Overview

This procedure operates exclusion screening for candidates, employees, and individual contractors: the pre-hire check, the monthly re-check, the evidence and the log, the handling of a potential match, and the removal that follows a confirmed match. It begins when an offer is ready to be finalized or when a calendar month opens, and it ends when Human Resources confirms the month's cycle complete to the Compliance Officer. The rules this procedure executes are printed in POL-011 (Exclusion Checks). Vendor screening is operated through the Vendor & Contract Arrangements Register (REG-002) and is outside this procedure.

Roles

Human Resources runs the procedure: builds the roster, searches the three lists, saves the evidence, keeps the exclusion screening log, forwards every potential match, and confirms each month's cycle complete.

The Compliance Officer verifies every potential match, decides whether a match is confirmed, directs the response to a confirmed match, decides on a candidate's disclosure, and reports screening completion and results to the Compliance Committee.

The Executive Director acts on a confirmed match: the employment or contract decision, and the resources the screening program needs.

A supervisor removes a confirmed excluded person from all federally and state-funded work the day the Compliance Officer directs it.

Every employee and contractor discloses an exclusion, suspension, debarment, or pending action to the Compliance Officer within one business day.

Screening Lists and Records

Three lists are searched for every person, every time. The lists are public records; searching them requires no consent from the person.

The procedure produces two records.

The person's disclosure and acknowledgment is Form CFM-011, signed at onboarding and filed in the personnel file. A confirmed match is handled in a compliance ticket under POL-003 and its Compliance Ticket Management SOP.

Procedure

Step 1: Pre-hire check

When an offer is ready to be finalized, or before an individual contractor begins work, Human Resources searches the candidate against the three lists in the Screening Lists table, using the legal name and every former or alternate name the candidate has given. Human Resources saves the evidence of each search, enters a row in the exclusion screening log with the cycle marked pre-hire, and records the result.

If every list returns no match, the result is Clear and the offer proceeds. If any list returns a possible match, Human Resources proceeds to Step 5 before the offer is finalized.

Step 2: Onboarding disclosure

Human Resources delivers Form CFM-011 in the onboarding notice packet and files the signed form in the personnel file before the first day of work. Human Resources copies the other names the person listed into the log so the monthly search covers them.

If the form carries a disclosure, Human Resources forwards it to the Compliance Officer the same day and holds the start date. The Compliance Officer decides whether the person may start and records the decision in a compliance ticket.

Step 3: Monthly roster

On the first business day of each month, Human Resources builds the month's roster from the HRIS: every current employee, every individual contractor active in the month, and each owner named in the MassHealth provider record. Human Resources adds each person's other names from the log.

Step 4: Monthly search and evidence

Human Resources searches every person on the roster against the three lists, using the legal name and each other name, and saves the evidence of each search. Human Resources enters one row per person in the log with the cycle marked as the month, each list checked, the result, and the evidence file name. The month's searches are complete by the tenth business day of the month.

Step 5: Potential match

A possible match is never resolved by the screener alone. Human Resources records the result as Potential match, forwards the evidence to the Compliance Officer the same day, and does not tell the person.

The Compliance Officer verifies identity using the identifiers in the Screening Lists table. If the identifiers do not match, the Compliance Officer records the result as Clear with the verification noted, and the cycle continues. If the identifiers match, the Compliance Officer records the result as Confirmed and proceeds to Step 6.

Step 6: Confirmed match

The Compliance Officer notifies the Executive Director the same day and opens a compliance ticket. The person's supervisor removes the person from all federally and state-funded work that day, and the Executive Director decides whether the employment or the contract continues.

The Compliance Officer reviews whether any claim included items or services the person furnished during the exclusion period, and coordinates disclosure and repayment with the payer under POL-013 and POL-006. The ticket is resolved under POL-003 and its Compliance Ticket Management SOP.

Step 7: Cycle confirmation

By the tenth business day of the month, Human Resources confirms to the Compliance Officer that every person on the roster has a logged result for the month, that every new employee and contractor who started that month has a signed Form CFM-011 on file, and lists every potential match forwarded. The Compliance Officer records the confirmation in the compliance program files and includes screening completion and results in the quarterly report to the Compliance Committee.

Gates

Five gates hold across every cycle.

1. An offer is finalized, and a contractor begins work, only with a Clear pre-hire result logged for every one of the three lists.
2. A new employee or contractor starts work only with a signed Form CFM-011 on file. A form that carries a disclosure holds the start date until the Compliance Officer decides.
3. Every person on the month's roster has a logged result for the month by the tenth business day. A month with an unlogged person is not complete.
4. A potential match is acted on only after the Compliance Officer verifies identity. The screener neither clears nor confirms a match, and the person is not told before the Compliance Officer decides.
5. A confirmed excluded person is removed from all federally and state-funded work the day the match is confirmed, before the claims review begins.

Records

The exclusion screening log and the search evidence file in the compliance program files, maintained by Human Resources and readable by the Compliance Officer. Each monthly cycle confirmation files with the log. Together they are the record that every person was checked against every list, every month.

Form CFM-011 files in the person's personnel file in the HRIS. A form that carries a disclosure also files, with the Compliance Officer's decision, in the compliance ticket opened for it.

A confirmed match, the removal, the claims review, and any disclosure and repayment file in the compliance ticket under POL-003.

Human Resources retains the log, the evidence, and the signed forms for at least six years after the check or after the person's employment ends, whichever is later (POL-011). The Compliance Officer's quarterly report to the Compliance Committee carries the cycle completion and results for the quarter.

Competency

A workforce member performs this procedure independently only after demonstrating it to the Compliance Officer. Each skill in the table is demonstrated unaided and error-free on two occasions, and at least one occasion uses a case the member has not seen in training: a name with a former or alternate spelling, or a search result that is a possible match.

The disclosure duty of every employee and contractor is trained under POL-011's training requirement, outside this table. The Verify a potential match skill is the Compliance Officer's; a designee performs it only after demonstrating it to the Compliance Officer.