University of Nebraska Medical Center

Compliance Program: Difference between revisions

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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]] | [[Electronic Digital Signatures and Records]]
[[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]] | [[Utilizing Generative AI|UNMC AI Use Guidelines]]
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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 />
<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]]
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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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| '''Environmental and Safety Compliance'''||  
| '''Environmental and Safety Compliance'''||  
|-
|-
| Safety || [https://unmc.edu/ehs/safety/ UNMC Environmental Health & Safety Department], UNMC Policy No. 2000, [[Safety]]
| Safety || [https://www.unmc.edu/ehs/ UNMC Environmental Health & Safety Department], UNMC Policy No. 2000, [[Safety]]
|-
|-
| Radiation Safety || [https://www.unmc.edu/ehs/ UNMC Environmental Health & Safety Department]  
| Radiation Safety || [https://www.unmc.edu/ehs/ UNMC Environmental Health & Safety Department]  
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| Bloodborne Pathogens || [https://univnebrmedcntr.sharepoint.com.mcas.ms/sites/infectioncontrolepid/SitePages/Home%20Page.aspx Infection Control], UNMC Policy No. 2004, [[Bloodborne Pathogens Exposure]]
| 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://www.unmc.edu/ehs/biosafety/biohazard-waste/index.htmlBiohazardous Waste Handling]
| Biosafety || [https://www.unmc.edu/ibc/ Institutional Biosafety Committee], UNMC Policy No. 2005, [https://www.unmc.edu/ehs/biosafety/biohazard-waste.html Waste Handling]
|-
|-
| 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/chemical-safety/hmdgshippingplan.pdf UNMC Hazardous Material/Dangerous Goods (HM/DG) Shipping Plan]


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|-
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| '''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]
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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]]
|-
|-
| 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]
|-
|-
| 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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| 30 Days || E-mail/verbal notice from unit management || E-mail/verbal notice from Dean’s office
| 30 Days || E-mail/verbal notice from unit management || E-mail/verbal notice from Dean’s office
|-
|-
| 60 Days || Communication from Human Resources || Letter from Senior Vice Chancellor for Academic Affairs; records placed on hold
| 60 Days || Communication from Human Resources || Records placed on hold
|-
|-
| 90 Days || Notification to Dean, access removed from all UNMC resources except Canvas until training has been completed ||
| 90 Days || Notification to Dean, access removed from all UNMC resources except Canvas until training has been completed ||
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