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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: '''03/31/17'''<br />
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Revised Date: '''02/02/18 DRAFT'''<br />
Reviewed Date: '''03/31/17'''<br />  
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Reviewed Date: <br />  
 
<br />
 
<br />
 
<big>'''Compliance Program Policy'''</big>
 
<big>'''Compliance Program Policy'''</big>
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== Compliance Program Structure ==
 
== Compliance Program Structure ==
 
[[File:Compliance-Flowchart3-10-17.jpg]]
 
[[File:Compliance-Flowchart3-10-17.jpg]]
===Associate Vice Chancellor for Compliance===
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===Senior Vice Chancellor for Academic Affairs===
The Associate Vice Chancellor for Compliance reports directly to the Vice Chancellor for Academic Affairs and is responsible for overseeing the development and implementation of policies, procedures and practices necessary to effect compliance with federal, state, and local laws and regulations.
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The Senior Vice Chancellor for Academic Affairs is responsible for overseeing the development and implementation of policies, procedures and practices necessary to effect compliance with federal, state, and local laws and regulations.  
 
===Compliance Officer===
 
===Compliance Officer===
The Compliance Officer shall report to the Associate Vice Chancellor of Academic Affairs for Compliance, 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:
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The 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 Business and Finance, Research, Deans 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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*oversee visits by regulatory agencies and responses to inquiries and investigations;  
 
*oversee visits by regulatory agencies and responses to inquiries and investigations;  
 
*report compliance matters directly to the UNMC Chancellor’s Council;  
 
*report compliance matters directly to the UNMC Chancellor’s Council;  
*coordinate with the Associate General Counsel for Health Care on legal issues;
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*coordinate with the Associate General Counsel on legal issues;
 
*coordinate with the Director of Internal Audit;
 
*coordinate with the Director of Internal Audit;
 
*coordinate with the Information Security Officer;
 
*coordinate with the Information Security Officer;
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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 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 Compliance Officer with managing the Compliance Program:
 
*Compliance Officer  
 
*Compliance Officer  
*Associate General Counsel for Health Care
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*Associate General Counsel
 
*Export Control Compliance Officer
 
*Export Control Compliance Officer
 
*Human Resources Director
 
*Human Resources Director
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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.
 
==Compliance Hotline==
 
==Compliance Hotline==
A UNMC 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]].
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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 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, students (including visiting students), and faculty (including but not limited to courtesy, adjunct, volunteers) must be knowledgeable of and comply with laws and regulations related to their duties or field of study as determined by the Compliance Officer and Compliance Committee.
 
All University of Nebraska Medical Center employees, students (including visiting students), and faculty (including but not limited to courtesy, adjunct, volunteers) must be knowledgeable of and comply with laws and regulations related to their duties or field of study as determined by the Compliance Officer and Compliance Committee.
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Mandatory compliance training is 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:
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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:  
    
{| class="wikitable" style ="text-align:center"
 
{| class="wikitable" style ="text-align:center"
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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 Vice Chancellor for Academic Affairs; records placed on hold
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| 60 Days || Communication from Human Resources || Letter from Senior Vice Chancellor for Academic Affairs; records placed on hold
 
|-
 
|-
 
| 90 Days || Notification to Dean, access removed from all UNMC resources except Blackboard until training has been completed ||
 
| 90 Days || Notification to Dean, access removed from all UNMC resources except Blackboard until training has been completed ||

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