306
edits
Compliance Program: Difference between revisions
→Additional Information
mNo edit summary |
Mhurlocker (talk | contribs) |
||
| (15 intermediate revisions by 3 users not shown) | |||
| Line 20: | Line 20: | ||
<br /> | <br /> | ||
[[Compliance Program]] | [[Compliance Hotline]] | [[Investigations by Third Parties]] | [[Research Integrity]] | [[Export Control]] | [[Code of Conduct]] | [[Use of Human Anatomical Material]] | [[Clinical Research and Clinical Trial Professional and Technical Fee Billing]] | [[Contracts]] | [[Conflict of Interest]] | [[Red Flag Identity Theft Prevention Program]] | [[Principles of Financial Stewardship]] | [[Human Tissue Use and Transfer]] | [[Disclosing Foreign Support and International Activities]] | [[Health Care Vendor Interactions]] | [[Credit Hour Definition]] | [[Whistleblower]] | [[Compliance Program]] | [[Compliance Hotline]] | [[Investigations by Third Parties]] | [[Research Integrity]] | [[Export Control]] | [[Code of Conduct]] | [[Use of Human Anatomical Material]] | [[Clinical Research and Clinical Trial Professional and Technical Fee Billing]] | [[Contracts]] | [[Conflict of Interest]] | [[Red Flag Identity Theft Prevention Program]] | [[Principles of Financial Stewardship]] | [[Human Tissue Use and Transfer]] | [[Disclosing Foreign Support and International Activities]] | [[Health Care Vendor Interactions]] | [[Credit Hour Definition]] | [[Whistleblower]] | [[Electronic Digital Signatures and Records]] | ||
<br /><br /> | <br /><br /> | ||
Policy No.: '''8000'''<br /> | Policy No.: '''8000'''<br /> | ||
Effective Date: '''11/01/06'''<br /> | Effective Date: '''11/01/06'''<br /> | ||
Revised Date: ''' | Revised Date: '''07/09/24'''<br /> | ||
Reviewed Date: ''' | Reviewed Date: '''07/09/24''' <br /> | ||
<br /> | |||
<big>'''Compliance Program Policy'''</big> | <big>'''Compliance Program Policy'''</big> | ||
== Basis for Policy == | == 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 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. | 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 reviews for adherence to compliance training and conflict of interest 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 == | == Compliance Program Structure == | ||
[[File:Compliance-flowchart-8-5-2020.jpg]] | [[File:Compliance-flowchart-8-5-2020.jpg]] | ||
| Line 50: | Line 49: | ||
*chair the Compliance Committee. | *chair the Compliance Committee. | ||
===Compliance 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 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 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: | 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: | ||
| Line 72: | Line 71: | ||
*Chief Student Affairs Officer | *Chief Student Affairs Officer | ||
*Library | *Library | ||
*Comparative Medicine/IACUC Director | |||
*Institutional Biosafety Administration | |||
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: | 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; | *develop policies related to compliance; | ||
| Line 126: | Line 127: | ||
| Radiation Safety || [https://www.unmc.edu/ehs/ UNMC Environmental Health & Safety Department] | | Radiation Safety || [https://www.unmc.edu/ehs/ UNMC Environmental Health & Safety Department] | ||
|- | |- | ||
| Bloodborne Pathogens || [https:// | | Bloodborne Pathogens || [https://univnebrmedcntr.sharepoint.com.mcas.ms/sites/infectioncontrolepid/SitePages/Home%20Page.aspx Infection Control], UNMC Policy No. 2004, [[Bloodborne Pathogens Exposure]] | ||
|- | |- | ||
| Biosafety || [https://www.unmc.edu/ibc/ Institutional Biosafety Committee], UNMC Policy No. 2005, [[Waste Handling]], [https:// | | Biosafety || [https://www.unmc.edu/ibc/ Institutional Biosafety Committee], UNMC Policy No. 2005, [[Waste Handling]], [https://www.unmc.edu/ehs/biosafety/biohazard-waste/index.htmlBiohazardous Waste Handling] | ||
|- | |- | ||
| Chemical Safety || [https://www.unmc.edu/ehs/ UNMC Environmental Health & Safety Department] | | Chemical Safety || [https://www.unmc.edu/ehs/ UNMC Environmental Health & Safety Department], [https://www.unmc.edu/ehs/_documents/HMDGShippingPlan.pdf UNMC Hazardous Material/Dangerous Goods (HM/DG) Shipping Plan] | ||
|- | |- | ||
| Line 148: | Line 149: | ||
|- | |- | ||
| '''Other''' || | | '''Other''' || | ||
|- | |||
|Clinical Compliance || See Institute or College specific policies or refer to [https://now.nebraskamed.com/policies-and-procedures-manual/ Nebraska Medicine Policies and Procedures Manual] | |||
|- | |- | ||
| Computer Use and Information Security || UNMC Policy No. 6051, [https://wiki.unmc.edu/index.php/Computer_Use/Electronic_Information Computer Use and Electronic Information Security] | | Computer Use and Information Security || UNMC Policy No. 6051, [https://wiki.unmc.edu/index.php/Computer_Use/Electronic_Information Computer Use and Electronic Information Security] | ||
| Line 153: | Line 156: | ||
| Export Control || UNMC Policy No. 8005, [[Export Control]], UNMC Policy No. 8014, [[Disclosing Foreign Support and International Activities]] | | Export Control || UNMC Policy No. 8005, [[Export Control]], UNMC Policy No. 8014, [[Disclosing Foreign Support and International Activities]] | ||
|- | |- | ||
| Human Resources || [https://www.unmc.edu/human-resources/ | | Human Resources || [https://www.unmc.edu/human-resources/index.html Human Resources] | ||
|- | |- | ||
| Internal Audit || [https://nebraska.edu/offices-policies/internal-audit-and-advisory-services | | Internal Audit || University of Nebraska Internal Audit Charter and [https://nebraska.edu/offices-policies/internal-audit-and-advisory-services UNMC Internal Audit and Advisory Services Webpage] | ||
|- | |- | ||
| Student Success || [https://www.unmc.edu/student-success/ Student Success], [https://catalog.unmc.edu/ UNMC CourseLeaf Catalog] [https:// | | Student Success || [https://www.unmc.edu/student-success/ Student Success], [https://catalog.unmc.edu/ UNMC CourseLeaf Catalog] [https://info.unmc.edu/policies/compliance/matrix.html Compliance Matrix], [https://www.unmc.edu/student-success/academic-records/ferpa.html FERPA Information] | ||
|- | |- | ||
| Title IX || UNMC Policy No. 1099, [[Non-Discrimination and Harassment]], UNMC Policy No. 1107, [[Sexual Misconduct]] | | 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 Policies], [https://www.unmc.edu/student-success/academic-records/ferpa | | Family Educational Rights and Privacy Act (FERPA) || [https://wiki.unmc.edu/index.php/Student_Policies Student Policies], [https://www.unmc.edu/student-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. | | 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.justice.gov/civil/false-claims-act False Claims Act 31 U.S.C. §§ 3729-3733] | ||
|- | |- | ||
| Foreign Corrupt Practices Act || Contact the Chief Compliance Officer (see also the UNMC Compliance Hotline, 1-844-384-9584 or www.nebraska.ethicspoint.com), [https://www. | | Foreign Corrupt Practices Act || Contact the Chief Compliance Officer (see also the UNMC Compliance Hotline, 1-844-384-9584 or www.nebraska.ethicspoint.com), [https://www.justice.gov/sites/default/files/criminal-fraud/legacy/2012/11/14/fcpa-english.pdf Foreign Corrupt Practices Act (FCPA) 15 U.S.C. §§ 78dd-1, et seq.] | ||
|} | |} | ||
| Line 177: | Line 180: | ||
All University of Nebraska Medical Center employees (including visitors and 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. | All University of Nebraska Medical Center employees (including visitors and 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 https:// | Mandatory compliance training is required of UNMC staff and students. All UNMC invited visitors on campus for seven (7) or greater days (does not have to be consecutive), 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 https://info.unmc.edu/policies/compliance/training-requirements/index.html and 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" | {| class="wikitable" style ="text-align:center" | ||
| Line 194: | Line 197: | ||
==Additional Information== | ==Additional Information== | ||
*Contact the [mailto:sarah.glodencarlson@unmc.edu Chief Compliance Officer] | *Contact the [mailto:sarah.glodencarlson@unmc.edu Chief Compliance Officer] | ||
*For a complete listing of Contacts and Compliance Topics see the [https:// | *For a complete listing of Contacts and Compliance Topics see the [https://info.unmc.edu/policies/compliance/matrix.html Compliance Matrix] for details. | ||
*[https://nebraska.edu/-/media/unca/docs/offices-and-policies/policies/executive-memorandum/sexual-misconduct-minimum-training-standards.pdf Sexual Misconduct Minimum Training Standards - Executive Memo No. 44] | |||
*UNMC Policy No. 1003, [[Drug Free Campus]] | *UNMC Policy No. 1003, [[Drug Free Campus]] | ||
*UNMC Policy No. 1049, [[Outside Employment]] | *UNMC Policy No. 1049, [[Outside Employment]] | ||
| Line 219: | Line 223: | ||
This page maintained by [mailto: | This page maintained by [mailto:mhurlocker@unmc.edu mh] | ||