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Basis for Policy

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.

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.

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, 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;
  • monitor day-to-day compliance activities;
  • develop, initiate, maintain and revise policies and procedures for compliance with laws and regulations applicable to UNMC;
  • oversee visits by regulatory agencies and responses to inquiries and investigations;
  • report compliance matters directly to the UNMC Chancellor’s Council;
  • coordinate with the Associate General Counsel on legal issues;
  • coordinate with the Director of Internal Audit and Advisory Services;
  • coordinate with the Information Security Officer;
  • coordinate with the University Compliance Officer and other campus compliance officers;
  • respond to compliance hotline calls;
  • participate on the University Compliance Council;
  • disseminate information to support compliance and training on the Compliance Program; and
  • chair the 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'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:

  • Chief Compliance Officer
  • Associate General Counsel
  • Export Control Compliance Officer
  • Human Resources Director
  • Information Security Officer
  • Chair of the Institutional Review Board or Compliance designee
  • Executive Director, Environmental Health & Safety
  • Intellectual Property Director
  • Director Internal Audit and Advisory Services
  • Nebraska Medicine Compliance Officer or Compliance Representative for Nebraska Medicine
  • Privacy Officer
  • Controller
  • Financial Compliance and Cost Analysis
  • Sponsored Programs Administration
  • Sponsored Programs Accounting
  • Procurement
  • Chief Student Affairs Officer
  • Library

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;
  • establish compliance training programs;
  • assist with identifying areas of potential compliance vulnerabilities;
  • 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.

Representatives would be from the following areas:

  • NU Director of Internal Audit and Advisory Services
  • Biosafety
  • Child Health Research Institute (CHRI)
  • College of Dentistry
  • College of Medicine
  • College of Nursing
  • College of Pharmacy
  • College of Public Health
  • College of Allied Health Professions
  • Graduate Studies
  • UNMC Physicians
  • Comparative Medicine/Institutional Animal Care and Use Committee
  • Eppley Institute/Fred & Pamela Buffett Cancer Center
  • Facilities Management
  • Munroe-Meyer Institute
  • Environmental Health & Safety
  • Student Success
  • Others as necessary

Compliance Responsibilities

Compliance Areas
Compliance responsibilities shall be established per UNMC and/or Board of Regents policies and procedures linked and referenced below:

Research Compliance

Environmental and Safety Compliance

Intellectual Property

Privacy and Information Security

Other

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 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

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

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 (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:

Employees

Days Overdue (days past deadline date)

  • 30 Days: E-mail/verbal notice from unit management 
  • 60 Days: Communication from Human Resources
  • 90 Days: Notification to Dean, access removed from all UNMC resources except Canvas until training has been completed

Students

Days Overdue (days past deadline date)

  • 30 Days: E-mail/verbal notice from Dean’s office
  • 60 Days: Letter from Senior Vice Chancellor for Academic Affairs; records placed on hold

Statement of Understanding

All employees and students shall sign a Statement of Understanding at the beginning of employment/start of school and annually thereafter, documenting that they have read, understand and agree to adhere to policies on: code of conduct, non-discrimination, sexual harassment; privacy and information security; and drug-free workplace.

Additional Information

Policy No.: 8000
Effective Date: 11/01/06
Revised Date: 02/28/23
Reviewed Date: 02/28/23