Purpose: To provide the highest standards and processes used by your Healthcare Facility and its subsidiaries to comply with all state and federal regulations when considering applicants for employment, selecting vendors and contractors from which it will purchase goods and services, and in allowing privileges to clinical staff that provide care to Healthcare Facility patients. To provide your Healthcare Facility and its subsidiaries monthly internal audit of mandatory exclusions of individuals and entities from participation in any Federal health care program (as defined in section 1320a?7b (f).

Scope: All Healthcare affiliated facilities, including but not limited to, hospitals, ambulatory surgery centers, outpatient imaging centers, home health agencies, long term care facilities, physician practices, service centers, imaging services and all Corporate and affiliated Departments.

Policy: It is your Healthcare Facility policy that any individual considered for employment with our Healthcare Facility have a background investigation performed by the Human Resource department or Human Resource?s designee which will include whether or not the applicant is listed on the Health and Human Services/Office of Inspector General (?HHS/OIG?) Cumulative Sanction Report and General Services Administration's (GSA) List of Parties Excluded from Federal Programs. All vendors and contracted agents are screened by Evolution Consulting LLC for sanction or exclusion on the HHS/OIG and GSA listings during the requisite pre-approval review process. Physicians and physician-extenders (such as physician assistants, nurse practitioners, etc.) are screened against the HHS/OIG listing as part of the determination of privileges and credentialing process. Sanction verification for current associate members, vendors/contractors, and medical staffs will be checked against the OIG Cumulative Sanction Report, the GSA, and Department of Treasury Office of Foreign Assets Control (OFAC) exclusion listing of terrorism-sponsored organizations at monthly.

Procedure for New Hires and Medical Staff:

1. Sanction verification will be reviewed during the routine hiring/investigation process according to the Healthcare Facility hiring practice prior to extending a job offer.

2. Sanction verification for new vendors or contracted agents will be performed by Evolution Consulting LLC staff by accessing the internet at www.evolutioncheck.com prior to approval and listing on the Healthcare Facility approved vendor list.

Procedure for Monthly Cumulative Reviews:

1. Once a month Corporate Compliance Officers and/or designated contacts at each of the Healthcare Facility family of companies will be requested to provide an electronic listing of all current employees at a specified date in the calendar year to the contact person at Evolution Consulting LLC in Information Technology (IT) using the specified informational format.

2. The IT contact person will instruct the designated contacts or other team members the correct format for the electronic listing submission.

3. The Evolution Consulting LLC OIGManager software system takes the data file and checks it against a variety of databases for association matches with the full name of the employee and/or vendor.

4. Any potential matches identified in the cumulative screening process will be reviewed and resolved by the Evolution Consulting LLC investigative team in accordance with the Office of Inspector General and General Services Administration Program Exclusion regulations.

5. Results of the monthly final report screenings will be conveyed to the designated contacts at Healthcare Facility and will provide the basis for the screening assurances by the Compliance Officer required in monthly Medicare/Medicaid cost report filing.