Coming Soon - FAMILY MEDICINE RESIDENCY PROGRAM

Effective Date: 1/15/2026

I. Purpose, Mission, and Commitment
The purpose of this policy is to define the governance, structure, and institutional authority for Graduate Medical Education (GME) at WVU Medicine Princeton Community Hospital, ensuring compliance with Accreditation Council for Graduate Medical Education (ACGME) Institutional Requirements.

WVU Medicine Princeton Community Hospital is developing graduate medical education programs to advance its core mission: to enhance the health of the communities we serve, one person at a time, by providing extraordinary, evidence-based, compassionate care. We commit to strive for excellence in graduate medical education, preparing physicians to lead, serve, and improve health outcomes in rural and underserved communities.

The WVU Medicine Princeton Community Hospital (WVU Medicine, PCH) Administrative Team affirms our commitment to Graduate Medical Education by ensuring ongoing institutional support through the allocation of the administrative, education, financial, clinical, and human resources necessary to support, maintain, and continuously improve high-caliber graduate medical education programs.

II. Sponsoring Institution Authority
WVU Medicine Princeton Community Hospital serves as the Sponsoring Institution for its ACGME-accredited and ACGME-applicant graduate medical education programs. The Sponsoring Institution maintains authority and oversight for all participating sites and ensures that all sites meet ACGME requirements for the learning and working environment.

Final authority for Graduate Medical Education resides with the Sponsoring Institution and its governing body.

III. Institutional Governance Structure
The Sponsoring Institution governs Graduate Medical Education through the following structure:

• Chief Executive Officer (CEO)
  Holds executive authority for the institution and is responsible for ensuring adequate resources and institutional support for GME.
• Chief Medical Officer (CMO)
  Provides senior clinical leadership oversight and serves as a reporting intermediary between the DIO and CEO.
• Designated Institutional Official (DIO)
  Acts on behalf of the Sponsoring Institution in matters related to GME accreditation, oversight, and compliance.
• Graduate Medical Education Committee (GMEC)
  Serves as the institutional committee responsible for oversight of all GME programs and the learning and working environment.

IV. Delegation of Authority
The Sponsoring Institution formally delegates operational oversight of Graduate Medical Education to the Designated Institutional Official and the Graduate Medical Education Committee, while retaining final institutional authority. 

Delegated responsibilities include, but are not limited to the following:

• Oversight of compliance with ACGME Institutional and Program Requirements
• Approval and review of GME policies annually
• Monitoring of the learning and working environment, including resident duty hours
• Review of program quality and performance
• Review of adequacy of institutional financial and personnel resources, including communication resources and technology needed to access the medical record system (e.g., Epic) and medical literature resources remotely
• Ensuring privacy for lactation support for breastfeeding residents in the program with safe and private refrigeration resources for proper milk storage
• Ensuring residents have the necessary resources to engage in scholarly pursuits
• Ensuring accommodations are available for residents with disabilities per WVU Medicine PCH policies
• Ensuring security measures are in place for safety in the workspaces
• Ensuring private rest facilities for residents that are too fatigued to safely travel home
• Ensuring safe transport home if the rest facility is unavailable
• Ensuring that residents have access to food during their clinical rotations and education assignment
• Ensuring enough protected time for the program director and core faculty so that they can provide effective supervision and teaching in their resident oversight

Effective Date: 01/15/2026

I. Purpose
This policy establishes the authority, responsibilities, and accountability of the Designated Institutional Official (DIO) and defines the institutional oversight structure for all ACGME-accredited and ACGME-applicant graduate medical education (GME) programs sponsored by WVU Medicine Princeton Community Hospital.

This policy is intended to ensure compliance with the ACGME Institutional Requirements and to promote a safe, effective, and educational learning and working environment for residents and fellows.

II. Scope
This policy applies to:

• All current and future ACGME-accredited residency and fellowship programs sponsored by the institution
• All residents, fellows, faculty, program directors, and institutional leaders involved in graduate medical education.

The DIO has direct and unencumbered access to the CEO and CMO for matters related to:

Effective Date: 01/15/2026

I. Purpose of the GMEC
The Graduate Medical Education Committee (GMEC) is the institutional committee responsible for oversight of all graduate medical education (GME) programs sponsored by WVU Medicine Princeton Community Hospital. The GMEC acts on behalf of WVU Medicine PCH to ensure compliance with the ACGME Institutional and Program

Requirements and to promote high-quality education, patient safety, and resident well-being. The Graduate Medical Education Committee will be responsible for the development of the policies and procedures necessary for the support of its training program(s). 

II. Authority

• The GMEC is delegated authority by the Sponsoring Institution to:
• Establish, review, and approve institutional GME policies
• Oversee all current and future ACGME-accredited and applicant programs
• Monitor compliance with ACGME requirements, including program policies
• Review the learning and working environment
• Address concerns related to patient safety, supervision, duty hours, professionalism, and resident well-being
• Monitor compliance of resident duty hours independently of the program
• Serve as the institutional body for review when conflicts of interest arise.

This authority is granted by the CEO of WVU Medicine PCH in accordance with ACGME Institutional Requirements.

B. Non-Voting Members
May include any or all of the following:

Significant concerns related to:

• Accreditation risk
• Patient safety
• Resident well-being

are escalated promptly to institutional leadership.

 X. Policy Review and Maintenance
All institutional GME policies are reviewed at least annually by the GMEC and updated as needed to remain compliant with ACGME requirements.

Final authority rests with the Sponsoring Institution and its governing body, as defined in the Sponsoring Institution Governance Policy.

Effective Date: 01/15/2026

I. Nature of Appointment
Resident Physicians are appointed for a fixed, time-limited term of one academic year. Appointment and reappointment are not automatic and are contingent upon continual satisfactory performance and completion of program and institutional requirements.

II. Accreditation and Educational Program
WVU Medicine Princeton Community Hospital (PCH) agrees to provide an educational program accredited by the Accreditation Council for Graduate Medical Education (ACGME). Residents agree to participate fully in all educational, clinical, and scholarly activities required by the program.

III. Licensure and Eligibility
As a condition of appointment, residents must abide by the following:

• Maintain eligibility for medical licensure or training permits as required by state law
• Successfully obtain and maintain required licenses, certifications, and hospital privileges
• Meet eligibility requirements for participation in the program and for advancement, including required licensing examinations, where applicable

Failure to maintain licensure or eligibility may result in non-renewal or termination of the appointment.

XV. Due Process and Grievance
Residents are entitled to due process and access to grievance and appeal mechanisms as outlined in institutional policy for any adverse action related to their appointment.

These processes are described in separate institutional policies and are not altered by this document.

 XVI. Non-Compete
WVU  Medicine  PCH  does  not  require  residents  or  fellows to sign non-competition, non-solicitation, or restrictive covenant agreements as a condition of appointment, reappointment, promotion, or completion of training. No resident or fellow shall be restricted from practicing medicine or pursuing employment opportunities upon completion or separation from their training program.

XVII. Acknowledgement
This policy does not constitute a contract of employment. In the event of a conflict, the resident agreement and institutional policies govern. Acceptance of appointment constitutes acknowledgement and agreement to comply with the Conditions of Appointment, institutional policies, and ACGME requirements

I. PURPOSE
The purpose of this policy is to define the standards and procedures for a resident’s eligibility, selection, appointment, and advancement consistent with the requirements of the Accreditation Council for Graduate Medical Education (ACGME), and to ensure that resident progression is founded upon the Specialty-Specific Milestones as evaluated by the Clinical Competency Committee, which meets at least quarterly and conducts formal review no less than biannually. Operational recruitment procedures may be further specified at the program level in accordance with this institutional policy.

II. NONDISCRIMINATION
WVU Medicine Princeton Community Hospital (PCH) does not discriminate in the recruiting and selection of candidates for our training program(s) with regard to race, gender, color, creed, religion, national origin, ancestry, age, marital status, disability, sexual orientation (including gender identity), status as a protected veteran, or physical disability, which would not directly impede the training process. This conviction of non-discrimination applies to residents, faculty, institutional leadership, and support staff who create the learning environment.

III. Eligibility Requirements
An applicant must meet one of the following qualifications to be eligible for appointment to an ACGME-accredited program as adopted from the ACGME standards acknowledged below:

a. graduation from a Medical School in the United States, accredited by the Liaison Committee on Medical Education (LCME) OR graduation from a College of Osteopathic Medicine in the United States, accredited by the American Osteopathic Association (AOA) Commission on Osteopathic College Accreditation (COCA); or

b. graduation from a medical school outside of the United States, and meeting one of the following additional qualifications:

• holding a currently valid certificate from the Educational Commission for Foreign Medical Graduates (ECFMG) prior to appointment; or,
• holding a full and unrestricted license to practice medicine in the United States licensing jurisdiction in which the ACGME-accredited program is located.

c. Exceptionally Qualified Applicants
Applicants who do not meet standard eligibility criteria but are considered exceptionally qualified may be appointed only with review and approval by the Graduate Medical Education Committee (GMEC), in accordance with ACGME requirements.

All prerequisite post-graduate clinical education required for initial entry or transfer into ACGME-accredited residency programs must be completed in ACGME-accredited residency programs, AOA-approved residency programs, Royal College of Physicians and Surgeons of Canada (RCPSC)-accredited or College of Family Physicians of Canada (CFPC)-accredited residency programs located in Canada, or in residency programs with ACGME International (ACGME-I) Advanced Specialty Accreditation.

Residency programs must receive verification of each resident’s level of competency in the required clinical field using ACGME, CanMEDS, or ACGME-I Milestones evaluations from the prior training program prior to matriculation.

IV. Selection
In selecting from qualified applicants, WVU Medicine PCH participates in the National Resident Matching Program (NRMP, the “Match”). Selection to the WVU Medicine PCH training programs is made from among eligible applicants. The selection criteria include the following: the individual’s probability to advance the mission and vision of the hospital with a community health focus, as well as their capability, aptitude, academic credentials, communication, and personal skills.

Each applicant shall submit an application through ERAS (Electronic Resident Application System), provide three reference letters, a Dean’s letter, board scores, medical school transcripts, medical school diploma, and appear for a series of interviews.

If any available positions remain unfilled following the NRMP process, we will also participate in the SOAP (Supplemental Offer and Acceptance Program).

The Matched applicants receive a one-year academic term appointment agreement between themselves and WVU Medicine PCH prior to the first day of training. This appointment agreement shall include a clause regarding circumstances of termination by either party. The Resident appointment agreement defines the educational, professional, and contractual responsibilities of both the resident and WVU Medicine PCH, including compensation, benefits, supervision, evaluation, promotion, remediation, due process, and compliance with ACGME requirements.

V. Evaluation, Advancement, and Reappointment
Advancement from PGY-1 to PGY-2, from PGY-2 to PGY-3, and eligibility for graduation are determined by the Program Director, informed by the recommendations of the Clinical Competency Committee, based on the resident’s demonstrated progress in achieving the ACGME Milestones, in accordance with ACGME standards. Advancement is based upon demonstrating competence. In addition, advancement from PGY-1 through PGY-3 is contingent on successful passage of either the USMLE Step 3 or COMLEX-USA Level 3. A resident who does not successfully complete the required licensing examination within the program-defined timeframe may be subject to non-promotion or non-renewal of the appointment agreement. Advancement and reappointment are not automatic.

VI. Resident Transfers
Before acceptance of a resident transfer, verification of previous educational experiences including a Summative Performance Evaluation with documented ACGME Milestones will be required.

VII. Remediation, Probation & Adverse Actions
The Program Director may initiate remediation or probation when performance concerns arise. The purpose of remediation is to provide structured support and focused educational intervention to assist residents in achieving required competencies and Milestones. A resident may be placed on remediation when performance deficiencies are identified through Milestone assessments, faculty evaluations, direct observation, or other programmatic assessment tools indicating insufficient progress. A remediation plan will be individualized, time-limited, and documented in writing and will include the following:

1. Areas of deficiency mapped to applicable Milestones
2. Specific goals and expected outcomes
3. Educational interventions and support strategies
4. Methods of assessment and timelines for reassessment.

Resident progress during remediation will be reviewed by the Clinical Competency Committee at regular intervals. Possible outcomes include successful completion of remediation, probation, non-promotion, or non-reappointment, in accordance with WVU Medicine PCH policy. Probation represents a more serious academic action than remediation and may place the resident at risk of non-promotion or non-renewal. The Program Director shall be the final authority within the program on promotion, reappointment, and advancement to the next year of training, subject to institutional due process and grievance policies.

VIII. Due Process and Grievance Rights
Residents are entitled to due process and access to grievance and appeal mechanisms as outlined in the Sponsoring Institution’s Due Process and Grievance Policy for any adverse action related to their appointment.

Effective Date: 01/15/2026

I. Purpose
We are committed to fostering a learning and working environment where residents can raise concerns, report mistreatment, and provide feedback confidentially as appropriate and without fear of intimidation or retaliation, and where grievances are addressed through a fair process with due process protections. Residents will be afforded due process, including notice of the concern and an opportunity to be heard, in all formal grievance proceedings.

II. Definitions and Scope
Grievance is a resident’s written complaint alleging unfair treatment or violation of program/institution policy related to the training program. Some examples of grievances include the following:

• Educational environment concerns (supervision, teaching)
• Evaluation disputes, promotion decisions, or perceived unfair application of program policies
• Professionalism concerns, mistreatment, or disruptive behaviors
• Scheduling/duty assignments impacting the educational experience
• Retaliation concerns regarding reporting

This policy does not replace institutional processes for discrimination, harassment, sexual misconduct, patient safety event reporting systems, or employment HR processes unrelated to residency training.

When appropriate, the matter will be routed to the relevant institutional office while maintaining this policy’s non-retaliation protections. This policy applies to grievances and due process at both the program and institutional level and ensures that residents have access to a fair and impartial review process. This policy is distinct from institutional human resources, discrimination, and harassment policies, which may be invoked concurrently when applicable.

III. Non-Retaliation and Confidentiality
Retaliation against a resident for raising a concern or filing a grievance in good faith is prohibited. Any alleged retaliation will be reviewed promptly and may result in corrective action.

The program will handle grievances with discretion and will share information only with individuals who have a legitimate need to know, consistent with institutional policies and reporting obligations.

All grievance proceedings will be handled with circumspection. Information will be shared only with individuals who have a legitimate need to know. The documentation will be maintained securely and separately from the resident’s academic file unless disciplinary action is required. Filing a grievance in good faith will not, by itself, adversely affect a resident’s standing, evaluations, or advancement.

IV. Informal Resolution
Residents are encouraged to attempt informal resolution when feasible by discussing concerns with a Faculty Advisor or Mentor, Chief Resident, or the Program Director. Informal resolution is optional and may be bypassed if the resident prefers a formal process or if the issue is serious.

V. Formal Grievance Procedure
A resident may file a formal grievance by submitting a written statement to the Program Director or DIO. If the grievance involves the Program Director or DIO, the grievance can be submitted to the Graduate Medical Education Committee via the Chief Medical Officer. The grievance must include the following:

• Summary of the concern, relevant dates, and individuals involved
• Any supporting documentation
• Requested Resolution

The grievance will be acknowledged in writing within five business days, and a brief outline will be given for the next steps and anticipated timeline. If necessary, the GMEC may appoint an investigation panel. The panel may meet with the resident (an optional support person can be admitted at the resident’s request), the other involved parties, review relevant records, and consult with GMEC as needed. The support person may not act as legal counsel or speak on behalf of the resident. The panel will complete the review and have a written outcome within 30 business days, excluding extenuating circumstances. Records of grievances will be retained in accordance with institutional record retention policies.

VI. Appeal Process
If the resident disagrees with the outcome, they may submit a written appeal within 10 business days of receiving the decision. Appeals are limited to procedural errors, new information not previously available, or evidence of bias. Appeals will be reviewed by the GMEC or its designee, or by the DIO if the GMEC is not involved in the underlying decision. The decision at this level is final. This policy will be reviewed at least annually by the GMEC and updated as needed to remain compliant with ACGME and institutional requirements.

I. Purpose
The purpose of this policy is to define leave provisions for residents and fellows sponsored by WVU Medicine Princeton Community Hospital in a manner that supports resident well-being, patient safety, and compliance with ACGME Institutional Requirements.

II. Scope
This policy applies to all residents and fellows in ACGME-accredited programs sponsored by WVU Medicine Princeton Community Hospital.

III. Types of Leave
Residents may be granted leave in accordance with institutional policy and program requirements, including but not limited to:

• Vacation / Paid Time Off (PTO)
• Medical Leave
• Parental Leave
• Family and Caregiver Leave
• Bereavement Leave (3 days provided; additional time off for funeral attendance of the death of a close relative as defined by WVU Medicine PCH)
• Military Leave
• Jury Duty (3 days provided by WVU Medicine PCH in accordance with HR policy)
• Other Approved Leave

Specific procedures for requesting and documenting leave are determined by individual programs in accordance with this policy.

IV. Paid Leave Entitlement and Salary Continuation
Residents and fellows must be provided with a minimum of six weeks of approved medical, parental, or caregiver leave at 100 % salary, plus at least one additional week of paid time off outside of those six weeks, in accordance with ACGME Institutional Requirements. The six weeks of approved medical, parental, or caregiver leave at 100% salary is available at least once and at any time during an ACGME-accredited program.

Leave provisions outlined here operationalize the leave entitlements described in the Conditions of Appointment. PTO is available for use from the first day of required reporting for matriculation at WVU Medicine PCH if a qualifying reason such as medical, parental, or caregiver leave of absence is needed. Otherwise, Vacation/PTO must be scheduled in advance whenever possible and approved by the Program Director to ensure continuity of patient care and educational requirements. This policy is available for review by residents and applicants at all times.

V. Educational and Professional Leave
Residents may be granted up to one (1) additional week of educational or CME leave per academic year for approved educational activities. Educational leave is separate from vacation/PTO and must be approved by the Program Director.

VI. Leave of Absence Approval Process
Residents and fellows requesting a leave of absence must submit a written request to the Program Director or designee as soon as reasonably possible. Requests should specify the type of leave and the requested dates.

The Program Director will review the request in accordance with institutional policy, ACGME requirements, program requirements, and applicable board eligibility rules. Routine leave requests that fall within policy limits may be approved at the program level.

Requests that involve prolonged leave, may impact the resident’s ability to meet graduation requirements, or may require an extension of training must be reviewed by the Designated Institutional Official (DIO) or designee.

The resident will receive written confirmation of the approval, including the approved dates of leave and any impact on training, graduation timeline, or requirements.

For medical, mental health, or impairment-related leaves, WVU Medicine PCH may require appropriate documentation and/or fitness-for-duty clearance prior to return to clinical duties.

All leaves of absence are administered in a manner that is non-retaliatory and consistent with ACGME requirements and institutional policy.

VII. Medical, Parental, and Family Leave
Residents are eligible for medical, parental, and family leave in accordance with:

• Institutional policies
• Applicable state and federal laws
• ACGME requirements

Leave for medical, parental, or family reasons will be handled in a manner that supports resident well-being and does not result in retaliation or adverse action solely for taking approved leave. Health and disability insurance benefits for residents and their eligible dependents will continue during their approved leave(s) of absence.

VIII. Impact of Leave on Training and Program Completion
Programs will work with residents who take leave to:

• Maintain educational continuity
• Meet program and board eligibility requirements when feasible

Residents will be informed if the amount or timing of leave may require:

• Extension of training
• Modification of rotations
• Adjustments to graduation timelines

Such determinations will be made transparently and in accordance with ACGME and specialty board requirements, and timely notice of the approved leave effect on program completion will be given to the resident as soon as the determination is made.

IX. Duty Hours and Coverage During Leave

• Leave time is not counted as duty hours
• Coverage arrangements must comply with duty hour limits and supervision requirements
• Residents will not be required to make up leave time in a manner that violates duty hour standards

X. Non-Retaliation
Residents may request and take approved leave without fear of retaliation, intimidation, or adverse action.

Concerns related to leave approval or treatment may be reported through established grievance and due process mechanisms.

XI. Documentation and Reporting
Leave must be documented in accordance with:

• Program requirements
• Institutional policies
• GME administrative systems

Programs are responsible for tracking leave and ensuring compliance with accreditation requirements.

XII. GMEC Oversight
The Graduate Medical Education Committee:

• Monitors institutional leave practices
• Reviews trends related to leave and well-being
• Recommends policy modifications as needed to ensure compliance and support resident wellness

Nothing in this policy is intended to reduce or limit rights under FMLA or applicable state law.

XIII. Policy Review
This policy is reviewed at least annually by the GMEC and updated as necessary to remain compliant with ACGME Institutional Requirement

Effective Date:01/15/2026

I. Purpose
To ensure safe, effective, accurate, and standardized communication during transitions of care and clinical handoffs involving residents, faculty, and other clinical providers in order to reduce patient harm, promote continuity of care, improve situational awareness, and ensure accountability.

II. Policy
Faculty and residents must use standardized, institution-approved handoff processes during all transitions of care. Education and professional development regarding effective handoff communication for core faculty and residents is provided at onboarding and reinforced through annual training.

III. Key Requirements
Transitions of care must include, at a minimum:

• Use of a standardized handoff tool (e.g., I-PASS or equivalent) with ongoing monitoring of compliance
• Clear identification of the responsible provider(s) at all times
• Opportunity for questions, clarification, and closed-loop communication
• Minimization of interruptions during handoffs whenever clinically feasible

IV. Faculty Oversight
Faculty must be readily available to support residents during transitions of care and must ensure appropriate supervision and continuity of patient care.

V. Monitoring and Oversight
The GMEC, or its designee, will review transition-of-care–related patient safety events, concerns, and compliance trends as part of the institution’s quality and patient safety oversight processes and will ensure that appropriate corrective actions are taken when indicated.

Effective Date:01/15/2026

I. Purpose
To ensure patient safety and effective resident education through appropriate supervision in all clinical settings, consistent with ACGME requirements, and to promote progressive responsibility and autonomy as residents demonstrate increasing competence.

II. Policy
Residents must be supervised at all times by qualified faculty members.

• The level of supervision is based on:
• The resident’s level of training
• The resident’s demonstrated competence

The complexity of the patient and clinical situation Supervision must be sufficient to ensure:

• Patient safety
• Quality of care
• Appropriate resident education
• A supportive learning environment

Supervision is available at all times (24/7) in all clinical settings.

Residents must not be required to perform clinical duties beyond their level of competence.

Each ACGME-accredited program must define, in writing, the required level of supervision for each rotation and each level of training.

III. Levels of Supervision
Supervision is categorized as follows:

• Direct Supervision:
  Supervising physician is physically present with the resident and the patient.
• Indirect Supervision: Immediately Available:
  Supervising physician is immediately available in the clinical site or by electronic means and can come to the bedside.
• Indirect Supervision – Available:
  Supervising physician is available by phone or electronic communication.
• Oversight:
  Supervising physician reviews care provided by the resident after it is delivered.

IV. Responsibilities

Program Directors:

• Define supervision levels by rotation and by level of training
• Ensure residents and faculty understand supervision expectations Supervising Physicians:
• Are responsible for patient care decisions
• Must be readily available for consultation, guidance, and patient care support

Residents:

• Must seek supervision whenever clinical situations exceed their competence
• Must know how and when to contact supervising physicians

V. Escalation and Safety
If supervision is not adequate or concerns arise, residents may contact:

• The supervising physician
• The Program Director
• The Designated Institutional Official (DIO)

Residents may raise supervision concerns without fear of retaliation.

VI. GMEC Oversight
The GMEC monitors supervision across all programs through:

• Resident and faculty evaluations
• Patient safety reports
• Learning environment reviews
• Institutional oversight processes

Effective Date:01/15/2026

I. Purpose The purpose of this policy is to:

• Define standards of professional behavior for all individuals participating in Graduate Medical Education (GME) at WVU Medicine Princeton Community Hospital (PCH)
• Establish a fair, consistent, and transparent process for the identification, reporting, review, and management of professionalism concerns
• Promote a safe, respectful, ethical, and effective Learning and Working Environment
• Support resident, fellow, and faculty well-being in accordance with ACGME Institutional Requirements II. Scope This policy applies to:
• All residents and fellows in ACGME-accredited or applicant programs
• All faculty, program leadership, and staff involved in GME
• All clinical and educational settings affiliated with WVU Medicine Princeton Community Hospital

III. Professionalism Standards
Professionalism includes, but is not limited to:

• Ethical behavior and integrity
• Respectful and civil conduct
• Accountability and responsibility
• Commitment to patient safety and quality care
• Respect for patients, learners, faculty, staff, and colleagues
• Compliance with institutional policies, laws, and accreditation standards
• Appropriate self-care to maintain fitness for duty Education regarding professional responsibilities is provided at onboarding and at least annually thereafter.

IV. Definition of Breach of Professionalism
A breach of professionalism is any behavior or action that violates ethical, behavioral, or professional standards and undermines:

• Patient safety
• The Learning and Working Environment
• Institutional values
• The integrity of the educational program

V. Examples of Breaches of Professionalism
Breaches may include, but are not limited to:

A. Conduct and Behavior

• Disrespectful, abusive, disruptive, or intimidating behavior
• Harassment, discrimination, bullying, or retaliation
• Inappropriate language or conduct

B. Ethics and Integrity

• Dishonesty, falsification of records, evaluations, duty hours, or logs
• Plagiarism or misrepresentation
• HIPAA or confidentiality violations
• Failure to disclose conflicts of interest

C. Responsibility and Reliability

• Repeated tardiness or unexcused absences
• Failure to fulfill clinical or educational duties
• Abandonment of patients or duties
• Failure to follow supervision or safety policies

D. Boundaries and Patient Safety

• Boundary violations or inappropriate relationships
• Practicing beyond scope or without supervision
• Failure to follow institutional safety protocols

VI. Reporting of Professionalism Concerns
Concerns may be reported by:

• Residents, fellows, faculty, staff, leadership, patients, or families

Reports may be made through:

• Program leadership
• The DIO
• Institutional reporting systems
• Compliance, risk management, or patient safety systems

All reports will be handled confidentially to the extent possible and without retaliation.

VII. Review and Initial Assessment
Reported concerns will be reviewed by:

• The Program Director and/or
• The DIO
• Human Resources when appropriate

The review will determine:

• Whether a professionalism concern exists
• The severity and impact
• Whether immediate action is required to protect patient safety or the learning environment

VIII. Management and Corrective Action
Depending on severity and pattern, actions may include:

• Informal counseling or feedback
• Formal written warning
• Professionalism remediation plan
• Required education or coaching
• Monitoring or probation
• Disciplinary action per institutional policy
• Referral to GMEC or Human Resources

Serious or repeated breaches may be addressed under:

• The Resident Discipline, Remediation, and Due Process Policy
• Faculty or staff disciplinary policies
• The institutional Impairment or Fitness for Duty policies, when applicable

IX. Fitness for Duty and Safety
If a professionalism concern suggests impairment, fatigue, emotional distress, or risk to patient safety:

• The individual may be immediately removed from duty in a non-punitive manner
• The matter will be managed under the Duty Hours, Fatigue Mitigation, and Fitness for Duty Policy and/or the institutional impairment policy

X. GMEC Involvement and Conflicts of Interest
The GMEC will be involved when:

The Program Director or DIO is the subject of the concern

• A conflict of interest exists
• Institutional-level oversight is required
• The matter reflects a systemic Learning Environment concern

XI. Due Process and Non-Retaliation

• Individuals subject to review are afforded due process per institutional policy
• Retaliation against anyone who raises concerns in good faith is strictly prohibited

XII. Well-Being Support and Resources
WVU Medicine Princeton Community Hospital provides:

• Access to mental health and wellness resources
• Education on burnout, depression, substance use, stress, and resilience
• Annual education on recognizing symptoms and seeking care
• Self-screening tools reviewed annually Confidential Support Resources
• SAMHSA National Helpline: 1-800-662-HELP (4357) or Text 24740 to 435748
• West Virginia Medical Professionals Health Program (PHP): (304) 933-1030
• Employee Assistance Program (Resources for Living): 1-800-865-3200 (24/7)

These resources are confidential and may be accessed without institutional disciplinary action.

If there are concerns about risk of harm, suicidal ideation, violent behavior, or inability to function safely, leadership should be notified through the institutional chain of command.

XIII. Oversight and Monitoring

• The GMEC monitors trends in professionalism concerns and well-being indicators
• The GMEC recommends institutional or programmatic interventions as needed

XIV. Related Policies

• Duty Hours, Fatigue Mitigation, and Fitness for Duty Policy
• Supervision Policy
• Resident Discipline, Remediation, and Due Process Policy

Effective Date:01/15/2026

I. Purpose
The purpose of this policy is to promote patient safety, support resident and faculty well-being, and ensure a safe and effective learning environment by:

• Establishing standards for resident duty hours
• Providing education and resources for fatigue mitigation and alertness management
• Ensuring that residents and faculty are fit for duty
• Defining processes for relief from duty, backup coverage, and safe transitions of care

II. Policy
WVU Medicine Princeton Community Hospital (PCH) is committed to maintaining a culture in which patient safety and resident well-being take priority over all other educational or service obligations.

Residents and faculty must be fit for duty to provide safe patient care. WVU Medicine PCH ensures that:

• Resident duty hours comply with ACGME requirements
• Residents and faculty receive education in fatigue recognition and mitigation
• Mechanisms exist for relief from duty and backup coverage when fatigue, illness, or impairment threatens safety
• Such relief is provided in a non-punitive, non-retaliatory manner

III. Definitions

Duty Hours:
All clinical and academic activities related to the residency program, including in-house call, clinical work, conferences, and all internal and external moonlighting.

Fitness for Duty:
The ability to safely and effectively perform clinical responsibilities without impairment due to fatigue, illness, emotional distress, or any physical or cognitive condition.

IV. Duty Hour Standards
Resident duty hours must comply with the following institutional standards in accordance with ACGME requirements:

• Maximum 80 hours per week, averaged over four weeks
• Minimum one day off in seven, averaged over four weeks
• Maximum 24 hours of continuous scheduled clinical work, with up to 4 additional hours for transitions of care if needed
• Minimum 8 hours off between scheduled duty periods (10 hours encouraged)
• In House and out of facility Moonlighting hours must be included in the maximum 80 hours per week

V. Fatigue Mitigation and Alertness Management
1. Residents and faculty receive education on the following at onboarding and annually thereafter:

• Recognition of fatigue and impairment
• Alertness management strategies
• Sleep hygiene and fatigue mitigation techniques

2. WVU Medicine PCH provides:

• Access to quiet and restful sleep facilities when needed
• Access to safe transportation when a resident or faculty member is too fatigued to safely drive
• A non-punitive process to request relief from duty

Residents who feel too fatigued to provide safe patient care must notify their supervising faculty and utilize the institutional backup coverage system.

VI. Fitness for Duty

1. Residents and faculty share responsibility for:

• Self-monitoring for fatigue, illness, or impairment
• Identifying colleagues who may be unfit for duty
• Taking appropriate action to protect patient safety

2. Any resident who is determined by themselves, supervising faculty, the Program Director, or the DIO to be unfit for duty due to fatigue, illness, or impairment will be relieved of clinical responsibilities immediately in a non-punitive manner.

3. Fitness-for-duty concerns include, but are not limited to:

• Fatigue or sleep deprivation
• Acute illness
• Emotional or psychological distress
• Cognitive or physical impairment

VII. Backup Coverage and Transitions of Care

1. Each training program and the Sponsoring Institution must maintain a system for backup clinical coverage when a resident is unable to continue assigned duties.

2. When a resident is relieved from duty:

• A safe, structured handoff of patient care must occur in accordance with the institutional Transitions of Care Policy.
• Continuity of patient care must be maintained without disruption to patient safety.

VIII. Faculty Responsibilities
Faculty members are responsible for:

• Monitoring residents for signs of fatigue or impairment
• Intervening when patient safety or resident well-being may be compromised
• Supporting residents in accessing rest, relief from duty, and backup coverage
• Ensuring appropriate supervision and safe transitions of care

IX. Reporting and Non-Retaliation

1. Residents must accurately report duty hours in the designated Graduate Medical Education system.

2. Concerns regarding:

Duty hour violations

• Fatigue
• Fitness for duty
• Unsafe clinical conditions may be reported to the Program Director, DIO, GMEC, or other institutional leaders.

3. Residents may request relief from duty or report fatigue or impairment without fear of reprisal, retaliation, or adverse academic consequence.

X. Oversight and Monitoring
The GMEC is responsible for:

• Reviewing duty hour compliance
• Monitoring fatigue mitigation effectiveness
• Reviewing trends, safety events, and reports related to fatigue or impairment
• Requiring corrective action when systemic issues are identified

The Sponsoring Institution will use this data to continuously improve the learning environment and patient safety culture.

XI. Related Policies

• Supervision Policy
• Transitions of Care Policy
• Professionalism and Resident Well-being Policy

Effective Date:01/15/2026

I. Purpose
The purpose of this policy is to ensure that moonlighting activities do not interfere with resident education, patient safety, resident well-being, or compliance with ACGME duty hour and fatigue mitigation requirements.

II. Policy

1. Moonlighting is voluntary and is not required by the Sponsoring Institution or any training program.

2. Moonlighting is not part of the educational program and must not interfere with:

• The resident’s ability to achieve educational goals
• Clinical performance
• Fitness for duty
• Patient safety

3. Patient safety, resident well-being, and educational priorities take precedence over all moonlighting activities.

4. All moonlighting must:

• Comply with ACGME duty hour requirements
• Be approved in advance and in writing by the Program Director
• Be counted toward the 80-hour weekly duty hour limit

5. Moonlighting is not permitted during scheduled clinical or educational duty periods.

6. PGY-1 residents may not moonlight.

III. Approval and Eligibility

1. Residents may not engage in moonlighting until they have:

• Successfully completed PGY-1
• Received written approval from the Program Director 2.

The Program Director will consider:

• The resident’s academic standing
• Clinical performance
• Professionalism
• Fatigue risk and fitness for duty before granting approval.

IV. Fitness for Duty and Fatigue

1. Moonlighting must not compromise a resident’s fitness for duty.

2. If moonlighting activities:

Contribute to fatigue

• Impair performance
• Jeopardize patient safety
• Interfere with educational responsibilities

the Program Director may immediately suspend or revoke moonlighting privileges.

3. Residents remain subject to all provisions of the Duty Hours, Fatigue Mitigation, and Fitness for Duty Policy. \

V. Duty Hours and Reporting

1. All internal and external moonlighting hours must be logged in the designated GME duty hour reporting system.

2. Moonlighting hours count toward the 80-hour weekly limit.

VI. Licensure and Liability Coverage

1. Residents must maintain appropriate licensure for any moonlighting activity.

2. Moonlighting must be covered by professional liability insurance that is separate from institutional coverage unless otherwise explicitly approved in writing by WVU Medicine Princeton Community Hospital.

3. The Sponsoring Institution is not responsible for professional activities performed while moonlighting outside approved institutional arrangements.

VII. Oversight and Enforcement

1. The Program Director and the GMEC are responsible for:

• Monitoring moonlighting activities
• Reviewing duty hour compliance
• Monitoring resident performance and fatigue risk

2. In the event that moonlighting adversely affects:

• Resident performance
• Professionalism
• Patient safety

Educational progress moonlighting privileges will be suspended or withdrawn.

VIII. Related Policies

• Duty Hours, Fatigue Mitigation, and Fitness for Duty Policy
• Supervision Policy
• Professionalism and Resident Well-being Policy

Effective Date: 04/23/2026

I. Purpose

The purpose of this policy is to ensure the safety of residents, patients, faculty, and staff and to maintain continuity of Graduate Medical Education (GME) during disasters or emergency situations, in compliance with ACGME Institutional Requirements.

II. Scope

This policy applies to all residents, fellows, faculty, and Graduate Medical Education programs sponsored by WVU Medicine Princeton Community Hospital (PCH). III. Definitions A disaster or emergency includes, but is not limited to:

• Natural disasters (e.g., severe weather, flooding, earthquakes)
• Public health emergencies or pandemics
• Fire, utility failure, or infrastructure disruption
• Mass casualty events 2
• Acts of violence or security threats
• Information technology or communication system failures

IV. Institutional Emergency Management Framework

WVU Medicine PCH maintains an institutional Emergency Operations Plan (EOP) that governs emergency response and disaster management, including activation of the Hospital Incident Command System (HICS). Graduate Medical Education operates within the institutional emergency management and incident command structure, and coordinates with the following:

• Hospital Administration
• Emergency Management
• Clinical Leadership
• Human Resources
• Security and Safety Services

V. Resident Safety and Supervision

During a disaster or emergency:

• Resident safety and well-being are prioritized.
• Residents will function within their scope of training.
• Appropriate faculty supervision will be maintained at all times.
• Residents will not be expected to perform duties beyond their level of competence.
• Residents may be removed from clinical duties if conditions pose an unreasonable risk to their safety.

VI. Duty Hours, Fatigue, and Well-Being During Emergencies

• Duty hour standards remain in effect to the greatest extent possible.
• Fatigue mitigation strategies, including rest periods and safe transportation, will be utilized.
• Residents may request relief from duties without fear of retaliation.
• Access to wellness and mental health resources will be maintained.

VII. Communication During an emergency

• The institution will use established communication systems to disseminate information.
• Residents will receive timely updates regarding:

1. Reporting expectations
2. Schedule changes
3. Safety instructions
4. Program status

Program Director(s), DIO, and faculty will serve as primary communication points for residents.

VIII. Continuity of Education and Program Operations

If normal educational activities are disrupted:

• Programs will implement alternative educational methods when feasible.
• Clinical assignments may be modified to ensure patient safety and educational value.
• Significant or prolonged disruptions will be reviewed by the GMEC.

IX. Resident Assignment and Reassignment

Residents may be temporarily reassigned during emergencies:

• Only when appropriately supervised
• Only within their competence
• With consideration of educational impact and well-being

Residents will not be required to assume responsibilities that compromise safety or violate ACGME requirements. They will not be used as substitute staff for absent personnel. Residents may be temporarily relocated to affiliated or other approved clinical sites if necessary to ensure continuity of education and patient care, under the oversight of the DIO and GMEC and in compliance with ACGME requirements.

X. Escalation and Reporting

Residents may report concerns related to disaster response, safety, supervision, or well-being to:

• Supervising faculty
• Program Director
• Designated Institutional Official (DIO)

Graduate Medical Education Committee (GMEC) Concerns may be reported confidentially and without fear of retaliation.

XI. GMEC Oversight

The Graduate Medical Education Committee:

• Reviews emergency-related impacts on the learning and working environment
• Evaluates resident safety, supervision, and duty hour concerns
• Recommends corrective actions or policy updates as needed

XII. Extraordinary Circumstances and ACGME Notification

In the event of a disaster or emergency that significantly disrupts or threatens the continuation of resident education or patient care, the Designated Institutional Official (DIO) will notify the ACGME in accordance with ACGME policies on Extraordinary Circumstances.

The GMEC will oversee institutional and program-level contingency planning, including potential temporary relocation of residents, restructuring of educational activities, or other actions necessary to ensure continued compliance with accreditation requirements and resident safety.

XIII. Salary, Benefits, and Contractual Protections

In the event of a disaster or emergency, WVU Medicine PCH will make every reasonable effort to ensure continuation of resident salary, benefits, and contractual protections. If disruptions to operations require changes in training arrangements, residents will be informed promptly, and all actions will comply with ACGME requirements and institutional policies regarding appointments, reassignments, or closures.

XIV. Policy Review

This policy is reviewed at least annually by the GMEC and updated as necessary to ensure compliance with ACGME Institutional Requirements and institutional emergency preparedness standards. WVU Medicine PCH has an existing institutional emergency preparedness infrastructure and disaster response plan. This policy supplements and does not replace existing policies and procedures. Its purpose is to establish resident roles and responsibilities during emergencies and disasters and to outline the Sponsoring Institution’s commitment to maintaining resident safety, support, educational continuity and well-being during such events.

Effective Date: 04/23/2026

I. Purpose

The purpose of this policy is to:

• Protect patient safety
• Promote the health and well-being of residents, fellows, and faculty
• Establish a clear, fair, and non-punitive process for the identification, evaluation, and management of individuals who may be impaired
• Ensure that individuals who are not fit for duty are promptly removed from clinical responsibilities
• Provide a structured pathway for treatment, monitoring, and safe return to duty

This policy fulfills WVU Medicine Princeton Community Hospital’s (PCH) obligations under ACGME Institutional Requirements related to patient safety, the Learning and Working Environment, supervision, and well-being.

II. Scope

This policy applies to:

• All residents and fellows in ACGME-accredited or applicant programs
• All faculty involved in Graduate Medical Education
• Any individual whose impairment may affect patient safety or the Learning and Working Environment within GME-sponsored clinical or educational activities

III. Definitions of Impairment

Any condition that interferes with an individual’s ability to safely and effectively perform clinical or professional responsibilities, including but not limited to:

• Substance use or misuse (alcohol, prescription, or illicit drugs)
• Mental health conditions (e.g., severe depression, suicidality, psychosis)
• Cognitive impairment
• Physical illness or medical conditions
• Severe fatigue or sleep deprivation
• Behavioral or emotional dysregulation

Fitness for Duty: The ability to perform clinical and professional responsibilities safely, effectively, and reliably without risk to patients, learners, or colleagues.

IV. Guiding Principles

1. Patient safety is paramount.
2. Early identification and intervention are encouraged.
3. WVU Medicine PCH promotes a supportive, non-punitive approach to impairment when appropriate.
4. Confidentiality will be maintained to the extent possible.
5. This policy is not primarily disciplinary, though disciplinary processes may be used when necessary.

V. Identification and Reporting of Concerns

Concerns about possible impairment may be raised by:

• The individual themselves
• Residents, fellows, faculty, staff, or leadership
• Patients or families

Institutional reporting systems

Reports may be made to:

• The Program Director
• The DIO
• Faculty
• Department or hospital leadership
• Human Resources
• Compliance, risk management, or patient safety reporting systems

All reports will be taken seriously and handled confidentially to the extent possible and without retaliation.

VI. Immediate Safety Actions

1. If an individual is suspected of being acutely impaired or not fit for duty:

• They will be immediately relieved of clinical duties in a non-punitive manner to protect patient safety.
• Individuals are encouraged to self-report impairment or fitness-for-duty concerns without fear of retaliation or punitive action for seeking help.
• Retaliation against any individual who raises a good-faith concern is strictly prohibited.

2. Authority to remove from duty includes:

• Program Director
• DIO
• Supervising faculty
• Department or hospital leadership

3. A safe transition of care must occur in accordance with WVU Medicine PCH Transitions of Care Policy.

4. Acute fatigue-related fitness-for-duty issues are managed under the Duty Hours, Fatigue Mitigation, and Fitness for Duty Policy. This policy addresses broader or ongoing impairment concerns.

5. If necessary, emergency medical or psychiatric services will be engaged.

VII. Initial Evaluation and Triage

Following removal from duty, the Program Director and/or DIO, in collaboration with:

• Human Resources
• Medical Staff leadership
• Occupational Health
• Risk Management
• Legal counsel (as appropriate) will determine:

1. The nature of the concern
2. The level of risk
3. The appropriate next steps, including referral for evaluation

VIII. Referral for Evaluation and Support

Depending on the nature of the concern, the individual may be referred to:

• West Virginia Medical Professionals Health Program (PHP)
• Employee Assistance Program (EAP)
• Occupational Health
• Treating physician, psychiatrist, or other qualified professional

Such referrals may be:

• Voluntary
• Mandatory, when patient safety or institutional risk requires it

IX. Management, Treatment, and Monitoring

1. If impairment is confirmed, a management plan will be developed, which may include:

• Treatment or counseling
• Work restrictions
• Monitoring agreements
• Compliance requirements

2. For residents and fellows, the Program Director and DIO will oversee compliance in coordination with:

• The PHP or treating professionals
• GMEC, when appropriate

3. For faculty, management will occur in coordination with:

• Human Resources
• Medical Staff leadership
• Applicable WVU Medicine policies

X. Return to Duty

1. Return to clinical duties will occur only when:

• The individual is deemed fit for duty by an appropriate evaluator
• Any required treatment or monitoring plan is in place
• Institutional leadership approves the return

2. Return-to-duty may include:

• Phased return
• Modified duties
• Ongoing monitoring

XI. Relationship to Discipline and Due Process

1. This policy is not primarily disciplinary.

2. However, disciplinary action may occur when:

• There is refusal to comply with evaluation or treatment
• There are repeated or serious violations
• There is misconduct independent of illness

3. For residents, any adverse academic or disciplinary action will follow: The Resident Discipline, Remediation, and Due Process Policy

XII. Confidentiality and Records

Information will be shared only with those who have a legitimate need to know.

Records will be maintained in accordance with institutional, legal, and regulatory requirements, consistent with HIPAA and applicable state and federal law.

Records will be kept separate from the academic file when required by law

XIII. Education and Prevention

• Education on impairment, wellness, and fitness for duty is provided at onboarding and at least annually.
• The institution promotes early self-reporting and peer concern reporting.

XIV. Oversight and Monitoring

• The DIO and GMEC provide oversight of impairment processes involving residents and fellows.
• The GMEC monitors trends and recommends system-level improvements to the Learning and Working Environment.

XV. Related Policies

• Duty Hours, Fatigue Mitigation, and Fitness for Duty Policy
• Professionalism and Resident Well-Being Policy
• Supervision Policy
• Transitions of Care Policy
• Resident Discipline, Remediation, and Due Process Policy
• WVU Medicine HR and Medical Staff impairment policies (as applicable)

Effective Date: 04/23/2026

I. Purpose

The purpose of this policy is to ensure that all relationships between WVU Medicine Princeton Community Hospital’s Graduate Medical Education (GME) programs and external vendors, contractors, and service providers are managed in a manner that:

• Preserves the integrity of the educational environment
• Protects patient safety and quality of care
• Maintains compliance with ACGME Institutional and Program Requirements
• Avoids conflicts of interest and undue commercial influence
• Ensures appropriate oversight by the Sponsoring Institution

II. Scope

This policy applies to:

• All ACGME-accredited and developing residency and fellowship programs sponsored by WVU Medicine Princeton Community Hospital (PCH)
• All faculty, residents, fellows, administrators, and staff involved in GME
• All external vendors, contractors, consultants, and service providers who interact with or support the GME enterprise, including but not limited to:

1. Educational software and GME management systems
2. Simulation and educational services
3. Recruitment and application services
4. Consulting services
5. Evaluation, survey, or assessment vendors
6. Any entity providing services, content, or systems used in GME administration or education

III. Policy Statement

WVU Medicine PCH is committed to ensuring that all vendor and external entity relationships related to GME are structured to support the educational mission, protect learners and patients, and comply with ACGME requirements and institutional policies. No vendor or external entity may:

• Direct, control, or unduly influence educational content
• Directly supervise or evaluate residents or fellows
• Make decisions regarding resident promotion, remediation, discipline, or dismissal
• Interfere with the Program Director’s or faculty’s authority over education and training
• Compromise patient safety, educational quality, or institutional integrity

IV. Oversight and Approval

The DIO has ultimate responsibility for oversight of all vendor and external entity relationships related to GME. All GME-related vendor relationships must be:

• Reviewed and approved through institutional contracting and compliance processes
• Reviewed by the DIO (or designee) for educational and regulatory appropriateness
• Reported to the GMEC when they materially affect GME operations, education, or compliance

Graduate Medical Education Committee (GMEC)

The GMEC:

• Maintains oversight of the learning and working environment
• Reviews any vendor relationships that may impact:

1. Educational quality
2. Resident supervision
3. Patient safety
4. Program or institutional compliance

• May require modification or termination of vendor relationships that pose risk or conflict with GME standards

V. Standards for Vendor and External Entity Relationships

All vendor and external entity relationships must:

• Support the educational mission of the Sponsoring Institution
• Comply with ACGME Institutional and Program Requirements
• Comply with institutional compliance, legal, and contracting policies
• Avoid real or perceived conflicts of interest
• Maintain confidentiality and data security
• Preserve institutional and program control over:

1. Curriculum
2. Evaluation
3. Promotion and graduation decisions
4. Disciplinary actions

Faculty appointment and supervision

Any vendor-supported educational activity must be under faculty oversight, with transparent disclosure of any financial relationships or support. Potential conflicts of interest must be disclosed to the DIO and managed in accordance with institutional conflict-of-interest policy.

VI. Prohibited Activities

Vendors and external entities may not:

• Provide direct clinical supervision of residents
• Perform resident or faculty evaluations
• Participate in Clinical Competency Committee (CCC) or Program Evaluation Committee (PEC) decision-making
• Influence resident selection, promotion, remediation, or dismissal decisions
• Market or solicit residents directly without DIO/Institutional approval.
• Control or dictate educational content without faculty oversight and approval

VII. Contractual Requirements

All vendor relationships involving GME must:

• Be governed by a formal written agreement
• Be reviewed through institutional legal and compliance channels
• Include provisions addressing:

1. Data security and confidentiality
2. Compliance with institutional and ACGME standards
3. Termination for non-compliance or risk to education/patient safety

Preservation of institutional authority over education and training

GME and the Sponsoring Institution retain ownership/control of resident educational records and evaluation data; vendors may not sell, mine, or use data for secondary purposes without written institutional approval. Contacting residents directly for marketing or sales purposes without DIO/Institutional approval is prohibited.

VIII. Monitoring and Review

• The DIO and Institutional GME Office will monitor vendor relationships for compliance and appropriateness. The DIO may require GMEC review of vendor relationships that impact resident education, supervision, or institutional compliance prior to implementation.
• Concerns regarding vendor conduct or influence must be reported to the DIO.
• The GMEC may review and take action regarding any vendor relationship that threatens educational quality, patient safety, or compliance with ACGME requirements.

IX. Violations Violations of this policy may result in:

• Termination of vendor contracts
• Institutional corrective action
• Reporting to appropriate institutional compliance offices
• Other actions as deemed necessary to protect the GME enterprise

X. Review Cycle

This policy will be reviewed at least annually, or more frequently as required by changes in ACGME requirements or institutional policy. This policy supports the Sponsoring Institution’s responsibility for oversight of the learning and working environment, protection from undue external influence, and maintenance of educational and patient care standards, consistent with ACGME Institutional Requirements. This policy supplements existing WVU Medicine PCH vendor and external entity policies and does not replace or supersede institutional requirements already in effect.

Effective Date: 04/23/2026

I. Purpose

The purpose of this policy is to define the procedures and institutional responsibilities of WVU Medicine Princeton Community Hospital (PCH) in the event of:

• Closure of a residency or fellowship program
• Closure of the Sponsoring Institution
• Reduction in the approved resident or fellow complement of a program

This policy ensures compliance with ACGME Institutional Requirements and protects the educational, financial, and professional interests of residents and fellows.

II. Policy Statement

WVU Medicine PCH is committed to:

Maintaining the continuity of graduate medical education for all appointed residents and fellows

• Making every reasonable effort to assist affected residents/fellows in securing positions in other ACGME-accredited programs
• Providing timely notification to all affected parties 21
• Supporting residents/fellows with appropriate funding and benefits during transitions whenever feasible

This policy applies regardless of whether the action is due to financial exigency, loss of accreditation, institutional restructuring, or other administrative or operational reasons.

III. Scope

This policy applies to all ACGME-accredited and ACGME-accredited-on-initial-accreditation programs sponsored by WVU Medicine PCH as well as all residents and fellows appointed to those programs.

IV. Definitions

• Reduction in Complement: A permanent or temporary decrease in the number of ACGME-approved resident or fellow positions in a program.
• Program Closure: The permanent discontinuation of a residency or fellowship program.
• Sponsoring Institution Closure: The cessation of operations or withdrawal from graduate medical education by the Sponsoring Institution.

V. Authority and Governance

1. The authority to close a program, reduce complement, or close the Sponsoring Institution rests with the Sponsoring Institution’s Executive Leadership and Governing Body.

2. The Designated Institutional Official (DIO) is responsible for:

• Oversight of the process
• Communication with the ACGME
• Coordination of resident/fellow transition efforts

3. The Graduate Medical Education Committee (GMEC) will:

• Review the situation
• Provide oversight and recommendations
• Monitor the implementation of this policy

VI. Notification Requirements In the event of a program closure, closure of WVU Medicine PCH, or reduction in resident/fellow complement, WVU Medicine PCH will:

1. Provide timely written notice to:

All affected residents/fellows

• The ACGME
• Program Directors
• The GMEC
• The institutional leadership

2. When applicable, also notify:

• The NRMP
• Other relevant regulatory or accrediting bodies

VII. Commitments to Residents and Fellows WVU Medicine Princeton Community Hospital commits to:

1. Make every reasonable effort to:

• Place affected residents/fellows in other ACGME-accredited programs in the same specialty
• Assist with identification of receiving programs
• Provide letters of verification, evaluation, and good standing

2. Make reasonable efforts to ensure continuity of funding and benefits, consistent with:

• Institutional resources
• Legal and contractual obligations

3. Support educational continuity, including:

• Transfer of educational records
• Verification of training completed
• Assistance with licensure and credentialing documentation

Under no circumstances will residents or fellows be left without institutional support or guidance during a closure or reduction process.

VIII. Process

A. In the Event of Program Closure or Sponsoring Institution Closure:

1. The DIO will:

• Immediately notify the ACGME
• Convene the GMEC
• Oversee execution of resident/fellow transition plans

2. The Sponsoring Institution will:

• Develop an individualized transition plan for each affected resident/fellow
• Actively assist in securing positions at other ACGME-accredited programs
• Maintain documentation of all efforts

B. In the Event of Reduction in Complement:

1. The Sponsoring Institution will:

• Notify the ACGME in advance
• Ensure no resident/fellow is displaced without: A defined transition plan, or A reasonable opportunity to complete training

This process applies to both temporary and permanent reductions in complement.

2. The GMEC will:

• Review and monitor the impact on educational quality and resident progression

IX. Financial Support

The Sponsoring Institution will make reasonable efforts, consistent with applicable laws, contracts, and available resources, to continue salary and benefits for affected residents/fellows during the transition period or to otherwise provide financial support while transfer arrangements are being finalized.

X. Recordkeeping and Oversight

All actions taken under this policy will be documented and maintained by the Office of Graduate Medical Education.

The GMEC will review outcomes and ensure institutional compliance with ACGME requirements.

XI. Related Policies

• Resident Grievance, Due Process, and Non-Retaliation Policy
• Resident Recruitment, Eligibility, Selection, Advancement, and Remediation Policy
• Conditions of Appointment

XII. ACGME Compliance Statement

This policy is intended to ensure compliance with the ACGME Institutional Requirement 4.15 regarding:

• WVU Medicine PCH responsibilities for program closure
• Reduction in complement
• Protection of residents/fellows and continuity of education

Effective Date: 04/23/2026

I. Purpose

The purpose of this policy is to define the institutional requirements and procedures for the acceptance of residents and fellows transferring into WVU Medicine Princeton Community Hospital (PCH) ACGME-accredited or applicant programs, ensuring compliance with ACGME Institutional Requirements and protection of educational quality and patient safety.

II. Scope

This policy applies to all ACGME-accredited and ACGME-accredited-on-initial-accreditation programs sponsored by WVU Medicine PCH and to all residents or fellows seeking to transfer into those programs.

III. Definitions

Transfer Resident/Fellow: A resident or fellow who has completed some portion of training in another ACGME-accredited, ACGME-I accredited, AOA-approved, RCPSC-accredited, or CFPC-accredited program and seeks to continue training at WVU Medicine PCH. 27

IV. Policy Statement

WVU Medicine PCH will accept transfer residents/fellows only when such transfers are consistent with educational capacity, supervision resources, funding, and ACGME requirements.

V. Institutional Requirements for Transfer

Prior to acceptance of any transfer resident/fellow, the following must be obtained and reviewed:

1. Written verification of prior training from the previous program director, including:

• Dates of training
• Rotation history
• Level of competence using ACGME Milestones or equivalent
• Documentation of any remediation, probation, or disciplinary actions

There must be a summative competency-based performance evaluation from the transferring program that documents the resident’s performance up to the point of transfer, and this must be received prior to acceptance.

2. Verification of the resident’s/fellow’s eligibility and credentials.

3. Confirmation of funding and institutional resources to support the transfer.

4. Review and approval by the Program Director and the Designated Institutional Official (DIO).

VI. Educational Placement and Credit

1. The Program Director will determine the appropriate level of training placement and the amount of credit awarded toward program completion based on documented prior training and competence.

2. The receiving program must ensure that the resident/fellow can meet all program and board eligibility requirements.

VII. Institutional Oversight

1. All transfer requests must be reported to the DIO.

2. Transfers that impact complement or resources require GMEC review.

3. Transfers will be processed in compliance with ACGME and NRMP policies, as applicable.

VIII. Documentation and Records

All documentation related to transfer review, approval, and placement will be maintained by the Office of Graduate Medical Education.

IX. Policy Review

This policy is reviewed at least annually by the GMEC and updated as necessary.

X. ACGME Compliance Statement This policy is intended to ensure compliance with ACGME Institutional Requirements regarding resident eligibility, verification of prior training, and oversight of resident transfers.

Effective Date: 04/23/2026

I. Purpose

To define which program changes require review and approval by institutional leadership and notification or submission to the ACGME.

II. Scope

Applies to all GME programs sponsored by WVU Medicine Princeton Community Hospital (PCH).

III. Policy Statement

Certain program changes require institutional oversight to ensure continued compliance with ACGME requirements and protection of educational quality.

IV. Changes Requiring Review and Approval

Examples include, but are not limited to:

• Change in Program Director
• Change in participating sites or major clinical assignments
• Substantial curriculum restructuring
• Change in complement
• Change in program format or length
• Addition or removal of participating institutions

V. Approval Process

1. The Program Director must submit proposed changes to the DIO.

2. The DIO will determine whether GMEC review is required.

3. The GMEC will review changes that may impact educational quality, resources, or compliance.

4. The DIO is responsible for determining and executing required ACGME notifications or applications via the ACGME Accreditation Data System (ADS).

VI. Implementation

No change requiring ACGME approval or notification may be implemented until appropriate institutional and ACGME processes are completed.

VII. Documentation

All approvals and communications will be documented and maintained by the Office of Graduate Medical Education.

VIII. Policy Review

Reviewed at least annually by the GMEC.

IX. ACGME Compliance Statement

This policy supports compliance with ACGME Institutional Requirements regarding institutional oversight, program changes, and accreditation communications.

Effective Date: 04/23/2026

I. Purpose

To establish a formal institutional process for requesting increases in approved resident or fellow complement.

II. Scope

Applies to all GME programs sponsored by WVU Medicine Princeton Community Hospital (PCH)

III. Policy Statement

Requests for complement increases must demonstrate adequate educational resources, supervision, clinical volume, and funding. IV. Request Requirements Programs must submit:

• Educational rationale
• Supervision and faculty capacity analysis
• Clinical volume and learning environment impact assessment
• Space and resource assessment
• Funding confirmation

V. Review and Approval

1. Program Director submits request to the DIO.

2. GMEC reviews and makes a recommendation.

3. Institutional leadership confirms resource and funding availability.

4. The DIO submits the request to the ACGME, if approved.

VI. Implementation

No increase may occur until ACGME approval is obtained.

VII. Documentation

All requests and approvals will be maintained by the GME Office.

VIII. Policy Review

Reviewed annually by the GMEC.

IX. ACGME Compliance Statement

This policy ensures compliance with ACGME requirements regarding complement management and institutional resource oversight.

Effective Date: 04/23/2026

I. Purpose

To define institutional oversight of participating sites and Program Letters of Agreement (PLAs).

II. Scope

Applies to all participating sites used by WVU Medicine PCH-sponsored programs.

III. Policy Statement

All participating sites must be approved, monitored, and governed by a current PLA.

IV. PLA Requirements

Each PLA must define:

Faculty supervision and teaching responsibilities

Resident roles and responsibilities

Educational content

Duration and renewal process

Policies governing resident supervision and evaluation

V. Approval and Review

1. All PLAs require Program Director and DIO approval.

2. PLAs will be reviewed and renewed in accordance with applicable ACGME Program Requirements and institutional policy.

3. Sites that materially affect education may be reviewed by the GMEC.

VI. Monitoring

Programs and the GME Office will monitor participating sites for educational quality, supervision, and safety.

VII. Documentation

PLAs will be maintained by the Office of Graduate Medical Education.

VIII. Policy Review

Reviewed annually by the GMEC.

IX. ACGME Compliance Statement

This policy ensures compliance with ACGME Institutional Requirements regarding participating sites and educational oversight.

Effective Date: 04/23/2026

I. Purpose

To ensure annual, systematic review of the Sponsoring Institution’s GME performance.

II. Policy

The GMEC will conduct an Annual Institutional Review (AIR) that includes, at minimum:

• the most recent institutional letter of notification from the ACGME,
• results of ACGME resident/fellow and faculty surveys, and
• each program’s accreditation status and citations.
• Patient safety and quality metrics
• Duty hours and well-being indicators
• Previous action plan follow-up 36

III. Executive Summary

The DIO will prepare and submit a written Annual Executive Summary of the AIR to the Sponsoring Institution’s Governing Body that includes:

Key findings

• Action plans
• Monitoring strategies
• Resource needs

The GMEC reviews and approves the AIR prior to submission.

IV. Documentation

AIR materials and the Executive Summary will be maintained by the GME Office.

Effective Date: 04/23/2026

I. Purpose

To ensure timely identification, review, and improvement of underperforming programs in accordance with ACGME Institutional Requirements.

II. Criteria for Identifying Underperformance

Programs will undergo Special Review when any of the following occur:

Required Criteria:

• Initial Accreditation with Warning
• Continued Accreditation with Warning
• Probationary Accreditation
• Accreditation Withheld
• Withdrawal or Administrative Withdrawal of Accreditation
• Expedited Withdrawal of Accreditation

Reduction in resident complement Additional Institutional Criteria:

• Significant concerns identified through ACGME surveys
• Persistent duty hour or supervision violations
• Patient safety or quality concerns involving residents
• Failure to meet defined educational outcomes
• GMEC determination of risk to accreditation or educational quality

III. Process and Timeline

A Special Review will be initiated within 30 days of identification of underperformance

• The DIO will appoint a review team

The review will include:

1. program data review
2. interviews with residents, faculty, and leadership
3. review of surveys and performance metrics

IV. Special Review Report

A written report will be completed and presented to the GMEC and will include:

• Identified deficiencies
• Root cause analysis
• Quality improvement goals
• Specific corrective actions
• Defined timelines
• Assigned responsible parties

V. GMEC Monitoring The GMEC will:

• Review and approve the Special Review report
• Monitor progress at defined intervals
• Require follow-up reports until resolution
• Escalate concerns if progress is insufficient

VI. Completion

The Special Review process concludes when the GMEC determines that:

• deficiencies have been resolved, and
• program performance is stable and compliant

Effective Date: 04/23/2026 I

I. Purpose

To ensure timely notification to the ACGME in the event of adverse actions affecting the Sponsoring Institution or participating sites.

II. Policy

WVU Medicine Princeton Community Hospital shall maintain appropriate patient care accreditation and licensure.

III. Notification Requirements

The DIO must notify the ACGME Institutional Review Committee within 30 days if:

• The Sponsoring Institution or a major participating site:

1. Loses patient care accreditation
2. Is placed on probation or similar adverse status
3. Has its license denied, restricted, suspended, or revoked

IV. Response Plan

Such notification must include:

• Description of the adverse action
• Impact assessment on GME programs
• Corrective action plan and timeline

Appendix A: WVU Medicine System Policies Supporting GME

Effective Date: 04/23/2026

This policy is adopted in its entirety from WVU Health Systems and will be provided to the residents and fellows.

WEST VIRGINIA UNIVERSITY HEALTH SYSTEM POLICY AND PROCEDURE MANUAL REASONABLE ACCOMMODATIONS SCOPE:

All West Virginia University Health System (WVUHS) Entities* PURPOSE Policy V.105S 1st Effective 02/19/2020 Revised 06/30/2025 Reviewed 06/30/2025 WVUHS complies with the Americans with Disabilities Act (ADA), the Pregnant Workers Fairness Act (PWFA), Title VII of the Civil Rights Act of 1964, and all applicable state and local fair employment practices laws and is committed to providing equal employment opportunities to qualified individuals with disabilities, workers affected by pregnancy, childbirth, or related medical conditions, and workers with sincerely held religious beliefs that conflict with work requirements.

This policy sets forth the procedures to be followed to ensure reasonable accommodations are provided to qualified individuals with known disabilities, those with limitations related to pregnancy or childbirth, and those whose sincerely held religious beliefs conflict with work requirements.

Furthermore, it is WVUHS's policy not to discriminate against individuals on the basis of religious beliefs or practices (or lack thereof), disability, or pregnancy, in regard to application procedures, hiring, advancement, separation, compensation, training or other terms, conditions or privileges of employment.

Unless doing so would create an undue hardship for WVUHS, WVUHS will provide a reasonable accommodation to any qualified applicant or employee with a disability if the reasonable accommodation would allow the individual to perform the essential functions of the job; for known limitations related to pregnancy or childbirth, and of an applicant or employee's sincerely held religious beliefs if the accommodation would resolve a conflict between the individual's religious beliefs or practices and a work requirement.

To the extent that any provision of this policy is inconsistent with the requirements under federal, state, or local law, then the relevant law will apply and supersede the terms of this policy. *

West Virginia University Health System adopts this policy and procedure for WVU Hospitals, Inc.; Summersville Regional Medical Center; WVUHS Home Care, LLC; WVUHS Medical Group; Reynolds Memorial Hospital; Berkeley Medical Center; Jefferson Medical Center; Potomac Valley Hospital of W.Va., Inc.; United Summit Center; United Hospital Center, Inc.; Wheeling Hospital, Inc.; Barnesville Hospital Association; Harrison Community Hospital, Inc.; United Physician's Care, Inc.; St. Joseph's Hospital of Buckhannon, Inc.; Camden-Clark Memorial Hospital Corporation; Camden-Clark Physician Corporation; Braxton County Memorial Hospital, Inc.; Jackson General Hospital; Wetzel County Hospital; Uniontown Hospital; Allied Health Services, Inc.; West Virginia United Insurance Services, Inc.; Accountable Care Organization of West Virginia, LLC(ACO); AHS, LLC; Gateway Home Health Care, LLC; Peak Health Holdings, LLC; Population Health Services, LLC; Garrett Regional Medical Center; Princeton Community Hospital Association, Inc.; Grant Memorial Hospital, Inc.; and Thomas Health System, Inc.

PROCEDURE FOR REQUESTING ACCOMMODATION

A. Disability and Pregnancy

1. Employees who believe they need an accommodation because of a disability or a pregnancy-related condition are responsible for requesting a reasonable accommodation from HROneSource in one of the following ways:

2. a. b. Calling the Leave of Absence Team through HROneSource at 833-599-2100, Option 5 Using the Employee Self-Service portal which can be accessed via Connect > Applications>Human Resources > Leave of Absence / Absence Tracker WVUHS will recognize any reasonable accommodation request made on behalf of an employee by a direct supervisor, a supervisor or manager in the employee's direct chain of command, or Human Resources. Supervisors or managers who receive accommodation requests are responsible for referring the employee to HROneSource and assisting the employee in making contact with HROneSource, if necessary.

B. Religious Beliefs or Practices

1. Employees who believe they need an accommodation because of their religious beliefs or practices or lack thereof should request an accommodation from the Human Resources Department. WVUHS encourages employees to make their request in writing including relevant information, such as:

• A description of the accommodation requested.
• A statement of the employee's beliefs or practices (or lack thereof) and how they conflict with work requirements such that an accommodation is needed.
• How the accommodation will help resolve the conflict.

2. After receiving the employee's oral or written request, WVUHS will engage in a dialogue with the employee to explore potential accommodations that could resolve the conflict between the employee's religious beliefs and practices and one or more work requirements. WVUHS encourages the employee to suggest specific reasonable accommodations that the employee believes would resolve any such conflict. However, WVUHS is not required to make the specific accommodation requested and may provide an alternative, effective accommodation, to the extent any accommodation can be made without imposing an undue hardship on WVUHS.

GUIDELINES

1. WVUHS encourages employees to make their request in writing on WVUHS's reasonable accommodation request form. This form is provided to the employee by HROneSource once the accommodation request has been submitted. Employees are encouraged to provide relevant information, such as: a. b. C.

2. A description of the accommodation requested The reason the accommodation is needed How the accommodation will help the employee perform the essential functions of his or her job After receiving the accommodation request, WVUHS will engage in the interactive process to assess what job duties are a challenge for the employee and explore what, if any, reasonable accommodation may be appropriate. The interactive process is an ongoing exchange of information between an employee and WVUHS to determine if reasonable accommodation can be provided. Employees/applicants are expected to fully cooperate in the interactive process, which may include attending meetings, discussing potential accommodations and providing any requested medical information regarding the disability/impairment.

3. WVUHS encourages employees to suggest specific reasonable accommodations they believe would allow them to perform their jobs. However, WVUHS is not required to make the specific accommodation requested and may provide an alternative, effective accommodation, to the extent any reasonable accommodation can be made without imposing an undue hardship on WVUHS.

4. If it is determined a proposed accommodation is unreasonable, WVUHS will re-initiate the interactive process with the employee to try to arrive at a mutually agreeable alternative to the originally proposed accommodation. If no effective accommodation can be found, or if those identified would result in an undue hardship to WVUHS or create significant safety risk, WVUHS will work with the employee to determine the appropriate next step(s).

5. If an employee is unable to perform the essential functions of his/her job even when provided reasonable accommodation (to the extent they exist), a leave of absence or alternative employment decision may be the appropriate next step.

6. Leave of absence may be considered a reasonable accommodation if an employee is not eligible for or has exhausted all other applicable leave entitlements and requires time out of work related to their disability or pregnancy-related condition. Indefinite leave is not a reasonable accommodation.

For additional information regarding leave, refer to the WVUHS Leave of Absence policy.

SUPPORTING INFORMATION

A. Disability and Pregnancy

1. If an employee's disability or need for accommodation is not obvious, WVUHS may request supporting documents showing that a disability exists within the meaning of the ADA and applicable state or local laws, and that the disability necessitates reasonable accommodation.

2. If the information provided in response to this request is insufficient, WVUHS may require clarification from the provider, or require that the employee see a health care professional of WVUHS's choosing, at WVUHS's expense. Failure to provide the requested information or comply with WVUHS' request to be seen by a healthcare professional may result in a denial of the accommodation request.

3. For workers affected by pregnancy, childbirth, or related medical conditions, WVUHS may require the employee to provide written documentation from the employee's health care provider that specifies the employee's limitations and suggests what accommodations would address those limitations.

4. WVUHS will keep confidential any medical information that it obtains in connection with a request for reasonable accommodation. All medical information will be retained separately from the employee's HR file.

B. Religion

1. WVUHS may ask employees or applicants requesting accommodations about their religious practices or beliefs and the accommodation requested. If the employee or applicant fails to provide the requested information, the request for accommodation may be denied.

DETERMINATION

1. WVUHS makes determinations about reasonable accommodations on a case-by-case basis considering various factors and based on an individualized assessment in each situation.

2. Determinations on reasonable accommodation requests will be made expeditiously, and the individual will be informed once a determination has been made. Any questions regarding the status of reasonable accommodation requests may be directed to HROneSource Leave of Absence Team.

3. Employees who cannot be accommodated in their current roles may be eligible for job reassignment to a vacant position for which they are qualified and able to perform the essential duties, with or without accommodation. Generally, reassignment will only be considered if no reasonable accommodation is available to enable the employee to perform the essential functions of his or her current job, or if the only effective accommodation would cause undue hardship.

4. In considering whether there are positions available for reassignment, the employer and the employee requesting the reassignment must work collaboratively to identify vacant positions within the organization for which the employee may be qualified, with or without reasonable accommodation.

NO RETALIATION

1. Individuals will not be retaliated against for requesting an accommodation in good faith. WVUHS expressly prohibits any form of discipline, reprisal, intimidation, or retaliation against any individual for requesting an accommodation in good faith.

2. WVUHS is committed to enforcing this policy and prohibiting retaliation against employees and applicants who request an accommodation in good faith. However, the effectiveness of our efforts depends largely on individuals telling us about inappropriate workplace conduct. If employees or applicants feel that they or someone else may have been subjected to conduct that violates this policy, they should report it immediately to their supervisor, the Human Resources Department, or the hospital's Title IX coordinator (where applicable). If employees do not report retaliatory conduct, WVUHS may not become aware of a possible violation of this policy and may not be able to take appropriate corrective action.

ADMINISTRATION OF THIS POLICY

1. WVUHS HROneSource is responsible for the administration of this policy. If you have any questions regarding this policy or questions about disability or pregnancy-related accommodations that are not addressed in this policy, please contact HROneSource.

EMPLOYEES COVERED UNDER A COLLECTIVE BARGAINING AGREEMENT

1. The employment terms set out in this policy work in conjunction with, and do not replace, amend, or supplement any terms or conditions of employment stated in any collective bargaining agreement that a union has with WVUHS or its affiliates.

2. Employees should consult the terms of their collective bargaining agreement. Wherever employment terms in this policy differ from the terms expressed in the applicable collective bargaining agreement, employees should refer to the specific terms of the collective bargaining agreement, which controls. REFERENCES: Americans with Disabilities Act of 1990, 42 U.S.C. § 12101, et seq. Pregnant Workers Fairness Act, 42 U.S.C. § 2000gg, et seq. Title VII of the Civil Rights Act of 1964, 42 U.S.C. § 2000e, et seq.

CROSS REFERENCES

A. WVUHS Equal Employment Opportunity Policy (EEO)

B. WVUHS Fitness for Duty Policy C. WVUHS Leave of Absence Policy *This system policy supersedes any company specific policy.

Effective Date: 04/23/2026

This policy is adopted in its entirety from WVU Health Systems and will be provided to the residents and fellows.

WEST VIRGINIA UNIVERSITY HEALTH SYSTEM POLICY AND PROCEDURE MANUAL SCOPE: All West Virginia University Health System (WVUHS) Entities* Policy V.220S

1st Effective 05/18/2018

Revised 01/26/2026

Reviewed 01/26/2026

EMPLOYEE NON-DISCRIMINATION & ANTI-HARASSMENT POLICY

PURPOSE: This Employee Non-Discrimination and Anti-Harassment Policy ("Policy") is intended to comply with all federal, state, and local non-discrimination laws. It provides information about prohibited discrimination, harassment, and retaliation, and how complaints are filed, investigated, and resolved.

DEFINITIONS: For the purposes of this Policy, discrimination means conduct that is based upon an individual's Protected Status (as defined below) and that: adversely affects term or condition of the individual's employment; is used as the basis for or a factor in decisions affecting the individual's employment; or has the purpose or effect of unreasonably interfering with an individual's work performance or creating an intimidating, hostile, or offensive work environment.

Unwelcome conduct that is based on a Protected Status Harassment becomes unlawful where 1) enduring the conduct becomes a condition of continued employment or 2) the conduct is severe or pervasive enough to create a work environment that a reasonable person would consider hostile, intimidating, harmful or offensive.

Harassment may include, but is not limited to offensive jokes, slurs, epithets, or name calling, physical assaults or threats, intimidation, ridicule or mockery, insults or put-downs, offensive objects or pictures, and interference with work performance. Harassment can be in the form of direct interaction, by phone, email, text message, voice mail, print material or in social media. *

West Virginia University Health System adopts this policy and procedure for WVU Hospitals, Inc.; Summersville Regional Medical Center; WVUHS Home Care, LLC; WVUHS Medical Group; Reynolds Memorial Hospital; Berkeley Medical Center; Jefferson Medical Center; Potomac Valley Hospital of W.Va., Inc.; United Summit Center; United Hospital Center, Inc.; Wheeling Hospital, Inc.; Barnesville Hospital Association; Harrison Community Hospital, Inc.; United Physician's Care, Inc.; St. Joseph's Hospital of Buckhannon, Inc.; Camden-Clark Memorial Hospital Corporation; Camden-Clark Physician Corporation; Braxton County Memorial Hospital, Inc.; Jackson General Hospital; Wetzel County Hospital; Uniontown Hospital; Allied Health Services, Inc.; West Virginia United Insurance Services, Inc.; Accountable Care Organization of West Virginia, LLC(ACO); AHS, LLC; Gateway Home Health Care, LLC; Peak Health Holdings, LLC; Population Health Services, LLC; Garrett Regional Medical Center; Princeton Community Hospital Association, Inc.; Grant Memorial Hospital, Inc.; and Thomas Health System, Inc.

Protected Status: A personal characteristic including race (including protected hairstyles and traits such as braids, twists, locks, hair texture and afro hairstyles), color, ethnicity, culture, ancestry, gender, sex, sexual orientation, sexual identity, gender identity and expression, socioeconomic status, language, national origin, religious affiliation, spiritual practice, mental and physical disability, pregnancy or childbirth (or medical condition related to pregnancy or childbirth), genetic information, veteran status, service in the uniformed services, trauma history, age, or any other characteristic protected by law.

Sexual Harassment: Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature when submission to such conduct is made, either explicitly or implicitly a term of condition of an individual's employment; submission to or rejection of such conduct is used as a basis for employment decisions affecting the individual or such conduct has the purpose or effect of unreasonably interfering with an individual's work performance by creating an intimidating, hostile or offensive work environment. This provision applies to the target of such conduct as well as individuals who may observe or be affected by it. Following are some examples, which if unwelcome to any individual, may constitute sexual harassment, including but not limited to:

a) Physical conduct such as unwanted touching, pinching, poking, or brushing against another person's body

b) Unwanted sexual advances, propositions, or other sexual comments, such as sexually oriented gestures, remarks, jokes or comments about a person's sexuality or sexual experiences

c) Sexually explicit emails, texts, or other written communications

d) Pressuring someone to go on a date

e) Preferential treatment or promises of preferential treatment for submitting to sexual conduct

f) Displaying pictures, posters, calendars, objects, or other materials that are sexually suggestive, sexually demeaning, or pornographic

Sexual harassment can occur in a variety of circumstances, including but not limited to the following:

a) The victim can be of the same or opposite sex

b) The harasser can be the victim's supervisor, a supervisor in another area, a co- worker, or a non-employee

c) The victim does not have to be the person harassed but could be anyone affected by the offensive conduct.

d) The conduct does not have to take place on WVUHS premises Any person associated with a WVUHS entity and includes employees, members of the medical staff, volunteers, agency, or contracted staff. Any level of supervisory leadership, clinical or administrative, responsible for the employee and who has authority to conduct tangible employment actions, specifically to hire, fire, demote, promote, transfer, or discipline.

POLICY: A. This Policy prohibits all forms of Discrimination and Harassment based on Protected Status. It also prohibits retaliation against individuals who report Discrimination or Harassment in good faith and those who participate in investigations of complaints of Discrimination or Harassment.

1. Discrimination This Policy prohibits Discrimination based upon Protected Status, including conduct that unreasonably interferes with or limits:

a. An employee's or applicant for employment's access to employment or conditions and benefits of employment (e.g., hiring, advancement, assignment).

b. An authorized volunteer's ability to participate in a volunteer activity; or

c. A guest's or visitor's ability to participate in, access, or benefit from the WVUHS' services.

Discrimination includes failing to provide reasonable accommodations that do not create undue hardship, consistent with state and federal law, to a qualified person with a disability, for pregnancy or related medical conditions, and to a qualified person who has a sincerely held religious belief. A reasonable accommodation is a necessary and appropriate modification or adjustment to the work environment that enables a qualified individual to participate in the application process or to perform essential job functions to the extent that the modification or adjustment does not result in a fundamental alteration of a WVUHS program or of the essential functions of a job or impose an undue burden on WVUHS.

2. Harassment

This Policy prohibits Harassment, which is a type of Discrimination that occurs when unwelcome verbal, physical, electronic, or other conduct based on an individual's Protected Status is severe, persistent, or pervasive enough to interfere with the Complainant's

(a) work environment (e.g., hiring, advancement, assignment);

(b) participation in a WVUHS program or activity; or

(c) receipt of legitimately-requested services (e.g., disability, pregnancy or childbirth, or religious accommodations), thereby creating Hostile Environment

Harassment or Quid Pro Quo Harassment, as defined below.

i. Hostile Environment Harassment Unwelcome conduct based on Protected Status that is so severe, persistent, or pervasive that it alters the conditions of employment or participation in a WVUHS program or activity, thereby creating an environment that a reasonable person in similar circumstances and with similar identities would find hostile, intimidating, or abusive.

An isolated incident, unless sufficiently severe, does not amount to Hostile Environment Harassment.

ii. Quid Pro Quo Harassment Unwelcome conduct based on Protected Status where submission to or rejection of such conduct is used, explicitly or implicitly, as the basis for decisions affecting an individual's employment, or participation in a WVUHS program or activity.

B. This Policy expressly prohibits sexual violence and sexual exploitation, which involve conduct of a sexual nature and are prohibited forms of sexual or gender-based harassment.

C. This Policy prohibits complicity for knowingly assisting in an act that violates this Policy and retaliation, intimidation, threats, coercion, or attempts thereof, whether direct or indirect, by any Staff Member against an individual because of their good faith participation in the reporting, investigation, or adjudication of violations of this Policy.

D. WVUHS is committed to a work environment that is free from all forms of unlawful discrimination and harassment based upon two key relationship principles:

1. All individuals are to be treated with dignity and respect.

2. Staff Members are expected to uphold high standards of personal conduct at work. Individuals who have concerns or complaints about conduct or behavior that they have experienced or observed are encouraged to use the processes and resources outlined in this Policy.

Each member of the WVUHS community is responsible for fostering mutual respect, for being familiar with this Policy, and for refraining from conduct that violates this Policy.

E. Employees, Staff Members, and non-employees (e.g., visitors, volunteers, vendors, and contractors) while on WVUHS property, participating in a WVUHS sponsored activity, or providing services to the WVUHS, or applicants for employment with WVUHS may bring complaints of violations of this Policy.

F. WVUHS prohibits filing complaints or reports of discrimination, harassment and/or related retaliation that the complainant knows to be false. The filing of intentionally false complaints may result in disciplinary action.

G. Supervisors have an affirmative duty and are required to report promptly to the Human Resources Director or designee any forms of harassment that they observe, learn about from others, or reasonably suspect have occurred.

H. WVUHS is committed to prompt, thorough, and impartial investigation of harassment complaints. While WVUHS strives to maintain confidentiality and conduct the investigation as discreetly as possible, at times it may be necessary for the identity of the complainant and nature of the complaint to be revealed to witnesses and the individual who is the subject of the investigation.

I. WVUHS is committed to promptly addressing all claims of prohibited conduct and to taking appropriate action, consistent with this Policy, in response to such reports. WVUHS employees who violate this Policy may face discipline up to and including termination.

J. Acts of harassment that involve criminal activity may be referred to law enforcement agencies and/or licensing boards.

K. The processes described in this Policy do not preempt or supersede any legal procedures or remedies otherwise available to a victim of harassment under local, state, or federal law.

REPORTING ALLEGATIONS OF HARASSMENT OR DISCRIMINATION

If a Staff Member believes that he or she has been subjected to, or becomes aware of, any harassment or discrimination in violation of this Policy, the Staff Member has the responsibility to promptly report the incident to the Staff Member's immediate supervisor. If the complaint involves the Staff Member's immediate supervisor, or if the employee feels uncomfortable discussing the matter with the supervisor, WVUHS has established processes to assure that complaints are promptly, thoroughly, and impartially investigated.

Any Staff Member who reports an incident in accordance with this Policy may, if comfortable under the circumstances, inform the person responsible for the conduct that it is unwelcome and offensive, and request that it cease. Taking this action will not, however, relieve the Staff Member of the Staff Member's obligation to report the incident as set forth above.

If a Staff Member is not sure whether he or she has been the victim of harassment or discrimination, the Staff Member is encouraged to speak with a supervisor or member of the Human Resources Department for assistance and clarification.

STAFF MEMBER AND SUPERVISOR RESPONSIBILITIES

All Staff Members are expected and required to comply with this Policy. All Staff Members, and particularly members of management, which includes without limitation all administrative and clinical supervisors, are responsible for keeping the work environment free of harassment and discrimination. Any Staff Member who becomes aware of an actual or alleged incident of harassment or discrimination must promptly report it using any of the options identified in this Policy.

If a Supervisor observes or receives information regarding an actual or alleged incident of harassment or discrimination, the Supervisor MUST take immediate action to stop it, whenever possible or appropriate, and is obligated to report the incident immediately to Human Resources.

Any Supervisor who is made aware of harassment or discrimination and fails to report it may be subject to disciplinary action, up to and including termination of employment. Supervisors must take effective measures to ensure that no further apparent or alleged harassment or discrimination occurs pending completion of Human Resource's investigation. Supervisors should consult with HR in this regard. Any Staff Member who knowingly submits a false or frivolous claim of harassment or discrimination may be subject to disciplinary action up to, and including, termination of employment.

FILING A COMPLAINT

Any Staff Member who believes that he or she has been the victim of, affected by or observes harassment is strongly encouraged to file a complaint. All reports will be taken seriously and all information regarding the investigation will be kept confidential to the extent possible.

1. A complaint may be made verbally or in writing to the Staff Member's supervisor or to any level in the line of supervision

2. A complaint may be made to the entity Director of Human Resources or designee

3. A complaint may be made to the Compliance Hotline by calling 1-855-236-2041 or by accessing the Compliance Hotline at http://www.wvuhs.ethicspoint.com/

4. In WVUHS entities covered by Title IX, a complaint may be made by contacting the Title IX Coordinator by email at [email protected] or calling 1-833-599-2100.

When a supervisor receives a complaint of harassment, he or she is required to notify the entity Director of Human Resources or designee immediately. A supervisor cannot delay or avoid contacting Human Resources, even if requested by the complainant to do so. If the complaint involves anyone in the Human Resources Department, the complaint is to be filed with the WVUHS Compliance Officer or with the entity Chief Executive Officer or designee.

COMPLAINT INVESTIGATION

When Human Resources becomes aware of an alleged violation of this Policy, Human Resources or its designee will conduct a prompt, thorough, and impartial investigation. Human Resources will seek to complete discrimination and harassment investigations within 30 days of notice or less, but some investigations may take longer to complete depending upon the nature and scope of the allegations; the number of witnesses involved; the availability of the parties, witnesses, or evidence; evidence gathering in a concurrent law enforcement investigation.

All Staff Members, whether complainant, witness, or the subject of the investigation, are required to be truthful, forthcoming, and cooperative throughout the investigation. Human Resources seeks to conduct a thorough investigation, and refusal to participate in the investigation may result in disciplinary action, up to and including termination of employment.

Depending on the outcome of the investigation, Human Resources will take appropriate corrective action to stop the discrimination or harassment and prevent its recurrence.

Any employee who is found to have engaged in discrimination or harassment prohibited by this Policy will be subject to appropriate disciplinary action, up to and including termination of employment.

Non-employee Staff Members will be subject to other appropriate remedial action including termination of contracts, suspension, or removal from the premises.

The purpose of the investigation is to establish whether there is a reasonable basis for determining that there has been a violation of this Policy. The investigation may include:

1. Interviews with the person making the complaint and the person accused.

2. Interviews with witnesses, such as other employees, supervisors, and visitors believed to have relevant information.

3. Gathering of any physical evidence, which may include objects, photos, surveillance videos, emails, text messages, voice mails, documents, etc.

4. Monitoring the situation to make sure that the person making the complaint or any party to the complaint suffers no discrimination or retaliation.

Final investigative reports are filed with the local Human Resources entity.

COMPLAINT RESOLUTION

Depending on the outcome of the investigation, WVUHS will take appropriate remedial action. Such action is based on the severity or frequency/pervasiveness of the conduct and may include any of the following:

1. Verbal or written reprimand.

2. Coaching, education or training and a commitment to modify conduct.

3. An apology.

4. Suspension.

5. Termination of employment.

6. Termination of or refusal to allow any resident or employee to continue or begin training.

7. Refusal or rescinding access to WVUHS property unless it is for the need of medical services.

If any employee or former employee is dissatisfied with the response to a complaint, he/she may file a problem review request as provided under WVUHS Problem Review policy.

NON-RETALIATION

WVUHS prohibits retaliation against individuals who report harassment or discrimination in good faith and who participate in an investigation of a harassment or discrimination complaint. Any employee who has filed a complaint or has participated in an investigation under this Policy must immediately notify HR or a supervisor (who must promptly notify HR) if the employee believes he or she has been subjected to retaliation or intimidation.

Retaliation may include but is not limited to, actions such as: Disciplining, changing work assignments of, providing inaccurate work information to, or refusing to cooperate or discuss work-related matters with any employee because that employee has complained about or resisted, or participated in the investigation of harassment, discrimination, or retaliation. Subjecting the person's work to greater scrutiny or making the person's work more difficult. Providing less favorable evaluations, scheduling, or promotion/transfer consideration. Intentionally pressuring, falsely denying, lying about, or otherwise covering up or attempting to cover up conduct such as that described immediately above. Employee-to-employee isolation, ridicule, intimidation, “silent treatment," or embarrassment; or Encouraging others to retaliate.

CONFIDENTIALITY

Human Resources will protect the confidentiality of individuals who file complaints and who are involved in an investigation to the extent possible and will enforce its non-retaliation policy. While Human Resources strives to conduct the investigation as discretely as possible, Human Resources may need to disclose information, including but not limited to the identity of the complainant and/or witnesses, to appropriately conduct the investigation and take appropriate action.

OTHER INFORMATION

Nothing in this Policy provides any contractual rights regarding terms and conditions of employment, nor does anything in this Policy alter or modify the employment relationship between WVUHS and its employees. Further, nothing in this Policy creates an employment relationship for members of the workforce who are not employed by WVUHS. Cross System References: (Please refer to your local applicable policies)

A. WVUHS PROBLEM REVIEW, V210S

B. WVUHS CORRECTIVE ACTION AND DISCHARGE, V.230S

C. WVUHS NEPOTISM, V.052S

D. Title IX policy, as applicable by WVUHS facility Federal Regulations:

A. Age Discrimination Act of 1975 ("Age Act")

B. Americans with Disabilities Act of 1990, as amended ("ADA")

C. Section 504 of the Rehabilitation Act of 1973

D. Section 1557 of the Affordable Care Act (ACA)

E. Title VI of the Civil Rights Act of 1964

F. The Genetic Information Nondiscrimination Act of 2008

G. Federal Regulations: 29 C.F.R. § 1604.11