FPO

Employee Handbook
2016 Edition
 Our Mission Statement
We are a community of caregivers
committed to a ministry of healing,
embracing the tradition of Catholic principles,
the pursuit of professional excellence,
and conscientious stewardship.

We help our community achieve the

highest attainable level of health
through education, prevention,
and treatment.
 Dear Employee:

It is my pleasure to welcome you to Holy Name Medical Center. As a

leading health care provider, we take great pride in fostering a caring
and respectful work environment. Our image in the community is
reflected in the way we treat our patients, their families, and each other.

Every employee of Holy Name Medical Center is an important member

of the caregiving team, and we all contribute in some way to the health
and well-being of our patients. Whatever your position, you play an
important role in ensuring that we provide the highest quality health
care possible.

I encourage you to carefully read this Employee Handbook and retain it

for future reference. It contains important information about the Medical
Center and our employment practices. If you have any questions, your
supervisor or the Human Resources Department will be happy to assist
you at any time.

On behalf of the Sisters of St. Joseph of Peace and the Board of Trustees,
welcome to Holy Name Medical Center.

Sincerely,

Michael Maron, President and CEO

i
IMPORTANT NOTICE: Please Read

Employment Relationship
This Handbook is a guide to provide a summary of the Medical Center’s Human
Resources policies and procedures. This Handbook is not intended to be compre-
hensive or to address all the possible applications or exceptions to the general
policies and procedures outlined. Neither the policies in this Handbook, nor any
other written or verbal communication by a supervisor or management, are
promises of any kind by Holy Name. This Handbook is not a contract between
you and Holy Name Medical Center, expressed or implied. Policies and proce-
dures relating to these and other legal obligations are also available on the
Intranet. This guide, and the policies and procedures available on the Intranet,
are subject to change by the Medical Center at its discretion.
This Handbook supersedes and replaces any and all previous handbooks and
any other statements of the Medical Center’s policies, rules, and procedures
relating to the same subject matter. In all instances, the Medical Center’s policies
and procedures will comply with applicable laws, and this Handbook and any
Intranet policy or procedure will be deemed modified, if necessary, to conform to
such laws.
It is your responsibility to read and comply with the policies contained in this
Handbook and any revisions made to it.

Employee Benefits
The information contained in this Handbook is only a brief summary of the
benefits that the Medical Center offers its employees. For a full explanation of
particular benefits, all employees should consult, where applicable, the specific
plan documents. If the benefit summaries contained in this Handbook conflict
with any statement contained in the formal plan documents, those plan docu-
ments supersede anything contained in the Handbook.
The Medical Center reserves the right to interpret, apply, alter, amend, modify,
or discontinue any or all of the benefits provided to employees at its sole and
absolute discretion. The Medical Center will attempt to inform employees as
promptly as possible of any changes in benefits; however, this is not always
practical or possible, and, where this is the case, the Medical Center reserves its
right, in its sole and absolute discretion, to make changes in employee benefits
without prior notice.

ii
 Employment at Will
It is our hope that each employee will find Holy Name Medical Center to be a
fulfilling place to work. Nevertheless, employment with the Medical Center is not
guaranteed. The employment relationship between you and the Medical Center is
at will. This means that either the employee or the Medical Center may terminate
the employment relationship at any time and for any reason with or without
prior notice. Just as an employee may terminate employment with the Medical
Center at any time and without reason, the Medical Center may terminate one’s
employment at any time without cause or prior notice.

Equal Employment Opportunity

Holy Name Medical Center (HNMC) provides equal employment opportu-
nities to all employees and applicants for employment regardless of age, race,
creed, color, religion, national origin, nationality, ancestry, sex (including
pregnancy), familial status, marital status, domestic partnership or civil
union status, affectional or sexual orientation, gender identity or expression,
atypical hereditary cellular or blood trait, genetic information, liability for
military service, and mental or physical disability, perceived disability, AIDS
and HIV status, veteran status and/or any other reasons prohibited by law,
consistent with good faith job qualifications. No form of unlawful discrimi-
nation or unlawful harassment, including sexual harassment, is tolerated.
This policy applies to all terms and conditions of employment, including, but
not limited to, hiring, promotion, termination, benefits, and compensation.
Furthermore, both New Jersey and federal laws prohibit employers from
discriminating against an individual with respect to his/her pay, compensa-
tion, benefits, or terms, conditions, or privileges of employment because of
the individual’s sex under the New Jersey Law Against Discrimination, Title
VII of the Civil Rights Act of 1964, and the Equal Pay Act of 1963.

iii
 Contents
Preface
Letter from the President and CEO i
Employment Relationship ii
Employee Benefits ii
Employment at Will iii
Equal Employment Opportunity iii

Welcome to Holy Name Medical Center 9

History of Holy Name Medical Center 9

Culture & Communication 11

No Harassment or Discrimination 11
Orientation Period and Performance Evaluation 14
Employment Process and Background Checks 15
Information Provided to Holy Name Medical Center 17
Pre-Employment Physical 17
Verification of Licenses and Certification 17
Change of Personal Information 17
Employment Status 18
Overtime 19
Mandatory Overtime 19
Exemptions to Mandatory Overtime 19
Lunch and Break Time 20
Shift and Weekend Differential 20
On-Call Duty 20
Direct Deposit 21
Pay Periods 22
Job Posting 22
Outside Employment 22
Benefits & Time Off 23
Paid Time Off 23
Long-Term Illness Bank 24
Holidays 26
Jury Duty 26
Bereavement 26
Weather Emergency 27
References and Personal Inquiries 27
Employment of Relatives 27

Employee Services 29
LiveWell 29
Employee Health Services (EHS) 29
Occupational Health Services (OHS) 29
Employee Assistance Program (EAP) 29
Smoke-Free Environment and Good Neighbor Policy 30
Lactation and Breastfeeding 30
Security Department Procedures 31
Lost and Found 31
Workplace Safety 31
Chapel 32
Elevators 33
Library 33
Cafeteria 33
Vending Services 33
“Our Gang” Child Care Center 34
Sniffles Club 34
Credit Union 34

Opportunities for Learning 35

Seminars 35
Tuition Reimbursement 35
Business Meeting Etiquette 36
Solicitation and Distribution 37
News Media 37
Telecommuting 37
Communication Tools 39
Cell Phones and Other Mobile Electronic Devices 46
Photographing, Videotaping, or Recording 47
Computerized Data 48
Language Bank 48

Workplace Standards 49
Language Awareness 49
Dress Code 49
Workplace Violence 52
Substance Abuse and the Impaired Professional 54
Fit for Duty 56
Unacceptable Behavior and Disciplinary Action 56

Counseling & Discipline 59

HNMC’S Counseling Guidelines 59
Attendance 60
Problem Resolution Procedure 63

Leaves of Absence 65
Family and Medical Leave of Absence 65
Accommodations 69
Extended Medical Leave 70
Workers’ Compensation 70
New Jersey SAFE Act 71
Emergency Disaster Leave 73
Personal Leave 74
Educational Leave 74
Military Leave 74
Employment Notices 75
Confidentiality and Security Agreement 75
Conflicts of Interest and Ethical Conduct 79
Deficit Reduction Act Policy Summary 79
Staff Rights and Responsibilities 81

If You Should Leave 82

Resignation 82
Unemployment 82
Re-Employment 82
Retirement 83
Death 83

PTO Appendix 84
Welcome
to Holy Name Medical Center
The History of Holy Name
Medical Center
Holy Name Hospital and Holy Name
School of Nursing were both founded
in 1925 by the Sisters of St. Joseph of
Peace. The main hospital, which
housed 115 patient beds, was erected
on the estate of the late William
Phelps. Today, now known as Holy
Name Medical Center, the facility
has expanded to 361 beds on its
main campus with off-site locations
throughout northern New Jersey. The
Medical Center provides high quality
health care across a continuum that
encompasses education, prevention,
early intervention, comprehensive
treatment options, rehabilitation, and
wellness maintenance—from pre-
conception through end of life.
Over the last decade Holy Name
Medical Center has grown significantly,
opening a medical fitness center,
HNH Fitness, and an off-site Center
for Physical Rehabilitation — both
in Oradell — and Villa Marie Claire
in Saddle River, the only freestanding
residential hospice facility in Bergen
County. A new and expanded Emer-
gency Care Center and Center for
Physical Rehabilitation have also
opened on the Teaneck campus to
accommodate increased patient
volume. The Medical Center has
recently established the Institute for
Simulation Learning to provide
innovative training methods that
9
WELCOME
enhance quality, safety, and performance
by bringing together professionals
from multiple disciplines who
replicate medical and non-medical
scenarios. It is the only such facility in
Bergen County and one of only two in
New Jersey registered with the Society
for Simulation in Healthcare.
The Medical Center has not only
grown structurally, it has developed
award-winning cultural outreach
programs in recognition of the diverse
needs of our patient population. Holy
Name Medical Center’s Asian Health
Services is committed to breaking
down barriers to health care by
providing Korean-Americans,
Chinese-Americans, and Filipino-
Americans in the greater New York
and New Jersey area with culturally
and linguistically sensitive medical
services and community outreach
programs. More than 40,000 Asian-
Americans are served annually by the
program. The Hispanic Outreach
Program was developed to create
10
awareness of Holy Name’s commitment
to ensuring the highest level of health
care to members of the Hispanic
community and, consistent with the
Medical Center’s ministry of healing,
to providing services and programs in
a culturally sensitive environment.
Holy Name Medical Center has
grown not only in size but in its
reputation. With awards and recogni-
tion from numerous prestigious
organizations, including The Joint
Commission, American Nurses
Credentialing Center, American
Heart Association/American Stroke
Association, and NJBIZ, Holy Name
Medical Center is ranked among the
top hospitals in our state and the nation
for patient care, clinical performance,
and workplace excellence.
As another milestone anniversary
approaches, look for more advance-
ments and renovations to our Medical
Center.
Culture &
Communication
Holy Name Medical Center is
committed to fostering a high
performance culture. We believe
that consistent, ethical, and quality
patient care and consistent perfor-
mance with our patients, employees,
and community will result in loyal,
long-term relationships. We believe
our service should exceed industry
standards and be the best value for
the community we so dearly serve.
The Medical Center believes in open
communication and values an open
flow of communication with employ-
ees. We have several avenues of
communication, which include
the HR Link, the Intranet, bulletin
boards outside the employee cafeteria,
department meetings, town halls, and
quarterly management meetings for
all managers.
We do great things at Holy Name
and that greatness should be recognized.
We encourage you to communicate
recognition of fellow co-workers and
employees through your supervisor,
Vice President, and/or Human
Resources.
In addition, and just as we encourage
recognition, the Medical Center
encourages open communication
and dialogue across all fronts. Don’t
let a small problem become a big one.
When problems, issues, or questions
arise that affect your work, we encourage
you to raise a concern. While we
maintain an open door policy, we
encourage you to first meet with your
supervisor. If you are not comfortable
with speaking to your supervisor, you
may speak with your manager, Vice
President, and/or Human Resources.
Allegations involving unlawful harass-
ment, discrimination, retaliation, or
workplace violence follow a separate
procedure and must be immediately
reported according to those separate
procedures as described in this
Handbook.
No Harassment or
Discrimination
Holy Name is committed to providing
its employees with a work environment
that is free of unlawful discrimination,
including harassment, on the basis of
any legally protected status. Accordingly,
it is the policy of Holy Name to
prohibit harassment based on age,
race, creed, color, religion, national
origin, nationality, ancestry, sex
(including pregnancy), familial status,
marital status, domestic partnership
or civil union status, affectional or
sexual orientation, gender identity or
expression, atypical hereditary cellular
or blood trait, genetic information,
liability for military service, and mental
11
CULTURE & COMMUNICATION
or physical disability, perceived
disability, AIDS and HIV status, and/
or any other reasons prohibited by law
or any other factor prohibited by
applicable law. Holy Name also
expressly prohibits retaliation against
any employee for making a bona fide
complaint under this policy or for
assisting in a complaint investigation.
It is Holy Name’s objective to
provide a work environment that
fosters mutual respect and working
relationships free of unlawful harass-
ment by or toward employees, clients,
visitors, or suppliers. This policy
applies to conduct at the workplace,
as well as during any Medical Center-
related business activity, whether on
or off Medical Center premises, to
include any posts or content on any
social media websites.
Harassment based on a protected
class constitutes discrimination and is
illegal under federal and state laws.
Sexual or other unlawful harassment
or unlawful discrimination of or by an
employee will not be tolerated, and
appropriate disciplinary action, up to
and including termination of employ-
ment, will be taken against anyone
who violates this policy.
It is the responsibility of each
member of management to create an
atmosphere free of discrimination or
unlawful harassment, sexual or other-
wise, and to immediately report any
reliable information regarding the
same to the Vice President of Human
Resources or his/her designee.
12
In addition, it is the responsibility of
each employee to respect the rights of
his or her co-workers and to utilize
the complaint procedure set forth
below. All personnel are required to
avoid any behavior or conduct that
constitutes prohibited harassment.
In this regard all personnel need
to ensure that their own workplace
behavior and interactions are free
from any behavior that is unwelcome
or offensive, or reasonably could be
perceived as such, or interferes with
the work effectiveness of others.
Sexual Harassment
For the purposes of this policy, sexual
harassment is defined as unwelcome
sexual advances, requests for sexual
favors, and other verbal or physical
conduct of a sexual nature when, for
example: (i) submission to such
conduct is made, either explicitly or
implicitly, a term or condition of an
individual’s employment; (ii) submis-
sion to or rejection of such conduct by
an individual is used as the basis for
employment decisions affecting such
individual; or (iii) such conduct has
the purpose or effect of unreasonably
interfering with an individual’s work
performance or creating an intimidat-
ing, hostile, or offensive working
environment.
Sexual harassment might include
a range of subtle and not so subtle
behaviors and might involve individuals
of the same or different gender.
Although it is not possible to list all
examples of conduct that constitute
sexual harassment, the following are
some examples of conduct, which, if
unwelcome, may constitute sexual
harassment depending upon the
totality of the circumstances, includ-
ing the severity of the conduct and its
pervasiveness:
• Physical contact including
sexually suggestive touching,
groping, kissing, fondling,
pinching, pushing, or brushing
against the body.
• Sexually oriented or explicit
remarks; sexual innuendos;
lewd, off-color, sexually
oriented comments; “dirty”
jokes; or computer images.
• Foul or obscene language.
• Unwanted or offensive Email
or voice-mail messages.
• Graphic or obscene gestures,
suggestive or insulting sounds,
leering, or whistling.
• Display of sexually suggestive
objects or pictures.
• Repeated requests for dates or
repeated sexual flirtations.
• Sexual propositions, demands,
and threats.
• Sexual comments about
someone’s body.
Report and Claim Procedure
It is the policy of Holy Name to
swiftly investigate any claim of
unlawful harassment and take such
measures as are necessary and
appropriate up to and including
termination of employment against
the offending employee.
1. Notification of Appropriate Staff
Personnel who believe they have been
aggrieved by or witnessed conduct
that violates Holy Name’s policies
against discrimination and/or
unlawful harassment should submit a
written complaint to the immediate
attention of their immediate supervisor
or the Vice President of Human
Resources or other members of the
Human Resources Department in
writing; with whomever the employee
is more comfortable discussing the
complaint. Under no circumstances is
an employee required to report a
complaint to the alleged harasser.
Holy Name also encourages individuals
who believe they have been aggrieved
to promptly advise the offender that
his or her behavior is unwelcome or
offensive, but recognizes that it is
not necessary for an individual to
talk to an alleged offender if this is
uncomfortable.
While Holy Name takes all allega-
tions of harassment, discrimination,
and retaliation seriously, employees
should be aware that anonymous
complaints impede the investigative
process.
2. Investigation
Each complaint will be promptly and
thoroughly investigated, regardless of
whether the employee making the
13
CULTURE & COMMUNICATION
allegations desires to refrain from any
further action.
Holy Name expects and requires
full cooperation from all employees in
connection with any investigation.
Depending upon the severity of an
offense, employees may be placed on
suspension pending a full investiga-
tion of the infraction or concern that
was brought forward.
3. Confidentiality
Confidentiality will be maintained
throughout the investigatory process
to the extent practicable and appro-
priate under the circumstances to
protect the privacy of the persons
involved.
4. Protection Against Retaliation
Holy Name forbids retaliation against
anyone for reporting harassment,
registering a complaint pursuant to
this policy, assisting in making a
harassment complaint, or cooperating
in a harassment investigation. Anyone
experiencing or witnessing any conduct
they believe to be retaliatory is to
immediately follow the procedures
outlined above. Appropriate disci-
plinary action will be taken against
the offending employee, up to and
including termination of employment.
5. Responsive Action
In the event that Holy Name deter-
mines that a violation of its policies
against discrimination and/or unlawful
harassment has occurred, appropriate
disciplinary action will be taken, up
14
to and including termination of
employment.
Holy Name recognizes that false
and malicious accusations of sexual or
other harassment or discrimination
can negatively affect innocent people.
Accordingly, if Holy Name determines
that a complaint is not bonafide and
was made maliciously or that false
information was provided, appropri-
ate disciplinary action will be taken
against that employee.
Holy Name reserves the right to
determine what prohibited conduct is
or not under this policy and to take
whatever action it deems necessary
with respect to such conduct. While
this policy sets forth Holy Name’s
goals of promoting a workplace that is
free of sexual and any other form of
unlawful harassment, the policy is not
designed or intended to limit Holy
Name’s authority to discipline or take
remedial action for any workplace
conduct that Holy Name deems
unacceptable, in its sole discretion,
regardless of whether that conduct
satisfies the definition of sexual or
other unlawful harassment.
Orientation Period and
Performance Evaluation
There are several mechanisms by
which the Medical Center provides
training, education, and ongoing
performance management. This
includes but is not limited to: hospital
orientation, clinical orientation and
education (role specific), department
specific orientation, competency
assessment and education (role
specific), and evaluations.
Orientation periods are typically as
follows: for a full-time non-manage-
ment employee, 90 days; newly hired
part-time and per diem employees, six
months; and management level
employees for six months. An
employee’s orientation period may be
extended, in conjunction with Human
Resources, an additional 30 days to
validate the employee’s performance
and/or work habits. This is a time for
both you and your supervisor to get to
know each other. During your
orientation period, you will be
assessed to see if you have the skills,
qualifications, and standards of
competency needed to succeed and
required for your job. The successful
completion of an orientation period
should not be construed as creating a
contract or as guaranteeing employ-
ment for a specific duration.
Employees who transfer into a new
role shall be in an orientation period
for 90 days. This shall apply to
transfers where there is a title change,
department change, and/or a signifi-
cant increase or change in the
employee’s duties and responsibilities.
Status changes, i.e. full-time to
part-time, or part-time to per diem
etc., shall not be considered as being
on orientation.
Competency assessment is an
ongoing, annual process, which is part
of your performance evaluation. Your
annual performance evaluation is an
opportunity for you and your
manager to review goals, performance
factors, and development plans and
make adjustments where needed. The
performance evaluation will become
part of your Human Resources record.
Further, a positive performance
evaluation is not a guarantee of
continued employment or that the
individual will receive a merit
increase or promotion.
While performance evaluations are
designed to provide a basis for better
understanding between employees
and the hospital with respect to job
performance, potential, and profes-
sional development, a performance
evaluation may not list all perfor-
mance deficiencies. Take the initiative
to ask for feedback from your supervi-
sor throughout the year. It will help
you get the information you need to
do your best.
Employment Process and
Background Checks
All employees of Holy Name Medical
Center must undergo a satisfactory
criminal background check, reference
check, and pre-employment physical
that includes a drug screen and
physical demands testing (for roles
that require physical demands
testing). A satisfactory background
check includes, but is not limited to,
the absence of a criminal record that
bears a demonstrable relationship to
15
CULTURE & COMMUNICATION
the applicant/employee’s suitability to
perform the essential duties and
responsibilities of the position.
A conviction, a plea of guilty, no
contest, or a verdict of guilty of an
offense may not necessarily prevent
employment. Various factors may be
considered when reviewing an
employee’s criminal record such as,
but not limited to:
• Nature and gravity of the criminal
offense to include the facts and
circumstances surrounding the
offense or conduct
• Nature of the duties and
responsibilities of the position
• Pattern of other related criminal
convictions
• Age of the applicant when the
criminal offense occurred
• Length of time since the offenses
were committed
• The number of offenses
• Any evidence that the individual has
performed the same type of work
post-conviction with no issues
• The length and consistency of
employment history before and
after the offense or conduct
• Any rehabilitation efforts, e.g.
education/training, etc.
• Employment or character
references and any other
information regarding fitness
for the particular position
• Whether the individual is
bonded under a federal, state, or
local bonding program
16
A complete disclosure of all
convictions for such offenses, except
those that have been expunged or
erased through executive pardon, is
necessary after the initial employment
application process (which is defined
as any period of time after the first
interview) and prior to being consid-
ered for employment. Failure to make
a complete disclosure of such convic-
tions may result in the offer being
rescinded or if already employed,
termination.
Additional background checks
Searches will be conducted with the
Office of Inspector General (OIG)
exclusion list, the Social Security
Administration, and the National
Criminal Database. Verifications of
education will be conducted for
positions requiring a college degree
or above as a minimal requirement,
license and certifications for positions
requiring a license or certification,
and DMV records (for positions
requiring operation of a vehicle).
The Medical Center reserves the
right to request an updated back-
ground check for employment
purposes, including but not limited
to, as part of an internal investigation,
and/or if the Medical Center receives
information that may impact an
employee’s ability to perform his or
her role.
Information Provided to
Holy Name Medical Center
The accuracy of information contained
on the employment application, as well
as the accuracy of other information
you have provided throughout the
hiring and employment process is
very important. Providing false
information, misrepresentation, or
omission of information may result
in termination of employment.
Pre-Employment Physical
A pre-employment physical, which
includes physical demands testing (for
roles that require physical demands
testing) and a drug screen, is required
as part of the pre-employment process
at Holy Name Medical Center. A
refusal to participate in either the
physical demands testing and/or in
the pre-employment substance abuse
screening will result in the offer being
rescinded (refer to Employee Health
Policy: Pre-Placement Physical Exams).
Failure to successfully complete
one or all portions of the required
pre-employment process will result
in the offer of employment being
rescinded.
Verification of Licenses and
Certification
We expect our professional and
technical staff members to keep
current with licensing (to include
driver’s license for positions requiring
operation of a vehicle) and certifica-
tion requirements as determined and
mandated by the job description, State
of New Jersey, or other licensing
agencies.
All professional and technical staff
applicants must present their license
or certification for review during the
interview process or before they begin
work.
Administration must notify the
appropriate licensing or certification
agency of reportable incidents involv-
ing a licensed or certified employee as
required by law. Similarly, current
employees are responsible for immedi-
ately notifying the Medical Center of
any action, pending action, and/or
potential action that may have been
taken or will be taken against their
professional license or driver’s license
as required by the job description.
You may not continue to work in
your professional capacity if you do
not comply with state licensing or
certification standards. In the event
your license or certification is revoked,
your employment will be terminated
immediately.
Change of Personal
Information
Please remember to record any
personal changes such as a change of
name, address, telephone number,
person to notify in case of emergency,
or marital/dependent status with the
Human Resources Department.
17
CULTURE & COMMUNICATION
In reaching you when you are
absent, or after you cease working for
the Medical Center, Holy Name will
use the information in your personnel
file. As a result, it is extremely
important that contact information is
kept up to date. If you wish for the
Medical Center to contact you at a
phone number or address different
from what is contained in your
personnel file, you are responsible for
providing Human Resources with this
new contact information in writing—
providing the new contact informa-
tion to your supervisor or a co-worker
is not sufficient.
Employment Status
Holy Name has established several
employment classifications. Various
employment classifications help to
ensure appropriate staffing levels in all
departments/units that allow flexibility.
Staffing levels may be adjusted on an
as-needed basis. The Medical Center
does not guarantee the number of
hours or days or shifts an employee
is scheduled to work. Full-time,
part-time (benefit-eligible), part-time,
and per diem are defined below and
flexible hours and schedules are
required, based on fluctuating patient
volumes.
An employee’s status will be
determined by Holy Name, and its
determination shall be final and
binding on all persons. These statuses
and classifications do not guarantee
employment for any specific period
18
of time, and employment remains
“at will.” Regardless of employment
classification, all employees are vital
to Holy Name’s success.
Full-time
Full-time employees are regularly
scheduled to work and work 36 – 40
hours per week or 72 – 80 hours per
pay period. They are eligible for Holy
Name benefits subject to the terms,
conditions, and limitations of each
benefit program.
Part-time/Benefit-Eligible
Part-time employees are regularly
scheduled to work and work a
minimum of 40 hours, but less than
72 hours, per pay period. They are
eligible for Holy Name benefits
subject to the terms, conditions, and
limitations of each benefit program
and typically on a pro-rated basis.
Part-time/Non Benefit-Eligible
Employees who are regularly sched-
uled to work and work less than 40
hours per pay period are generally
not eligible for employee benefits
including, but not limited to those
set forth in this manual.
Per Diem
Per diem employees are hired to work
on an “as needed” basis. Their work is
not pre-scheduled, and they are often
required to work holidays so our
regularly scheduled staff have an
opportunity to take time off. Per diem
employees must be flexible in accepting
work assignments. Those who
consistently decline assignments may
be terminated. Per diem employees
are not eligible for benefits regardless
of the amount of hours they work or
are scheduled to work. Per diem
employees shall not work more than
thirty (30) hours per week, or more
than one thousand five hundred and
sixty (1,560) hours per year.
Overtime
If you are non-exempt, you will be
paid time-and-one-half for hours
worked in excess of 40 hours in any
one work week in accordance with
federal and state Wage and Hour Laws.
Exempt employees are not eligible
for overtime pay.
Mandatory Overtime
Holy Name Medical Center strictly
prohibits and shall not require or
mandate hourly employees who
provide direct patient care to work in
excess of an agreed to, predetermined
and regularly scheduled daily work
shift, not to exceed 40 hours per week.
Direct patient care activities are
defined as activities in which an
employee provides direct service to
patients in a clinical setting, including
the emergency department, inpatient
bedside, operating room, or other
clinical specialty treatment areas.
An employee may agree to work
overtime strictly on a voluntary basis
or volunteer to be on call.
An employee’s refusal to accept
overtime shall not be grounds for
retaliatory action, workplace discrimi-
nation, dismissal, discharge, or any
other penalty or adverse employment
actions.
Exemptions to Mandatory
Overtime
Overtime may be mandated in the
case of unforeseeable, emergent
circumstances only as a last resort and
where the employer has exhausted
reasonable efforts to obtain staffing.
An “unforeseeable emergent
circumstance” means an event that
is unpredictable and non-recurring
relating to health care delivery that
requires immediate action.
A reasonable effort is defined
as follows:
• Seeks individuals to volunteer to
work extra time from all available
qualified staff who are working at
the time of the unforeseeable
emergent circumstance;
• Contacts qualified employees who
have made themselves available to
work extra time and contacts
employees on call;
• Seeks and makes use of per diem staff;
• Seeks personnel from a contracted
temporary agency when such
staffing is permitted by law, or
regulation.
All efforts to seek additional staff
and resources must be documented
(i.e. who was called, what time they
were called, and their response). This
requirement shall not apply in the
19
CULTURE & COMMUNICATION

event of any declared national, state, in later or leave earlier. Such practice
or municipal emergency, or a disaster is granted on an exception basis
or other catastrophic event that and must be approved by Human
substantially affects or increases the Resources.
need for health care services or causes
Holy Name Medical Center to activate
its emergency or disaster plan. Shift and Weekend
The Medical Center may provide
Differential
the employee with necessary time, up If you are a non-exempt employee
to a maximum of one hour, to arrange and work four or more hours on an
for the care of the employee’s minor established shift, you will be paid a
children or elderly or disabled family shift differential for those hours
members. worked on the established shift.
The evening shift is established as
3:00 p.m.–11:30 p.m. The night shift
Lunch and Break Time is established as 11:15 p.m.–7:15 a.m.
If you are scheduled to work five
The weekend shift differential
hours or more, you are entitled to one
starts at 11:15 p.m. Friday and ends
half-hour meal period without pay. If
11:30 p.m. Sunday.
you are required to work through
your lunch, you will be compensated
for the one half-hour. Employees On-Call Duty
should avoid working through their
On-call duty is scheduled by your
meal period unless it is required.
supervisor on an equitable basis in
When this happens, the employee
order to have qualified personnel
must inform his/her manager that he/
available to cover emergency situa-
she was unable to take the scheduled
tions.
time for a break and the employee will
be compensated for that time. If you are on call, you are responsible
for ensuring that you can be located if
You may also receive two 15-minute
your services are needed immediately.
breaks during an eight-hour shift.
If you are on call, you should be
Part-time employees who work five
within thirty minutes response time
or more hours, but less than eight
from the Medical Center unless
hours a day may receive one 15-minute
otherwise approved by your supervisor.
break. Breaks are considered time
You are required to provide reliable
worked with pay. Holy Name does not
contact information should we need to
endorse nor allow the practice of
reach you. Employees who have the
terminable breaks, i.e. breaks cannot
responsibility for on-call shifts must
be used at the start or end of an
remain in an unimpaired and fit
employee’s shift in an attempt to come
condition for the entire on-call period.
20
 If you are required to perform
on-call duty, you will be paid at the
established on-call rate, which is
adjusted from time to time by the
Medical Center and may be depart-
ment-specific. Employees called into
work will be paid a minimum of four
hours at a premium rate of time and
one-half their regular rate of pay.
If you are called back a second
time within the same four-hour
period, you will be paid for the actual
time you work during the second call
in. If you are called back a second
time, after the four-hour period has
ended, you will be paid a second
minimum of four hours pay at time
and one-half for the second call in.
If you are scheduled to be on call
for less than the four-hour minimum,
you will receive time and one-half
only for the hours designated as on
call, not for the full four hours.
Treatments or procedures that run
late are considered part of the normal
work day and not on call.
Per diem employees are eligible for
on-call pay. They are not eligible,
however, to receive time and-one-half
their regular rate of pay if called into
work, unless hours worked are in
excess of 40 hours in a work week.
Per diem employees are eligible to be
paid the minimum of four hours at
straight time.
Department directors or managers
decide when to initiate the on-call
system for their area. They are also
responsible for indicating the number
of on-call hours you are paid based on
your time record.
Any exception to this or any
Medical Center policy must be
approved by the Chief Executive
Officer or his/her designee.
Direct Deposit
You have the option of having your net
pay deposited automatically into a
checking or savings account with any
bank that is a member of the Auto-
mated Clearing House System. You
are encouraged to use direct deposit,
and we provide great flexibility with
how you choose to set up your
accounts. You may choose to deposit
all or a portion of your paycheck, and
you may choose to use one or as many
direct deposit accounts as you like.
Some of the benefits of direct
deposit are:
• Peace of Mind: No worries about
mail delays or having checks lost
or stolen.
• Prompt Payment: Deposits are
credited to your account(s) on
payday.
• Convenience: No special trips to
pick up or deposit paychecks.
• Freedom: Payments are automati-
cally deposited, even if you are
traveling on PTO.
• Savings: No check cashing fees.
Many banks offer free or lower
cost checking with direct deposit.
21
CULTURE & COMMUNICATION
Additional information and
applications for direct deposit are
available in the Human Resources
Department.
Pay Periods
Holy Name Medical Center’s work
week consists of seven consecutive
24-hour periods. You will be paid
every other Thursday for pay periods
comprised of two consecutive work
weeks. A pay period consists of two
full weeks, starting on a Saturday at
11:00 p.m. and ending on a Saturday
at 11:00 p.m.
Job Posting
Generally, it is the practice of Holy
Name Medical Center to post all
positions below the director level.
However, in some cases, a position
will not be posted. For instance, a
position may not be posted due to
business reasons or due to confidenti-
ality or employee sensitivity.
You must have completed a
minimum of six months in your
position and be in good standing to
be eligible to apply for a position.
Employees who transfer into a new
position shall be ineligible to transfer
for six months. In addition, employees
who transfer into a new role shall be
subject to and considered in an
orientation status for 90 days. This
shall apply to transfers where there is
a title change, department change,
and/or a significant increase, decrease
22
or change in the employee’s duties
and responsibilities. Status changes,
i.e. full-time to part-time, or part-
time to per diem etc., are not subject
to and shall not be considered in an
orientation status.
Employees with disciplinary action
(written warning or above) or who are
on a Performance Improvement Plan
shall not be eligible for a transfer for
six months following the issuance of
the disciplinary action and/or the
completion of the Performance
Improvement Plan.
Based upon business needs, these
eligibility requirements may be waived
with the written approval of the Vice
President of Human Resources.
Employees are responsible for
monitoring the HNMC careers website
and for completing and filing the
requisite documentation during the
posting period for a specific position.
Outside Employment
Employees who choose to accept
outside employment must understand
that the outside employment cannot
interfere with their regular work
hours or schedules at Holy Name
Medical Center. Regardless of any
existing outside work requirements,
employees are expected to report to
work as scheduled.
Outside employment must also
not present a conflict of interest or
give the appearance of impropriety.
Benefits &
Time Off
Holy Name Medical Center currently
provides full- and part-time benefit-
eligible employees with a variety of
benefits such as medical, dental, and
life insurance. Current summary plan
descriptions about these insurance
benefits are available from the Human
Resources Department. A complete
description of these benefits is found
in the master plan documents. If the
information in this manual or the
summary plan descriptions contradicts
information in the master plan
documents, the master plan documents
shall govern in all cases. Additionally,
no Holy Name representative has the
authority to enter into any agreement
that contradicts the summary plan
descriptions or master plan documents.
Holy Name utilizes a time bank
system for the purpose of paid time
off depending on employment status.
PTO is a terminable benefit. LTI is not
a terminable benefit.
Paid Time Off
Holy Name’s PTO policy consists of
two (2) banks of time:
1) PTO Bank (Paid Time Off )
2) LTI Bank (Long-Term Illness)
Full-and part-time employees
scheduled to work 20 or more hours
per week will accrue PTO. Part-time
benefit-eligible employees accrue PTO
on a pro-rated basis, depending on
their scheduled hours (refer to PTO
Appendix on page 86).
PTO is based on position and
length of service and may be taken
after completion of three months of
employment. Length of service is
recognized at 5, 10, and 25 years.
Specifically, employees in Category 1
move to a Category 2 after five (5)
years of service; employees in Category 2
move to a Category 3 after ten (10)
years of service; and employees in
Category 3 move to Category 4 after
twenty-five (25) years of service. PTO
time must be scheduled with the
approval of your supervisor, according
to the staffing needs of your department.
Unscheduled absences disrupt patient
care as well as departmental operations,
and are therefore subject to discipline
under the Medical Center’s Attendance
Policy.
PTO is accrued at the conclusion
of each pay period. Accrual rates and
23
BENEFITS & TIME OFF
maximum accrual levels are shown
below.
Hourly employees are encouraged
to use their PTO time on full-day or
half-day increments; however, PTO
may be used in hourly increments on
an exception basis. Salaried employees
may only use their PTO bank in
full-day increments. When taking
PTO, accrued Holiday time will be
used prior to accessing an employee’s
PTO bank.
Employees out on any leave of
absence will not accrue PTO. Employees
out on family leave (i.e. care of a child
and/or the placement of adoption or
foster care of a child; or to care for a
family member with a serious health
condition) may use PTO time in order
to maintain salary continuation during
the leave.
You may continue to accrue PTO
time until you reach the maximum
accrual, which is your annual entitle-
Accrual Rates and Maximum Accrual Levels
Full-time Employees
Eligible For: Accrual Rate:
Category 1 5.84 hours
Category 2 7.38 hours
Category 3 8.92 hours
Category 4 10.46 hours
24
ment in addition to 40 hours (prorated
based on scheduled hours). Once the
maximum accrual has been reached,
you will stop accruing additional PTO
time until your balance falls below the
maximum.
You are encouraged to be aware of
your PTO accumulations, and use
PTO appropriately, to avoid reaching
the maximum accrual and forfeiting
the accumulation of additional time.
Upon involuntary discharge by
Holy Name for any reason, or job
abandonment, any banked and unused
PTO days will be forfeited and not be
paid out. In order for an employee to
be eligible for reimbursement for
unused hours in his/her PTO, the
employee must give notice equivalent
to his/her yearly entitlement.
Long-Term Illness Bank
The purpose of the Long-Term Illness
(LTI) bank is to provide benefit-eligible
Yearly Allotment: Maximum Accrual:
152.00 hours 192.00 hours
192.00 hours 232.00 hours
232.00 hours 272.00 hours
272.00 hours 312.00 hours
employees with continuation of salary
while an employee is out on an
approved Medical Leave of Absence
for his/her own medical condition.
LTI may not be used for family leave
purposes (i.e. bond/care of a child
and/or the placement of adoption or
foster care of a child; or to care for a
family member with a serious health
condition).
Long-Term Illness time may be
paid to eligible employees after
completion of 12 months of employ-
ment, and accrues at a rate of 2.16
hours per pay period for full-time
employees. Part-time employees
will have their LTI time prorated
accordingly.
The first 40 hours (or five days) of
a scheduled or unscheduled medical
leave of absence due to an employee’s
own illness or injury will be deducted
from an employee’s PTO Bank (PTO
used for a medical leave of absence
shall be prorated based on scheduled
hours). The sixth day of absence, and
any subsequent consecutive scheduled
days of absence associated with an
employee’s medical leave of absence as
designated by Human Resources, will
be deducted from the LTI bank. Each
time there is another occurrence of
illness or disability, the first 40 hours
(or five days) will be deducted from
an employee’s PTO bank. If the PTO
bank is depleted, the employee will
take the five days unpaid.
Full-time employees are allowed
to accrue up to a maximum of 1440
hours in their LTI bank, and part-time
employees will accrue a maximum of
720 hours. All employees hired on or
before the inception of this policy
with an LTI balance greater than the
maximum of 1440 hours will have all
of those hours frozen and will not be
eligible to accrue additional LTI time
until the hours in their LTI bank drops
below the maximum as noted above.
While out on a leave of absence,
employees will not accrue Long-Term
Illness hours for the duration of the leave.
Employees on leave of absence due
to their own medical condition and
who file for short-term disability
benefits with the state will receive 2/3
of their average weekly wage up to a
maximum (which is established and
determined by the state). Any
employee with a balance of at least
240 hours of LTI may use LTI to
supplement the 2/3 pay the employee
will receive from state disability in
order to receive a whole check.
An employee who transfers from
a benefit-eligible accruing category
(full-time or part-time) into a
non-benefit-eligible non-accruing
category will not be paid out for any
accrued unused LTI time. Additionally,
pay for unused LTI time is not
provided upon termination, resignation,
or retirement.
Upon separation from Holy Name
Medical Center for any reason
(whether voluntary or involuntary),
25
BENEFITS & TIME OFF
and in the event the employee is not
rehired within ninety (90) days of
separation, all unused time in an
employee’s LTI bank will be forfeited.
LTI time will be forfeited regardless of
whether an employee gives advanced
notice of resignation.
Holidays
Holy Name Medical Center recognizes
the following holidays and provides
holiday pay based on the following
eligibility criteria:
• New Year’s Day
• Good Friday
• Memorial Day
• July 4th
• Labor Day
• Thanksgiving Day
• Christmas Day
All non-exempt and per diem
employees who are scheduled and
approved to work any of the holidays
designated by the Medical Center will
receive holiday premium pay equal to
time and-one-half of their regular rate
of pay regardless of the total hours
worked in the work week. In addition,
non-exempt, benefit-eligible employees
working a designated holiday will have
eight hours of holiday time deposited
in their Holiday bank. When taking
time off, accrued Holiday time will be
used prior to accessing an employee’s
PTO bank.
Full-time employees who do not
26
work the holiday and are not on a
leave of absence will receive eight
hours of pay at their regular rate for
scheduled holidays. Part-time benefit-
eligible employees who do not work
the holiday and are not on a leave of
absence will be paid on a prorated
basis at their regular rate.
If you work shifts of more than
eight hours, PTO time can be used
to supplement Holiday pay.
Jury Duty
If you are served notification for Jury
Duty, it is your responsibility to
inform your supervisor immediately.
The respective manager may request,
with your consent, that you be excused
from Jury Duty if your services are
essential to the department.
Full- and part-time benefit-eligible
employees will be paid the difference
between the daily amount paid by the
Court and their regular pay for
scheduled work days.
Evening and night shift employees
will be at their regular rate including
shift differential.
If you perform Jury Duty for only
part of the work day, you are expected
to return to work for the balance of the
work day.
Bereavement
Full- and part-time benefit-eligible
employees are eligible for up to three
working days off with pay immediate-
ly following the death of a parent,
legal spouse, child, brother, or sister.
One working day off with pay is
granted for the death of a grandparent,
grandchild, parent-in-law, brother/
sister-in-law, step-child, or step-par-
ent or any family member who lives
in your immediate household.
Weather Emergency
If the President of Holy Name
Medical Center or his/her designee
declares a weather emergency, you are
encouraged to make every effort to
report to work.
If you are less than two hours late
for work, you will be paid as if you
had worked the entire shift. If you
are more than two hours late, you will
be paid for two hours excused time,
plus the amount of hours worked.
Non-exempt employees who work
beyond their regular scheduled shift
will receive time and one-half for
additional time worked.
If you are not able to report to
work as scheduled during a Medical
Center declared emergency you may
use your accrued PTO time. You are
also responsible for informing your
department that you will not be in.
References and Personal
Inquiries
All requests by prospective employers
for verification of your employment at
Holy Name Medical Center should be
referred to our Human Resources
Department.
To that end, all personal phone
calls and/or inquiries regarding an
employee and/or his/her status
regarding either employment or
current availability at work should
be directed to Human Resources.
Human Resources will neither
confirm nor deny the employee’s
status but rather ensure delivery of
the message to the employee.
Employment of Relatives
Working with an immediate family
member or a close relative can create
problems in reporting relationships or
conflicts of interest — whether in a
work assignment or as a result of a
transfer or promotion.
Immediate family members or
close relatives may not be permitted
to work in the same department. In
general, this may include a spouse,
domestic partner, brother, sister,
parent, parent-in-law, child, step-child,
sister, sister-in-law or brother-in-law,
daughter-in-law or son-in-law, or
other members of your household. In
departments where family members
are working together or where family
relationships exist or develop that
pose or may pose a potential conflict
of interest, one family member must
transfer at first opportunity and/or
be required to separate employment
within a reasonable time frame as
27
BENEFITS & TIME OFF

determined by the Medical Center. members from working within the

The affected employees will be
permitted to choose who will resign,
but if they cannot do so, the Medical
Center will make the decision as to
which of the employees will leave.
Applicants seeking employment
with the Medical Center and current
employees looking to transfer in or out
of their departments must disclose any
potential conflict of interest due to
family relationships at the time of hire
and/or transfer. Family relationships
do not necessarily preclude family
Medical Center; rather the supervisory
oversight (such as lead roles, charge
roles or supervisory/managerial roles,
reporting relationship and/or chain of
command within the department in
which the employees will be working)
shall determine the appropriateness
of the hire and/or transfer.

28
Employee
Services
LiveWell
Holy Name Medical Center estab-
lished LiveWell, a program to enhance
employee health and wellness. As part
of the program you will have the
opportunity to participate in various
wellness programs and initiatives.
Employee Health Services is open
five days a week: Monday –Friday
Employee Health Services from 7:30 a.m. to 4:00 p.m. Please
arrive by 3:30 p.m.
(EHS)
Employee Health Services provides
required pre-placement physical Occupational Health Services
examinations for all new hires. Once (OHS)
onboard, mandatory annual medical
Initial care for injuries that occur at
surveillance screenings for tuberculosis
work is provided to injured employees
are provided through Employee Health
free of charge. Your care will be
Services, as well as the required wellness
directed through OHS. Employees
screenings for the LiveWell program.
who become ill while at work and
The annual flu vaccination program is
need immediate treatment will be seen
also spearheaded through EHS on a
either through OHS or the Emergency
seasonal basis with flu shots available
Department, as clinically appropriate.
free of charge.
In all cases ill employees will be referred
Education regarding wellness and to their primary physician for further
the wellness programs will be provided treatment.
through EHS in tandem with the
LiveWell initiative.
Physician resources for employees Employee Assistance
regarding their own medical care are Program (EAP)
available through the department as Holy Name Medical Center recognizes
well as on the Intranet under Physician the importance of fostering an environ-
Listings. ment that supports the well-being of

29
EMPLOYEE SERVICES
its employees. The EAP is available to
you and your immediate family as the
first resource to consider when help is
needed in coping with a difficult
situation. Resources and referrals are
available for financial, legal, marital
and family issues, in elder care, as well
as in times of emotional stress or
personal crisis.
Strictest confidentiality is main-
tained for all participants. Additional
information about EAP is available in
Human Resources and/or Employee
Health Services.
The methods by which the EAP
may be accessed are as follows:
Voluntary Referrals — An employee
can contact the EAP provider whenever
he/she has an issue.
Supervisory Referrals — As a
manager you can recommend that an
employee contact the EAP provider if
the employee is having personal issues,
especially if those issues are having an
adverse effect on the employee’s ability
to perform well at work.
Mandatory Referrals — In serious
circumstances, employees may be
required to contact the EAP provider
if Human Resources decides EAP
assistance is needed. Mandatory
referrals are considered a condition
of continued employment with the
Medical Center; otherwise, your
employment may be terminated.
Only Human Resources can make
mandatory referrals, and employees
30
who are referred must contact the
EAP and follow the recommended
interventions.
Smoke-Free Environment
and Good Neighbor Policy
Holy Name’s campus is completely
smoke-free. Residents within the
community we serve have expressed
concern about our employees smoking
and congregating near their homes. To
improve neighbor relations, we are
compelled to implement this Good
Neighbor Policy, which prohibits
smoking and/or congregating by
employees on the streets adjacent to
our campus. As a smoke-free campus,
and in consideration of our neighbors,
we need to better ensure that smoking
is not pushed off campus toward our
neighbors’ properties. This policy
applies to smoking in any form
through use of tobacco products
(pipes, cigars, and cigarettes) or
vaping with e-cigarettes.
Lactation and Breastfeeding
Holy Name Medical Center supports
breastfeeding mothers by accommo-
dating the mother who wishes to
express breast milk during her
workday when separated from her
newborn child. For up to one year
following the child’s birth, an employee
who is breastfeeding her child will be
provided reasonable break times to
express breast milk for her newborn
each time the employee has a need to
express milk. It is your responsibility
to clearly state that the reason you are
requesting the break at a particular
time is in order to express breast milk.
If you do not believe you are being
provided with the requested breaks,
you must immediately bring this to
Human Resources’ attention. Employees
seeking to express milk can do so in
Labor & Delivery.
Security Department
Procedures
Employee protection is a shared
responsibility with the Security
Department. Security has developed
policies specific to your safety. As part
of the Medical Center’s initiatives to
improve patient and employee safety
and treatment, a video monitoring
system has been installed in the
Medical Center. The video monitoring
system operates only in public areas of
the Medical Center and will not be
implemented in areas that would
otherwise be considered private (e.g.
restrooms, locker rooms, etc.). In light
of this policy, employees should have
no expectation of privacy in their
activity conducted in the public areas
of the Medical Center. This system will
record and retain footage captured in
the Medical Center to ensure that we
are providing high-quality service to
our patients. In addition, it is a violation
of Medical Center policy to disable
or otherwise tamper with any video
monitoring system.
In addition, photo IDs are required
to be worn by all employees, and
employees are not allowed to share or
otherwise utilize another employee’s
badge at any time for any reason. This
helps identify you to patients, visitors,
and staff. Security should be alerted to
any suspicious situation or individual.
Lost and Found
You are required to notify the Security
Department regarding any item
reported missing. Security maintains a
log of all items found that may belong
to patients, visitors, or employees.
Holy Name Medical Center is not
responsible for personal property or
valuables that may be lost or stolen on
the premises.
Workplace Safety
It is everyone’s job to keep Holy Name
Medical Center a safe place for patients,
visitors, and staff. The HNMC Safety
Committee is a multi-disciplinary
group that is charged with the coordi-
nation of our Medical Center-wide
safety program.
You are required to be vigilant in
adhering to the many policies and
programs established to enhance
workplace safety. Safety Committee
rounds are conducted regularly in
every department to monitor employee
awareness of important issues such as
the fire and disaster plans, electrical
safety precautions, and equipment
maintenance procedures.
31
EMPLOYEE SERVICES
You are also responsible for
reporting unsafe acts or unsafe
conditions to your supervisor, who
will endeavor to correct the situation.
Supervisors are responsible for
educating staff about occupational
hazards, specific workplace safety
practices, and availability of equip-
ment designed to protect you and
enhance environmental safety.
Chapel
The Medical Center accommodates
the patient’s right to religious and
other spiritual service.
In recognition of the healing support
of prayer, Holy Name Medical Center
has available a chapel as a place of
Chapel — Scheduled Services
Roman Catholic Eucharistic Service
Roman Catholic Eucharistic Service
Roman Catholic Eucharistic Service
32
worship for private and/or ritual use.
Designed with flexibility, it welcomes
use by all faiths including — Christian,
Hebrew, Moslem, Hindu, Buddhist,
and interfaith events.
The chapel is located on the lobby
level. The furnishings in the chapel
have been recycled from furnishings
that were used in the original chapel
of the Sisters of St. Joseph of Peace.
They include stained glass, marble, wood
sculpture, paintings, and bronze works.
Check with the Pastoral Care office
for further information and/or service
request. Please see the chart of
scheduled services.
The Eucharist is distributed daily
from 9:00 a.m.–4:00 p.m. Jewish
services are held on major holy days.
Monday – Friday • 11:30 a.m.
Saturday • 8:00 a.m. and 3:45 p.m.
Sunday • 8:00 a.m.
 An emergency baptism may be
requested should a baby be in crisis.
A Catholic priest is always available
for the Sacrament of the Sick or
Reconciliation, and/or for patient/
family prayer support. A Pastoral Care
staff member visits patients daily. A
book of prayer intentions is available
in the chapel for individual intentions.
The chapel is open at all times.
ALL ARE WELCOME.
Elevators
Patients always have first priority for
elevator service. Avoid using elevators
that have been designated for patient
transport and ancillary services.
The stairways are recommended for
use whenever possible. During a fire
alarm or emergency, elevators should
not be used.
Library
Holy Name Medical Center maintains
a library to serve the informational,
educational, and research needs of its
employees, students, and medical staff.
The Library has an audio-visual room
for listening and viewing as well as
access to the Internet.
Library hours are Monday through
Friday from 8:00 a.m. to 4:30 p.m.
You are welcome to use the library
during your non-working hours. The
Medical Center’s policies, including
but not limited to, Communication
Tools, Security, and Confidentiality
apply to the use of equipment in the
Library.
Cafeteria
The Terrace Cafe employee cafeteria is
located on the first floor adjacent to the
Oak Elevators. Meals are available for
breakfast, lunch, dinner, and break
times Sunday through Saturday, 7:00
a.m. –7:00 p.m. The cafeteria offers a
wide variety of food choices. Prices are
subsidized by the Medical Center as a
benefit to employees.
Breakfast is available 7:00 a.m.
- 9:45 a.m. to accommodate various
shifts and morning breaks. Lunch
service begins at 11:00 a.m. through
2:00 p.m. After 2:00 p.m. the self-
service areas remain available to
accommodate employees who require
later meal service. Dinner service
begins at 4:30 p.m. through 7:00 p.m.
Our aim is to offer appealing and
wholesome food in an area of relax-
ation from the fast-paced work day.
Feel free to share with the Department
of Food and Nutrition Services any
suggestions to help us serve you better.
Vending Services
Vending areas are located next to the
Maple Elevators on the Lobby Level
and in the Emergency Department
waiting area. They are provided for
the convenience of employees and
visitors alike.
33
EMPLOYEE SERVICES

“Our Gang” Child Care Center

“Our Gang” provides a program
designed to care for your child and
foster his or her growth and develop-
ment in a safe, comfortable, and
stimulating environment.
We meet the educational, social,
emotional, and physical needs of
children 2-1/2 months to 5 years of
age. This on-site facility opens its years who are too sick to attend their
doors at 6:45 a.m. and closes at 6:30 regular child care center or school.
p.m., Monday through Friday. We are Your child may stay as many hours as
open all year round except for major needed on weekdays between 6:30
holidays. a.m. to 6:00 p.m.
“Our Gang” is licensed by the State The “Sniffles Club’s” services are
of New Jersey, Department of Children available to full- and part-time
and Families. employees at no cost. You must
pre-register your child well in
advance of admission.
Sniffles Club
When you are unable to stay home to
care for your mildly ill child, the
Credit Union
“Sniffles Club” of Holy Name Medical As a Holy Name Medical Center
Center can give your child the medical employee, you are eligible to join the
care and attention he or she needs to Central Bergen Federal Credit Union.
get well. Applications are available in the
Human Resources Department.
The “Sniffles Club” cares for
children ages three months to 14

34
Opportunities
for Learning
Seminars
If you are a full- or part-time benefit-
eligible employee, you will be paid at
your regular rate of pay while attending
an approved outside meeting, seminar,
or convention that is directly related to
your job or to gather information that
is relevant to the operation of the
Medical Center. You will be asked to
provide receipts for reimbursement
of expenses.
All requests to attend a meeting
outside the Medical Center must be
in writing and submitted at least one
month in advance for approval from
the Department Head and appropriate
Vice President.
Tuition Reimbursement
If you are a full- or part-time benefit-
eligible employee who has completed
three full months of employment prior
to course registration, you may apply
for tuition reimbursement for certain
courses.
Courses must directly relate to your
current job or departmental work or
be part of a formal program leading to
a degree with a major in an area that
could be beneficial to the interests of
the Medical Center to be eligible for
tuition reimbursement. Courses for
ification
license or certifi tion are not covered
by tuition reimbursement.
In order to be eligible to receive
tuition reimbursement, prior to course
registration, you must submit a com-
pleted application for approval to your
Department Head, the appropriate
Vice President, and the Human
Resources Department. Forms and
additional information are available in
the Human Resources Department.
Reimbursement will be made after
the course, program, or semester is
completed when:
• You receive a course grade of C
or better (or its equivalent).
• You are an active employee in a
full- or part-time benefit-eligible
status.
• You have submitted proof of
payment and grades to Human
Resources.
Reimbursement benefits will be
forwarded to you from Human
Resources. You are responsible for
any federal or state taxes which may
be due.
35
OPPORTUNITIES FOR LEARNING
Current Tuition Reimbursement
Benefit Schedule Per Tuition
Reimbursement Year
(September through August)
Full-time Employees/Benefit-Eligible
1. Undergraduate Degree: “up to” a
maximum of $5000.00 per tuition
reimbursement year.
2. Graduate Degree: “up to” a
maximum of $5000.00 per tuition
reimbursement year.
Part-time Benefit-Eligible
1. Undergraduate Degree: prorated
“up to” a maximum of $2500.00
per tuition reimbursement year.
2. Graduate Degree: prorated “up to”
a maximum of $2500.00 per tuition
reimbursement year.
Upon successful completion of the
degree and receipt of the final tuition
reimbursement payment, the employee
will have a work obligation require-
ment of one year of continued
employment. If the employee resigns
before this one year period, the
amount of tuition reimbursement
received during the final 12 months
prior to receiving the degree will be
reimbursable to the Medical Center.
The amount reimbursed will be
prorated based on the length of time
worked after receiving the degree.
Business Meeting Etiquette
Meetings are an effective tool for
generating ideas, expanding on
thoughts, and managing group
36
activity. But they can easily fail and be
a waste of time and resources without
adequate preparation, leadership, and
involvement. Choosing the right
participants is critical to the success of
any meeting. The role of the meeting
chairperson is to limit participation to
a small number of individuals who are
relevant to the topics to be discussed
and who can make decisions. Guiding
the meeting to ensure everyone’s
thoughts and ideas are heard so that
there is a free flow of conversation
with no one individual dominating the
discussion is critical. Someone should
always be appointed to take minutes so
that major decisions or action points
are documented. Minutes also provide
a review document for use at the next
meeting so that progress can be
measured.
As a participant, it is important
not to engage in behaviors that
can be disruptive or inconsiderate
of others. Some basic guidelines
include the following:
• Arrive on time. This indicates
respect for the person planning the
meeting and shows that you are
organized and considerate of other
people’s schedules.
• Hold your comments to others
until after the meeting is adjourned.
Conversation during a meeting
is disruptive to other attendees and
inconsiderate of the speaker.
• Abstain from electronics. Silence
cell phones and pagers and do not
put your Blackberry, Treo, or other
 email organizer on the table. Do
not talk on your phone during the
meeting. If the call is an emergency,
excuse yourself from the meeting
and take the call in a private area
where others will not be disturbed.
• Do not dominate the conversation.
Listen to what is being said and
resist the urge to argue with any
one. Allow everyone an opportunity
to express their ideas and opinions.
• Finally, it can be a serious breach
of business etiquette to divulge
information to others about a
meeting. What has been discussed
should be considered as confidential
unless stated otherwise.
• By following these simple guide
lines, the chances of the meeting
achieving successful outcomes will
be greatly enhanced.
Solicitation and Distribution
To ensure against any interruption of
the necessary continuity of Medical
Center activities and for the protection
of patients, employees may not post or
distribute literature or printed materials
of any kind, sell merchandise, solicit
financial contributions, or solicit for
any other cause during working time
without advance administrative
approval. Working time does not
include breaks, mealtime, or the
time before or after the end of the
working shift.
Employees who are not on working
time may not solicit employees who
are on working time for any cause or
distribute literature of any kind to
them. This policy also prohibits
solicitations via the Medical Center’s
email and other telephone communi-
cation systems.
Distribution of literature by employ-
ees is prohibited in work areas and any
patient care areas at all times.
Non-employees are likewise
prohibited from distributing material
or soliciting employees on the Medical
Center’s premises at any time.
Anyone discovering a non-employee
soliciting or distributing literature on
Medical Center premises should
immediately notify Security. Security
shall take appropriate measures to
remove the individual(s) from the
premises and shall notify Administra-
tion accordingly.
News Media
Responses to requests for media cover-
age, press interviews, or story content
will be managed through the Marketing/
PR Department. Any media inquiries
should be directed to the HNMC
Marketing/PR Department. During off
hours, they should be referred to the
nursing administrative supervisor who
in turn will contact the administrator
on call.
Telecommuting
Telecommuting allows certain
authorized employees to work at
37
OPPORTUNITIES FOR LEARNING
home, or at an alternate work station
other than their regular work station
within the Medical Center, as part of
their regular workweek. Telecommuting
is not conducive to every employee
and/or position.
No particular positions have been
designated as “telecommuting
positions”; rather, certain positions
may from time to time be suitable for
performance outside the workplace,
and in such a case, Human Resources,
with input from an employee’s
immediate supervisor, manager, and
Vice President, may provide written
authorization to allow all, or part of,
the duties of the position to be
performed away from the office on a
temporary or ongoing basis. However,
no such arrangement is promised or
guaranteed, and no particular duration
of telecommuting is guaranteed. If
telecommuting is allowed for a
position, it does not change the fact
that attendance may be an essential
function of the position and the
telecommuting was allowed only
on a temporary basis. Even when a
telecommuting arrangement has been
approved, an employee must be
available to work at the regular work
site on telecommuting days if necessi-
tated by work requirements.
If telecommuting is allowed for a
position, it will last for as long as Holy
Name Medical Center determines (in
its sole discretion), that it is appropriate
for the employee, organization, and
the patients we serve.
38
Telecommuting utilizes computer
technology, monitoring technology,
telephone systems, voicemail, fax
machines, and similar technology to
connect employees with the rest of the
organization while they are at an
off-site location. All equipment and
materials provided by the Medical
Center remain the property of the
Medical Center, and the Medical
Center reserves the right to enter the
remote work location at any time to
audit and/or remove the equipment
and/or work materials for compliance
purposes.
Electronic communication systems
that are provided for telecommuting
purposes, including, but not limited
to, laptops, must be used only for Holy
Name Medical Center’s business
activities, and within the scope of the
employee’s job functions. Unlike
electronic communication systems
located on Holy Name Medical
Center’s premises, incidental personal
use is not permissible. All other
policies and procedures relating to the
Medical Center’s communication tools
shall apply to employees who telecom-
mute. Employees should not enter any
personal matter or information into
any of the equipment that the employee
is provided for the purpose of tele-
commuting.
By using Holy Name’s electronic
communication systems, servers, or
equipment to telecommute, an
employee is consenting to the Medical
Center’s monitoring of the employee’s
actions and productivity and any Communication Tools
electronic information or communica-
The appropriate use of communication
tion that the employee created, sent, or
tools, including phones, beepers,
received, transmitted through or
email, voicemail, and Internet access,
stored on Holy Name’s electronic
is provided to make our jobs easier.
communications systems, servers, or
They are Holy Name property and
equipment, regardless of whether the
not intended for personal use. The
employee was working from home or a
following policy outlines the parameters
remote site. Employees who do not
for the acceptable use of these resources:
wish for their actions or productivity
to be monitored in their home or in a This policy defines the boundaries
remote location should not telecom- for the “acceptable use” of Holy Name
mute. Under no circumstances can Medical Center’s electronic resources,
employees use their own personal including software, hardware devices,
computers to telecommute. Internet, email, and network systems.
Hardware devices, software programs,
Employees with written approval
Internet access, email, and network
for telecommuting are expected to
resources purchased and provided by
meet all their job responsibilities,
Holy Name Medical Center are to be
including providing services to patients
used only for creating, researching,
and customers regardless of the work
and processing Medical Center-related
site. Telecommuting is not a substitute
business. By using the Medical
for child or dependent care, and a
Center’s electronic resources, you
telecommuting employee must make
assume personal responsibility for
arrangements for child and dependent
their appropriate use and agree to
care during designated telecommuting
comply with this policy and other
hours. A telecommuting employee
applicable Medical Center policies, as
must minimize personal disruptions
well as city, state, and federal laws and
such as non-work telephone calls and
regulations.
visitors during his or her telecommuting
hours. Hours of actual work while 1. Hardware Devices
telecommuting must coincide with the
All hardware devices acquired by or
employee’s regular work schedule.
on behalf of the Medical Center are
Shift differential is not available in a
Medical Center property. This includes
telecommuting arrangement. Any
but is not limited to desktop comput-
telecommuting arrangement made will
ers, laptop computers, printers,
be on a trial basis for the first three
telecommuter home computers that
months, and may be discontinued, at
are provided by the Medical Center,
will, at any time at the request of the
pagers, cell phones, and smartphones.
Medical Center.

39
OPPORTUNITIES FOR LEARNING
Upon separation, any hardware
devices issued to employees for
portable personal, mobile, or home
use must be returned to the Medical
Center. Employees may be personally
liable for any hardware devices not
returned.
2. Software
All software acquired by or on behalf
of the Medical Center is Medical
Center property.
Holy Name Medical Center does
not lend out or make copies of Medical
Center-owned licensed software for
employees to install on their personal
home computers.
Holy Name Medical Center’s
Information Technology (IT) depart-
ment is exclusively responsible for
installing and supporting all software
on Medical Center computers. Non-IT
employees are not permitted to install
software on Medical Center comput-
ers; this includes, but is not limited to:
software purchased for one’s home
computer, downloaded titles from the
Internet, or pirated copies of any title.
The IT department utilizes PC
monitoring tools that catalog the
software installed on each PC. If
unauthorized software (unauthorized
software is defined as any software not
installed by IT department personnel)
is found on a PC, the department
director will be notified and the
software may be uninstalled. If the
software was uninstalled and then
reappears, an investigation will be
done, and the employee responsible
40
may be subject to disciplinary action
up to and including termination.
3. Internet
Holy Name Medical Center provides
Internet access at many of its PC
resources. The purpose of such access
is outlined below.
Appropriate use. Individuals at Holy
Name Medical Center are encouraged
to use the Internet to further the goals
and objectives of Holy Name Medical
Center. The types of activities that are
encouraged include:
• Communicating with fellow
employees, business partners of
Holy Name Medical Center, and
clients within the context of an
individual’s assigned responsibilities.
• Acquiring or sharing information
necessary or related to the perfor-
mance of an individual’s assigned
responsibilities.
• Participating in educational or
professional development activities.
Inappropriate use. Internet use at
Holy Name Medical Center will
comply with all federal and state laws,
and all Holy Name Medical Center
policy. This includes, but is not limited
to, the following:
• The Internet may not be used for
illegal or unlawful purposes,
including, but not limited to:
copyright infringement, obscenity,
libel, slander, fraud, defamation,
plagiarism, harassment, intimida-
tion, forgery, impersonation, illegal
 gambling, soliciting for illegal
pyramid schemes, and computer
tampering (e.g. spreading computer
viruses).
• The Internet may not be used in
any way that violates Holy Name
Medical Center’s policies, rules, or
administrative directives including,
but not limited to, Holy Name
Medical Center’s separate VPN
agreement, Confidentiality and
Security Agreement, Code of
Conduct, and other IT-related
policies. Use of the Internet in a
manner that is not consistent with
the mission of Holy Name Medical
Center, misrepresents Holy Name
Medical Center, or violates any
Holy Name Medical Center policy
is prohibited.
• In the interest of maintaining
network performance, users should
not send unreasonably large electronic
mail attachments.
Streaming media. Streaming media
broadcasts, such as those that work
with Microsoft Corp.’s Windows
Media Player, RealNetworks, Inc.’s
RealOne Player, Apple Computer, Inc.’s
QuickTime Player, Musicmatch Inc.’s
Musicmatch Jukebox On Demand,
WebShots, and other streaming media
applications, consume significant
network bandwidth and can delay
access to and/or prevent other employees
from accessing legitimate business
resources and completing business-
critical tasks. Streaming media files
also require large amounts of storage
space when saved to a hard disk. In
order to ensure the organization’s
resources are used properly, and in
order to minimize costs, employees
may only download streaming media
files which serve specific business-
related purposes.
Instant Messaging. Instant Messaging
(IM), also known as real-time Internet
chat, is prohibited at Holy Name Medical
Center. Examples of IM applications
include AOL Instant Messenger, MSN
Messenger Service, Yahoo! Messenger,
and ICQ. Besides using up a portion of
the available network bandwidth, some
IM applications provide file transfer,
which could introduce a virus on to
the Medical Center’s network, and
finally may distract one’s ability to
perform his/her job.
Monitoring and filtering. Holy Name
Medical Center may monitor any
Internet activity occurring on Holy
Name Medical Center equipment.
Holy Name Medical Center employs
filtering software to limit access to sites
on the Internet. If Holy Name Medical
Center discovers activities that do not
comply with applicable law or depart-
mental policy, records retrieved may be
used to document the wrongful content
in accordance with due process.
4. Electronic Communication
(email, voicemail, paging,
and fax).
As a productivity enhancement tool,
Holy Name Medical Center encourages
the business use of electronic commu-
nication (email, voicemail, paging, and
41
OPPORTUNITIES FOR LEARNING
fax). Electronic communication systems
and all messages generated on or
handled by electronic communication
systems, including back-up copies, are
considered to be the property of Holy
Name Medical Center and are not the
property of users of the electronic
communications services.
Authorized usage. Holy Name
Medical Center’s electronic communi-
cation systems generally must be used
only for business activities. Incidental
personal use is permissible so long as:
• It does not consume more than a
trivial amount of resources;
• It does not interfere with staff
productivity;
• It does not preempt any business
activity.
Employees should not enter
personal matter into Holy Name
Medical Center’s electronic communi-
cation systems. Contents of personal
web-based email accounts accessed
through use of Holy Name Medical
Center’s electronic communication
systems and/or the Medical Center’s
servers and equipment may be stored
42
on hard drives and may be forensically
retrieved and read by the Medical
Center. By accessing a personal
web-based email account on Holy
Name Medical Center’s electronic
communication systems, an employee
is consenting to the Medical Center’s
access to the employee’s personal
web-based email account. By using
Holy Name’s electronic communication
systems, servers, or equipment, an
employee is consenting to the Medical
Center’s monitoring of any electronic
information or communication that
the employee created, sent, or received
transmitted through or stored on Holy
Name’s electronic communication
systems, servers, or equipment,
regardless of whether it was for
personal use.
Email address. Holy Name Medical
Center issues an email address to
employees whose job duties require
electronic communication via email.
Employees are reminded that their
email address is their business email
address and should not be used as
their personal email.
No default protection. Employees are
reminded that Holy Name Medical
Center’s electronic communications
systems are not encrypted by default.
If sensitive information must be sent
by electronic communication systems,
encryption or similar technologies to
protect the data must be employed.
Contact the Information Technology
department if this requirement is
needed.
No Expectation of Privacy. By using
Holy Name’s electronic communication
systems, servers, or equipment, an
employee is consenting to the Medical
Center’s monitoring of any electronic
information or communication that
the employee created, sent, received,
or transmitted through, or stored, on
Holy Name’s electronic communication
systems, servers, or equipment. Holy
Name Medical Center, in its discretion,
reserves the right to monitor and to
access any matter created, received, or
sent by its electronic communication
systems, on its systems, or on its
equipment.
Statistical data. Consistent with
generally accepted business practice,
Holy Name Medical Center collects
statistical data about electronic
communications. As an example,
call-detail-reporting information
collected by telephone switching
systems indicates the numbers dialed,
the duration of calls, the time of day
when calls are placed, etc. Using such
information, IT staff monitors the use
of electronic communications to
ensure the ongoing availability and
reliability of these systems.
Message forwarding. Recognizing
that some information is intended for
specific individuals and may not be
appropriate for general distribution,
electronic communications users
should exercise caution when forward-
ing messages. Holy Name Medical
Center sensitive information must not
be forwarded to any party outside
Holy Name Medical Center without
the prior approval of a director or vice
president.
5. Passwords
For security purposes, users may not
share account or password information
with another person. Attempting to
obtain another user’s account password
is strictly prohibited. Users are
required to obtain a new password if
they have reason to believe that any
unauthorized person has learned their
password. Individual passwords do not
guarantee confidentiality or prevent
access by Holy Name Medical Center.
All passwords are the property of Holy
Name Medical Center.
6. Limited Personal Use
This is defined as any personally
initiated online activity (including
email and Web usage) that is conducted
for purposes other than those listed
above. It is limited by the following
considerations:
• It shall not cause any additional
expense to the Medical Center
or department;
43
OPPORTUNITIES FOR LEARNING
• It shall be infrequent and brief;
• It shall not have a negative impact
on overall employee productivity;
• It shall not interfere with the
normal operation of your
department or work unit;
• It shall not consist of downloading,
transmitting, viewing, or possessing
electronic information or materials
that may be considered pornogra-
phic, sexually explicit, profane,
racist, sexist, or offensive materials;
• It shall not consist of work for
another employer or be for
purposes of self-employment;
• It will be ethical and not violate
any policies of the Medical Center.
7. Failure to Comply
Violations of this policy will be treated
like other allegations of wrongdoings
at Holy Name Medical Center.
Allegations of misconduct will be
handled according to HR procedures.
Sanctions for inappropriate use of
the Internet may include, but are not
limited to, one or more of the
following:
• Disciplinary action up to and
including termination according
to applicable Holy Name Medical
Center policies;
• Legal action according to applicable
laws and copyright agreements.
8. Social Media
Social media includes all aspects of
internal and external social media and
44
social networking tools and channels,
including blogs, defined as a website,
usually maintained by an individual
with regular entries of commentary,
descriptions of events, or other
material such as graphics or video,
Facebook, LinkedIn, Twitter, Wikis,
social video (such as YouTube),
photography sharing sites (such as
Flickr), etc.
This policy applies to employees,
physicians, contractors, vendors,
volunteers, student nurses, and all
other students using Holy Name
Medical Center (HNMC) facilities for
teaching purposes (“Covered Persons”).
Everyone associated with HNMC
who communicates via social media
must do so in a responsible manner,
and within the guidelines outlined in
this policy. Social media activities are
not permitted during working hours,
including accessing social media sites
through a personal computer, smart
phone, or other technology during a
work shift, or in working areas. When
using social media while off duty and
in non-work areas, Covered Persons
are bound by all HNMC policies,
procedures, and rules governing
workplace conduct that include, but
are not limited to, those that pertain to
patient privacy, the use and disclosure
of confidential and proprietary
information, and discrimination and
harassment.
In order to ensure that HNMC and
Covered Persons adhere to their
ethical and legal obligations, all
Covered Persons are required to
comply with HNMC’s Social Media
Policy. The intent of this Policy is not
to restrict the flow of useful and
appropriate information, but to
minimize the risk to HNMC and its
employees.
No patient information is to be
posted on any social media at any
time. Covered Persons may not use
non-hospital-issued cell phones with
photographic capability in patient care
areas. Covered Persons are advised not
to engage in social networking with
current or former patients as it could
constitute a HIPAA violation. However,
should circumstances exist that would
necessitate such networking, Covered
Persons must abide by all applicable
codes of conduct and/or ethics
associated with their profession,
certification, license, etc. Also,
Covered Persons must comply with
applicable HNMC policies concerning
employee-patient relationships and/or
communications.
Blogs/posts may not contain any
content that:
a. Violates any laws pertaining to
privacy of patients or Covered
Persons.
b. Impersonates other Covered Persons
(e.g. borrowing passwords).
c. Infringes upon any third-party rights
(including intellectual property
rights).
d. Is defamatory or libelous or might
be construed as discrimination,
harassment, or disparagement on
the basis of race, color, religion, sex,
sexual orientation, national origin,
age, disability, or any other status
protected by applicable law.
e. Violates any HNMC workplace
policy, including but not limited to
policies against discrimination,
harassment, disruptive conduct, and
violence in the workplace.
f. May be considered disparaging
about HNMC, its employees,
volunteers, or physicians in violation
of HNMC’s Harassment policy.
g. Constitutes an endorsement of a
commercial product by HNMC.
h. Discloses information that refers to
HNMC or its business operations,
personnel, products, or services
or if the Covered Person’s name is
generally associated by the general
public with HNMC, the Covered
Person blogger/poster must make it
clear to readers that views expressed
are his/her alone and that they do
not reflect the views of HNMC, by
stating, for example, “The views
expressed in this blog or posting are
my own. They have not been
reviewed or approved by HNMC.”
i. Contains the HNMC logo or any
registered trademarks.
j. Represents himself or herself as
spokesperson or agent of HNMC.
These guidelines apply even if a
Covered Person is posting anony-
mously or under a pseudonym.
HNMC will take steps, when appro-
priate, to determine the identity of a
person posting information about
45
OPPORTUNITIES FOR LEARNING

HNMC. HNMC also reserves the right
to take any legal action that may be
necessary to protect patient privacy
and HNMC’s registered trademarks,
service marks, and proprietary or
confidential information.
If the Covered Person has any
uncertainty about what is considered
suitable content of any blog/post, or if
a Covered Person needs clarification of
any aspect of this policy, the Covered
Person should consult with the
Marketing and Public Relations
Department or the Human Resources
Department before making the
blog/post.
Failure to comply with this policy
and its guidelines may lead to disci-
plinary action up to, and including,
termination.
Cell Phones and Other
Mobile Electronic Devices
Cell phones and other mobile elec-
tronic devices such as smart phones
and pagers have become important
tools for both business and personal
applications. In cases where it may be
necessary to have immediate access to
an employee the Medical Center may
issue cell phones and pagers for
work-related communications.
At the same time, these devices can
be a distraction in the workplace. In
order to minimize disruption to
co-workers and to ensure the effective-
ness of meetings, employees are asked
to leave cell phones and pagers in
silent/vibrate mode and to refrain
from answering calls or emails while
meetings are in progress. Similarly, the
use of cell phones at the workplace for
personal calls should be limited to
emergency situations. Emergencies are
interpreted in a broad way to acknowl-
edge the type of quality-of-life
situations where the use of a cell
phone would be appropriate. Examples
include a school nurse calling to say
your child is ill, children calling to let
you know they arrived home from
school safely, and family emergencies
that require your immediate attention.
Even in these instances it remains
unacceptable to answer a cell phone
call while attending a meeting or in a
public setting in your work area.
While at meetings or at your work-
place you should either let the call go
to voicemail or find a private place to
make or receive the call where your
conversation cannot be overheard by
others. In all cases, personal calls

46
during working time should be kept as
brief as possible. In addition, it is both
inappropriate and in violation of this
policy for employees to walk around
the Medical Center with ear buds and/
or to be walking and texting.
You should not be putting in
personal electronic data, photographs,
or videos on any Medical Center
issued cell phone. By using a Medical
Center phone that is connected to the
Medical Center’s network, you are
consenting and agreeing that the
Medical Center has the right, at any
time and for any reason, to review,
monitor, and preserve any communi-
cation that utilizes the Medical Center’s
network in any way, including data,
photographs, and voicemails. The
Medical Center, without notification,
may remotely erase data relating to the
Medical Center, its patients, service, or
business from your issued cell phone.
The remote erasing may affect other
applications and data and result in the
loss of personal data such as pictures,
photographs, or videos.
Employees whose job responsibilities
include regular or occasional driving
or who are issued a cell phone for
business use are expected to refrain
from using their phones while driving.
If acceptance of a call is unavoidable
and stopping the vehicle is not an
option, employees are expected to use
a hands-free device, keep the call
short, and not engage in conversations
that are of a complicated or emotional
nature. Employees who are charged
with traffic violations resulting from
the use of phones while driving will be
solely responsible for all liabilities that
result from such actions.
The Medical Center will not be liable
for the loss of personal cell phones that
are brought into the workplace. Employ-
ees in possession of Medical Center
equipment are expected to protect the
equipment from loss, damage, or theft.
Employees who separate from
employment without returning
Medical Center issued equipment in
good working order will be considered
to have left employment on unsatisfac-
tory terms and may be subject to legal
action for recovery of the loss.
Photographing, Videotaping,
or Recording
An employee’s use of a camera or
audio/video device to record an image
and/or sound recording of a patient or
visitor is prohibited, unless specific
written permission from the patient or
visitor has been obtained in advance.
Specific written authorization must
also be obtained from the patient or
visitor before any patient photography
or recording can be released.
Any employee’s intentional use
of a camera or audio/video device
to record an image and/or sound
recording of another employee is
prohibited unless permission from the
other employee has been obtained in
advance or if the recording is for the
purpose of carrying out a specific
47
OPPORTUNITIES FOR LEARNING

authorized job function. Any use by an • If you leave your computer

employee of a camera or audio/video
recording device that may uninten-
tionally pick up the image and/or
sound recordings of a patient, visitor,
or another employee is prohibited
unless for the purpose of carrying out
a specific authorized job function.
An employee’s use of the camera
or recording function of any mobile
device, such as, but not limited to, a
cell phone or personal handheld
device, is prohibited on Medical
Center premises at all times.
This section should in no way be
interpreted as limiting Holy Name
Medical Center’s right to monitor
or survey the work environment,
including, without limitation the use
of surveillance cameras or as limiting
the Medical Center’s ability to cooperate
with law enforcement.
unattended, make sure no one
else can access information.
• All computer printouts are confiden-
tial and should only be shared with
authorized individuals.
We consider any breach of confi-
dentiality or computer security a
serious matter. Any breach of these
policies may result in disciplinary
action and possible termination.
Language Bank
Human Resources maintains a
Language Bank of employees who
speak foreign languages fluently to
assist patients who need an interpreter.
Only clinical staff are to be interpreters
unless an extreme emergency exists.
The Language Line phone is the first
method to be used unless the patient
refuses and requests another method.

Computerized Data
Sensitivity to confidentiality and privacy
extends to the information stored in
our computer systems.
Here are some important guidelines
to remember when using Medical
Center computers or accessing data:
• You are responsible for keeping your
password confidential.
• Sharing a password or using someone
else’s password is prohibited.
• Computer users are responsible for
all transactions processed under
their password.

48
Workplace
Standards
Language Awareness
Holy Name Medical Center remains
committed to the expression of its
diversity efforts, which include the use
of languages other than English, but
realizes that specific operational and
patient care requirements necessitate
that communication be clear, concise,
and distinct. To that end, and in order
to ensure that all operational and
patient care requirements are met, the
use of English will be required as
outlined below:
• English will be used when dealing
with or in front of employees,
patients, and/or family members
who express a preference or the
expectation that our employees
speak and communicate in English.
• All directions and/or work directives
will be provided in English. In
addition, all employees shall be
expected to communicate in English
while performing or engaged in such
job duties, tasks, or directives to
better promote cooperation and
efficiency in the workplace.
• All safety, facility, and security-related
materials will be provided in English,
and/or departmental meetings that
relate to business operations, safety,
facility, and/or personal security will
be expected to be conducted in
English.
• English will be used in emergencies
i
or other situations to promote safety
within the workplace.
While this policy will not apply to
casual conversations between employ-
ees on break or who are not currently
performing or otherwise engaged in
the performance of their job duties,
Holy Name expects that all employees
strive to contribute to a collegial and
inclusive environment where co-workers
feel valued as team members. Employees
who are communicating with patients
who have Limited English Proficiency
(“LEP”) are to follow Hospital
Administration’s policy on Language
Interpretation. Employees who violate
this policy may be subject to disci-
plinary action up to and including
termination.
Dress Code
Employees contribute to the organiza-
tional culture and reputation of Holy
Name Medical Center (HNMC) in
the way they present themselves. A
professional appearance is essential to
a favorable impression with patients,
49
WORKPLACE STANDARDS
co-workers, and the community. Good
grooming and appropriate dress reflect
employee pride and inspire confidence.
They are essential to maintaining the
professional atmosphere of HNMC.
Departments will determine if
employees are required to wear
uniforms, or professional or business
attire in accordance with Medical
Center policy. In addition to the Dress
Code, employees who are required to
wear a uniform must review the
Uniform Policy.
Employees requiring the use of
uniforms are issued vouchers at the
time of hire. Employees are issued
uniforms based on their employment
status as follows: full-time employees
are issued three (3) sets, part-time
employees are issued two (2) sets, and
per diem employees are issued one (1)
set upon hire.
In order to maintain a continuous
professional appearance employee
uniforms will be replenished on a
yearly basis. Uniform replenishment
is based on Compensation Level and
Status as identified in the Tiers below.
Tier 1
FT 3 2
PT 2 1
PD 1 1
50
Beginning in January of each year
department heads will issue employees
uniform vouchers that will be redeem-
able for their respective amount of
uniforms as illustrated above. In
addition, uniforms that become
damaged or destroyed through the
normal course of business will be
replaced at the discretion of the
Department Head.
Employees working in areas
requiring the use of scrubs are
required to change into scrub attire in
designated dressing areas upon the
start of their shift, and employees must
change out of the scrubs at the
completion of their shift. Scrubs are to
be discarded into the appropriate
soiled receptacles within the employee’s
respective departments. Employees
arriving to work in scrubs will be
required to change, or at the discretion
of the manager be sent home for the
remainder of their shift. In addition,
employees may not wear scrubs
outside the Medical Center, and
Medical Center-provided scrubs may
not be taken home and may not be
laundered by the employee.
Tier 2 Tier 3
1
1
1
 Employees who work in an office
environment or who are not required
to wear a uniform will follow the
guidelines below for classic professional
business attire.
Options for women include:
• Dress pants with a classic style
blouse or sweater, skirted or
pant suit.
• Sleeveless tops and dresses with
full shoulder
• Cotton twill full-length pants
• Short- or long-sleeved oxford
style dress shirt
• Dresses and skirts of appropriate
and modest length with or without
a jacket.
Options for men include:
• Dress trousers and a short- or
long-sleeved professional-style
shirt, tucked in, with or without tie
• Short- or long-sleeved oxford style
dress shirt
• Tailored sweaters
• Sport coat or suit
• Cotton twill trousers
Employees who normally wear
business attire to work may elect to
wear business casual clothes to work
on Fridays. When considering the
appropriateness of casual business
wear, employees should remember
that their appearance must be consis-
tent with HNMC’s professional image
in the community.
All clothing, uniforms, and
business attire must be clean, neatly
pressed, properly fitted, and suitable
to the professional environment. Attire
should not be tight, revealing, faded,
or in need of repair.
The following items are not in
accordance with this policy:
• Mini-skirts or mini-dresses
• Shorts
• Halter-neck, strapless, spaghetti
strap, tank-top, or low-cut garments
• Casual style Capri pants
• Leggings or spandex
• Sheer clothing
• Sweat pants, sweatshirts, or hoodie
sweatshirts
• Jeans of any color
• Garments made of denim fabric
• Golf shirts
• Casual T-shirts
• Clothing containing messages
• Sneakers for non-clinical personnel
• Flip flops or thong sandals
• Caps or hats
Identification Badge
Employees are required to wear an
Identification Badge while on duty.
The ID badge must be worn on a
hospital-issued lanyard, with name,
title, and picture visible at all times.
The wearing of pins and other insignia
except for the Identification Badge,
school pin, and service pin is prohibited.
Hygiene
Employees are expected to maintain
proper hygiene. Perfumes and
51
WORKPLACE STANDARDS
aftershave, if used, should be worn in
moderation. Hair should be kept neat,
clean, and well groomed at all times.
In areas affecting patient care or food
service, long hair must be neatly
pinned or netted to fulfill state law.
Facial hair may be worn to a conserva-
tive length and neatly trimmed.
Footwear must be clean, neat, in
good condition and appropriate for
the work area. Shoes that expose the
toes are not permitted for patient
contact staff. Clinical clogs are
permitted but may not have holes in
the top that could allow blood and
body fluid, or liquids to seep through.
Jewelry is to be kept to a minimum
and should not be excessive in size or
create an unsafe or hazardous condition.
Employees are required to wear
appropriate undergarments. Undergar-
ments should not be visible at any time.
Employees with patient contact may
not have nails longer than ¼ inch.
Polish may be worn but it must be
intact. No artificial nails, charms,
decals, appliqués, or rhinestones may
be worn as per compliance with CDC
Hand Hygiene guidelines. In non-pa-
tient contact areas nails are to be neatly
groomed and to a length that will not
interfere with job performance.
Religious Accommodations
HNMC recognizes the importance of
individually held religious beliefs to
persons within its workforce. HNMC
will reasonably accommodate a staff
member’s religious beliefs in terms of
workplace attire unless the accommo-
52
dation creates an undue hardship, or
results in issues of safety and security
for the particular employee, patients,
or co-workers. Requests for accommo-
dation based on religious beliefs should
be referred to your supervisor and
reviewed by Human Resources.
Managers and supervisors are
responsible for ensuring that staff
members are dressed in a manner
consistent with this policy and the
Uniform Policy. Employees who report
to work in unacceptable dress may be
required to go home, and nonexempt
employees will not be paid for that
time off.
Workplace Violence
Holy Name Medical Center is commit-
ted to preventing workplace violence
and maintaining a safe environment
for patients, visitors, vendors, and
employees. The Medical Center will
not tolerate workplace violence. Any
employee who commits an act of
workplace violence is subject to
disciplinary action up to and including
termination and, if appropriate,
notification to the authorities.
In order to minimize the potential
for workplace violence, the Medical
Center has an emergency response
team, “Code Grey,” that can initially
deal with a workplace violence
situations and/or emergencies. Holy
Name Medical Center provides
restraint training for staff members
in high-risk departments and the
emergency response team.
 Holy Name Medical Center also
strives to prevent violence in the
workplace through, among other
things, the development, implementa-
tion, and maintenance of a Workplace
Violence and Prevention Plan. Each
Holy Name Medical Center staff
member can be an asset to the
Workplace Violence and Prevention
Plan. An alert staff member is capable
of recognizing potential workplace
violence situations and/or risks. Staff
members receive workplace violence
training at new employee orientation
and on a continuing education basis.
Staff members are also responsible for
attending all required workplace
violence education and training
programs and using prescribed
entrance points and showing their
identification badges prior to entrance.
Although it is not possible to list
all examples, the following are some
examples of conduct that may constitute
workplace violence:
• Behavior that exhibits signs of
extreme resentment, hostility, and
anger including, but is not limited
to: yelling, using profanity or
vulgarity, verbally abusing others,
making inappropriate demands,
or refusing a reasonable request for
identification;
• Behavior that includes physical
actions short of actual contact/
injury (moving closer aggressively),
oral or written threats to a person
or property, whether in person, or
other means of communication;
• Behavior that includes physical
assault, with or without weapons;
• Behavior that creates incidents that
are stressful or traumatic and/or
that interfere with an individual’s
or group of individuals’ ability to
effectively function in their work
environment;
• Using greater physical size/strength
or greater institutional power to
intimidate another person;
• Discussing weapons or bringing
them onto Holy Name Medical
Center property.
All Holy Name Medical Center
personnel are responsible for promptly
notifying their manager, the Human
Resources Department, and Security
of any potentially dangerous situa-
tions, including violent acts or threats
of violence that they have witnessed,
received, or have been told that
another person has witnessed or
received. In case of an emergency,
employees are to dial “55,” announce
the emergency “Code Grey,” and notify
the security officer as to the problem
and location (an alternative is to dial
extension “7777”).
When making a report, personnel
should be as specific and detailed as
possible. Employees are responsible for
making this report regardless of the
nature of the relationship between the
individual who initiated the threatening
behavior and the person or persons
who were the focus of the threatening
behavior. Any employee who takes, or
53
WORKPLACE STANDARDS
facilitates another person, to take any
reprisal, regardless of the magnitude
of the reprisal, against a person who
reports any threat of workplace
violence is subject to immediate
discipline, up to and including
termination of employment.
Employees determined to have
committed acts of violence in the
workplace are subject to disciplinary
action, up to and including termination
of employment and may be reported
to appropriate authorities.
In order to minimize the potential
for workplace violence, HNMC:
• Has an emergency response team,
“Code Grey,” that can initially deal
with workplace violence situations
and/or emergencies.
• Provides restraint training for staff
members in high-risk departments
and the emergency response team.
• Has security guards trained on
how to respond to threatening
situations.
Staff Member’s Role and
Responsibilities
Each HNMC staff member can be an
asset to the Workplace Violence and
Prevention Plan. An alert staff
member is capable of recognizing
potential workplace violence situations
and/or risks. Staff members receive
workplace violence training at new
employee orientation and on a
continuing education basis.
54
Staff members are responsible
for the following:
• Promptly and accurately reporting to
their supervisor, the Security
Department, and Human Resources,
all incidents that could be construed
as potentially dangerous situations,
including violent acts or threats
of violence.
• Attending all required workplace
violence education and training
programs.
• Using prescribed entrance points
and showing their identification
badges prior to entrance.
Substance Abuse and the
Impaired Professional
Holy Name is committed to creating
and maintaining a drug-free environ-
ment. The unlawful or improper
presence or use of drugs/alcohol by
Medical Center employees adversely
affects the care delivered to patients
and presents a danger to everyone.
Therefore, the unlawful or unautho-
rized manufacture, distribution,
dispensation, solicitation, sale,
purchase, transfer, or possession of
drugs/alcohol while on Medical
Center property/premises, vehicles, on
paid time or while otherwise engaged
in activities for or on behalf of the
Medical Center or reporting to work
under the influence of same, is strictly
prohibited. Employees who violate this
policy will be subject to disciplinary
action up to and including termination.
Employees are expected to report to
work unimpaired, fit for duty, and free
from the influence of drugs or alcohol.
Employees who have the responsibility
for on-call shifts must remain in an
unimpaired and fit condition for the
entire on-call period.
Reasonable Suspicion
An employee who is reasonably
suspected to be under the influence of
drugs/alcohol while on duty will be
requested by the Medical Center, in all
cases, to report directly to Employee
Health Services, Occupational Health
Services, or the Emergency Department
after hours for medical evaluation and/
or a breath, urine, or other medical
test to determine the presence of
drugs/alcohol. Reasonable suspicion
may be present in situations where an
employee is seen using or in possession
of drugs/alcohol, or exhibits symptoms
of being under the influence of drugs/
alcohol such as the employee’s appear-
ance, odor, conduct, or any abnormal
or erratic behavior. Reports from
law enforcement and/or health care
professionals may also trigger reason-
able suspicion.
Employees under Prescribed
Medical Treatment
Employees using over-the-counter
medications that may impair their
ability to perform their job responsi-
bilities must report this to Employee
Health. Employees undergoing
medical treatment with any prescribed
drug that may impair their ability to
perform their jobs must report the
prescription drug use to Employee
Health. An employee may continue
to work under the influence of a
prescribed drug or over-the-counter
medication only if, after consultation
with Employee Health, it is determined
that such use does not pose a safety
risk and the employee’s job perfor-
mance is not negatively impacted and/
or can be reasonably accommodated.
Prescribed medication must be used
within the limits of a valid prescription
and over-the-counter medications
must be used according to the
packaged instructions.
If justified by medical information
and the employee’s work performance,
the Medical Center may restrict an
employee’s work activity, place the
employee on a leave of absence, or take
other appropriate action to ensure the
safety of the employee and/or action
that will not adversely affect patient care.
Employees who have been found to
be under the influence of drugs/
alcohol will result in the Medical
Center reporting the employees’
behavior to the appropriate licensing
agency, where applicable.
Nothing in this policy is intended
to apply in a manner that is inconsistent
with either the Americans with
Disability Act (ADA) or any other
related federal or state law or regulation.
55
WORKPLACE STANDARDS
Fit for Duty
Employees are responsible for manag-
ing their health in such a way that they
can safely perform their essential job
functions, with or without reasonable
accommodation. When an employee is
having an observable difficulty
performing his/her work duties in a
manner that is unsafe for the employee
and/or patients or his or her co-workers,
or is posing an imminent and serious
safety threat to self or others, the
Medical Center may request that the
employee submit to fit for duty testing.
Fit for duty testing will assist in
determining whether an employee is
capable of safely performing the
essential functions of their role with or
without reasonable accommodation.
Supervisors may refer employees for
fit for duty evaluation only after
consultation with Human Resources.
Employees who are referred for fit for
duty testing will be evaluated by
Employee Health, and the evaluation
may include one or more of the
following: medical, psychological,
alcohol, or other drug conditions. An
employee referred for a fit for duty
evaluation will be relieved of his/her
duties pending completion of the
evaluation.
If an employee is found to be unfit
for duty, his/her employment status
will be determined on a case-by-case
basis. Conversely, employees found to
be fit for duty may only be returned to
work after full medical clearance from
Employee Health, and the employee’s
56
behavior/performance that led to the
request for fit for duty must be discussed
and addressed where applicable and
appropriate.
Unacceptable Behavior and
Disciplinary Action
When an employee’s behavior is
unacceptable, a supervisor or Depart-
ment Head, in consultation with HR,
has the responsibility to take disci-
plinary action. Types of disciplinary
actions vary and may include one,
several, or all of the following: verbal
counseling, written warning, final
warning, and/or termination.
There is no guarantee of progressive
discipline, and employment at Holy
Name Medical Center remains at
will. Any and all action will be within
the sole discretion of the Medical
Center’s administration and manage-
ment staff including termination.
It is impossible to anticipate every
form of conduct that might require
disciplinary action. Although Holy Name
Medical Center reserves the right to
decide what discipline is appropriate,
misconduct of the following nature may
result in disciplinary action up to and
including immediate termination. The
following list is not all-inclusive and
is only intended to provide you with
examples of unacceptable behavior.
The list may be altered or amended
by the Medical Center at any time.
• Conduct or actions that might
endanger patients, employees,
or visitors;
• Patient abuse, neglect, abandonment,
or exploitation;
• Unsatisfactory work performance,
poor work performance, or poor
work habits;
• Loitering in the Medical Center
before or after work, or loitering
while on or off duty at a coworker’s
desk who is on duty;
• Creating or contributing to unsafe
conditions;
• Possession and/or under the
influence of controlled substance,
prescription drugs not being
used within the limits of a valid
prescription, or violation of the
Medical Center’s Substance
Abuse Policy;
• Poor attendance, a pattern of
absences, excessive or unauthorized
absences from work, or abuse of
leave policies;
• Violations of the Medical Center’s
Fit for Duty Policy;
• Sleeping on duty;
• Leaving your work area without
authorization;
• Destruction or theft of Medical
Center’s, patient’s, employee’s, or
visitor’s property;
• Unauthorized use of a computer
security code, Medical Center email/
voicemail system, or unauthorized/
inappropriate use of the Internet;
• Insubordination;
• Unauthorized possession of
firearms, weapons, or explosives
on Medical Center premises;
• Gambling on Medical Center
premises;
• Unauthorized disclosure of Medical
Center records or patient
information;
57
WORKPLACE STANDARDS
• Carelessness or damaging use of
Medical Center equipment or
supplies;
• Fighting, coercing, or threatening
fellow employees with violence
or engaging in disruptive behavior
on Medical Center property, during
working time, or during a Medical
Center sponsored event;
• Violating Medical Center dress
standards or uniform policy;
• Sexual or other forms of unlawful
harassment or unlawful
discrimination;
• Solicitation or acceptance of tips,
gratuities, or personal favors, or
violations of the non-solicitation
policy;
• Swiping another employee’s ID
badge for the purpose of recording
time and attendance, permitting
another employee to swipe your
badge, or tampering with your or
another employee’s time and
attendance record;
• Working overtime without approval;
58
• Conduct, action, or language that
might offend patients or visitors;
• Conduct that is deemed immoral,
unethical, or indecent;
• Falsification of Medical Center
records, including time records,
employment application, employee
medical histories, benefit forms, or
patient records;
• Conduct detrimental to the
Medical Center’s operations or
reputation in the community;
• Breach of confidentiality or
violating HIPAA; or
• Violations of any Medical Center
policy.
Each department has its own
individual rules, and employees must
check with their supervisors regarding
Department policies and procedures.
Failure to comply with departmental
requirements may also result in
disciplinary action, up to and includ-
ing, immediate termination.
Counseling
& Discipline
There are times when an individual
employee is not meeting performance
standards or exhibits conduct that the
Medical Center deems unacceptable.
In those instances, a formal process for
counseling and discipline may be used
to try to correct the situation. All
formal disciplinary measures must be
addressed within 30 (thirty) days of
the occurrence/incident.
Note: The following statements
should only serve as a guide and should
not be relied upon or construed as a
promise or assurance of any kind that
progressive discipline will be followed
in any particular circumstance. The
Medical Center reserves the right to
skip, advance, or repeat any level of
discipline it deems appropriate. Further,
the Medical Center reserves the right
to terminate employees at any time
without cause or notice and without
prior discipline. Any and all actions
will be within the sole discretion of the
Medical Center’s administration and
management staff including termination.
HNMC’s Counseling Guidelines:
Counseling can be conducted through
the use of a Performance Improvement
Plan (“PIP”), a Measurable Action
Plan (“MAP”), or through formal
disciplinary actions.
PIP
A PIP is a tool by which a supervisor
documents the areas of an employee’s
performance that need improvement
and where an action plan is established
addressing each of those areas. Managers
should consult with HR to discuss the
specific concerns as well as the action
plan prior to discussing with the
employee.  Employees who fail to meet
or sustain their improvement as
compared to the criteria of the PIP
may be subject to disciplinary action
up to and including termination.
MAP
A MAP is a tool in which a supervisor
establishes departmental goals and
targets. A MAP is not required but
may be used at any stage in the
coaching or discipline process to help
the manager and employee outline
goals and targets aimed at improving
the employee’s performance and/or
behavior. Unlike a PIP, which is
typically used as one or more steps of
progressive discipline, the MAP may
be used at any time.
59
COUNSELING & DISCIPLINE
Verbal Counseling
If there is a problem with your
performance, your supervisor will
meet with you to talk about it. This
Verbal Counseling is intended to make
you aware of the seriousness of the
situation and to get you back on track.
If it is determined that you need
additional training, your supervisor
and you will need to decide together
what needs to be done in order to
correct the situation.
Written Warning
A Written Warning may be issued
based on continued unacceptable job
performance, conduct, or an infraction
or conduct that warrants this level of
disciplinary action. Your supervisor
will communicate to you in writing
the seriousness of the problem, the
required action and time period by
which the problem needs to be
corrected, and the consequences of
your failure to improve.
If you are issued a Written Warning
by your supervisor, you have the
option to submit your comments in
writing to your Department Head.
Both the Written Warning and
comments become part of your
Human Resources file.
Final Warning or Suspension
If conduct occurs that warrants a final
warning and/or suspension, your
supervisor will communicate to you in
writing the seriousness of the problem.
You will be advised that this is a final
60
warning or suspension, depending on
the circumstances, and if immediate
improvement does not occur, your
employment with the Medical Center
will be terminated.
Depending upon the severity of an
offense, employees may be placed on
suspension pending a full investigation
of the infraction or concern that was
brought forward. Similar to a Written
Warning, your supervisor will document
the Final Warning or Suspension in
writing. You have the option to submit
your comments in writing to your
Department Head. These will also
become part of your Human Resources
file.
Termination
You may be terminated for unacceptable
performance, conduct, inability to per-
form the job, or an initial infraction
that warrants immediate termination.
Attendance
The purpose of Holy Name Medical
Center is to provide the highest quality
patient care and outstanding customer
service. Every employee’s contribution
is an essential part of fulfilling our
mission. The very nature of the
Medical Center’s organization requires
employees to report to work as
scheduled in order to provide high
quality patient care and dependable
service. Attendance is also an important
component of your work record and
job performance. Unscheduled or
unexcused absences, tardiness, or early
departures disrupt patient care and the
operation of your department, and
create a hardship on co-workers who
must pick up your workload in your
absence.
You are expected to be at your
assigned area and ready to begin work
at the start of your shift. In the case of
an unavoidable, unscheduled absence,
tardiness, or the need to leave work
early, you must contact your supervisor
as far in advance as possible and in
accordance with departmental
guidelines. You are expected to contact
your supervisor each day you are
unable to report to work unless other
arrangements are made with your
supervisor.
An employee with excessive
absenteeism, lateness, early departure,
and/or missed time and attendance
swipes is subject to disciplinary action,
up to and including termination.
Absenteeism lateness early departure
Absenteeism, lateness, departure,
and/or missed swipes that warrant
counseling is determined by, among
other things, the number of occurrences
of unscheduled absences, lateness,
early departure, and/or missed swipes
an employee may have. With regard to
absenteeism, an occurrence is defined
as one or more consecutive days of
unscheduled absence, regardless of
what benefit time is used to pay the
unscheduled absence (PTO or
holiday) and regardless of having
provided a doctor’s note. With regard
to lateness, early departure, and
missed swipes, one occurrence is
defined as being late, leaving early, or
having missed a swipe on two separate
occasions in a four-week period.
Leaves of absence pursuant to the
federal Family Medical Leave Act or
New Jersey Family Leave Act will not
be considered an occurrence.
61
COUNSELING & DISCIPLINE
By way of a guideline only, the
following disciplinary action may
be implemented:
• A Verbal Warning may be issued
when an employee incurs five
occurrences in the 12 months
preceding the date of the last
occurrence.
• A Written Warning may be issued
when an employee incurs six
occurrences in the 12 months
preceding the date of the last
occurrence.
• A Final Written Warning may be
issued when an employee incurs
seven occurrences in the 12 months
preceding the date of the last
occurrence.
• Termination may be issued when
an employee incurs eight or more
occurrences in the 12 months
preceding the date of the last
occurrence.
Holy Name Medical Center
reserves the right to accelerate the
level of disciplinary action depending
on the circumstances, including, but
not limited to immediate termination
and the guidelines set forth above
should not be read to the contrary.
By opting to provide an employee
with corrective action measures as set
forth above, Holy Name Medical
Center is not implementing progressive
discipline. Holy Name Medical Center
can terminate such corrective action
measures at any time, solely at its own
discretion. It remains an “at-will”
employer.
62
In addition to and irrespective of
the above, an employee may also be
subject to disciplinary action, up to
and including immediate termination
if the employee:
• Does not report to work as scheduled
and without notification to his/her
supervisor (i.e. No Call/No Show).
• Does not report to work before or
after a scheduled day off, including
holidays, vacation days, weekends
off, or personal days.
• Does not report to work on a day
where a previous request for time
off was denied.
An employee who does not report
to work as scheduled and without
notification for three consecutive days
is considered as having resigned from
his/her position, and he/she is removed
from the Medical Center payroll.
When you anticipate that you will
be late, you are expected to notify your
supervisor as soon as possible in
advance and in accordance with your
departmental policy. If you anticipate
you have to leave work early, you are
expected to notify your supervisor in
advance to obtain permission.
Managers are responsible for
ensuring their employees’ compliance
with the attendance policy.
Each time an employee incurs an
unscheduled absence, lateness, early
departure, or a missed swipe, the
supervisor and/or manager will review
12 months from the date of the most
recent absence, lateness, early departure,
and/or missed swipe and count the
number of occurrences. For example,
if an employee incurs an unscheduled
absence on May 5, 2016, the manager
will review the employee’s time and
attendance record for the time period
covering May 5, 2016 through May 5,
2015 and will count the number of
occurrences.
An employee with excessive
absenteeism, lateness, early departure,
and/or missed swipe is subject to
disciplinary action up to and including
termination based on the guidelines
listed below. However, any abusive
patterns of the attendance policy, even
over an extended period of time,
including in excess of 12 months, will
be subject to disciplinary action.
The above attendance guidelines are
intended to be progressive. When first
counseling an employee in accordance
with this policy, supervisors and
managers must always begin with a
verbal warning. For example, if an
employee incurs seven occurrences
but was never otherwise counseled for
those occurrences the supervisor and/
or manager must first issue a verbal
warning. Upon the employee’s eighth
occurrence within the 12 months
preceding the seventh occurrence, the
employee will then be issued a written
warning.
After three consecutive work days
of absence due to illness or injury, an
employee must contact Employee
Health Services for clearance before
returning to work. This is to ensure
that an employee is well, can safely
return to work, and has no residual
infection.
In addition to the Medical Center-
wide counseling guidelines stated
earlier each department may have
specific policies and practices that are
to be followed or you are subject to
counseling and disciplinary action.
In addition, supervisors and
managers should discuss each occur-
rence with employees in order to make
the employee aware of the concern and
the need to correct the deficiency. If an
employee’s absenteeism, lateness, early
departure, and/or missed swipes
continues despite the various discus-
sions and coaching sessions, managers
should take progressive disciplinary
action in accordance with this policy.
Problem Resolution
Procedure
Holy Name Medical Center uses a
formal procedure, known as the
Appeal Process, to resolve employee
problems or concerns as they relate to
disciplinary action or discharge, such
as demotion, reassignment, written
warning, suspension, or termination.
Allegations involving unlawful
harassment, discrimination, retaliation,
or workplace violence follow a
separate procedure and must be
immediately reported according to
those separate procedures as described
in this handbook and the Human
Resources Policies.
63
COUNSELING & DISCIPLINE
You must initiate this process
within five working days of issuance
of the disciplinary action. This policy
does not apply to employees within
their orientation period. Employees
in their orientation period have no
recourse under this policy. The appeal
will not be considered if you do not
follow these steps.
Step 1: You must start with your
immediate supervisor. You should
present your issue or complaint and
your desired conclusion in writing.
Your supervisor will consult with your
Department Head. You will receive
their decision in writing, usually
within five working days.
Step 2: If you are not satisfied with
their decision, you need to present
64
your written statement and their reply
to the Vice President of Human
Resources and/or his/her designee
within five working days from receipt
of the decision. The Vice President of
Human Resources or his/her designee
may speak or meet with you where
appropriate and necessary to further
discuss your statement and render a
decision in writing, usually within five
working days from the discussion.
Step 3: If you disagree with the
decision, you may submit a written
explanation to the President within
five working days from receipt of the
step 2 decision. The President will
review your written explanation and
the appeal file and will issue a written
determination that is final and binding.
Leaves of
Absence
Family and Medical Leave
of Absence
The federal Family and Medical Leave
Act (FMLA) provides 12 weeks of
unpaid leave in a 12-month period,
which can either be taken continuous-
ly and/or on an intermittent basis,
depending on the reason for leave. The
twelve (12)-month period is calculated
by measuring backwards from the start
date an employee uses any FMLA leave.
To be eligible for leave under the
FMLA, you must have worked at Holy
Name Medical Center for at least 12
months and have worked at least 1,250
hours during the 12-month period
immediately preceding the start of the
FMLA leave.
You may request a leave of absence
under the FMLA for the following
reasons:
Birth and care of a child and/or
the placement of adoption or
foster care of a child in your care
Family Leave for the birth, adoption,
or placement of a child or foster child
will normally be taken in 12 consecu-
tive weeks up to a maximum of 12
weeks. The leave must begin within
12 months of the birth, placement, or
adoption. With the agreement of Holy
Name, and business circumstances
l a e may be taken on an
permitting, leave
intermittent or reduced schedule basis
in the event of a birth, adoption, or
placement of a child.
Care for a family member with a
serious health condition. A family
member is defined as your child,
spouse, or parent.
Family Leave for the serious health
condition of a family member can be
taken consecutively, intermittently, or
on a reduced work schedule, based on
certified medical necessity.
A serious health condition for
purposes of FMLA leave is an illness,
injury, impairment, or physical or
mental condition that involves either
an overnight stay in a medical care
facility or continuing treatment by a
health care provider for a condition
that prevents the qualified family
member from participating in school
or other daily activities.
Care for your own serious health
condition that makes you unable
to perform the function of your
position.
Your request for leave must be made
as soon as you become aware of the
65
LEAVES OF ABSENCE
need for such a leave. If you are absent
from work for more than five calendar
days, you will be placed in leave status,
if eligible.
A serious health condition for
purposes of FMLA leave is an illness,
injury, impairment, or physical or
mental condition that involves either
an overnight stay in a medical care
facility or continuing treatment by a
health care provider for a condition
that prevents the employee from
performing the functions of the
employee’s job.
For a qualifying exigency arising
out of the foreign deployment
of an employee’s spouse, son,
daughter, or parent.
Qualifying exigencies may arise
when the employee’s spouse, son,
daughter, or parent who is a member
of the Armed Forces (including the
National Guard or Reserves) and who
is on active duty or had been notified
of an impending call or order to
covered active duty.
To care for a service member
with a serious injury or illness if
the employee is the spouse, son,
daughter, parent, or next of kin of
the covered service member.
Eligible employees may take up to
26 weeks of leave during a single
12-month period to provide care for a
covered service member. For the
purposes of this policy, a covered
service member is a member of the
Armed Forces, National Guard, or
66
Reserves who is undergoing treatment
for a serious injury or illness incurred
in the line of active duty.
The twelve (12)-month period for
leave to care for a covered service
member with a serious injury or
illness will begin on the first day the
employee takes FMLA leave to care for
the covered service member.
Employees on intermittent leave
must make reasonable efforts to
schedule leave for planned medical
treatments so as not to unduly disrupt
operations. In such instances, Holy
Name Medical Center will follow
applicable federal and state laws in
reviewing and approving such leave
requests.
Employees may continue their
health insurance benefits while on a
leave of absence by paying the full cost
of the employee portion of their
premium to remain covered each
month during the leave.
All accrued PTO time (when
applicable) must be used as
part of, and not as an extension
of, family leave.
Leaves of absence will be without
pay except where state benefits or paid
time off are available. Days for which
family leave insurance benefits are
received will be counted as part of, and
not in addition to, the twelve (12)
week family leave. An employee will
not receive any monetary payments
once all applicable family leave
insurance benefits, state benefits, and/
or paid time off benefits are exhausted.
While on a leave of absence, employ-
ees will not accumulate additional
paid time off or seniority.
Information regarding the FMLA is
posted in the building. If you have any
questions regarding the applicability
or eligibility requirements under the
FMLA, please contact the Human
Resources Department for details.
Workers’ Compensation Benefits
for your own Medical Condition:
Employees out on workers’ compen-
sation leave who are FMLA eligible
will have the time spent on workers’
compensation leave count against their
overall FMLA entitlement.
Temporary State Disability
Benefits for your own Medical
Condition:
If an employee is eligible for FMLA
and is out of work receiving disability
benefits, the time out of work will be
included in the twelve (12)-week leave
granted by the FMLA.
New Jersey Family Leave Act
(NJFLA):
The New Jersey Family Leave Act
(NJFLA) provides 12 weeks of unpaid
leave in a 24-month period. To be
eligible for NJFLA, you must have
worked at Holy Name Medical Center
for at least 12 months and must have
worked 1,000 base hours immediately
preceding the 12-month period.
You may request an unpaid leave of
absence under the NJFLA for the
following reasons:
• The birth or adoption of a child; or
• In the event of a serious illness or
health condition of a family
member. A family member is
defined as a spouse, parent, spouse’s
parent, child, or partner in a civil
union couple
The NJFLA does not provide time off
due to an employee’s own disability.
When an employee takes a leave of
absence for a purpose covered under
both the FMLA and NJFLA (e.g., child
care for a newborn or care for a
parent, child, or spouse with a serious
health condition), the leaves will run
concurrently and are counted against
an employee’s entitlement under both
the FMLA and NJFLA.
Upon return from either FMLA
and/or NJFLA leave, the Medical
Center will make every effort to return
you to your former position or a
substantially equivalent position with
equivalent employment benefits, pay,
and other terms and conditions of em-
ployment. Exceptions to this provision
may apply if business circumstances
have changed (e.g., if the employee’s
position is no longer available due to a
job elimination). Exceptions may also
apply for certain highly compensated
employees under certain conditions.
In the event an employee fails to
return to work after his or her FMLA
and/or NJFLA leave, job reinstatement
is not guaranteed.
67
LEAVES OF ABSENCE
Requesting a Leave:
When the need for leave is foreseeable,
the employee must notify the Human
Resources Department and his or her
manager and provide at least 30 days’
advanced notice of the need for leave.
If 30 days’ notice is not practicable,
you must give notice as soon as
practicable (within one (1) to two (2)
days of learning of your need to leave).
For foreseeable leave due to a qualifying
exigency, notice must be provided as
soon as practicable, regardless of how
far in advance such leave is foreseeable.
If an emergency situation arises and
this is not possible, you must give
notice as soon as practicable.
When leave is requested, under
either the FMLA and/or NJFLA,
employees are required to provide
necessary documentation (e.g., such
as a doctor’s certification of illness or
disability, etc.), supporting the need
for a leave of absence, and the Medical
Center may periodically require the
employee to provide such supporting
documentation during the leave of
absence.
The certification will be required
to state:
1. The date on which the serious
health condition began;
2. The probable duration of the
condition; and
3. The medical facts within the
provider’s knowledge regarding
the condition.
68
Additional leave may be available
under Holy Name’s Extended Leave
Policy at the expiration of a medical
leave due to an employee’s own serious
health condition.
When you return to work from a
medical leave, you will be required to
provide a certification for fitness for
duty and be cleared to return to work
by Employee Health Services.
Your benefit coverage will be
continued during your leave. If you
are in a paid leave status routine pay-
roll deductions will continue. If you
are receiving State Disability, and/or
if you are in an unpaid status, you will
be billed monthly at your current
benefit coverage rate. Your check for
benefit coverage should be made pay-
able to Holy Name Medical Center and
mailed to the attention of the Benefits
Coordinator by the 1st of each month.
Failure to make timely payments can
result in cancellation of coverage.
New Jersey Family
Leave Insurance:
New Jersey Family Leave Insurance
(NJFLI) provides a monetary benefit
of a maximum of six weeks of partial
wage replacement in a 12-month
period. The 12-month period is the
365 consecutive days that begins on
the first day that you establish a valid
first claim for NJFLI benefits.
NJFLI benefits can be filed for six
consecutive weeks, or for intermittent
weeks (must be seven consecutive
days) or a total of 42 days during a
12-month period beginning with the
first date of claim. If you claim family
leave benefits intermittently, you and
your manager must both agree to the
intermittent schedule. In accordance
with state law, employees intending to
take leave to bond with a newborn or
newly adopted child must provide a
minimum of 30 days’ notice. You will
be required to use up to two weeks of
PTO and/or holiday time prior to
collecting any FLI benefits from the
state. The maximum NJFLI allowance
will be reduced by the amount of PTO
taken.
You may file a claim for Family Leave
Insurance for the following reasons:
• To bond with a newborn or newly
adopted child during the first 12
months after the birth of a child or
the placement of adoption.
• To participate in the care of a
family member with a serious
health condition. A family member
is defined as your spouse, domestic
partner, civil union partner, parent,
or child.
A serious health condition means
any illness, injury, impairment or
physical or mental condition that
requires inpatient care in a hospital,
hospice, or residential medical facility
or continuing medical treatment or
continuing supervision by a health
care provider. If an employee takes
leave to care for a family member with
a serious health condition, the employee
will be required to provide a medical
certification from a health care
provider as part of his or her claim for
Family Leave Insurance benefits.
All employees will be advised of
their rights and how to apply for this
benefit by way of notices upon hiring,
at the employee’s request, or when the
Medical Center is informed of a
qualifying event.
Reinstatement is not guaranteed
when returning from a leave pursuant
to the New Jersey Paid Family Leave Act.
Accommodations
Holy Name Medical Center complies
with all state and federal laws prohibit-
ing discrimination in the workplace
based on an individual’s disability.
These laws include the American with
Disabilities Act (ADA) and the New
Jersey Law Against Discrimination
(NJLAD). The Medical Center prohibits
any discrimination against any qualified
person with a disability (as defined by
state or federal law) who can perform
the essential functions of his or her
job with or without a reasonable
accommodation.
Additionally, the Medical Center
will consider any request for an
accommodation to the known physical
or mental limitations of an otherwise
qualified applicant or employee,
including employees affected by
pregnancy, and will provide such
accommodations in accordance with
69
LEAVES OF ABSENCE
applicable law. Employees and/or
applicants who believe they are
disabled and that an accommodation
could assist them in performing the
essential functions of their position
should notify Human Resources.
Employees who are requesting an
accommodation are encouraged to
take an active part in the process and
speak with Human Resources so that
an interactive process can be utilized
to determine if a reasonable accommo-
dation can be made.
Extended Medical Leave
A leave beyond the duration of a
FMLA leave for an employee’s own
health condition is considered an
Extended Medical Leave. An employee
not meeting the eligibility require-
ments for a leave pursuant to the
FMLA may still be eligible for an
Extended Medical Leave. An employee
who believes he or she has a health
condition that makes the employee
unable to perform the duties of his/her
position and wishes to apply for an
Extended Medical Leave, should
contact Human Resources and
complete the requisite documentation.
Extended Medical Leave requests are
granted and/or denied at the discre-
tion of Holy Name Medical Center.
Reinstatement to an employee’s
position is not guaranteed.
An employee may not accept other
employment or become self-employed
while on an Extended Medical Leave.
An employee who obtains other
70
employment while on an Extended
Medical Leave will automatically be
deemed to have resigned as of the date
of commencement of such other
employment.
Workers’ Compensation
All employees are covered under the
terms of the New Jersey Workers’
Compensation Laws for work-in-
curred accidents, occupational
sickness, and disease.
An employee who becomes injured
or develops a work-related illness is to
report that information to his/her
supervisor even if the employee feels
or believes that he/she has not sustained
an injury. All work-related incidents
and/or injuries must be reported. To
that end, all incidents and/or injuries
must be reported immediately
following the incident but not later
than 72 hours. Failure to report the
incident within 72 hours may result in
benefits being jeopardized, and the
employee may be subject to disci-
plinary action for failure to follow
reporting procedures under this policy
Both an employee safety report and
incident report are to be completed by
the employee along with the supervisor/
manager. Completed employee safety
reports will be forwarded automatically
to Occupational Health Services (OHS),
Security, Departmental Manager, and
Human Resources. The safety report
will be reviewed by OHS, and OHS
will follow-up on any required
documentation.
 Holy Name Medical Center
(including all outpatient services) and
the Holy Name Physician Network will
serve as the primary point of care for
all work-related injuries. Referrals
outside of the Medical Center and/or
Network will be made on an as-needed
basis at the sole discretion of the
Medical Center. To that end, all
expenses related to an employee
seeking care from providers outside of
the Medical Center network or care or
treatment that was not directed by the
Medical Center will be the responsibility
of the employee. The Medical Center
will only pay for medical treatment
directed by the Medical Center.
Employees who fail to adhere to the
provider’s prescribed course of
treatment, and/or an employee’s failure
to maintain appointments and/or
otherwise adhere to the prescribed
course of treatment (i.e. medication,
supportive equipment etc.), will put
their benefits at risk. Cancellation and/
or no shows for two appointments
may be grounds for immediate
termination of compensation and care.
Please refer to Occupational Health
Services policy: Workers’ Compensation.
New Jersey SAFE Act
The New Jersey Security and
Financial Empowerment Act (“New
Jersey SAFE Act”) provides for eligible
employees to request an unpaid leave
of absence to address circumstances
resulting from domestic violence or a
sexually violent offense. Whenever
permissible under applicable law, Holy
Name Medical Center will run NJ Safe
Act leave concurrently with any leave
under the federal Family and Medical
Leave Act (“FMLA”) and/or the New
Jersey Family Leave Act (“NJFLA”).
Employees Eligible for Leave
To be eligible for leave under the NJ
Safe Act, employees must: (1) have
worked for Holy Name Medical
Center for at least 12 months; and
(2) have worked at least 1,000 base
hours during the 12-month period
immediately preceding the leave.
NJ SAFE Act Leave Entitlements
An eligible employee who was a victim
of an incident of domestic violence or
a sexually violent offense, as defined
under state law, or whose child, parent,
spouse, domestic partner, or civil
union partner was a victim may
receive up to 20 days of unpaid leave
in one 12-month period, to be used in
the 12-month period next following
any incident of domestic violence or
any sexually violent offenses. An
employee may take leave intermittently
in intervals of no less than one day.
Each incident of domestic violence
or any sexually violent offense consti-
tutes a separate offense for which an
employee is entitled to unpaid leave,
provided the employee has not
exhausted the allotted 20 days for
the 12-month period.
71
LEAVES OF ABSENCE
Leave may be used for any of the
following activities as they relate to
the incident of domestic violence or
sexually violent offense:
1. Seeking medical attention for, or
recovering from, physical or
psychological injuries caused by
domestic or sexual violence to the
employee or the employee’s child,
parent, spouse, domestic partner, or
civil union partner;
2. Obtaining services from a victim
services organization for the
employee or the employee’s child,
parent, spouse, domestic partner, or
civil union partner;
3. Obtaining psychological or other
counseling for the employee or the
employee’s child, parent, spouse,
domestic partner, or civil union
partner;
4. Participating in safety planning,
temporarily or permanently relocat-
ing, or taking other actions to
increase the safety of the employee, or
the employee’s child, parent, spouse,
domestic partner, or civil union
partner from future domestic or
sexual violence or to ensure eco-
nomic security;
5. Seeking legal assistance or remedies
to ensure the health and safety of the
employee or the employee’s child,
parent, spouse, domestic partner, or
civil union partner, including
preparing for, or participating in, any
civil or criminal legal proceeding
related to or derived from domestic
or sexual violence;
72
6. Attending, participating in, or
preparing for a criminal or civil
court proceeding relating to an
incident of domestic or sexual
violence of which the employee or
the employee’s child, parent, spouse,
domestic partner, or civil union
partner was a victim.
Requesting a Leave
If the need for leave is foreseeable,
employees must provide Holy Name
Medical Center advance written notice
of the need for leave as far in advance
as is reasonable and practical under
the circumstances.
Documentation Supporting Leave
Request
Holy Name Medical Center reserves
the right to require employees who
request leave for domestic violence or
sexually violent offenses to provide
documentation that supports the basis
of the leave.
An employee can provide one or
more of the following as sufficient
documentation:
• A domestic violence restraining
order or other documentation of
equitable relief issued by a court of
competent jurisdiction;
• A letter or other written documen-
tation from the county or municipal
prosecutor documenting the
domestic violence or sexually
violent offense;
• Documentation of the conviction
 of a person for the domestic
violence or sexually violent offense;
• Medical documentation of the
domestic violence or sexually
violent offense;
• Certification from a certified
Domestic Violence Specialist or
the director of a designated
domestic violence agency or Rape
Crisis Center, that the employee or
employee’s child, parent, spouse,
domestic partner, or civil union
partner is a victim of domestic
violence or a sexually violent
offense; or
• Other documentation or
certification of the domestic
violence or sexually violent offense
provided by a social worker,
member of the clergy, shelter
worker, or other professional who
has assisted the employee or
employee’s child, parent, spouse,
domestic partner, or civil union
partner in dealing with the
domestic violence or sexually
violent offenses.
Any of the above information that
is submitted by an employee regarding
a leave taken pursuant to this policy
and any failure of an employee to
return to work will be retained in the
strictest confidentiality possible, unless
the employee voluntarily authorizes
the disclosure in writing or if Holy
Name Medical Center is required to
disclose such information by applicable
federal or state law, rule, or regulation.
Pay During Leave
Employees may use any accrued paid
time off while taking leave. The use of
accrued paid time off during the leave
does not extend the length of leave.
Employees will not accrue paid time
off while out on leave. Employees may
however be eligible for compensation,
such as state temporary disability
benefits or Family Leave Insurance
benefits.
Emergency Disaster Leave
Employees are eligible to request an
emergency disaster leave if they have
been adversely affected by a major
disaster. An employee is considered to
be adversely affected by a major disaster
if the disaster has caused severe
hardship to the employee or a family
member of the employee that requires
the employee to be absent from work.
A disaster is defined as an event
that causes extensive and/or severe
threat to or destruction of life and/or
property. Such situations, whether
natural or man-made, may include but
are not limited to wind, earthquake,
hurricane, tornado, widespread fire,
flood, exposure to chemical or
radiological hazards, and/or effects of
terroristic acts.
To be eligible for leave under this
policy, an employee must meet one
of the following criteria:
• The event resulted in a formal
declaration of a State of Emergency
73
LEAVES OF ABSENCE

by the President of the United Personal Leave

States or by the Governor of New
You may request a personal leave for
Jersey or HNMC; or
up to four weeks due to an urgent
• The employee’s primary residence personal matter. Personal leave
was located in the officially declared requests are granted or denied at the
disaster area; or discretion of Holy Name. Reinstate-
• The employee’s primary residence ment after a personal leave of absence
was located in an area of mandatory is not guaranteed. It is always possible
evacuation; or that a vacancy may not be available.
• The employee suffered severe or
catastrophic damage to or loss of
Educational Leave
their primary residence; or
An educational leave of absence may
• A federal or state agency has
be granted for up to one year so that
rendered the employee’s primary
you may pursue verifiable full-time
residence temporarily or perma-
study at a recognized educational
nently uninhabitable; or
institution. Educational leave requests
• The employee is adversely impacted
are granted or denied at the discretion
by a disaster as determined by
of Holy Name. It is your responsibility
HNMC.
to pay the cost of your insurance
HNMC may request formal premiums while on leave.
documentation from recognized
disaster relief organizations or
insurance companies for verification Military Leave
of the severe loss of personal property Employees who enter military service
as a result of the disaster. will be granted leaves of absence and all
A reasonable determination will be rights and privileges guaranteed by law.
made by HNMC, based on need and
severity, as to how much leave each
approved leave recipient may receive
under this policy. Additionally, leave
may be granted for a period of time
after the major disaster occurs based
on the severity of the disaster in order
to address the aftermath caused by the
catastrophic event. This policy does
not include vacation or second homes,
nor property owned but not occupied
by the employee.

74
Employment
Notices
Confidentiality & Security
Agreement
The following is a reminder of the
contents of Holy Name Medical Center’s
separate Confidentiality & Security
Agreement. The Confidentiality &
Security Agreement is reviewed and
signed by every employee at the onset
of their employment.
I understand that Holy Name
Medical Center (HNMC) for which I
work, volunteer, or provide services
manages health information as part of
its mission to treat patients. Further, I
understand that HNMC has a legal and
ethical responsibility to safeguard the
privacy of all patients and to protect
the confidentiality of their patients’
health information. Additionally,
HNMC must ensure the confidentiality
of its human resources, payroll, fiscal,
research, internal reporting, strategic
planning information, or any informa-
tion that contains Social Security
numbers, health insurance claim
numbers, passwords, PINs, encryption
keys, credit card or other financial
account numbers (collectively, with
protected health and identifiable
information, “Confidential Informa-
tion”).
In the course of my employment/
assignment at HNMC, I understand
that I may come into the possession
i off
this type of Confidential Information.
I will access and use this information
only when it is necessary to perform
my job-related duties in accordance
with HNMC’s Privacy and Security
Policies, which are available on the
HNMC Intranet (on the Policies
Page). I further understand that I must
sign and comply with this Agreement
in order to obtain authorization for
access to Confidential Information or
HNMC systems.
General Rules
I will act in the best interest of HNMC
and in accordance with its Code of
Conduct at all times during my
relationship with HNMC.
1. I understand that I should have no
expectation of privacy when using
HNMC information systems.
HNMC may log, access, review, and
otherwise utilize information stored
on or passing through its systems,
including email, in order to manage
systems and enforce security.
2. I understand that violation of this
Agreement may result in disci-
75
EMPLOYMENT NOTICES
plinary action, up to and including
termination of employment,
suspension, and loss of privileges,
and/or termination of authorization
to work within HNMC, in accor-
dance with HNMC’s policies.
3. I understand that violation of this
Agreement could result in action
against me personally, including
civil action (e.g., being sued
directly) or criminal prosecution
by affected persons.
Protecting Confidential
Information
4. I will not disclose or discuss any
Confidential Information with
others, including friends or family,
who do not have a business need to
know it. I will not take media or
documents containing Confidential
Information home with me unless
specifically authorized to do so as
part of my job.
5. I will not publish or disclose any
Confidential Information to others
using personal email, or to any
Internet sites, or through Internet
blogs or social media sites such as
Facebook or Twitter. I will only use
such communication methods when
explicitly authorized to do so in
support of HNMC business and
within the permitted uses of
Confidential Information as
governed by regulations such as
HIPAA.
6. I will not in any way divulge, copy,
76
release, sell, loan, alter, or destroy
any Confidential Information except
as properly authorized. I will only
reuse or destroy media in accor-
dance with HNMC Information
Security Standards and HNMC
record retention policy.
7. In the course of treating patients,
I may need to orally communicate
health information to or about
patients. While I understand that my
first priority is treating patients, I will
take reasonable safeguards to protect
conversations from unauthorized
listeners. Such safeguards include,
but are not limited to: lowering my
voice or using private rooms or
areas where available.
8. I will not make any unauthorized
transmissions, inquiries, modifica-
tions, or purgings of Confidential
Information.
9. I will not transmit Confidential
Information outside the HNMC
network unless I am specifically
authorized to do so as part of my
job responsibilities. If I do transmit
Confidential Information outside of
HNMC using email or other
electronic communication methods,
I will ensure that the Information is
encrypted according to HNMC
Information Security Standards.
10. I will not transmit Confidential
Information through non-HNMC
approved methods, which include
text messaging and paging.
Following Appropriate
Access
11. I will only access or use systems or
devices I am officially authorized
to access, and will not demonstrate
the operation or function of
systems or devices to unauthorized
individuals.
12. I will only access software systems
to review patient records or HNMC
information when I have a business
need to know, as well as any
necessary consent. By accessing a
patient’s record or HNMC informa-
tion, I am affirmatively representing
to HNMC at the time of each access
that I have the requisite business
need to know and appropriate
consent, and HNMC may rely on
that representation in granting such
access to me.
Using Portable Devices and
Removable Media
13. I will not copy or store Confidential
Information on removable media
or portable devices such as laptops,
cell/smartphones, personal digital
assistants (PDAs), CDs, thumb
drives, external hard drives, etc.,
unless specifically required to do
so by my job. If I am permitted to
copy or store Confidential Informa-
tion on removable media, I will
encrypt the information while it is
on the media according to HNMC
Information Security Standards.
14. I will not configure portable
devices to remember my password.
15. I understand that these devices
should not be considered diagnos-
tic quality for patient care deci-
sions, and should not contain
Protected Health Information
(PHI), unless incorporated as part of
an officially HNMC approved,
standard application.
16. I agree to report the loss of any
mobile device (smartphone, PDA,
etc.) that synchronizes HNMC
data (e.g., HNMC email and pages)
to the IT Helpdesk and my
manager.
17. I agree to apply necessary security
controls (such as an access PIN
and automatic locking) on any
portable device that synchronizes
HNMC data regardless of it being
a HNMC or personally owned
device.
18. I understand that any mobile
device that synchronizes HNMC
data (e.g., HNMC email and pages)
may contain Confidential Informa-
tion and as a result, must be
protected. Because of this, I
understand and agree that HNMC
has the right to:
a. Require the use of only encryp-
tion capable devices.
b. Prohibit data synchronization to
devices that are not encryption
capable or do not support the
required security controls.
c. Remotely “wipe” any synchro-
nized device that: has been lost,
stolen, or belongs to a terminated
77
EMPLOYMENT NOTICES
employee or affiliated partner,
which will delete all data
including personal files.
d. Restrict access to any mobile
application that poses a security
risk to the HNMC network.
Doing My Part–Personal Security
19. I understand that I will be assigned
a unique identifier (e.g., User ID)
to track my access and use of Confi-
dential Information and that the
identifier is associated with my
personal data provided as part of
the initial and/or periodic creden-
tialing and/or employment
verification processes.
20. I will:
a. Use only my officially assigned
User ID and password (e.g.,
secure ID card).
b. Use only approved licensed
software.
c. Use a device with virus
protection software.
21. I will never:
a. Disclose passwords, PINs, or
access codes.
b. Use tools or techniques to break/
exploit security measures.
c. Connect unauthorized systems
or devices to the HNMC network.
22. I will practice good workstation
security measures such as locking
up thumb drives and other external
devices when not in use, using
screen savers with activated
78
passwords, and positioning screens
away from public view.
23. I will immediately notify my
manager who will then notify the
appropriate individual(s) if:
a. My password has been seen,
disclosed, or otherwise compro-
mised;
b. Media with Confidential
Information stored on it has
been lost or stolen;
c. I suspect a virus infection on any
system;
d. I believe there was a breach of
Confidential Information;
e. I am aware of any activity that
violates this agreement, privacy
and security policies; or
f. I am aware of any other incident
that could possibly have any
adverse impact on Confidential
Information or HNMC systems.
Upon Termination
24. I agree that my obligations under
this Agreement will continue after
termination of my employment,
expiration of my contract, or my
relationship ceases with HNMC.
25. Upon termination, I will immedi-
ately return any documents or
media containing Confidential
Information to HNMC.
26. I agree that I will immediately
return any hardware devices issued
to me by HNMC and I understand
that I may be personally liable for
any devices not returned.
27. I understand that I have no right to
any ownership interest in any
Confidential Information accessed
or created by me during and in the
scope of my relationship with
HNMC. By signing this document,
I acknowledge that I have read this
Agreement and I agree to comply
with all the terms and conditions
stated above.
Conflicts of Interest and
Ethical Conduct
Holy Name Medical Center’s manage-
ment and staff have a legal and ethical
duty to avoid relationships, activities,
and interests that conflict in any way
with the interests of the Medical Center.
The Medical Center expects you to
act in good faith when acting on its
behalf. We must be certain that all
employees who promote the Medical
Center and its policies or are responsi-
ble for its welfare and financial health
are not hampered by any conflicts of
interest or the appearance of a conflict
of interest.
You should not accept any gifts,
services, travel, cash and/ or loans
from any patient, company, or
individual doing business with Holy
Name Medical Center. In addition,
administrative and management
employees are required to read and
complete a Conflict of Interest and
Ethical Conduct statement annually.
We are responsible for doing the
best job we possibly can in the best
interests of the Medical Center and
our patients. We share a responsibility
to comply with federal, state, and local
laws as we conduct ourselves on a
day-to-day basis. We are also obligated
to hold ourselves to the highest ethical
standards and comply with established
policies and procedures instituted by
the Medical Center.
Any deliberate action that violates
Medical Center policies on Conflicts
of Interest or Ethical Conduct is taken
very seriously and may result in
immediate termination.
Deficit Reduction Act Policy
Summary
It is the policy of Holy Name Medical
Center to obey all federal and state
laws, to implement and enforce
procedures to detect and prevent
fraud, waste and abuse regarding
payments to Holy Name Medical
Center from federal or state health
care programs, and to provide
protections for those who report
actual or suspected wrongdoing. This
Policy applies to all directors, officers,
administrators, managers, employees,
employed and contracted physicians,
and other contractors and agents of
Holy Name Medical Center.
Below are summaries of the major
laws regarding false claims. This is not
meant to be a list of all applicable laws,
but only a summary as required by the
Deficit Reduction Act of 2005. Further
information on these laws is contained
79
EMPLOYMENT NOTICES
in the Medical Center’s policy on
Deficit Reduction Act.
Federal False Claims Act, Federal
Program Fraud Civil Remedies Act,
New Jersey Health Care Claims
Fraud Act and New Jersey Medical
Assistance and Health Services Act:
These laws, while not identical,
basically define health care claims
fraud as making, or causing to be
made, a false, fraudulent or misleading
statement or omitting a fact, related to
submission of a bill for health care
services. It applies whether the person
actually knows the information is
false, or only acts in deliberate
ignorance or reckless disregard of
whether the claim is false.
Penalties can include fines of several
times the extra payment obtained or
up to $10,000 for each offense, loss of
health care license, and jail.
If You Have Concerns About the
Medical Center’s Compliance with
These Regulations:
Any employee who observes
activity that they believe may violate
the False Claims Act or any other
regulation is encouraged to report it
within the Medical Center right away.
You may report through your supervi-
sor. If you are uncomfortable talking
with your supervisor about your
concerns, or if you do not get a
satisfactory answer, you may contact
the Compliance Officer. If you wish to
80
remain anonymous, you may use the
Medical Center’s anonymous email or
call the compliance hot line at ext. 7251
and leave a voicemail message. It is the
Medical Center’s policy not to retaliate
against any employee who raises a
compliance concern in good faith.
“Whistleblower” Protections:
Individuals within an organization
who observe activities or behavior that
they believe in good faith may violate
a law and who report their observa-
tions either to management or to
governmental agencies are provided
protections under certain laws.
Protections are afforded to people
who file qui tam lawsuits under the
Federal False Claims Act. This law
states that any employee who is
discharged, demoted, suspended,
threatened, harassed, or in any other
manner discriminated against by their
employer because of lawful actions
taken in a qui tam action is entitled to
recover damages. The New Jersey
Conscientious Employee Protection
Act provides similar protection against
retaliation for employees but requires
that, in most cases, the employee
provide the employer with written
notice of the issue and enough time to
correct it before reporting to a public
body.
Holy Name Medical Center’s Policies
and Procedures for Detecting and
Preventing Fraud:
 Holy Name Medical Center
maintains an active compliance
program. The program is overseen
by the Compliance Committee.
The Medical Center’s policies
related to compliance are available
on the Intranet:
• Compliance Plan
• Code of Conduct
• Compliance Investigations
• Statement of Organizational Ethics
• Deficit Reduction Act
If you do not have access to the
Intranet, you may obtain a copy of
any of these policies by calling the
Compliance Officer at ext. 7251.
arrange for coverage if the employee is
excused from participating in an aspect
of a patient’s care.
The requesting employee must
provide appropriate care until alterna-
tive arrangements are made.
Refusal to provide patient care/
treatment may result in constructive
performance feedback up to and
including termination. However,
HNMC will attempt to make reasonable
accommodation for all employee
requests it deems justified.

Staff Rights and

Responsibilities
It is the policy of HNMC to establish a
mechanism by which an employee
may request to be excused from
participating in an aspect of patient
care in situations where the prescribed
patient care presents a conflict with
the employee’s cultural values, ethics,
or religious beliefs. Under no circum-
stances, however, will a request be
granted if it is believed that doing so
would negatively affect the care of a
patient.
The employee must notify his/her
supervisor in writing of his/her
concerns and to request to be excused
from participating in a certain aspect
of a patient’s care. The request must be
timely so that there is sufficient time to
81
IF YOU SHOULD LEAVE
If You
Should
Leave
If you should leave Holy Name
Medical Center, Human Resources is
available to review benefits to which
you may be entitled. Employees who
leave Holy Name Medical Center are
offered an opportunity to complete an
exit interview. Comments provided
during an exit interview assist us in
identifying our strengths and focusing
on areas where improvement is needed.
Resignation
In order for an employee to be eligible
for reimbursement for unused hours
in his/her PTO, the employee must
give notice equivalent to his/her yearly
entitlement.
Unemployment
The State of New Jersey provides
weekly Unemployment Compensation
Insurance benefits to terminated
employees who meet eligibility
requirements. If you are terminated,
Human Resources will provide you
with information about how to file for
Unemployment Insurance.
82
Re-Employment
Individuals who have resigned in good
standing are eligible for re-employment.
Re-employment is in the discretion of
Holy Name Medical Center.
Your former work history at Holy
Name will be reviewed in considering
your application for re-employment.
If you are re-employed within 90
days of the date of your termination,
it will not be considered a break in
service. If you are a full- or part-time
benefit-eligible employee, your benefits
will be re-activated the first of the
month following your re-employment.
If you are re-employed into your
previous position, you will be re-hired
at the rate of pay you were receiving
on the date of your termination,
adjusted for any general increase since
the termination. Conversely, if hired
into a position other than your
previous one, the rate of pay will be
based on the position’s salary range.
If you are re-employed after 90 days
of the date of termination, you will be
re-hired as a new employee.
Retirement
The Human Resources Department
will assist you in understanding and
processing your retirement benefits.

Death
In the event of your death, your estate
will receive all accrued earned wages
and accrued holiday and PTO time.
To update beneficiary information
contact Human Resources.

83
 PTO Appendix
Category 1 Accrual
Weekly Hours Biweekly Annual Maximum
20 2.92 75.92 95.92
24 3.50 91.00 115.00
32 4.67 121.42 153.42
36 5.26 136.76 172.76
40 5.84 152.00 192.00

Category 2 Accrual
Weekly Hours Biweekly Annual Maximum
20 3.69 95.94 115.94
24 4.43 115.18 139.18
32 5.90 153.40 185.40
36 6.64 172.64 208.64
40 7.38 192.00 232.00

Category 3 Accrual
Weekly Hours Biweekly Annual Maximum
20 4.46 115.96 135.96
24 5.35 139.10 163.10
32 7.14 185.64 217.64
36 8.03 208.78 244.78
40 8.92 232.00 272.00

84
 718 Teaneck Road | Teaneck, NJ 07666 | www.HolyName.org

For more information, call Human Resources, ext. 3199.