Compliance Program: Difference between revisions

(updated links to False Claims Act, Foreign Corrupt Practices Act, Infection Control, Compliance Matrix (appears 2x) and compliance training requirements URL)
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[[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]]
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Policy No.: '''8000'''<br />
Policy No.: '''8000'''<br />
Effective Date: '''11/01/06'''<br />
Effective Date: '''11/01/06'''<br />
Revised Date: '''02/28/23'''<br />
Revised Date: '''07/09/24'''<br />
Reviewed Date: '''02/28/23'''<br />
Reviewed Date: '''07/09/24''' <br />
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<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]]
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*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 shall oversee and monitor department response to identified risks as identified by the Chancellor's Risk Assessment as well as data generated through monitoring and individual reporting.
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:
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*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;  
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| 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]
| 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]
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|-
| Chemical Safety || [https://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]
| 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]


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| '''Other''' ||  
| '''Other''' ||  
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|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]
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|-
| 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]
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| 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]]
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|-
| Human Resources || [https://www.unmc.edu/human-resources/about/contact-hr.html Human Resources]
| Human Resources || [https://www.unmc.edu/human-resources/index.html Human Resources]
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| 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]
| 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]
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*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://info.unmc.edu/policies/compliance/matrix.html Compliance Matrix] for details.
*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]]
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