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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 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 auditing 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 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 auditing 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- | [[File:Compliance-flowchart-8-5-2020.jpg]] | ||
===Senior Vice Chancellor for Academic Affairs=== | ===Senior Vice Chancellor for Academic Affairs=== | ||
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. | ||
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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 Risk | 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 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 | ||
The Compliance Committee or 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; | ||
*establish compliance training programs; | *establish compliance training programs; | ||
| Line 96: | Line 96: | ||
*Student Success | *Student Success | ||
*Others as necessary | *Others as necessary | ||
==Compliance Responsibilities== | ==Compliance Responsibilities== | ||
[http://www.unmc.edu/academicaffairs/compliance/areas/ Compliance Areas]<br /> | [http://www.unmc.edu/academicaffairs/compliance/areas/ Compliance Areas]<br /> | ||
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| Code of Conduct || UNMC Policy No. 8006, [[Code of Conduct]] | | Code of Conduct || UNMC Policy No. 8006, [[Code of Conduct]] | ||
|- | |- | ||
| IRB || [http://www.unmc.edu/irb/ Institutional Review Board] | | IRB || [http://www.unmc.edu/irb/ Institutional Review Board] https://www.unmc.edu/ibc/ | ||
|- | |- | ||
| IACUC || [http://www.unmc.edu/iacuc/ Institutional Animal Care and Use Committee], BOR Policy 3.2.8 | | IACUC || [http://www.unmc.edu/iacuc/ Institutional Animal Care and Use Committee], BOR Policy 3.2.8 | ||
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| Research Integrity || UNMC Policy No. 8003, [[Research Integrity]] | | Research Integrity || UNMC Policy No. 8003, [[Research Integrity]] | ||
|- | |- | ||
| Sponsored Programs Administration | | Sponsored Programs Administration, Sponsored Programs Accounting and Financial Compliance & Cost Analysis || UNMC Policy No. 3001, [[Sponsored Programs]], UNMC Policy No. 6100, [[Sponsored Programs Costing]], UNMC Policy No. 6102, [[Institutional Base Salary]], UNMC Policy No. 6104, [[Sponsored Project Cost Share]], UNMC Policy No. 6105, [[Effort Certification]], UNMC Policy No. 6106, [[Cost Transfer]], UNMC Policy No. 6107, [[Service Center]], UNMC Policy No. 6108, [https://wiki.unmc.edu/index.php/Subrecipient_Policy Subrecipient], UNMC Policy No. 6110, [[On-Campus and Off-Campus Indirect Cost Rates on Federally Sponsored Projects]] | ||
|- | |- | ||
| '''Environmental and Safety Compliance'''|| | | '''Environmental and Safety Compliance'''|| | ||
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| Bloodborne Pathogens || [http://www.unmc.edu/academicaffairs/compliance/areas/infection.html Infection Control], UNMC Policy No. 2004, [[Bloodborne Pathogens Exposure]] | | Bloodborne Pathogens || [http://www.unmc.edu/academicaffairs/compliance/areas/infection.html Infection Control], UNMC Policy No. 2004, [[Bloodborne Pathogens Exposure]] | ||
|- | |- | ||
| Biosafety || [ | | Biosafety || [https://www.unmc.edu/ibc/ Institutional Biosafety Committee], UNMC Policy No. 2005, [[Waste Handling]], [http://info.unmc.edu/safety/safety-office/biohazardous-waste/2005-waste-handling-attachments-2014.pdf Biohazardous Waste Handling] | ||
|- | |- | ||
| Chemical Safety || [http://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 || [http://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] | ||
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| Internal Audit || University of Nebraska Internal Audit Charter and UNMC Internatl Audit and Advisory Services Webpage | | Internal Audit || University of Nebraska Internal Audit Charter and UNMC Internatl Audit and Advisory Services Webpage | ||
|- | |- | ||
| Student | | Student Success || [https://www.unmc.edu/student-success/ Student Success], [http://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] | ||
|- | |- | ||
| 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 | | 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/ 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.unmc.edu/academicaffairs/_documents/compliance/False_Claims_Act.pdf False Claims Act 31 U.S.C. §§ 3729-3733] | | 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.unmc.edu/academicaffairs/_documents/compliance/False_Claims_Act.pdf False Claims Act 31 U.S.C. §§ 3729-3733] | ||
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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 | 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. | ||
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. It is the individual's responsibility to complete the compliance training requirements at http://www.unmc.edu/academicaffairs/compliance/training-requirements/index.html. 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: | 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. It is the individual's responsibility to complete the compliance training requirements at http://www.unmc.edu/academicaffairs/compliance/training-requirements/index.html. 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: | ||