CRIMINAL AND PERSONAL BACKGROUND CHECK POLICY PURPOSE The purpose of this policy is to: Promote a safe environment for patients, employees, Trainees, Students, and other members of The University of Texas MD Anderson Cancer Center s (MD Anderson) workforce by performing appropriate background checks. Comply with eligibility requirements for participation in federally funded health care programs by conducting background checks for health care offenses through the Office of Regulatory Affairs of the United States Department of Health and Human Services. POLICY STATEMENT It is the policy of MD Anderson to conduct appropriate background checks on Post-Offer Applicants, employees, Trainees, Students, volunteers, and appropriate non-employees conducting work on site at MD Anderson or otherwise on behalf of MD Anderson as permitted by law including Texas Education Code Section 51.215(c), Texas Government Code Sections 4411.094(a)(2)(e), The University of Texas System Policy 124 (UTS124), and directives of the United States Department of Health and Human Services. All Positions at MD Anderson are designated as Security Sensitive for purposes of Criminal Background Checks and Personal Background Checks. MD Anderson performs the following background checks as set forth in this policy: (1) Personal Background Checks; (2) Criminal Background Checks, as appropriate; and (3) Sanctions Checks for federally excluded individuals through the databases maintained by the Office of the Inspector General, the Office of Research Integrity, and the Office of Regulatory Affairs of the United States Department of Health and Human Services. MD Anderson reserves the right to review other background records as permitted by law, including those from all educational institutions, all places of employment, and all locations of residence. MD Anderson requires all workforce members to report/disclose whether they are registered as a sex offender or required to register as a sex offender; and any criminal complaints, criminal information, criminal indictments, no contest pleas, guilty pleas, or criminal convictions related to any criminal offense except for misdemeanor offenses punishable only by fine. Using authorized databases, all MD Anderson background checks will take into consideration the nature of the Position, information obtained from the United States government in connection with the visa process, and information regarding the permanent, temporary, and educational residences for any individual who has lived outside the State of Texas since the age of 17. Page 1 of 10
SCOPE This policy applies to: Current employees, including administrative staff, classified staff, faculty, faculty serving without compensation, and visiting scientists; Trainees and Students; Volunteers; and Non-employees, including, but not limited to, vendor personnel and sponsored research study monitors conducting work-related activities on behalf of MD Anderson. Post-Offer Applicants; Compliance with this policy is the responsibility of all faculty, Trainees, Students, and other members of MD Anderson s workforce. TARGET AUDIENCE The target audience for this policy includes, but is not limited to all employees, Trainees, Students, Post- Offer Applicants, and other members of MD Anderson s workforce, including faculty serving without compensation, visiting scientists, and volunteers. DEFINITIONS Criminal Background Check: A process of checking information collected by a criminal justice agency that consists of identifiable descriptions and notations of arrests, indictments, and other formal criminal charges and dispositions, more fully described in Section 411.082 of the Texas Government Code. See Criminal Background Information Requiring Disclosure for a list of specific information which a Criminal Background Check must include. Criminal Background Check Committee: A committee composed of representatives from Human Resources, Academic and Visa Administration, Legal Services, and the Institutional Compliance Office responsible for reviewing job-related Risk assessments involving all current employees, Trainees, Students, and other members of MD Anderson s workforce covered by this policy and making recommendations for further action by MD Anderson. Personal Background Check: Information concerning the professional references, education, previous employment, or other credentials of a Post-Offer Applicant, a post-appointment Trainee, or a postacceptance Student. Position: Any MD Anderson full-time, part-time, hourly, or per diem employment Position, whether the Position is filled by a regular or temporary worker, with the exception of a Position filled by a temporary placement agency. The temporary placement agency is responsible for conducting the Criminal Background Check on all workers placed in temporary Positions at MD Anderson as set forth in MD Anderson s contract with the placement agency. For purposes of this policy, the term Position shall also include all appointments of Students, Trainees, volunteers, faculty members without compensation and visiting scientists. Page 2 of 10
Post-Offer Applicant: An individual who applied for a Position with MD Anderson and received an offer of employment from Human Resources or an appointment from Academic and Visa Administration. Post- Offer Applicants also include those individuals applying for an appointment as a trainee or faculty member without compensation or an appointment as a visiting scientist. Risk: The case-by-case determination that the individual represents an unacceptable level of potential harm or liability to MD Anderson patients, visitors, or workforce members. All individuals registered as a sex offender or required to register as a sex offender will automatically be deemed a Risk subject to the review provided for in Section 7.0 of this policy. The determination an individual poses an unacceptable Risk in connection with other information revealed by a Criminal Background Check will be based on factors which include the following: Specific duties of the Position. Number of offenses. Nature of offense. Length of time between offense and acceptance into MD Anderson s workforce. Employment history. Efforts of rehabilitation. Level of cooperation in reviewing the criminal background information. Information included on the individual s application. Criminal background record information may only be used for employment purposes and shall in no way be used to discriminate on the basis of race, color, religion, age, national origin, sex, sexual orientation, gender identity/expression, disability, veteran status, genetic information, or any other basis protected by federal, state, or local laws, unless such distinction is required by law. Sanctions Check: Information obtained from the federal databases maintained by the United States Office of the Inspector General, Office of Research Integrity, and Office of Regulatory Affairs of the United States Department of Health and Human Safety, regarding an individual s debarment, exclusion, or other ineligibility for participation in federally funded health care programs. Security Sensitive: Positions which require a Criminal Background Check to be performed. All Positions at MD Anderson have been designated as Security Sensitive. Student: For the purpose of this policy, an individual accepted into MD Anderson s School of Health Professions. Trainee: For the purpose of this policy, an individual appointed to or attending one of MD Anderson s clinical, research, or other education programs outside the School of Health Professions, including Graduate School of Biomedical Sciences (GSBS) students. Page 3 of 10
PROCEDURE 1.0 Self-Reporting Requirement 1.1 Current employees, Trainees, Students of the School of Health Professions, and volunteers must complete the Criminal Background Self-Disclosure Form and submit the form to the Human Resources EEO and HR Regulations Department within five (5) business days of any of the following events: A. Registered as a sex offender or are required to register as a sex offender; and B. Any criminal complaints, criminal indictments, no contest pleas, guilty pleas, or criminal convictions related to any criminal offense. Note: Misdemeanors punishable only by a fine do not need to be reported. For specific definitions, see Criminal and Personal Background Check Information Requiring Disclosure. Individuals violating any portion of this policy are subject to progressive disciplinary action, up to and including termination. 1.2 Post-Offer Applicants along with individuals applying for Trainee appointments, the School of Health Professions, or volunteer Positions are required to report the following: A. Registered as a sex offender or required to register as a sex offender; and B. Any criminal incidents occurring after the acceptance of the respective Position with MD Anderson, excluding any charges or convictions for misdemeanor offenses punishable only by fine. 1.3 The self-reporting requirement under this policy is in addition to any other reporting requirements, including licensure. 1.4 Falsification of an application or omission of criminal record information required to be reported is grounds to reject an application. 2.0 Personal and Criminal Background Checks 2.1 MD Anderson requires Personal Background Checks, Criminal Background Checks, and monthly Sanctions Checks to be conducted on the following individuals: A. Current employees upon acceptance of a promotion or transfer to a new Position at MD Anderson or when the President (or designee) determines such check is warranted. Promotions and transfers are contingent upon satisfactory results from the Personal Background Check and Criminal Background Check. When a Criminal Background Check is required for a current employee, MD Anderson may rely on a Criminal Background Check conducted at MD Anderson within the past twelve (12) months contingent on the following: The employee did not have a break in service greater than six (6) months; The Criminal Background Check utilized is appropriate for the new Position the individual accepted; and The Criminal Background Check included a sex offender registration check. Page 4 of 10
B. Individuals accepted as Trainees, Students, and prospective volunteers. These individuals must complete applicable notice and authorization forms in advance of the background check being conducted. C. Non-employees conducting work for or on behalf of MD Anderson irrespective of whether the non-employee is physically on MD Anderson premises while conducting the work. This includes, but is not limited to, vendor personnel, sponsored research study monitors, and other such individuals not employed by MD Anderson but who may pose a Risk under the relevant authority on federally excluded entities. Any vendor requesting an exception to this requirement must obtain a waiver in writing from the Vice President, Business Operations (or designee). In the case of sponsored research study monitors or other employees of a research sponsor, the outside company s Human Resources Department is to provide written confirmation that all individuals collaborating with MD Anderson on behalf of the company have successfully completed a Criminal Background Check. Any other non-employee requesting an exception must obtain a waiver in writing from the Vice President, Human Resources (or designee). MD Anderson may rely on the Criminal Background Check conducted by an agency of the federal government to satisfy the requirements of this policy for an individual on assignment from an agency of the federal government if MD Anderson receives documentation from that federal agency showing that the Criminal Background Check conducted by the federal agency included a sex offender registry check. D. All Post-Offer Applicants: Employment (or appointment as a faculty member without compensation or as a visiting scientist) is contingent upon satisfactory results from all Personal Background Checks, Criminal Background Checks, and Sanctions Checks. Post-Offer Applicants must complete applicable notice and authorization forms before a background check is completed. If any background check reveals a Risk, the offer will be withdrawn, or if the individual has started with MD Anderson, the individual will be terminated. The individual will be ineligible to reapply for employment or appointment at MD Anderson for six (6) months. If a Student or Trainee becomes a Post-Offer Applicant, MD Anderson may rely on a Criminal Background Check conducted by MD Anderson within the previous twelve (12) months contingent on the following: The Student or Trainee did not have a break in enrollment or appointment greater than six (6) months; The Criminal Background Check relied on is appropriate for the Position sought; and The Criminal Background Check included a sex offender registration check. 3.0 Risk Determination Current Workforce 3.1 When criminal information is identified in the background check results, The University of Texas Police Department at Houston (UTP-H) will review all pertinent data and make a preliminary determination of whether the individual constitutes a Risk. Page 5 of 10
3.2 If UTP-H makes a preliminary determination an individual constitutes a Risk, the information utilized by UTP-H to make the preliminary determination will be shared with the individual, except as provided by law or Texas Department of Public Safety policy or procedure. The individual will be informed of the right to (1) challenge the accuracy and completeness of the report and (2) submit additional information relating to the criminal background record, along with reasons it should not affect MD Anderson s decision. If the report is obtained by a thirdparty vendor, the required Fair Credit Reporting Act pre- and post-adverse action disclosures will be provided. 3.3 The individual will be provided five (5) business days to submit additional information for consideration by MD Anderson. 3.4 In the case of a current employee, Trainee, Student, or other member of MD Anderson s workforce covered by this policy, UTP-H will forward all available information to the Criminal Background Check Committee to review and determine if the individual constitutes a Risk or whether corrective action is appropriate. 3.5 Current employees, Students and Trainees may appeal decisions affecting appointment or employment status under applicable grievance, corrective action or appeal policies. 4.0 Risk Determination Post Offer Applicants and Prospective Volunteers, Students, and Trainees 4.1 In the case of a Post-Offer Applicant, a prospective volunteer, Student, or Trainee, UTP-H will consult with Human Resources, the School of Health Professions, Academic and Visa Administration, or Volunteer Services, as applicable, to review all pertinent information and determine whether the individual constitutes a Risk. 4.2 MD Anderson s decisions regarding Risk, appointments and employment status in accordance with this policy are final and may not be appealed. 5.0 Confidentiality and Disposition of Criminal Background Information All criminal background information received by UTP-H will be treated as privileged and confidential and will be handled and retained in compliance with all applicable state and federal laws. 6.0 Sanctions Checks Pre-Hire Sanctions Checks 6.1 Human Resources will ensure Sanctions Checks are conducted on all Post-Offer Applicants for classified and administrative staff Positions. 6.2 Academic and Visa Administration will ensure Sanction Checks are conducted on all Post- Offer Applicants for faculty Positions, Post-Offer Applicants for faculty appointments without compensation, Post-Offer Applicants for visiting scientist Positions, and Trainees accepted into an education program. 6.3 The School of Health Professions will ensure Sanction Checks are conducted on all Students accepted into the School of Health Professions. 6.4 All potential Risks identified by Sanctions Checks on Post-Offer Applicants, new Trainees, and new Students of the School of Health Professions will be reported to the Institutional Compliance Office (ICO). The ICO will notify Human Resources, Academic and Visa Page 6 of 10
Administration, and the School of Health Professions, as appropriate, regarding any actions to be taken with an individual identified as a potential Risk by the Sanctions Check. Post-Hire Sanctions Checks 6.5 The ICO conducts monthly Sanctions Checks on all individuals in MD Anderson s Human Resources Management System and informs the appropriate manager regarding any individual identified through the Sanctions Check as being debarred, excluded, and/or ineligible for participation in federally funded health care programs and will determine the corrective action to be taken. In the case of any faculty member, faculty serving without compensation, visiting scientist, or other employee, the ICO will inform the applicable department administrator. In the case of a Trainee, the ICO will inform the designated manager in Academic and Visa Administration Trainee and Alumni Affairs (AVA-TAA). In the case of any Student, the ICO will inform the dean of the School of Health Professions. (Refer to the Corrective and/or Disciplinary Action Section of the Hospital Compliance Plan.) 6.6 The ICO will maintain the confidentiality and security of any information received pursuant to the Sanctions Checks. 6.7 If results of the Sanctions Checks will be retained, such information will be maintained in a separate secure file. 7.0 Sex Offender Registration 7.1 Subject to the Risk determination in Section 7.2 below, MD Anderson will not employ, continue to employ, appoint, or continue to appoint an individual if information is obtained that the individual has been convicted or placed on deferred adjudication for an offense that would require: A. The individual to register as a sex offender under Chapter 62, Code of Criminal Procedure, which includes, but is not limited to, such offenses as Continuous Sexual Abuse of Young Child, Sexual Assault, Aggravated Sexual Assault; or B. An offense under the laws of another state or federal law that is equivalent to an offense requiring such registration. 7.2 MD Anderson may employ, continue to employ, appoint, or continue to appoint an individual registered as a sex offender or required to register as a sex offender only if all of the following criteria is met: A. The hiring or appointing official, as appropriate, articulates a compelling justification for hiring or appointing the individual; B. The Vice President of Human Resources of MD Anderson, the UTP-H Chief of Police, and the President of MD Anderson concur with that justification; and C. The individual has no higher than a level one (low) Risk as determined by the Risk assessment screening tool implemented pursuant to Chapter 62, Code of Criminal Procedure. If no Risk level had been previously assigned using such Risk assessment screening tool, the Risk level cannot exceed a low Risk as determined by the UTP-H Chief of Police. Page 7 of 10
ATTACHMENTS / LINKS Criminal Background Self-Disclosure Form. Criminal and Personal Background Check Information Requiring Disclosure (Attachment # ATT2051). Hospital Compliance Plan. RELATED POLICIES APRN, RN, and LVN Responsibilities Upon Notification from the Texas Board of Nursing Or Compact Licensing Entity / Regulatory Agency of an Order Policy (UTMDACC Institutional Policy # CLN0634). Classified Employees Appeal Policy (UTMDACC Institutional Policy # ADM0268). Drug Detection and Deterrence Policy (UTMDACC Institutional Policy # ADM0309). Drug-Free Campus & Workplace Policy (UTMDACC Institutional Policy # ADM0278). Grievance Policy (UTMDACC Institutional Policy # ADM0266). Internal Job Application Policy (UTMDACC Institutional Policy # ADM1161). Rightsourcing Temporary Agency Personnel Policy (UTMDACC Institutional Policy # ADM0311). JOINT COMMISSION STANDARDS / NATIONAL PATIENT SAFETY GOALS EC.02.01.01: The hospital manages safety and security risks. Comprehensive Accreditation Manual for Hospitals (CAMH), 2017. HR.01.02.05: The hospital verifies staff qualifications. Comprehensive Accreditation Manual for Hospitals (CAMH), 2017. LD.04.01.01: The hospital complies with law and regulation. Comprehensive Accreditation Manual for Hospitals (CAMH), 2017. OTHER RELATED ACCREDITATION / REGULATORY STANDARDS Texas Education Code, Section 51.215(c), http://www.statutes.legis.state.tx.us/docs/ed/pdf/ed.51.pdf Texas Government Code, Section 411.082, http://www.statutes.legis.state.tx.us/docs/gv/pdf/gv.411.pdf Texas Government Code, Section 411.094(1)(2), http://www.statutes.legis.state.tx.us/docs/gv/pdf/gv.411.pdf Page 8 of 10
Texas Government Code, Section 411.094(a)(2)(e), http://www.statutes.legis.state.tx.us/docs/gv/pdf/gv.411.pdf Texas Health Safety Code, Section 481.002, http://www.statutes.legis.state.tx.us/docs/hs/htm/hs.481.htm Texas Government Code, Section 559.001, http://www.statutes.legis.state.tx.us/docs/gv/pdf/gv.559.pdf The University of Texas System Policy 124 (UTS124). REFERENCES Bylaws of the Medical Staff Rules and Regulations Organizational Manual Fair Hearing Manual http://inside.mdanderson.org/departments/medical-staff-credentialingservices/files/bylaws.pdf Criminal Background Search as Part of Medical Staff Credentialing. The Department of Health and Human Services. Page 9 of 10
POLICY APPROVAL Approved With Revisions Date: 04/05/2017 Approved Without Revisions Date: Implementation Date: 04/05/2017 Version: 38.0 RESPONSIBLE DEPARTMENT(S) Human Resources Page 10 of 10