POLICY NO: 8000
EFFECTIVE DATE: 11/01/06
REVIEWED DATE: 11/01/06
Compliance Program Policy
Basis for Policy
The University of Nebraska Medical Center (UNMC) shall comply with all applicable federal, state and local laws and regulations and University of Nebraska and UNMC Policies and Procedures.
Compliance Program Structure
Compliance Officer. The Compliance Officer is responsible for overseeing the development of and coordinating the implementation of policies, procedures and practices necessary to effect compliance with federal, state, and local laws and regulations. The compliance officer shall report to the Vice Chancellor for Academic Affairs, but has the authority to communicate directly with the Chancellor or Vice Chancellors for Business and Finance and Research on compliance matters. The Compliance Officer shall:
- analyze laws and regulations applicable to UNMC and coordinate with subject matter experts to ensure compliance with them.
- monitor day-to-day compliance activities.
- establish compliance audits of risk areas and develop corrective action plans in response to identified deficiencies.
- oversee visits by regulatory agencies and responses to inquiries and investigations.
- make periodic reports regarding compliance matters directly to the UNMC Chancellor’s Council.
- coordinate with the Associate General Counsel for Health Care on legal issues.
- respond to compliance hotline calls.
- chair the compliance committee.
Compliance Committee. The Compliance committee shall support the Compliance Officer in meeting his/her responsibilities. The committee shall analyze UNMC’s risk areas and oversee the monitoring of internal audits and external investigations. The Compliance Committee shall be composed of representatives from the following departments:
Associate General Counsel for Health Care
College of Dentistry
College of Medicine
College of Nursing
College of Pharmacy
Information Technology Services
Institutional Animal Care and Use Committee (IACUC)
Institutional Review Board (IRB)
Sponsored Programs Accounting
Sponsored Programs Administration
The Nebraska Medical Center
Compliance Committee representatives shall assist the Compliance Office with communicating compliance policies and procedures and other information within their respective units. The Compliance Committee shall meet no less than quarterly. The Compliance Office shall complete meeting minutes and maintain them on file for no less than seven years. The meeting minutes shall be confidential. Meeting minutes shall be distributed to committee members, vice chancellors, college deans and executive directors to inform UNMC leadership about compliance activities.
Compliance Hotline. A compliance hotline has been established to provide individuals with an additional communication channel to report compliance concerns. The Compliance Officer shall investigate concerns and take corrective action in response to identified issues.
For additional information, see UNMC Policy No. 8001, Compliance Hotline Policy.