe charges for additional 
acoountings We will inform you if there is a
charge and you have the right to withdraw
your request. or pay to proceed.

A, .

YOUR RIGHT TO BE NOTIFIE

OF A BREACH 
You have the right to be
breach of unsecured PHI.

YOUR RIGHT TO OBTAIN A PAPER
OF THIS NOTICE COPY

You have the right to obtain a paper copy of
this notice upon request. even if you have
agreed to receive the Notice electronically.

WHAT IF I HAVE A 

If you believe that your privacy has been
vrolated, you may ?le a complaint with

us or with the Secretary of Health and
Human Services in Washington, DC. We
will not retaliate or penalize you for ?ling a
complaint with us or the Secretary.

0 To file a complaint with us, please contact
our Risk Management Department or call
the UHS Compliance Hotline at
1-800-852-3449. Your complaint should
provide speci?c details to help us in
investigating a potential problem.

notified following a

0 To ?le a complaint with the Secretary of
Health and Human Services, write to:
200 Independence Ave. S.E.,
Washington, or call
1-877-696-6775.

CONTACT FOR ADDITIONAL
INFORMATION

If you have questions about this Notice

or need additional information, you can
contact our Risk Management Department
(or the UHS Compliance Hotline at
1300-8523449).

SOME OF OUR PRIVACY
OBLIGATIONS AND HOW WE
FULFILI. THEM

Federal health information privacy rules
require us to give you notice of our legal
duties and privacy practices with respect to
PHI and to notify you following a breach of
unsecured PHI. This document is our notice.
We will abide by the privacy practices set
forth in this notice. We are required to
abide by the terms of the notice currently
in effect. However, we reserve the right to
change this notice and our privacy practices
when permitted or as required by law. If we
change our notice of privacy practices, we
will provide you with a copy to take With
you upon request and we will post the
new notice.



COMPUANCE WITH CERTAIN
STATE LAWS

When we use or disclose y0ur PHI as
described in this notice, or when you
exercise certain of your rights set forth in
this notice, we may apply state laws about
the con?dentiality of health information
In place of federal privacy regulations.
We do this when these state laws provide
you with greater rights or protection for
yOur PHI. For example, some state laws
dealing with mental health records may
require your express consent before your
PHI could be disclosed in response to a
subpoena. Another state law prohibits us
from disclosing a copy of your record to you
until you have been discharged from our
hos ital. When state laws are not in con?ict
or i these laws do not offer you better
rights or more protection, we will continue
to protect your privacy by applying the
federal regulations.

Effective Date: This notice takes effect on
September 23. 2013 Version 1



 

PRINTCHARACTERS LIKETHIS CORR 
#55 I ABCDE 98765 om 3mg;

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Room 130-A 600 Ave. N. W., Washington, D. C. Egon-consumer Response

5mm!? of Your Rights Under the Fair Credit Reporting Act

7419 federal Farr _CredIt Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of
consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty
agencies (such as agencres that sell information about check writing histories, medical records, and rental history records).
Here IS a summary of your major rights under the FCRA. For more Information, Including Information about additional

9? *0 or write to: Consumer Res onse Center -
600 AVG. N.W., Washington, D.C. 20580. I 00'" 130 A. Federal Trade Commission,

You must be told If Inforrnatlon In your ?le has been used against you. Anyone who uses a credit report or
another type of consumer report to deny your application for credit, insurance, or employment or to take another

adverse action against you - must tell you, and must give you the name, address, and phone number of the agency
that provided the information.

0 You have the right to know what Is In your file. You may request and obtain all the information about you in the
?les of a consumer reporting agency (your "file disclosure"). You will be required to provide proper identification,
which may include your Social Security number. in many cases, the disclosure will be free. You are entitled to a
free ?le disclosure if:

a person has taken adverse action against you because of information in your credit report;

you are the victim of identify theft and place a fraud alert in your file;

your ?le contains inaccurate information as a result of fraud; CO

you are on public assistance; py
you are unemployed but expect to apply for employment within 60 days.

In addition, by September 2005 all consumers will be entitled to one free disclosure every 12 months upon request from
each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See for

additional information.

0 You have the right to ask for a credit score. Credit scores are numerical summaries of your credit?worthiness
based on information from credit bureaus. You may request a credit score from consumer reporting agencres that
create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some
mortgage transactions, you will receive credit score information for free from the mortgage lender.

. You have the right to dlspute Incomplete or Inaccurate Information. If you identify information in your ?le that
is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless
your dispute is frivolous. See for an explanation of dispute procedures.

0 Consumer reporting agencies must correct or delete Inaccurate. Incomplete, or unverifiable information.
Inaccurate, incomplete or unveri?able information must be removed or corrected, usually Within 30 days. However,
a consumer reporting agency may continue to report information it has veri?ed as accurate.

 

- Consumer reporting agencies may not report outdated negative Information. In most cases, a consumer
reporting agency may not report negative information that is more than seven years old, or bankruptcres that are
more than 10 years old.

Access to your file ls limited. A consumer reporting agency may provide information about you only to people
with a valid need - usually to consider an application with a creditor, insurer, employer, landlord, or other business.
The FCRA speci?es those with a valid need for access.

0 You must give your consent for reports to be provided to employers. A consumer reporting agency may not
give out information about you to your employer, or a potential employer, without your written consent given to the
employer. Written consent generally is not required in the trucking industry. For more information, go to


- You may limit ?prescreened? offers of credit and Insurance you get based on Information In your credit
report. Unsolicited ?prescreened? offers for credit and insurance must include a toll-free phone number you can call

 

 



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PRINT CHARACTERS LIKE THIS

ABCDE 98765

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oose to remove your name and address from the lists these offers are based on. You may opt-out with the

. 
.4100"

ch .
wide credit bureaus at 1-888-5-OPTOUT (1-888-567-8888).

You may seek damages from vlolators. if a consumer reporting agency or in some cases a user of consumer
reports or a fumisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in

state or federal court.

identity theft victims and actlve duty military personnel have additional rights. For more information, visit

States may enforce the FCRA, and many states have their own consumer reporting laws. In
some cases, you may have more rights under state law. For more Information, contact your
state or local consumer protection agency or your state Attorney General. Federal enforcers

 

OF eusmass:

CONTACT:

 

Consumer reporting agencies. creditors and others not listed
below

Federal Trade Commission: Consumer Response Center 
FCRA Washington, DC 20580 1-877-382-4357

 

National banks. federal branches/agencies of foreign banks
(word

Of?ce of the Comptroller of the Currency

Compliance Management, Mail Stop 6-6 Washington, DC
800-613-6743

 

f'National" or initials appear in or after bank's name) 20219
Federal Reserve System member banks (except national Federal Reserve Consumer Help (FRCH)
Box 1200

banks. 
and federal branches/agencies of foreign banks)

Minneapolis. MN 55480

Telephone: 888-851-1920

Website Address: 
Email Address: 

 

Savings associations and federally chartered savings banks

Of?ce of Thrift Supervision
Consumer Complaints

 

 

word . . .
'('Federal" or initials appear in federal institution's Washington, DC 20552 800-842?6929
name . . . . . . .
biodegal credit unions (words "Federal Credit Union" appear National Credit Union Administration
in 1775 Duke Street
institution's name) Alexandria. VA 22314 703-519-4600
Federal Deposit insurance Corporation

 

 

h?S?tate-chartered banks that are not members of the Federal

Reserve
System

Consumer Response Center, 2345 Grand Avenue, Suite

100
Kansas City. Missouri 64108-2638 1-877-275-3342

 

 

Air, surface. or rail common carriers regulated by former

Department of Transportation Office of Financial
Management

 

 

 

 

 

 

. 'l . . .
gigrlonautics Board or interstate Commerce Commussron Washington, DC 20590 202-366-1306
Activities subject to the Packers and Stockyards Act-U 921 Department of Agriculture

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