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Compliance Program

465 bytes added, January 24
updated ferpa link
Policy No.: '''8000'''<br />
Effective Date: '''11/01/06'''<br />
Revised Date: '''08/1418/2021'''<br />Reviewed Date: '''08/1418/2021'''<br />
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<big>'''Compliance Program Policy'''</big>
== Basis for Policy ==
The purpose of the Compliance Program and Committee is to identify UNMC’s key compliance risks, as well as make recommendations and implement solutions, policies, procedures and standards of conduct to ensure that UNMC complies with all applicable federal, state and local laws and regulations; and University of Nebraska and UNMC Policies and Procedures. In support of this purpose, UNMC’s Compliance Program will designate a chief compliance officer and a compliance committee whose responsibilities will include the following: to provide for or conduct effective training and education, develop effective lines of communication, and conduct internal monitoring and auditing reviews for adherence to policies and procedures. The University of Nebraska Medical Center (UNMC) Compliance Program consistent with UNMC Policy No. 8006, [[Code of Conduct]], mandates that all UNMC faculty, staff, and students comply with: all applicable federal, state and local laws; all relevant regulations; and University of Nebraska and UNMC Policies and Procedures.
== Compliance Program Structure ==
[[File:Compliance-Flowchart2flowchart-18-185-2020.jpg]]
===Senior Vice Chancellor for Academic Affairs===
The Senior Vice Chancellor for Academic Affairs is responsible for overseeing the development and implementation of the policies, procedures and practices necessary to effect compliance with federal, state, and local laws and regulations; and University of Nebraska and UNMC Policies and Procedures.
===Chief Compliance Officer===
The Chief Compliance Officer shall report to the Senior Vice Chancellor for Academic Affairs, but has the authority to communicate directly with the Chancellor or Vice Chancellors for Academic Affairs, Business and Finance, Research, Deans , the Audit, Risk and Compliance Committee of the Board of Regents or others on compliance matters, which include, but are not limited to:
*coordinate with subject matter experts to analyze laws and regulations applicable to UNMC to ensure compliance;
*monitor day-to-day compliance activities;
*coordinate with the Director of Internal Audit and Advisory Services;
*coordinate with the Information Security Officer;
*coordinate with the University Compliance Officer and other campus compliance officers;
*respond to compliance hotline calls;
*participate on the University Compliance Council;
*disseminate information to support compliance and training on the Compliance Program; and
*chair the compliance committeeCompliance Committee.
===Compliance Committee===
The Compliance Committee assists the Chief Compliance Officer with the above duties and helps manage the Compliance Program. The Compliance Committee shall seek to leverage the compliance efforts of each area and avoid duplication of effort. The Compliance Committee shall analyze UNMC’s key risk areas, and monitor and promote compliance. The Compliance Committee shall oversee and monitor department response to identified risks as identified by the Chancellor 's Risk AssessmentInternal Audit Director’s annual audit plan Assessment as well as data generated through monitoring and individual reporting.
The Compliance Committee shall meet no less than quarterly. The Compliance Committee shall be composed of at least the following representatives who shall be responsible for the overseeing compliance and assist the Chief Compliance Officer with managing the Compliance Program:
*Sponsored Programs Administration
*Sponsored Programs Accounting
*Director of Procurement
*Chief Student Affairs Officer
*Library
The Compliance Committee or Chief Compliance Officer may request reports annually from certain representatives and others to address compliance issues as necessary. The purpose of the reports will be to:
*develop policies related to compliance;
*establish compliance training programs;
*assist with identifying areas of potential compliance vulnerabilities;
*assist with understanding the compliance risks and related regulations and laws; and
*assist with response to alleged violation of rules, regulations, policies, procedures , and other functions as needed to enforce this policy.<br />
Representatives would be from the following areas:
*Student Success
*Others as necessary
 
==Compliance Responsibilities==
[httphttps://www.unmc.edu/academicaffairs/compliance/areas/ Compliance Areas]<br />
Compliance responsibilities shall be established per UNMC and/or Board of Regents policies and procedures linked and referenced below:
{| class="wikitable"
| Code of Conduct || UNMC Policy No. 8006, [[Code of Conduct]]
|-
| IRB || [httphttps://www.unmc.edu/irb/ Institutional Review Board]https://www.unmc.edu/ibc/
|-
| IACUC || [httphttps://wwwinfo.unmc.edu/iacuc/ Institutional Animal Care and Use Committee], BOR Policy 3.2.8
|-
| Conflict of Interest || UNMC Policy No. 1049, [[Outside Employment]], UNMC Policy No. 8010, [[Conflict of Interest]], UNMC Policy No. 8015, [[Health Care Vendor Interactions]]
| Research Integrity || UNMC Policy No. 8003, [[Research Integrity]]
|-
| Sponsored Programs Administration and , Sponsored Programs Accounting and Financial Compliance & Cost Analysis || UNMC Policy No. 3001, [[Sponsored Programs]], UNMC Policy No. 6100, [[Sponsored Programs Costing]], UNMC Policy No. 6102, [[Institutional Base Salary]], UNMC Policy No. 6104, [[Sponsored Project Cost Share]], UNMC Policy No. 6105, [[Effort Certification]], UNMC Policy No. 6106, [[Cost Transfer]], UNMC Policy No. 6107, [[Service Center]], UNMC Policy No. 6108, [https://wiki.unmc.edu/index.php/Subrecipient_Policy Subrecipient], UNMC Policy No. 6110, [[On-Campus and Off-Campus Indirect Cost Rates on Federally Sponsored Projects]]
|-
| '''Environmental and Safety Compliance'''||
| Safety || [https://unmc.edu/ehs/safety/ UNMC Environmental Health & Safety Department], UNMC Policy No. 2000, [[Safety]]
|-
| Radiation Safety || [httphttps://www.unmc.edu/ehs/ UNMC Environmental Health & Safety Department]
|-
| Bloodborne Pathogens || [httphttps://www.unmc.edu/academicaffairs/compliance/areas/infection.html Infection Control], UNMC Policy No. 2004, [[Bloodborne Pathogens Exposure]]
|-
| Biosafety || [httphttps://www.unmc.edu/ibc/ Institutional Biosafety Committee], UNMC Policy No. 2005, [[Waste Handling]], [httphttps://infowww.unmc.edu/safetyehs/safety-officebiosafety/biohazardousbiohazard-waste/2005-waste-handling-attachments-2014index.pdf Biohazardous htmlBiohazardous Waste Handling]
|-
| Chemical Safety || [httphttps://www.unmc.edu/ehs/ UNMC Environmental Health & Safety Department], UNMC Policy No. 2002, [https://wiki.unmc.edu/index.php/Shipping_Hazardous_Materials Shipment of Hazardous Materials or Dangerous Goods]
|-
| Security || [httphttps://info.unmc.edu/safety/campus-security/index.html UNMC Campus Security]
|-
| '''Intellectual Property''' ||
| '''Privacy and Information Security'''||
|-
| Privacy, Confidentiality , and Information Security|| UNMC Policy No. 6045, [https://wiki.unmc.edu/index.php/Privacy/Confidentiality Privacy, Confidentiality and Information Security]
|-
| Use and Disclosure of Protected Health Information|| UNMC Policy No. 6054, [[Use and Disclosure of Protected Health Information]]
| Human Resources || [https://www.unmc.edu/human-resources/about/contact-hr.html Human Resources]
|-
| Internal Audit || University of Nebraska Internal Audit Charter and [https://nebraska.edu/offices-policies/internal-audit-and-advisory-services UNMC Internatl Internal Audit and Advisory Services Webpage]
|-
| Student Services Success || Student Success, [https://www.unmc.edu/studentservicesstudent-success/_documentsStudent Success], [https:/Handbook/catalog.pdf Student Handbookunmc.edu/ UNMC CourseLeaf Catalog] [https://www.unmc.edu/academicaffairs/compliance/matrix.html Compliance Matrix], [https://www.unmc.edu/studentservicesstudent-success/academic-records/ferpa/ .html FERPA Information]
|-
| Title IX || UNMC Policy No. 1099, [[Non-Discrimination and Harassment]], UNMC Policy No. 1107, [[Sexual Misconduct]]
|-
| Family Educational Rights and Privacy Act (FERPA) || [https://wiki.unmc.edu/index.php/Student_Policies Student ServicesPolicies], [https://www.unmc.edu/studentservicesstudent-success/academic-records/ferpa/ .html FERPA Information]
|-
| False Claims Act || Contact the Chief Compliance Officer (see also the UNMC Compliance Hotline, 1-844-384-9584 or www.nebraska.ethicspoint.com), [https://www.unmc.edu/academicaffairs/_documents/compliance/False_Claims_Act.pdf False Claims Act 31 U.S.C. §§ 3729-3733]
==Compliance Committee Meetings==
The purpose of Compliance Committee meetings shall be to analyze, assess, manage, coordinate , and develop corrective action(s) related to compliance risks identified for the purpose of compliance with UNMC’s Code of Conduct, University of Nebraska and UNMC Policies and Procedures.
The Compliance Office shall complete meeting minutes and maintain them on file for no less than seven years. The draft meeting minutes shall be distributed to committee members, vice chancellors, college deans and executive directors to inform UNMC leadership about compliance activities.
A UNMC compliance hotline (1-844-384-9584 or www.nebraska.ethicspoint.com) has been established to provide individuals with an additional communication channel to report compliance concerns. The Chief Compliance Officer shall investigate concerns and take corrective action in response to identified issues. For additional information, see UNMC Policy No. 8001, [[Compliance Hotline]].
==Compliance Training==
All University of Nebraska Medical Center employees (including visitorsand non-faculty volunteers), students (including visiting students and visitors), and faculty (including but not limited to courtesy, adjunct faculty, visitors, and volunteers) must be knowledgeable of and comply with laws and regulations related to their duties or field of study as determined by the Chief Compliance Officer and Compliance Committee.
Mandatory compliance training is required of UNMC staff and students. All UNMC invited visitors on campus for seven (7) or greater days , have access to UNMC software/databases or access to the UNMC Campus (ID Badge) must complete all mandatory compliance training required of UNMC faculty, staff and students. It is the individual's responsibility to complete the compliance training requirements listed at httphttps://www.unmc.edu/academicaffairs/compliance/training-requirements/index.htmland assigned via the UNMC Learning Platform. Failure to complete the training requirements will be grounds for corrective action up to and including dismissal or termination of employment. Delinquency notices will be sent according to the guidelines below:
{| class="wikitable" style ="text-align:center"

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