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Compliance Program: Difference between revisions
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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: '''08/ | Revised Date: '''08/18/21'''<br /> | ||
Reviewed Date: '''08/ | Reviewed Date: '''08/18/21'''<br /> | ||
<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 | 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. | ||
== Compliance Program Structure == | == Compliance Program Structure == | ||
[[File:Compliance-flowchart-8-5-2020.jpg]] | [[File:Compliance-flowchart-8-5-2020.jpg]] | ||
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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. | 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=== | ===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 or others on compliance matters, which include, but are not limited to: | 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; | *coordinate with subject matter experts to analyze laws and regulations applicable to UNMC to ensure compliance; | ||
*monitor day-to-day compliance activities; | *monitor day-to-day compliance activities; | ||
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*coordinate with the Director of Internal Audit and Advisory Services; | *coordinate with the Director of Internal Audit and Advisory Services; | ||
*coordinate with the Information Security Officer; | *coordinate with the Information Security Officer; | ||
*coordinate with the University Compliance Officer and other campus compliance officers; | |||
*respond to compliance hotline calls; | *respond to compliance hotline calls; | ||
*participate on the University Compliance Council; | |||
*disseminate information to support compliance and training on the Compliance Program; and | *disseminate information to support compliance and training on the Compliance Program; and | ||
*chair the | *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 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 oversee and monitor department response to identified risks as identified by the Chancellor Risk Assessment as well as data generated through monitoring and individual reporting. | ||
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*Sponsored Programs Administration | *Sponsored Programs Administration | ||
*Sponsored Programs Accounting | *Sponsored Programs Accounting | ||
* | *Procurement | ||
*Chief Student Affairs Officer | *Chief Student Affairs Officer | ||
*Library | *Library | ||
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*assist with identifying areas of potential compliance vulnerabilities; | *assist with identifying areas of potential compliance vulnerabilities; | ||
*assist with understanding the compliance risks and related regulations and laws; and | *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 /> | *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: | Representatives would be from the following areas: | ||
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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/about/contact-hr.html Human Resources] | ||
|- | |- | ||
| Internal Audit || University of Nebraska Internal Audit Charter and UNMC | | Internal Audit || University of Nebraska Internal Audit Charter and 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://www.unmc.edu/academicaffairs/compliance/matrix.html Compliance Matrix], [https://www.unmc.edu/student-success/academic-records/ferpa/ FERPA Information] | | Student Success || [https://www.unmc.edu/student-success/ Student Success], [https://catalog.unmc.edu/ UNMC CourseLeaf Catalog] [https://www.unmc.edu/academicaffairs/compliance/matrix.html Compliance Matrix], [https://www.unmc.edu/student-success/academic-records/ferpa/ FERPA Information] | ||
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==Compliance Committee Meetings== | ==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 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. | 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. | ||
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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]]. | 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== | ==Compliance Training== | ||
All University of Nebraska Medical Center employees (including visitors), 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 volunbteers), 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 must complete all mandatory compliance training required of UNMC staff and students. | 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://www.unmc.edu/academicaffairs/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: | ||
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