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PART ONE

Employee Issues and Legal Compliance:

A White Paper for HR Managers in the

Healthcare and Medical Industry

2

Introduction: Employee issues and

legal compliance are a necessary aspect

of human resources management. Even

so, many in human resources (HR)

feel that staying abreast of the laws,

policies, procedures, and documentation

requirements takes valuable time away

from focusing on what matters most to the

operation: ensuring that employees are

acting and being treated professionally.

Given that recruiting, screening,

interviewing, hiring, administration, and

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enough time to also research compliance

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for some. But, it’s the job of every HR

manager and specialist to know the laws

and keep the organization compliant

with all relevant legal requirements and

legislation. Without compliance, the

practice or the healthcare facility may be

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The list of laws for which the HR

department should be well aware

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Employment Opportunity (EEO), Fair

Labor Standards Act (FLSA), Family

Medical Leave Act (FMLA), Occupational

Safety & Health Act (OSHA), Immigration

Reform and Control Act (IRCA),

Workers’ Compensation, Americans with

Disabilities Act (ADA), as well as those

laws that govern drug testing, overtime,

documentation and recordkeeping.

Unfortunately, these laws governing

employee issues and compliance can

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frequently, and without much notice. To

stay well-informed and up-to-date on the

legal requirements that may impact their

practice or facility, some HR departments

turn to the aid of an HR consultant or

corporate attorney for help.

The expertise brought by an HR

consultant can help a busy healthcare

operation avoid a catastrophe. It’s

understood that not all HR departments

have the budget to hire professional

consultants or legal counsel, but given the

fact that HR effectiveness depends on a

thorough understanding of compliance

issues, some may be left wondering how

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informed and compliant without tipping

the organization into the red.

The rest of this white paper will describe

some of the common practices employed

by HR managers and HR departments

for staying up-to-date and informed on

employee issues and legal compliance that

affect their people and work environments.

Examples and advice have been drawn

from conversations and interviews with

a number of HR specialists and practice

managers who have openly shared their

knowledge and experience.

First, be informed. Understand that

state and federal laws change frequently.

These laws govern how your practice

or hospital operates in many respects.

Failure to align your HR strategy with legal

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Employee Issues and Legal Compliance:

A White Paper for HR Managers in the

Healthcare and Medical Industry

3

also important to note that the laws vary

depending on the number of employees

you have on staff. So, some aspects of

the laws may not be relevant to your

healthcare practice. If this creates a sense

of bewilderment in members of your HR

team, that’s understandable. But if that’s

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in hiring the services of a professional

agency that can consult with your practice

or facility on exactly what you need to do in

order to remain compliant.

If you don’t have time to stay

informed, hire an HR consultant.

Employment laws are often challenging

to understand and interpret. Remember:

ignorance of the law does not excuse

liability. For human resources managers

in the healthcare sector, there are litanies

of state and federal regulations with

which your healthcare practice must

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practices without the sage advice of

an internal HR professional, or no one

in the organization responsible for

assuring legal compliance, the effort to

stay informed and compliant can be a

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there is no lack of external help. As

mentioned earlier, the knowledge and

experience brought by a professional HR

consultant—one who specializes in legal

compliance—can help HR departments

small and large address issues and

care for their employees with all due

attention and respect. And, at the same

time, they can help to prevent any issues

with the law that might cause a negative

impact on the organization.

You can also subscribe to HR

newsletters and updates from

consulting sources. There is much

to be said for up-to-date information

found in newsletters that can be easily

read and understood—especially if the

information is tailored to your practice.

The Society for Human Resource

Management (SHRM) publishes the HR

Issues Update e-newsletter “every other

week when Congress is in session.” This

publication details topics and issues

in a jargon-free language. SHRM also

publishes a variety of free newsletters

that serve to keep their members

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Employee Relations & Engagement

e-newsletter covers policies, conduct

and performance management. The

Diversity e-newsletter covers topics such

as gender issues, religious differences, as

well as differences related to age, race,

language, and family status. The Safety &

Security e-newsletter includes updates

on OSHA initiatives. And the Workplace

Law Update offers a look at legislative

and regulatory news.

For many HR managers and staffers,

the SHRM site is an invaluable resource.

SHRM was founded in 1948 and

currently represents hundreds of

thousands of members in countries

all over the world. You can become a

member and sign up for any number of

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4

Identify and define your particular

needs and objectives. There’s

truth to the idea that you can’t create

a strategic HR plan or a series of

solutions to problems in the workplace

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strengths, weaknesses, and areas

where improvement may be necessary.

Many HR professionals will begin this

investigational process by conducting

an HR audit, one that looks at the entire

environment—people, practices, policies,

and procedures—in order to fully

understand the details and complexities.

At the very minimum, an HR audit

should be able to show members of

the HR team what needs to be done

in the organization and how changes

to compliance or best practices will

impact individuals, departments, and the

organization overall. Areas involved in an

HR audit may include, but should not be

limited to:

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401(k)

 Documentation of policies and

procedures in the employee

handbook

 Employee compensation and pay

equity

 Employee performance reviews and

appraisals

 Employer-employee relations

 Government reporting requirements

 Health, safety, and security policies

and practices (Drug-Free Workplace,

OSHA compliance, etc.)

 Legal compliance (FLSA, EEO, AA,

ADA, FMLA, IRCA, etc.)

 Personnel data and record-keeping

(W-2s, I-9s, W-4s, applications, etc.)

 Terminations and related

documentation

Hire a consulting group for your

HR audit. There are many consulting

groups that, for a fee, will come to

your practice or facility and conduct

an HR compliance and effectiveness

audit. This, of course, comes with an

associated cost to the HR department,

but they typically base their fee on the

number of employees you have on-

site. Although this may seem like it’s

an easy way to assess compliance and

identify opportunities to improve the

effectiveness of your team, it’s best to

keep in mind that a proper HR audit

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and the workplace. Your people and

workplace are unlike any other. As

such, the hired consulting group should

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directions by your team. Once the audit

(or investigation), report, and summary

meeting have been performed, and the

effectiveness of the existing HR programs

has been measured, the hired consulting

group may offer follow-up remediation

or, at very least, a set of action plans and

tools to help your HR team mitigate areas

of risk and ensure legal compliance.

Develop efficient, consistent

systems for productivity and

morale. One of the primary goals of the

HR department is to attract, recruit and

5

hire quality employees. But, as many HR

staff members know, the next challenge

is to identify, create, and enforce systems

that allow those employees to succeed in

their positions and be comfortable in their

work environment. Something as simple

as establishing workplace rules, or as

complex as instituting pay plans, provides

necessary structure and consistency in the

workplace. As such, the value of rules and

systems cannot be overstated.

To see the importance of reliable

HR systems, and the need for strict

compliance, one only has to look at

the concerns surrounding the basic

minimum wage and overtime pay—

something that affects most private and

public employers. Here, an important

piece of United States federal labor

legislation governs what is appropriate,

fair, and legal.

In regard to pay plans and compliance, it

should be noted that many wage, work

hours, and overtime pay provisions are

prescribed by the Fair Labor Standards

Act (FLSA). The FLSA, which was

adopted as a federal statute in 1938,

affects employers of full-time and part-

time workers in the public and private

sector. As many HR managers and staff

members know, understanding pay

rates, work hours, and overtime hours is

crucial to ensuring employees are treated

fairly and equitably under the rules,

regulations, and laws set by the FLSA. If,

for any reason, the healthcare practice or

hospital employs children under the age

of 16, it should be noted that the rules

and laws contain additional restrictions.

FLSA requirements also state that

employers must be compliant with

required recordkeeping, reporting,

notices and posters for those subject to

the FLSA’s minimum wage provision. But,

here’s where it gets tricky: Paid time off

(sick days, personal days, and vacation

days) has no federal requirement, and

the individual states have been left to

determine regulations. From an HR

viewpoint, it’s

important to

know where

your state

and your

organization

stands on

time off. It’s also

important to create a

formal written policy for

paid time off.

Summary: Human Resources is a major

administrative component with a broad

subset of interests and functions. In a

busy healthcare practice or hospital,

there’s no doubt that a variety of

employee issues and legal compliance

concerns will come up on a weekly basis.

As such, it’s understandable if an HR

team isn’t sure about how to correctly

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issue or complaint. Unfortunately, issues

such as workplace injuries, violence, and

harassment carry with them a number

of liabilities for the organization. As the

One of the primary

goals of the HR department

is to attract, recruit and hire

quality employees. But, as many

HR staff members know, the next

challenge is to identify, create, and

enforce systems that allow those

employees to succeed in their

positions and be comfortable

in their work environment.

6

practice or organization grows, so will

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decisions to these issues and many more.

This concludes Part 1 of our two-part

white paper series on employee issues

and legal compliance. In Part II, we’ll

look at delegation of duties and how to

mitigate risk by utilizing new hires and

outside HR agencies.

Major Research Links

http://smallbusinessesdoitbetter.

com/2013/12/operating-a-small-business-

without-a-dedicated-hr-department/

http://www.strategichrinc.com/legal-

compliance.htm

http://www.mohave.edu/documents/

SBDC/Resources/HR%20_Employment_

Law_Compliance_Guide_AZ_Employers.

pdf

http://www.strategichrinc.com/hr-audit.htm

http://www.shrm.org/Advocacy/

GovernmentAffairsNews/

HRIssuesUpdatee-Newsletter/Pages/

default.aspx

http://www.hr.com/en/communities/

benefits/healthcare_legislation_and_

compliance/

http://www.pebblehr.com/#!/page_

Solutions

http://www.greenoughgroup.com/wp-

content/uploads/2011/07/GCG-HR-Audit.pdf

http://www.shrm.org/TemplatesTools/

hrqa/Pages/WhatisanHRAudit.aspx

http://ipma-hr.org/sites/default/files/pdf/

hrcenter/HR%20Audit.pdf

http://humanresources.about.com/od/

motivationsuccess/a/manage_systems.htm

http://www.dol.gov/compliance/guide/

minwage.htm#RRN

http://www.hrsentry.com/site/small_

businesses

http://www.suny.edu/compliance/topics/

Topics%20In%20Compliance.cfm

http://www.teamonelogistics.com/nearly-

all-carriers-making-changes-for-health-

care-law-tcp-says/

http://www.valencerg.com/hr-services-2/

http://hrpmsi.com/cost.php

http://www.evancarmichael.com/Human-

Resources/3362/Operating-Without-A-

Human-Resources-Department.html

http://www.realmatch.com/what_we_do

http://www.villanovau.com/human-

resource-management-challenges/

http://www.dol.gov/whd/flsa/

http://www.mindtools.com/pages/article/

newLDR_98.htm

http://ucsfhr.ucsf.edu/index.php/pubs/

hrguidearticle/chapter-9-delegation/