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Policy No.: 6109
Effective Date: 10/16/04
Revised Date: 01/20/23
Reviewed Date: 07/09/24

Inspections and Investigations by Government Officials, Regulatory Agencies and Other Third Parties

Purpose

Government investigators, regulatory agency inspectors or other third parties may contact staff or arrive unannounced at UNMC or at the homes of staff members and seek interviews, documents, information or request to search the premises. The purpose of this policy is to establish procedures for an orderly response that protects the interests of UNMC and provides for appropriate cooperation. Examples of regulatory agency visits, investigations, or requests for information that are subject to this policy include but are not limited to the following:

• Routine inspections or investigative visits by regulatory agencies such as the Department of Health and Human Services (DHHS), Food and Drug Administration (FDA), United States Department of Agriculture (USDA), Environmental Protection Agency (EPA), Office of Human Research Protections (OHRP), or Internal Revenue Service (IRS), on an announced or unannounced basis;
• Law enforcement visits, including local, state and federal investigators;
• Licensure or permit-based inspections/investigations;
• Freedom of Information Act (FOIA) requests;
• Requests for information pursuant to the Nebraska public records law (Neb. Rev. Stat. §84-712);
• Sunshine Act requests (allows citizens to request government agency meeting records);
• Subpoenas (including subpoena duces tecum for the inspection or production of documents).

Procedures

1. Regulatory Agency Visits
   • UNMC staff members who are notified of a visit by a regulatory agency should notify their supervisor, director and/or dean (as appropriate to the type of visit) and the Chief Compliance Officer at 402-559-9576 or 402-559-6767. Notify Nebraska Medicine when a patient care area is involved or could be involved.
   • Any requests for information related to a patient, patient’s care or billing, also known as protected health information (PHI) pursuant to an investigation by a regulatory agency require notification of the Privacy Officer at 402-559-5136 or Privacy Officer prior to providing patient information.
   • During the visit, the regulatory agency official(s) should be escorted at all times by an individual who is knowledgeable about the area(s) visited.
   • Most regulatory agency visits are permitted pursuant to state or federal law, and the regulator may request copies of documents to assess compliance without providing a subpoena. Staff who are unsure about whether documents should be provided to regulators should ask their supervisor, the Chief Compliance Officer at 402-559-9576 or 402-559-6767 or the Office of the General Counsel, Varner Hall, 402-472-1201, for guidance.
   • Supervisory personnel and the Chief Compliance Officer should be informed of any serious compliance issues that may arise during the visit as soon as possible and shall be provided with reports of findings at the end of all visits.
2. Inspections/Investigations by Government Officials/Law Enforcement/Other Third Parties
   • If a UNMC staff member becomes aware of any contact by an agent, representative, investigator auditor or attorney from any governmental agency, law enforcement agency, or other third party (hereinafter, "investigator"), the staff member should ask to see the investigator's identification and business card for name and agency affiliation. If contact is by telephone, ask the investigator to fax a business card or other identification. Ask for the investigator's agency name and phone number and call them back to verify identity.
   • Inquire as to the reason for the visit if rationale has not already been provided.
   • Contact a supervisor, director or dean, and the Chief Compliance Officer at 402-559-9576 or 402-559-6767. If the Chief Compliance Officer is unavailable, contact the Office of the General Counsel, Varner Hall, 402-472-1201, for guidance. The Chief Compliance Officer shall notify the Office of the General Counsel, Varner Hall, 402-472-1201, of the investigation and coordinate with them as necessary. Notify Nebraska Medicine when a patient care area is involved or could be involved.
   • In the case of a possible concern for safety or compliance investigation disruption, compliance may contact public safety for assistance at 402-559-5111.
   • If the subject matter of the investigation is not in the staff member's area of responsibility, the Chief Compliance Officer should be contacted, so the investigator can be directed to the correct area.
   • Subpoenas/Search Warrants. If the investigator asks to search a UNMC facility or obtain any documents from UNMC, ask if there is a subpoena or search warrant to be served; and if so, make a copy of the document. Immediately contact the Office of the General Counsel, Varner Hall, 402-472-1201, to review the subpoena or warrant, to verify it is valid and to provide advice on responding to it. The Chief Compliance Officer and/or Associate General Counsel shall escort the investigator, along with personnel familiar with the area to be searched.
     

If documents are subpoenaed, the records custodian for the documents shall be consulted if they are not already involved (i.e. Medical Records Department for patient information; Human Resources Department for employee information, Student Success for student information). The Information Technology Security Office shall be contacted at https://support.security.unmc.edu if computer information, files or hardware is requested.

Individuals intending to serve subpoenas to employees for non-work-related matters should be instructed to report to the Human Resources Employee Relations Department to arrange service.

• Conditions of Search. If a search is conducted pursuant to a valid search warrant, the search shall be confined to the areas specified in the search warrant. If the investigator attempts to enter areas not specified in the search warrant, staff should object. Staff shall remain with the investigator at all times. If the search warrant is valid, the search may not be stopped. No staff member is required to speak to the investigator other than to provide administrative assistance with the search and provide the documents specified in the warrant. Under no circumstances should staff obstruct or interfere with the search.
• Record of Search. During the search, staff shall keep a written record of areas searched and documents and items seized, including a summary of their content. Staff should ask the investigator if they are willing to accept copies of documents instead of originals. Staff should coordinate closely with General Counsel for direction, and specifically with the Associate General Counsel and Director of University Records, 402-472-1201.
• Interviews. Staff members who shall be interviewed pursuant to an investigation may consult with the Office of the General Counsel, Varner Hall, 402-472-1201, for guidance before any requested interview. When responding to questions asked by investigators, staff shall always tell the truth. If staff do not recall something or have no knowledge about the topic, they should say so. Staff should not guess or speculate. Staff should be very careful to answer questions completely, accurately and concisely so that there will be no misunderstanding.
• Debriefing. After the investigator departs the premises, staff involved in the investigation shall take part in a debriefing with the Chief Compliance Officer and/or Office of the General Counsel, Varner Hall, 402-472-1201. Reports of the investigation shall be provided to senior personnel as appropriate.
• After Hours. In the unlikely event that an investigator requests information after hours, staff should contact the Office of the General Counsel, Varner Hall, 402-472-1201 or the Chief Compliance Officer through the operator at 402-559-4000.

Additional Information

• Chief Compliance Officer, Compliance Department, 402-559-9576 or 402-559-6767
• Privacy Officer, 402-559-5136
• University General Counsel, Varner Hall, 402-472-1201
• Associate General Counsel and Director of University Records, 402-472-1201
• Office of Information Security
• University of Nebraska Executive Memorandum 43, Policy on Records Requests and Contacts by Law Enforcement
• Nebraska Revised Statute §84-712
• Sunshine Act

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