Corporate Compliance

Human Resources

The purpose of the Montefiore Nyack Hospital Corporate Compliance Program is to develop and continuously improve processes that promote honest, ethical, and safe practices in our everyday activities.

This Code of Conduct is a resource to help guide each of us in handling both routine and non-routine situations we may encounter in our workplace. This Code of Conduct reflects our Mission, Vision, and Values and helps us gain a clear understanding of the business, professional, and personal ethics that are expected of us in the workplace. It applies equally to everyone, whether an employee, senior management, board member, or a vendor doing business with Montefiore Nyack Hospital.

Reporting Compliance Issues

If you suspect that another employee, including management, has violated the Code of Conduct; policies; procedures; or any applicable local, state, or federal statute, regulation, guideline or law; you should immediately report your concern. All reports of suspected violations will be treated in a confidential manner to the extent allowable by law. You have several options when seeking assistance with compliance issues:

Your Immediate Supervisor or Manager

Your immediate supervisor or manager should be contacted first, if possible. Others in the chain of command can be contacted, if appropriate.

Compliance Officer

You should report your concern to the Compliance Officer in the following situations:

  • You do not feel comfortable reporting the concern to your immediate supervisor or manager.
  • You are not satisfied with management’s response to your compliance concern.

The Compliance Officer should not be used as a substitute for the Department of Human Resources nor should the established chain of command for Human Resource issues be bypassed.

Compliance Hotline

All employees who, for whatever reason, are uncomfortable reporting compliance concerns through the internal chain of command are encouraged to call the Compliance Hotline at 888-568-8548. You can call the Hotline 24 hours a day and may choose to remain anonymous. You will receive a reference number on the initial call, which will enable you to follow up on the complaint while remaining anonymous.  You may also file a concern online by clicking on compliance reporting.

Compliance Investigation and Resolution

The Compliance Office will ensure the prompt and thorough investigation of all suspected violations and will coordinate appropriate follow-up action and resolution. All investigations will be conducted following established procedures for confidentiality.

Human Resources

Employment Practices

Montefiore Nyack Hospital is an equal opportunity employer and does not discriminate against employees or potential employees on the basis of race, color, creed, religion, sex, national origin, sexual orientation, veteran status, marital status, age or disability. Montefiore Nyack Hospital will not tolerate discrimination, verbal or physical harassment, or abuse (whether or not sexually related) by employees, supervisors, vendors, subcontractors or visitors. Montefiore Nyack Hospital is committed to actions and policies to assure fair employment, including equal treatment in hiring promotion, training, compensation, termination, and disciplinary action.

  • We recognize that our greatest strength lies in our people who create our success and determine our reputation as an institution of outstanding patient care.
  • We encourage and support employees in developing their individual skills, talents and understanding of their jobs.
  • We support an alcohol and drug free workplace and abide by the hospital policies prohibiting illegal possession, distribution, use or being under influence of illegal drugs, alcohol or other substances.
  • We will familiarize ourselves and comply with the contents of the employee handbook, as well as with the policies and procedures applicable to our employment and responsibilities at Montefiore Nyack Hospital.

Pre-Employment Information

  • Individuals applying for employment at the Hospital are required to provide accurate and truthful information to the Human Resource Department concerning their employment eligibility.
  • In evaluating candidates we take all reasonable steps necessary to hire and retain employees who have appropriate and current training, experience and competency. We also screen applicants to avoid hiring an individual, who is currently excluded, suspended, debarred or otherwise ineligible to participate in federal or state healthcare programs.


  • We do not allow any act of retaliation against employees who in good faith report a valid concern and/or a violation of a law, regulation, policy or the Code of Conduct. In the event of a violation, Human Resources will follow established disciplinary procedures.


  • Gifts and entertainment represent an area of potential conflict and at times may appear to influence the working relationship. Personal gifts should not be accepted if the acceptance would raise questions as to whether a business decision had been inappropriately influenced.