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]]
[[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: '''08/18/21'''<br />
Revised Date: '''02/28/23'''<br />
Reviewed Date: '''08/18/21'''<br />  
Reviewed Date: '''02/28/23'''<br />  
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<big>'''Compliance Program Policy'''</big>
<big>'''Compliance Program Policy'''</big>
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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 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's 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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| 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://www.unmc.edu/academicaffairs/compliance/areas/infection.html 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]]
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|-
| Biosafety || [https://www.unmc.edu/ibc/ Institutional Biosafety Committee], UNMC Policy No. 2005, [[Waste Handling]], [https://info.unmc.edu/safety/safety-office/biohazardous-waste/2005-waste-handling-attachments-2014.pdf Biohazardous 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]
|-
|-
| 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], UNMC Policy No. 2002, [https://wiki.unmc.edu/index.php/Shipping_Hazardous_Materials Shipment of Hazardous Materials or Dangerous Goods]
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| '''Privacy and Information Security'''||  
| '''Privacy and Information Security'''||  
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|-
| Privacy, Confidentiality and Information Security|| UNMC Policy No. 6045, [https://wiki.unmc.edu/index.php/Privacy/Confidentiality Privacy, Confidentiality and Information Security]
| Privacy, Confidentiality, and Information Security|| UNMC Policy No. 6045, [https://wiki.unmc.edu/index.php/Privacy/Confidentiality Privacy, Confidentiality and Information Security]
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| Use and Disclosure of Protected Health Information|| UNMC Policy No. 6054, [[Use and Disclosure of Protected Health Information]]
| Use and Disclosure of Protected Health Information|| UNMC Policy No. 6054, [[Use and Disclosure of Protected Health Information]]
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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]
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|-
| Internal Audit || University of Nebraska Internal Audit Charter and 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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| 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://info.unmc.edu/policies/compliance/matrix.html Compliance Matrix], [https://www.unmc.edu/student-success/academic-records/ferpa.html FERPA Information]
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| 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]]
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| 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]
| 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.html FERPA Information]
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| 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.justice.gov/civil/false-claims-act False Claims Act 31 U.S.C. §§ 3729-3733]
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| Foreign Corrupt Practices 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/foreign_corrupt_practices_act.pdf Foreign Corrupt Practices Act (FCPA) 15 U.S.C. §§ 78dd-1, et seq.]
| Foreign Corrupt Practices Act || Contact the Chief Compliance Officer (see also the UNMC Compliance Hotline, 1-844-384-9584 or www.nebraska.ethicspoint.com), [https://www.justice.gov/sites/default/files/criminal-fraud/legacy/2012/11/14/fcpa-english.pdf Foreign Corrupt Practices Act (FCPA) 15 U.S.C. §§ 78dd-1, et seq.]
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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 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.
All University of Nebraska Medical Center employees (including visitors and non-faculty volunteers), 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, 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:  
Mandatory compliance training is required of UNMC staff and students. All UNMC invited visitors on campus for seven (7) or greater days (does not have to be consecutive), 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://info.unmc.edu/policies/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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==Additional Information==
==Additional Information==
*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://www.unmc.edu/academicaffairs/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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