UTMB HANDBOOK OF OPERATING PROCEDURES

Section 6 Compliance Policies Subject 6.1 General Compliance Policy 6.1.2 Non-Retaliation Policy

4/11/2003 - Originated 12/13/2006 - Reviewed w changes - Reviewed w/o changes Office of Institutional Compliance - Author

Non-Retaliation Policy

Policy

All UTMB employees, students and volunteers shall be allowed to freely discuss and raise questions to managers or to the appropriate personnel about situations they feel are in violation of federal and state law, UTMB and/or UT System policy, and/or accreditation and regulatory requirements. All UTMB employees, students and volunteers have a personal obligation to report any activity that appears to violate applicable laws, regulations, rules, policies, procedures, or the Standards of Conduct Guide through the normal administrative process and procedures. However, employees may also make reports through the Fraud and Abuse Hotline (800-898-7679). UTMB will not intimidate, threaten, coerce, discriminate against, or take any retaliatory action against any employee, student, volunteer, patient, legally authorized representative, association, organization or group that in good faith and with honest and non-malicious intent: : (1) Discloses or threatens to disclose information about a situation they feel is inappropriate, or potentially illegal; (2) Provides information to or testifies against the alleged offending individual or UTMB; (3) Objects to or refuses to participate in an activity they feel are in violation of federal and/or state law, UTMB and UT System policy, or accreditation requirements; (4) Is involved in any compliance review or peer review process; or (5) Files a valid or legitimate report or a complaint, or an incident report. All supervisors are responsible for enforcing this policy. Individuals who violate this policy will be subject to the appropriate and applicable disciplinary process, up to and including termination or dismissal.

Investigation of Retaliation

The Office of Institutional Compliance will review any allegations of retaliation brought to its attention and will work with Human Resources to make sure a proper investigation is conducted.

Whistleblower Protection

UTMB employees are protected by Texas state law (Government Code, Chapt. 554, Protection for Reporting Violations of Law) from retaliation for reporting violations of law to governmental entities. The law states: (1) UTMB may not suspend, terminate or take adverse personal action against an employee for reporting in good faith a violation of law to an appropriate law enforcement authority. (2) UTMB must not retaliate against the employee in any fashion. The term “adverse personal action” could be interpreted as any action that cause harm to an employee. The U.S. Supreme Court broadened the anti-retaliation provision to include all forms of adverse action. Employers may be held liable for retaliation, not only for taking employment action such as suspension or termination, but also for adversely changing the workplace environment of the employee who reported a violation of law to the government. This could include removing the employee from work responsibilities or removing the employee from assignments to workgroups or committees; (3) UTMB employees who are suspended, terminated or have an adverse personnel action taken against them for reporting a violation of law covered in the previous section are entitled to sue for injunctive relief, actual damages, court costs and reasonable attorney fees. In addition, the employee is entitled to reinstatement to their position or an equivalent position, compensation for wages lost during the period of suspension or termination and reinstatement of fringe benefits and seniority rights lost because of the suspension or termination; (4) An employee suing UTMB based on retaliation for reporting violations to a governmental entity may not recover compensatory damages in an amount that exceeds $250,000; (5) An employee suing UTMB has the burden of proof to show UTMB is taking employment action against them based on retaliation for reporting violations to a governmental entity;

Whistleblower Protection, continued

(6) An employee must sue not later than the 90th day after the date on which the alleged suspension, termination or adverse personal action occurred or was discovered by the employee through reasonable diligence. Any time used to grieve or appeal the action is excluded from the 90 days; (7) An employee may file suit in the district court of the county in which the action occurred or in a district court of Travis County; (8) A supervisor, who suspends, terminates or takes adverse personal action against an employee for reporting in good faith a violation of law to an appropriate law enforcement authority, can receive a civil penalty up to $15,000.

References

45 C.F.R. §164.530(g) Texas Government Code, Chapt. 554, Protection for Reporting Violations fo Law IHOP Policy 3.10.1, Discipline and Dismissal IHOP Policy 7.1.3, Student Conduct and Discipline