DEPARTMENT: Human Resources
PAGE: 1 of 10
POLICY DESCRIPTION: Background
Investigations
REPLACES POLICY DATED: 8/1/99, 9/1/99,
1/1/02, 12/15/02, 5/31/04, 6/1/04, 2/1/05, 9/1/05,
10/1/05, 7/1/06, 3/1/07, 9/1/07, 3/1/08, 8/1/08, 11/1/08,
7/1/09, 11/1/09, 5/15/10, 8/1/10, 2/1/12
EFFECTIVE DATE: May 15, 2012
REFERENCE NUMBER: HR.OP.002 (formerly
HR.102)
APPROVED BY: Ethics and Compliance Policy Committee
SCOPE: All Company-affiliated subsidiaries including, but not limited to hospitals, ambulatory
surgery centers, outpatient imaging centers, physician practices, Parallon Workforce
Management Solutions, Corporate Departments, Groups, and Divisions (collectively, “Affiliated
Employers” and individually, “Affiliated Employer”).
PURPOSE: To ensure a standard requirement and process for obtaining and evaluating
background information on:
1. candidates for employment;
2. individuals who provide clinical services at the facility (e.g., students), other than individuals
who are solely privileged practitioners of the medical staff;
3. individuals who provide clinical services under contract with the facility (e.g., independent
contractors, employees or agents of staffing agencies); and
4. individuals who are reasonably expected to interact with patients or members of the public at
the facility (e.g., volunteers).
Such individuals are collectively referred to as “Subjects” and individually as “Subject.” The
background information may include various components based on the level of responsibility of
the Subject.
To ensure that all contractors sending individuals other than Subjects to perform services in or on
the premises of an HCA-affiliated facility (e.g., employees of contracted lawn service or
contracted repair services) provide the HCA-affiliated facility with an attestation that the
individuals sent to work in or on the premises of an HCA-affiliated facility are legally permitted
to work in the United States. Such individuals are collectively referred to as “Other Contract
Workers” and individually as “Other Contract Worker.”
POLICY: An Affiliated Employer must not permit a Subject to commence employment or
provide services in an Affiliated Facility until a satisfactory background investigation (otherwise
known as an “investigative consumer report”) has been obtained (See Analysis of Background
Investigation).
A change of a Subject’s Social Security Number for any reason or a change of name for other
than marital status requires a new, satisfactory background investigation.
An Affiliated Employer must not permit Other Contract Workers to provide services in or on the
premises of an Affiliated Facility until the Other Contract Workers’ employer provides an
attestation that such individuals are legally permitted to work in the United States.
4/2012
DEPARTMENT: Human Resources
PAGE: 2 of 10
POLICY DESCRIPTION: Background
Investigations
REPLACES POLICY DATED: 8/1/99, 9/1/99,
1/1/02, 12/15/02, 5/31/04, 6/1/04, 2/1/05, 9/1/05,
10/1/05, 7/1/06, 3/1/07, 9/1/07, 3/1/08, 8/1/08, 11/1/08,
7/1/09, 11/1/09, 5/15/10, 8/1/10, 2/1/12
EFFECTIVE DATE: May 15, 2012
REFERENCE NUMBER: HR.OP.002 (formerly
HR.102)
APPROVED BY: Ethics and Compliance Policy Committee
Contract language for Other Contract Workers must include the following provision:
Vendor will not employ or use any individual to perform Services under this Agreement who is
not legally authorized to work in the United States in the capacity required to perform the
Services. Vendor certifies that all employees and other individuals it assigns to perform Services
under this Agreement are legally authorized to work in the United States in the capacity required
to perform the Services and will provide upon request written documentation to support such
certification. Vendor agrees that if the status of any employee or other individual so assigned by
Vendor changes during the Term of this Agreement such that that person is not legally authorized
to work in the United States in the capacity required to perform the Services, Vendor shall
provide notice thereof to Purchaser and remove such employee or individual from performing
any Services. Vendor agrees to defend, indemnify and hold Purchasers harmless in the event of
any claim made against Purchaser related to any alleged failure of Vendor to comply with its
warranties, representations, and certifications. Such failure shall constitute a material breach of
this Agreement.
PROCEDURE:
Background Investigations for Subjects
1. Notice of Investigation. Subjects shall be provided with notice of the Affiliated Employer’s
policy and practice of conducting background investigations. An Affiliated Employer must
make clear that the Affiliated Employer has a policy of conducting background
investigations. A signed disclosure/release form is required prior to initiating the background
investigation.
2. Subjects.
a. New Employee: A qualified individual evaluated to be the best candidate for a position
may be extended an offer of employment contingent upon, at a minimum, the completion
of a signed application for employment and authorization for the procurement of a
background investigation (i.e., an investigative consumer report) for employment
purposes and a satisfactory report. The report must be received by the facility, as
evidenced by the date on the report, and reviewed prior to the qualified individual’s first
day of employment at the Affiliated Employer’s facility. The application for
employment, the authorization and the report are to be filed in the employee’s personnel
file (paper records or electronic records will suffice) or for applicants not employed, in a
master verification file in the Affiliated Employer’s Human Resources Department filed
by year and alphabetized. Affiliated Employers should limit access to an employee’s
personnel file in compliance to their policy and respective state law.
4/2012
DEPARTMENT: Human Resources
PAGE: 3 of 10
POLICY DESCRIPTION: Background
Investigations
REPLACES POLICY DATED: 8/1/99, 9/1/99,
1/1/02, 12/15/02, 5/31/04, 6/1/04, 2/1/05, 9/1/05,
10/1/05, 7/1/06, 3/1/07, 9/1/07, 3/1/08, 8/1/08, 11/1/08,
7/1/09, 11/1/09, 5/15/10, 8/1/10, 2/1/12
EFFECTIVE DATE: May 15, 2012
REFERENCE NUMBER: HR.OP.002 (formerly
HR.102)
APPROVED BY: Ethics and Compliance Policy Committee
b. New Employees via Acquisition: Prior to an acquisition which includes the employment
of the seller’s employees, Corporate Human Resources will compare the seller’s
background investigation policy to this policy in the required due diligence process.
Corporate Human Resources will make a recommendation to the Division President
expected to operate the newly acquired business based on that comparison. Without
regard to the background investigation decision, all employees of the acquired business
will be checked against the GSA List and OIG Sanction Report prior to the transaction
close date to determine any match of an Ineligible Person.
c. Transfers: Current employees may move among Affiliated Employers contingent upon,
at a minimum, the completion of an authorization for the procurement of a background
investigation and a satisfactory report. The report must be received by the facility, as
evidenced by the date on the report, and reviewed prior to the employee’s first day of
employment in the transferred position.
d. Promotions: Current employees who are not department managers or in a position with
responsibilities that includes a consumer Credit Report in the background investigation
report may be extended an offer of promotion to a department manager position or a
position with responsibilities that includes a Consumer Credit Report in the background
investigation contingent upon, at a minimum, the completion of an authorization for the
procurement of a background investigation and a satisfactory report. The report must be
received by the facility, as evidenced by the date on the report, and reviewed prior to the
employee’s first day of employment in the promoted position.
e. Rehires: If eligible for rehire, a background investigation report will be obtained in
accordance with the position level later described. An applicant not eligible for rehire
and with a termination date prior to October 1, 2005 will be considered on a case by case
basis and must be approved for employment by the Affiliated Employer’s Human
Resources Director.
f. Independent Contractors and Employees of Staffing Agencies or Contracted Service
Entities that provide clinical services, have access to patient records, or otherwise could
come into contact with patients or members of the public: Contracts or service
agreements must be entered into with all third parties providing temporary, PRN, agency
or contract employees who provide clinical services, have access to patient records, or
otherwise could come into contact with patients or members of the public. Similarly,
such contracts or service agreements must be entered into with third parties (other than
4/2012
DEPARTMENT: Human Resources
PAGE: 4 of 10
POLICY DESCRIPTION: Background
Investigations
REPLACES POLICY DATED: 8/1/99, 9/1/99,
1/1/02, 12/15/02, 5/31/04, 6/1/04, 2/1/05, 9/1/05,
10/1/05, 7/1/06, 3/1/07, 9/1/07, 3/1/08, 8/1/08, 11/1/08,
7/1/09, 11/1/09, 5/15/10, 8/1/10, 2/1/12
EFFECTIVE DATE: May 15, 2012
REFERENCE NUMBER: HR.OP.002 (formerly
HR.102)
APPROVED BY: Ethics and Compliance Policy Committee
State agencies or State employees) providing assistance to individuals in pursuing and/or
obtaining Medicaid coverage. The contracts or agreements must address:
i.
ii.
iii.
iv.
Stipulation to background investigations based on standards herein.
Liability insurance coverage.
Indemnification.
Retention and Audit requirements for files for policy compliance.
A background investigation report shall be completed in accordance with the position
levels later described for individuals who provide clinical services pursuant to contracts
with Staffing Agencies, Contracted Service Entities, or Independent Contractors. The
contractor must have the completed background investigation report prior to the
healthcare worker reporting for duty at a facility. A Contracted Service Entity or Staffing
Agency must comply with the terms below of item 3, Third Party Ownership of the
Background Investigation Report. An employee of the contractor with derogatory
information in the report shall not be presented for utilization by the Affiliated Employer.
An Independent Contractor must comply with the terms below of item 4, Company
Affiliate Ownership of the Background Investigation Report.
g. Parallon Workforce Management Solutions: Any Subject provided to an Affiliated
Employer by Parallon Workforce Management Solutions (PWMS), the Company’s
subsidiary staffing agency, is subjected to a background investigation completed either by
PWMS or by the subcontracted staffing vendors with which PWMS contracts. If a
Subject does not have a satisfactory background investigation or is missing other
information, he or she shall not be permitted to be scheduled for work. PWMS audits its
own employees and staffing vendors pursuant to the audit requirements articulated below,
and other Affiliated Employers are not required to audit PWMS employees or PWMS
subcontracted staffing vendors.
h. Volunteers and Auxiliary Organizations: As a requirement for participation, affiliated
volunteer organizations must agree to comply with this policy. The organization’s bylaws
should reference the requirement. The cost of the background investigation may be
negotiated between the Affiliated Employer and the volunteer organization.
i. Students: School Affiliation Agreements should include language consistent with this
policy as a requirement for student clinical rotation in affiliated facilities. The cost of the
background investigation may be negotiated between the Affiliated Employer and the
4/2012
DEPARTMENT: Human Resources
PAGE: 5 of 10
POLICY DESCRIPTION: Background
Investigations
REPLACES POLICY DATED: 8/1/99, 9/1/99,
1/1/02, 12/15/02, 5/31/04, 6/1/04, 2/1/05, 9/1/05,
10/1/05, 7/1/06, 3/1/07, 9/1/07, 3/1/08, 8/1/08, 11/1/08,
7/1/09, 11/1/09, 5/15/10, 8/1/10, 2/1/12
EFFECTIVE DATE: May 15, 2012
REFERENCE NUMBER: HR.OP.002 (formerly
HR.102)
APPROVED BY: Ethics and Compliance Policy Committee
school. If a school should refuse to assume responsibility either for obtaining or paying
for background investigations, the facility must make other arrangements for obtaining
and paying for the background investigations prior to the start of student clinical rotation
in an affiliated facility. Students who are not serving in a clinical rotation and will not be
in the facility on a recurring basis (e.g., one-day job shadow by a high school student),
should be treated like a visitor to the facility. All privacy and safety requirements of
visitors must be met.
3. Third Party Ownership of the Background Investigation Report and Audit Requirements
Volunteer organizations, schools, contract services entities, and staffing agencies that order a
background investigation in compliance with this policy retain ownership of the report of the
investigation. The volunteer organization, school, contract services entity, or staffing agency
may attest in writing to the Affiliated Employer (including PWMS) that it owns a satisfactory
report in lieu of providing a copy to the Affiliated Employer. A model attestation is available
on Atlas.
If attestations are accepted, the Affiliated Employer (including PWMS) must annually audit a
sample of files for one-third of those entities that provide attestations. The Affiliated
Employer must take into consideration the risk to patients presented by the type of
individuals provided by the entities that provide attestations and focus on those that present
the greatest risk (e.g., direct care providers present a greater risk than those who undertake
administrative support or property management services). A sufficient sample size will be
the greater of five percent (5%) or thirty (30) files for each of the third parties. Market-wide
audits are permissible under this policy in the event multiple hospitals in a market utilize the
same third party vendor(s). Using the same guidelines as stated above, the pool of files
audited must include all of the third party employees provided across the market and from
that pool the greater of 5% or thirty (30) files are chosen.
To permit Affiliated Employer review of files, the authorization for the procurement of a
background investigation (otherwise known as an investigative consumer report) that the
third party obtains must include the Affiliated Employer as well as the volunteer
organization, school, contracted service entity, or staffing agency.
4. Company Affiliate Ownership of the Background Investigation Report
Affiliated Employers that order a background investigation for a Subject in compliance with
this policy retain ownership of the report of the investigation.
4/2012
DEPARTMENT: Human Resources
PAGE: 6 of 10
POLICY DESCRIPTION: Background
Investigations
REPLACES POLICY DATED: 8/1/99, 9/1/99,
1/1/02, 12/15/02, 5/31/04, 6/1/04, 2/1/05, 9/1/05,
10/1/05, 7/1/06, 3/1/07, 9/1/07, 3/1/08, 8/1/08, 11/1/08,
7/1/09, 11/1/09, 5/15/10, 8/1/10, 2/1/12
EFFECTIVE DATE: May 15, 2012
REFERENCE NUMBER: HR.OP.002 (formerly
HR.102)
APPROVED BY: Ethics and Compliance Policy Committee
The authorization for the procurement of a background investigation (otherwise known as an
investigative consumer report) should indicate the relationship of the Subject of the
investigation with the Affiliated Employer.
Both the authorization and the report are to be filed by year and alphabetized if stored as hard
copies. Electronic storage is also an acceptable storage option provided the documents are
readily available on demand. A procedure for backing up documents in the event of system
malfunction should be established to ensure accessibility.
5. Minors
Minors may sign, with or without the co-signature of a parent or guardian, an authorization
for the procurement of a background investigation (otherwise known as an investigative
consumer report) that should indicate the relationship of the Subject of the investigation to
the Affiliated Employer, unless otherwise restricted by State law.
6. International Applicants
A properly documented U.S. visa, issued December 31, 2007 or later, satisfies the criminal
search component of this Background Investigation policy for the time period prior to
entering the United States.
7. Background Investigation. All Subjects will have a Level I background investigation.
Responsibilities may require a Level II and/or Level III background investigation as described
below:
Level I (All Subjects)
Social Security Number Verification (non-employee student SSN’s will not be verifiable with
the Social Security Administration)
Criminal Search (7 years or up to 5 criminal searches)
Employment Verification to include reason for separation and eligibility for re-employment
for each employer for 7 years*
Violent Sexual Offender and Predator Registry Search
OIG List of Excluded Individuals/Entities
GSA List of Parties Excluded from Federal Programs
U.S. Treasury, Office of Foreign Assets Control (OFAC), List of Specially Designated
Nationals (SDN)
Applicable State Exclusion List on Atlas
* This element of the Level I investigation is NOT required for students younger than
21 years of age. For students over 21 years of age, the school may eliminate
4/2012
DEPARTMENT: Human Resources
PAGE: 7 of 10
POLICY DESCRIPTION: Background
Investigations
REPLACES POLICY DATED: 8/1/99, 9/1/99,
1/1/02, 12/15/02, 5/31/04, 6/1/04, 2/1/05, 9/1/05,
10/1/05, 7/1/06, 3/1/07, 9/1/07, 3/1/08, 8/1/08, 11/1/08,
7/1/09, 11/1/09, 5/15/10, 8/1/10, 2/1/12
EFFECTIVE DATE: May 15, 2012
REFERENCE NUMBER: HR.OP.002 (formerly
HR.102)
APPROVED BY: Ethics and Compliance Policy Committee
employment verification provided there is language included in the school affiliation
agreement indemnifying the HCA affiliate and specifying that the school assumes
full liability for any/all performance and/or behavior of the student during the
clinical rotation.
Level II (All licensed or certified caregivers, as well as finance personnel, and department
managers)
Social Security Number Verification
Criminal Search (7 years or up to 5 criminal searches)
Employment Verification to include reason for separation and eligibility for re-employment
for each employer for 7 years
Violent Sexual Offender and Predator Registry Search
OIG List of Excluded Individuals/Entities
GSA List of Parties Excluded from Federal Programs
U.S. Treasury, Office of Foreign Assets Control (OFAC), List of Specially Designated
Nationals (SDN)
Applicable State Exclusion List on Atlas
Education Verification (highest level)
Professional License Verification
Certification & Designations Check
Professional Disciplinary Action Search
Department of Motor Vehicle Driving history, based on responsibilities.
Consumer Credit Report, based on responsibilities.
Level III (All senior level management to include Vice Presidents and above, facility CEO,
COO, CFO, CNO)
Social Security Number Verification
Criminal Search (7 years or up to 5 criminal searches)
Employment Verification to include reason for separation and eligibility for re-employment
for each employer for 7 years
Violent Sexual Offender and Predator Registry Search
OIG List of Excluded Individuals/Entities
GSA List of Parties Excluded from Federal Programs
U.S. Treasury, Office of Foreign Assets Control (OFAC), List of Specially Designated
Nationals (SDN)
Applicable State Exclusion List on Atlas
Education Verification (highest level)
4/2012
DEPARTMENT: Human Resources
PAGE: 8 of 10
POLICY DESCRIPTION: Background
Investigations
REPLACES POLICY DATED: 8/1/99, 9/1/99,
1/1/02, 12/15/02, 5/31/04, 6/1/04, 2/1/05, 9/1/05,
10/1/05, 7/1/06, 3/1/07, 9/1/07, 3/1/08, 8/1/08, 11/1/08,
7/1/09, 11/1/09, 5/15/10, 8/1/10, 2/1/12
EFFECTIVE DATE: May 15, 2012
REFERENCE NUMBER: HR.OP.002 (formerly
HR.102)
APPROVED BY: Ethics and Compliance Policy Committee
Professional License Verification
Certification & Designations Check
Professional Disciplinary Action Search
Department of Motor Vehicle Driving history, based on responsibilities.
Consumer Credit Report
Newspaper Articles & Clippings
Bankruptcy and Federal District Court Search
8. Hiring/Rehiring Ineligible Persons. Affiliated Employers may not employ or contract with,
and staffing agencies may not refer to an Affiliated Employer any Subject identified as an
Ineligible Person. Ineligible Person is defined as any individual or entity who is currently
excluded, suspended, debarred or otherwise ineligible to participate in the Federal health care
programs; or has been convicted of a criminal offense related to the provision of health care
items or services and has not been reinstated in the Federal health care programs after a period
of exclusion, suspension, debarment, or ineligibility, or any individual or entity currently
excluded on a state exclusion list.
9. Analysis of Background Investigation. The Affiliated Employer’s Human Resources
Department or third party owner of the background investigation report, as applicable, shall
notify the responsible Manager if a discrepancy arises between disclosed credentials and the
verified information or if the Subject is disqualified based upon the results of the background
investigation.
a. Derogatory information of the following nature as the result of a background
investigation is the basis to no longer consider a Subject qualified:
i. Inclusion on the list of Ineligible Persons.
ii. Ineligible for re-employment by a former employer not affiliated with HCA. (Any
exception to this element must be approved by the Affiliated Employer’s Human
Resources Director.)
iii. Termination from a previous job related to any of the following reasons:
a) Behavior which flagrantly or intentionally fails to conform to expected standards
of conduct;
b) Flagrant or intentional policy violation; or
c) Performance which flagrantly or intentionally fails to conform to legal or clinical
standards.
4/2012
DEPARTMENT: Human Resources
PAGE: 9 of 10
POLICY DESCRIPTION: Background
Investigations
REPLACES POLICY DATED: 8/1/99, 9/1/99,
1/1/02, 12/15/02, 5/31/04, 6/1/04, 2/1/05, 9/1/05,
10/1/05, 7/1/06, 3/1/07, 9/1/07, 3/1/08, 8/1/08, 11/1/08,
7/1/09, 11/1/09, 5/15/10, 8/1/10, 2/1/12
EFFECTIVE DATE: May 15, 2012
REFERENCE NUMBER: HR.OP.002 (formerly
HR.102)
APPROVED BY: Ethics and Compliance Policy Committee
b. Derogatory information of the following nature as the result of a background
investigation may be the basis to no longer consider a Subject qualified:
i.
Conviction of a felony or misdemeanor offense, based on responsibilities.
ii. Providing a false statement on credentials.
iii. A documented financial problem or issue, based on responsibilities.
iv. A documented traffic violation, based on responsibilities.
v.
Failure to maintain license.
vi. Restriction on license.
vii. Job abandonment.
viii. Refused assignment.
ix. Quit without notice.
x. Absenteeism.
This list is not exclusive or exhaustive. Managers should use good judgment when
evaluating information obtained through a background investigation report and, when in
doubt, consult with the Corporate Employee Relations or Legal Department.
Use of information obtained from a background investigation report must be taken in
context with the responsibilities intended for the Subject. Derogatory information learned
from a background investigation report should be considered with all other information
known, and a case-by-case determination should be made. The Affiliated Employer’s
Human Resources Director or responsible Manager may seek clarification from the
Subject regarding the derogatory information. Information obtained from a background
investigation report should remain confidential and not be shared with anyone except on a
need to know basis.
c. Before conveying an adverse action based on any information in a background
investigation (otherwise known as an investigative consumer report), the Subject must
first be provided with:
i. A copy of the background investigation (otherwise known as an investigative
consumer report).
ii. A written description of the Subject’s rights as prescribed by the FTC.
iii. The name, address and phone number of the consumer reporting agency that provided
the report.
iv. A notice of the Subject’s right to dispute the accuracy or completeness of the report
with the consumer reporting agency.
4/2012
DEPARTMENT: Human Resources
PAGE: 10 of 10
POLICY DESCRIPTION: Background
Investigations
REPLACES POLICY DATED: 8/1/99, 9/1/99,
1/1/02, 12/15/02, 5/31/04, 6/1/04, 2/1/05, 9/1/05,
10/1/05, 7/1/06, 3/1/07, 9/1/07, 3/1/08, 8/1/08, 11/1/08,
7/1/09, 11/1/09, 5/15/10, 8/1/10, 2/1/12
EFFECTIVE DATE: May 15, 2012
REFERENCE NUMBER: HR.OP.002 (formerly
HR.102)
APPROVED BY: Ethics and Compliance Policy Committee
Three days after the above is provided, the Subject must be provided with the following
required disclosure:
i. A notice of the adverse action.
ii. A statement that the consumer reporting agency did not make the decision to take the
adverse action and thus cannot tell the Subject the specific reason for the adverse
action.
10. Vendor. The Company recommends the background investigation reporting vendors listed
on Atlas.
Employer Attestation for Other Contract Workers
Attestation. An Affiliated Employer must require individuals and entities with which it contracts
for services that will be conducted in or on the premises of the Facility to provide a written
attestation that it has checked to ensure individuals provided to conduct services in or on the
premises of the Facility are legally permitted to work in the United States. A single attestation
stating any and all individuals provided are legally permitted to work in the United States is
permissible.
REFERENCES:
1. Recruitment Policy, HR.OP.027
2. Transfer-Promotion-Demotion Policy, HR.OP.035
3. Limitations on Employment Policy, HR.OP.019
4. Reference Inquiries, HR.OP.028
5. Employment Application
6. Fair Credit Reporting Rights
7. Fair Credit Reporting Act Background Research Form
8. Enhanced Border Security and Visa Entry Reform Act of 2002
4/2012