1. Hospitals, ambulatory surgical centers, and abortion facilities shall establish and implement a written policy adopted by each hospital, ambulatory surgical center, and abortion facility relating to the protections for employees who disclose information pursuant to subsection 2 of this section. This policy shall include a time frame for completion of investigations related to complaints, not to exceed thirty days, and a method for notifying the complainant of the disposition of the investigation. This policy shall be submitted to the department of health and senior services to verify implementation. At a minimum, such policy shall include the following provisions:

(1) No supervisor or individual with authority to hire or fire in a hospital, ambulatory surgical center, or abortion facility shall prohibit employees from disclosing information pursuant to subsection 2 of this section;

(2) No supervisor or individual with authority to hire or fire in a hospital, ambulatory surgical center, or abortion facility shall use or threaten to use his or her supervisory authority to knowingly discriminate against, dismiss, penalize or in any way retaliate against or harass an employee because the employee in good faith reported or disclosed any information pursuant to subsection 2 of this section, or in any way attempt to dissuade, prevent or interfere with an employee who wishes to report or disclose such information;

(3) Establish a program to identify a compliance officer who is a designated person responsible for administering the reporting and investigation process and an alternate person should the primary designee be implicated in the report.

2. This section shall apply to information disclosed or reported in good faith by an employee concerning:

(1) Alleged facility mismanagement or fraudulent activity;

(2) Alleged violations of applicable federal or state laws or administrative rules concerning patient care, patient safety or facility safety; or

(3) The ability of employees to successfully perform their assigned duties.

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All information disclosed, collected and maintained pursuant to this subsection and pursuant to the written policy requirements of this section shall be accessible to the department of health and senior services at all times and shall be reviewed by the department of health and senior services at least annually. Complainants shall be notified of the department of health and senior services’ access to such information and of the complainant’s right to notify the department of health and senior services of any information concerning alleged violations of applicable federal or state laws or administrative rules concerning patient care, patient safety or facility safety.

3. Prior to any disclosure to individuals or agencies other than the department of health and senior services, employees wishing to make a disclosure pursuant to the provisions of this section shall first report to the individual or individuals designated by the hospital, ambulatory surgical center, or abortion facility pursuant to subsection 1 of this section.

4. If the compliance officer, compliance committee or management official discovers credible evidence of misconduct from any source and, after a reasonable inquiry, has reason to believe that the misconduct may violate criminal, civil or administrative law, then the hospital, ambulatory surgical center, or abortion facility shall report the existence of misconduct to the appropriate governmental authority within a reasonable period, but not more than seven days after determining that there is credible evidence of a violation.

5. Reports made to the department of health and senior services shall be subject to the provisions of section 197.477, provided that the restrictions of section 197.477 shall not be construed to limit the employee’s ability to subpoena from the original source the information reported to the department pursuant to this section.

6. Each written policy shall allow employees making a report who wish to remain anonymous to do so, and shall include safeguards to protect the confidentiality of the employee making the report, the confidentiality of patients and the integrity of data, information and medical records.

7. Each hospital, ambulatory surgical center, and abortion facility shall, within forty-eight hours of the receipt of a report, notify the employee that his or her report has been received and is being reviewed.