When should I report compliance concerns?

If you have seen or heard something that you believe is a potential compliance concern, please call the Hotline or submit an online hotline report. Concerns regarding actual or potential violations of applicable law, regulation, policy, or procedure, or Moffitt's Code of Ethics and Professional Conduct should be reported. Hotline calls are taken very seriously. Situations are investigated and systemic problems are assigned to individuals or committees to be resolved within Moffitt. Some examples of compliance concerns include, but are not limited to:

• HIPAA privacy concerns, such as health information given to the wrong patient, the wrong patient chart used, wrong armband, lost/stolen device containing hospital/patient information, accessing protected health information (PHI) without a legitimate business reason (family members, co-workers, celebrities/VIPs, etc.)
• Specific instances of unacceptable or disruptive colleague behaviors (physical or verbal)
• Employee relations matters (hiring practices, retaliation, discrimination, harassment, workplace conflicts)
• Unsafe work environment
• Documenting or billing for services not provided
• Clinical scope of practice issues (nurse working without a valid certification, medical staff member practicing without the appropriate privileges)
• Using position or Moffitt resources for personal gain, non-work related reasons
• Ongoing, previously reported concerns that require an independent review
• Questions or guidance on matters where it is not possible to speak with an internal business partner or member of leadership

How do I report a compliance concern?

You can submit a compliance Hotline report via telephone at 1-844-760-5840 or online at https://app.mycompliancereport.com/report?cid=hlm

Can I remain anonymous when calling the Hotline or submitting an online report?

Yes, you can choose to remain anonymous when submitting a Hotline report. The Compliance Hotline is supported by a third-party vendor, ComplianceLine. The ComplianceLine does not attempt to identify reporters, whether submitting via telephone or electronically. Reporters have the option to remain anonymous or provide their name and other contact information.Reporters are provided a Report Key that allows for anonymous communication with a member of the Compliance Department.

What information do I need to provide about my complaint?

It is important to provide as many specific details as possible. To initiate a proper investigation, we need details about who is involved, what was said or done, or what reports should be examined. The Compliance team will keep knowledge of the case as confidential as possible until the investigation is complete. In general, details of an investigation are kept confidential even within Moffitt. Information needed to complete a thorough review may include:

• First/last name of person(s) or organization(s) engaged in the alleged wrongdoing
• Description of the event, location, and date/time when the event occurred
• Specific details or synopsis of the concern(s) being raised
• First/last names of witnesses to the event or others who may have knowledge of the concern(s) being raised
• How the event was discovered if the reporter was not a participant or directly involved
• Supporting documentation if available, including policies, memoranda, emails, text messages, etc.

What if I am not sure if I need to report a potential concern?

If you have a general compliance question or are unsure of what your next steps should be, please reach out to the Compliance Department. You can send an email to CorporateCompliance@Moffitt.org or reach out to a specific member of the Compliance team. Individual contact information can be found on MoffittNet

How can I find out if Moffitt has a policy about a topic I am concerned about?

You can search the Moffitt Policy Library using specific keywords and advanced search options including Policy Location and Primary Responsible Party.

Why should I report compliance concerns? What's in it for me?

It is common for Team Members to have second thoughts before reporting suspected or observed wrongdoings. The reluctance seems to come from these perceptions:

• It's disloyal to co-workers to report incidents of wrongdoing
• Fear of retribution or retaliation
• The belief that reporting wrongdoings won't change anything
• Fear that the investigation will be made public

Moffitt is committed to delivering compassionate, high-quality care for our patients while ensuring that our workforce members act with the utmost integrity and professionalism. Workforce members have an obligation to report unsafe practices, unethical behavior, or violations pertaining to the Code, policy or procedure, or applicable law or regulation. When someone's actions violate our Code, policies or procedures, or applicable laws or regulations, it can harm both our workforce members and patients. Moffitt takes any potential violation seriously. Reports of potential misconduct are reviewed carefully, and steps are taken to correct the situation, including disciplinary action when appropriate.

How long will an investigation take?

Each allegation reported through the Hotline is unique, so the estimated time of completion depends on many factors, such as the complexity of the issue, the number of people involved, the nature and extent of documents or other evidence involved, and the urgency of the matter. Reporters may use the Report Key to check on the status of a review or communicate with the lead investigator.

How do I get updates from investigators? How do I share additional details? How do I know the outcome of my report?

Reporters are provided a Report Key that allows for anonymous communication with the lead investigator and/or a member of the Compliance Department. The Report Key is a form of report identification number that allows the reporter to check on the status of a case review or communicate with the lead investigator. On the ComplianceLine homepage, click 'Follow-up' to ask questions, provide updates or inquire about the status of the review.

What does confidentiality mean? Is it the same as anonymity?

Confidentiality means that members of the Compliance Department will not disclose information to individuals outside of the reasonable "need to know" standard. This includes information received, used, maintained, or accessed during the course of normal duties, such as case reviews.
Anonymity (or "anonymous") means that Moffitt team members may report any concern through the ComplianceLine without disclosing their identity. Reports made in good faith will be taken and reviewed without an attempt to identify the reporter.

Be advised that:

• There are circumstances in which confidentiality and anonymity may not be maintained, such as disclosures pursuant to a subpoena or court order, a lawful discovery request, or a disclosure necessary to resolve a potential compliance matter.
• Anonymity applies to an individual's identity.
• Confidentiality applies to information received, used, maintained, or accessed.
• Reporters may choose to release their identity during or after a completed review.
• Information about a reporter's identity, if provided, will be retained in the Compliance Department's records.
• Information shared outside of the ComplianceLine case review process is not protected by the Compliance Department.
• Information shared through the ComplianceLine may lead to indirect identification of a reporter given the specific details provided.