Standards for the Protection of Minors

Attachment No. 1
to the management no. 07/2024
of the President of the Hospital in Kamień Pomorski
dated September 16

PROCEDURE FOR REPORTING IRREGULARITIES

AND PROTECTION OF WHISTLEBLOWERS

at the Hospital in Kamień Pomorski Sp. z o.o.

Based on the DIRECTIVE OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL (EU) 2019/1937 of October 23, 2019, on the protection of persons reporting breaches of Union law

§1 DEFINITIONS

Whenever this document refers to:

the President of the Management Board— it means the President of the Management Board of the Hospital in Kamień Pomorski Sp. z o.o.,
the Hospital– it means the Hospital in Kamień Pomorski Sp. z o.o.,
Employeeit means a person employed by the President of the Management Board within the meaning of Article 22 § 1 of the Labor Code;
Co-worker it means a person providing services to the President of the Management Board of the Hospital in Kamień Pomorski Sp. z o.o. under a civil law contract;
Whistleblowerit means a person making a report of irregularities who has been granted whistleblower status under the rules specified in this Procedure;
Irregularities— it means a factual state resulting from an action or inaction indicating the possibility of events that violate or may violate generally applicable provisions of law or internal regulations. It also includes any action or omission that constitutes or may constitute illegal or unethical conduct;
Procedureit means thisProcedure for reporting irregularities and protecting whistleblowers,
Personentitled to make a report it means a person who has the right and obligation to make a Report;
Report of irregularities/Reportit means the transmission in the manner specified in this Procedure by a person entitled to make a report of information that may indicate irregularities.
Reporting partyit means a person making a report of irregularities using the reporting channels specified in this Procedure;
Personresponsible for handling reportsit means the person responsible for reviewing the Report of Irregularities;
Preliminary analysis of the reportit means the verification of the content of the report regarding the existence of grounds for its recognition in the course of the explanatory proceedings and granting the reporting party whistleblower status, in which the person responsible for handling reports has the right to request the reporting party to supplement the data contained in the report of irregularities within the specified time.
Explanatory proceedingsit means the proceedings conducted in connection with the submitted Report, under the rules specified in this procedure;
Commission- it means the internal Commission appointed by the President of the Management Board to comprehensively clarify the circumstances described in the report of irregularities, operating according to the rules established for the explanatory proceedings;
Register of Irregularity Reports (Register)it means the register maintained in connection with the submitted reports

§2 GENERAL PROVISIONS

The strategy of the President of the Management Board is based on accountability, preventing corruption, and the emergence of other irregularities both within the organization and among cooperating entities, taking into account a number of aspects, particularly social interests, environmental protection, and relations with various groups of collaborators.
The procedure is part of the management control system, its primary purpose is to prevent irregularities at the Hospital in Kamień Pomorski Sp. z o.o..
The President of the Management Board conducts his activities based on absolute respect for the law, good practices, and the highest ethical standards.
The primary goal of the Procedure is to create a system for reporting irregularities at the Hospital in Kamień Pomorski Sp. z o.o. by establishing secure reporting channels that prevent any retaliatory actions against the whistleblower.
The Procedure specifies in particular:
1. the scope of irregularities covered by the procedure, the scope of entitled persons, the rules for reporting irregularities by persons entitled to make a report,
2. responsibility in the process of managing irregularities,
3. the process of reviewing and managing irregularities,
4. the rules for maintaining confidentiality, in particular the rules for keeping the reports of irregularities made by whistleblowers confidential and the identities of the persons making reports.

§3 SCOPE OF THE PROCEDURE

The procedure and its provisions apply to the following groups of persons entitled to make a report:
1. employees and collaborators, as well as former employees and collaborators of the hospital in Kamień Pomorski sp. z o.o.,
2. persons acting on behalf of and for the hospital in Kamień Pomorski sp. z o.o.,
3. any other persons in any way related to the hospital in Kamień Pomorski sp. z o.o., in particular: persons assisting in making reports of irregularities, interns, trainees, or job applicants if the information regarding irregularities was obtained during the recruitment process or other processes preceding the establishment of an employment relationship.
Reports of irregularities may concern in particular:
1. entities related to the hospital in Kamień Pomorski sp. z o.o.,
2. a natural person entitled to represent the hospital in Kamień Pomorski sp. z o.o.,
3. employees and collaborators of the hospital in Kamień Pomorski sp. z o.o. in connection with the provision of work for it,
4. a subcontractor or another entrepreneur who is a natural person, if their act attached to Appendix No. 1 to the Ordinance No. 07/2024 of the President of the Hospital in Kamień Pomorski of September 16 remained prohibited in connection with the execution of the contract concluded with the President of the Management Board,
5. an employee or collaborator or a person authorized to act in the interest of or on behalf of an entrepreneur who is not a natural person, if their act was related to the execution of the contract concluded by that entrepreneur with the President of the Management Board.
Irregularities are understood as the information possessed by persons entitled to make a report, in particular that may indicate:
1. suspicion of preparation, attempt, or commission of a prohibited act by the entities referred to in paragraph 2,
2. failure to fulfill obligations or abuse of authority by the entities indicated in paragraph 2,
3. failure to exercise due diligence required in the circumstances in the actions of the entities mentioned in paragraph 2,
4. irregularities in the organization of the hospital's operations in Kamień Pomorski sp. z o.o. that could lead to the commission of a prohibited act or cause damage,
5. violation of generally applicable laws under which the hospital in Kamień Pomorski sp. z o.o. operates,
6. violation of internal procedures and ethical standards adopted in the hospital in Kamień Pomorski sp. z o.o..

§4 PERSONS RESPONSIBLE FOR MANAGING REPORTS

The person responsible for receiving and handling reports of irregularities at the Hospital in Kamień Pomorski sp. z o.o., and overseeing the overall management of receiving and handling reports of irregularities at the Hospital is the Administration Manager.
Reports cannot be analyzed by persons who, based on the content of the report of irregularities, may be negatively involved in actions or omissions that constitute an irregularity.
In the event that a report of irregularities concerns a person indicated in paragraph 1, the President of the Management Board appoints another responsible person.

§5 WHISTLEBLOWER

According to the principle of good faith, every person entitled to make a report should report an irregularity if they have reasonable grounds to believe that the information provided is true.
A whistleblower acting in bad faith is one who acts contrary to the law or principles of social coexistence.
The decision about granting whistleblower status is made by the person responsible for handling reports.
Any reporter can obtain whistleblower status unless the preliminary analysis of the report gives grounds to assume that the reporter acted obviously in bad faith (presumption of good faith).
If the reporter did not make an anonymous report, the person responsible for handling reports confirms receipt of the report within 7 days from the date of its receipt.
Exceeding the above deadline is justified only in the case of the necessity to take additional actions within the preliminary analysis of the report (e.g., the need to supplement the report, gather additional evidence). The preliminary analysis of the report may not last longer than 14 days.
If during the clarifying proceedings it turns out that the reporter, who previously received whistleblower status, acted in bad faith, they will be deprived of the protection provided for whistleblowers.

§6 PROTECTION OF WHISTLEBLOWERS

A strict prohibition on taking retaliatory actions against whistleblowers is introduced, even in situations where the report of irregularities was made in good faith, and the conducted clarifying proceedings showed that the reported irregularity did not occur.
Whistleblowers are entitled to full protection against repressive actions, discrimination, bullying, and other forms of unfair treatment.
It is unacceptable to terminate the employment relationship or dissolve the mutual agreement with a whistleblower solely in connection with the report of irregularities made by the whistleblower.
Protection does not apply to a whistleblower who is also the perpetrator/co-perpetrator/accomplice of the irregularity.
The detailed rules for the protection of whistleblower data are specified inAnnex No. 4 to this Procedure.

§7 REPORTING IRREGULARITIES

Reports of irregularities can be submitted via:
1. a dedicated email box: zgloszenia@szpitalkamien.pl
2. by filling out a report of irregularities - the template for the report form is attachedAnnex No. 1 to this procedure,
3. in person to the Administration Manager,
4. by phone at 729 058 374,
5. by mail to the address: ul. Szpitalna 10, 72-400 Kamień Pomorski,
The report of irregularities should provide a clear and comprehensive explanation of the subject of the report and should include, in particular:
1. the date and place of the irregularity or the date and place of obtaining information about the irregularity,
2. a description of the specific situation or circumstances that create the possibility of irregularities occurring,
3. the entity to which the report of irregularities pertains,
4. the identification of any potential witnesses of the irregularity,
5. the indication of all evidence and information that the reporter possesses, which may be helpful in the process of addressing the irregularity.
The reporter is obliged to treat the information they possess regarding the suspicion of irregularities as confidential and to refrain from public discussions about the reported suspicions of irregularities, unless the person is required to do so by law.

§8 ANONYMOUS REPORTS

Anonymous reporting of irregularities is permitted via email to: zgłoszenia@szpitalkamien.pl or through the nVision Agent portal.
2. Each anonymous report is subject to entry in the register. If an anonymous report is left without action, the person responsible for handling reports must indicate the reasons justifying such a decision.
3. If, during the examination of an anonymous report, the identity of the reporter is established, the person responsible for handling reports shall immediately assign them the status of Whistleblower.

§9 FALSE REPORTS

Reports of irregularities may only be made in good faith.
Deliberately submitting false reports of irregularities is prohibited.
If it is established as a result of preliminary analysis of the report or during the explanatory proceedings that falsehood was consciously stated in the report of irregularities or the truth was concealed, the reporter who is an employee may be subject to disciplinary action specified in the Labor Code. Such conduct may also be classified as a serious violation of fundamental employee obligations and may result in termination of the employment contract without notice.
In the case of a reporter providing services to Szpital w Kamieniu Pomorskim Sp. z o.o. or supplying goods under a civil law agreement, the establishment of a false report of irregularities may result in the termination of that agreement and definitive cessation of cooperation between the parties.
Regardless of the consequences indicated above, a reporter who knowingly makes a false report of irregularities may be held liable for damages if the Hospital suffers a loss related to the false report.

§10 EXPLANATORY PROCEEDINGS

Access to the channels for reporting irregularities is limited to individuals responsible for the report.
Upon receipt of a report of irregularities, the person responsible for handling reports must immediately, but no later than within 3 working days from the date of receipt:
1. issue a confirmation of the report of irregularities on a form whose template is specified inAnnex No. 2 to this Procedure(possible only in the case of a non-anonymous report),
2. conduct a preliminary analysis of the report,
3. grant or not grant the reporting person the status of whistleblower.
If the report is suitable for consideration, the person responsible for handling reports initiates explanatory proceedings, which are conducted beforethe Explanatory Commission, under the rules specified in this Procedure.
Supervision over the explanatory proceedings conducted by the Commission is exercised by the person responsible for handling reports.
The deadline indicated above may only be exceeded in the event of the necessity to undertake additional actions as part of the preliminary analysis of the report (e.g., the need to supplement the report, gathering additional evidence). The preliminary analysis of the report may not last longer than 14 days.
The examination of the irregularity report takes place without unnecessary delay, within a period not exceeding 30 days from the date of initiating the explanatory proceedings, provided that the entity examining the report can gather the necessary documents and evidence during this time.
In particularly complicated cases, the examination of the irregularity report may take place within a period not exceeding 90 days from the date of initiating the explanatory proceedings.
From the conducted explanatory proceedings, the Commission prepares a report, which also includes the Commission's recommendations regarding the resolution of the matter and presents it to the President of the Management Board.
The person responsible for handling reports is obliged to inform the whistleblower of the manner of resolving the matter within 30 days of the completion of the examination of the report.
Detailed rules for conducting explanatory proceedings are specified in the annex.No. 5 to this Procedure.

§11 REGISTER OF IRREGULARITY REPORTS

Every irregularity report is registered in the Register of Irregularities, regardless of the further course of the explanatory proceedings.
The person responsible for maintaining the Register of Irregularities at the Hospital in Kamień Pomorski Sp. z o.o. is responsible for receiving and examining reports.
The Register of Irregularities contains in particular:
1. the contact details of the Whistleblower, unless the irregularity report was anonymous,
2. all detailed information available regarding the report,
3. the course of the analysis and examination of the irregularity report,
4. the persons and bodies involved in the process of analyzing and examining the report,
5. all decisions and escalations (if any).
The template of the Register of Irregularity Reports is attached.No. 3 to this Procedure.
In addition to maintaining the Register, the person responsible for handling reports, while observing confidentiality principles, is obliged to store all evidence, documents, and information collected during the analysis, as well as information regarding the examination of the report for a period of 5 years from the completion of the explanatory proceedings.

§12 FINAL PROVISIONS

The Procedure for Reporting Irregularities and Protecting Whistleblowers in the Hospital in Kamień Pomorski Sp. z o.o. comes into effect upon signing.
The announcement of the standards is made by posting on the Hospital's website and is available from the Administration Manager.
The announcement of the Procedure for the facility's employees is made by sending its text electronically to the Managers, who are obliged to pass this document to their subordinate employees, and the signed statement by each person, which constitutes attachment No. 6, is to be delivered to the HR Department.