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Institutional Compliance Plan
TABLE OF
CONTENTS
I. Mission Statement
The mission of The University of Texas Medical Branch is to excel
in the generation, dissemination, and application of knowledge to
better the health of society in a way which supports our core values
in an environment where professional behavior is expected by all.
As we pursue this mission, we are committed to conducting all of our
business in an ethical and law-abiding fashion. We will maintain a
business culture that builds and promotes compliance consciousness
and encourages employees and faculty to conduct all University business
with honesty and integrity. Our commitment to compliance includes:
communicating to all employees, faculty, consultants, and independent
contractors clear business ethical guidelines to follow; providing
general and specific training and education regarding applicable laws,
regulations, and policies; and providing monitoring and oversight
to help ensure that we meet our compliance commitment. We promote
open and free communication regarding our ethical and compliance standards
and provide a work environment free of retaliation.
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II. Introduction
The University of Texas Medical Branch is committed
to conducting its business in an ethical and law-abiding fashion.
We are intolerant of fraud, abuse, waste, or other violations of any
applicable federal, state, or local laws, and regulations. Responsibility
and accountability for actual compliance with laws, regulations, and
policies rests with each individual employee. The department chairman/head
or leader of each operating unit is accountable for ensuring that
their subordinates are adequately trained and for detecting noncompliance
with applicable policies and legal requirements when reasonable management
efforts would have led to the discovery of problems or violations.
To promote compliance and implement an institutional
compliance program we have developed an Office of Institutional Compliance
(OIC). The OIC is responsible for developing an institutional compliance
program that will pronote compliance with all applicable legal requirements,
foster and help ensure ethical conduct, and provide education, training,
and guidance to all employees and faculty. Our institutional compliance
plan and program is designed to prevent accidental or intentional
noncompliance with applicable laws and regulations; to detect such
noncompliance, if it occurs; to discipline those involved in noncompliant
behavior, and to prevent future noncompliance.
Our compliance program has been developed to include
the seven requirements of an effective compliance program included
in the Federal Sentencing Guidelines. These requirements are :
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establish compliance standards and procedures
to be followed by employees and faculty that are reasonably capable
of reducing the prospect of criminal conduct
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assign high-level personnel of the organization
to have overall responsibility to oversee compliance with such
standards and procedures
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use "due care not to delegate substantial
discretionary authority to individuals who the organization knew,
or should have known through the exercise of due diligence, had
a propensity to engage in illegal activity"
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communicate effectively compliance standards
and procedures to all employees by requiring participation in
training programs or by disseminating publications that explain
in a practical manner what is required
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take reasonable steps to achieve compliance with
standards by utilizing monitoring and auditing systems reasonably
designed to detect criminal conduct and by having in place and
publicizing a reporting system whereby employees and other agents
can report criminal conduct by others within the organization
without fear of retribution
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consistently enforce standards through appropriate
disciplinary mechanisms, including discipline of individuals responsible
for the failure to detect an offense
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take all reasonable steps to respond appropriately
to detected offenses and to prevent further similar offenses
The policies and procedures contained in this program
are intended to establish a framework to help ensure compliance but
are not to be considered all-inclusive.
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III. Standards of Conduct
The University of Texas Medical Branch is committed
to conducting UTMB business with integrity and in compliance with
all applicable laws. UTMB has developed a Standards of Conduct Guide.
The purpose of the Standards of Conduct Guide is to communicate to
all UTMB employees and students an expectation and requirement of
ethical conduct and compliance with all applicable laws, policies,
rules, and regulations. The UTMB Standards of Conduct Guide is a framework
within which all employees are expected to operate. The UTMB Standards
of Conduct Guide represents policies of UTMB, the University of Texas
System and the Rules and Regulations of the Board of Regents of the
University of Texas System, know as Regents' Rules and Regulations.
This booklet does not include all general compliance issues, nor does
it contain the special compliance issues that are job specific. Instead,
the UTMB standards of Conduct Guide should be regarded as a set of
guiding principles that apply to every UTMB employee.
The UTMB Standards of Conduct Guide applies to all UTMB employees,
including administration, faculty, fellows, residents, and students.
Moreover, the Standards of Conduct Guide is applicable to physicians
not employed by UTMB but serving on UTMB Hospitals medical staff as
well as university and hospital subcontractors, independent contractors,
and consultants.
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IV. Compliance Organization
and Oversight
The President of UTMB has appointed an Institutional
Compliance Officer (ICO) and an Institutional Compliance Committee
(ICC) to guide the compliance effort at UTMB. Together the ICC and
the ICO are responsible for implementing and monitoring a continuous
and proactive compliance function.
A. Institutional Compliance
Officer
The ICO for The University of Texas Medical Branch
reports directly to the President. The ICO is responsible for developing
a risk-based process that builds compliance consciousness into daily
business processes, monitoring the effectiveness of those processes,
and communicates instances of non-compliance to the ICC for corrective,
restorative, and/or disciplinary action. Moreover, the ICO is responsible
for the plan, design, implementation, and maintenance of the Institution's
compliance program and policies related to all compliance areas.
The responsibilities of the ICO include the following:
- establish policies and procedures to help ensure UTMB's compliance
with all state and federal laws and regulation, such as Affirmative
Action, Americans with Disabilities Act; Medicare and Medicaid,
and federal grants and contracts, etc
- responsible for monitoring the day-to-day compliance activities
of UTMB
- make periodic reports regarding compliance matters directly to
the ICC
- responsible for any reporting activities related to any compliance
related settlement agreement or Institutional Compliance Agreement
- develop an institutional compliance training program that includes
general compliance training for all employees and specialized training
for specific employees
- develop an institutional education program that educates staff
of proper billing procedures, medical record documentation, and
the importance of compliance (compliance awareness)
- develop and implement guidelines and procedures for monitoring
of current departmental billing activities to promote compliance
with applicable laws and regulations
- develop guidelines and procedures for compliance monitoring in
accordance with state and federal requirements
- participate in any external audit review process, resolves compliance
issues, and responds to legal or administrative inquiries related
to compliance issues or audits
- provide advice and direction to executive and senior management,
staff, and employees to facilitate compliance with statutory, regulatory,
and case law requirments
- maintain current knowledge of laws and regulations, keeping abrest
of recent changes that may affect the insitution's policies, procedures
and processes through personal research, seminars, peer contact,
and bench-marking compliance monitoring practices and implementation
strategies with other insitutions
- authorized to report to the UTMB President or the Chancellor of
the UT System at any time
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B. Institutional Compliance
Committee
The ICO chairs the ICC. The ICC consists of the following
administrative positions. The following positions are permanent members
of the ICC:
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UTMB President
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Institutional Compliance Officer
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Associate Dean for Research Administration
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Vice President and Chief Executive Officer for
UTMB Hospitals
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Chief Financial Officer
- Chief Academic Officer
- Chief Physician Executive Officer
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Director, Audit Services (ex-officio, non-voting)
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Director of Legal Affairs (ex-officio, non-voting)
Five (5) voting members of the committee consitute a
quorum. For any vote that is taken, a quorum must be present. The
ICO is the chair of the ICC committee. A quorum is not required for
issues that do not require a vote.
The ICC shall:
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ensure that an annual risk assessment is conducted
and that appropriate processes are implemented to control or manage
the identified risks
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ensure that the compliance program is designed
to prevent and/or detect violations of the law, UT System policies,
or UTMB policies
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ensure communication of the compliance program
to all employees, students, and contractors
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review and approve the UTMB Institutional Compliance
Plan and revisions to the Plan
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review and approve policies to guide the Office
of Institutional Compliance
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review and approve institutional compliance policies
to be submitted for inclusion in the Institutional Handbook of
Operating Procedures
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provide guidance to investigations being conducted
by the ICO unless such guidance would potentially compromise an
investigation.
V. Information, Education and
Training
A. Information
Occasional letters, articles in Impact, the institutional
semimonthly newsletter, and other publications, regarding the OIC
are sent to all employees. E-mail notifications and communications
are also sent to employees. The content of these publications may
be related to specific, and or general compliance issues and other
elements of the program. Every employee is given a copy of the UTMB
Standards of Conduct Guide. Employees must sign the acknowledgment
form printed at the end of the Standards of Conduct Guide. The form
is returned to the OIC, recorded and sent to Employee Records to
be filed in the employee's personnel file.
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B. Education and Training
UTMB is committed to communicating our standards
for ethical conduct and UTMB policies to all employees. The OIC
provides education and training to develop compliance awareness
and commitment. All administration, faculty, medical staff, and
employees must complete general compliance training that includes,
but is not limited to, the following topics:
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Standards of Conduct Guide
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employee's individual responsibility for knowledge
of and compliance with laws, regulations, and policies
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reporting violations or questionable conduct
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fraud and abuse
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compliance as a condition of employment and
as a function of job performance
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legal consequences of non-compliance
The education and training program includes annual
general compliance training and privacy training for all employees.
Specific training is required for all new faculty physicians and
practitioners. Employees are required to complete required training
assigned for their specific position in accordance with appropriate
time frames and frequency. The content of the training includes
laws and regulations applicable to specific job duties and responsibilities.
As new developments or concerns arise, the UTMB ICO may require
additional training for some or all UTMB employees. A variety of
teaching methods, materials, tools, and languages will be utilized
to instill compliance knowledge, awareness, and conduct in every
employee.
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C. Maintenance of Documentation
and Disciplinary Action
Compliance training is required of all employees and
is a condition of employment. Failure to meet education and training
requirements will result in disciplinary action, up to and including
termination. All persons in supervisory positions are responsible
for ensuring that each UTMB employee reporting to them has completed
the compliance training applicable to that person. Completion of
required compliance training will be closely monitored and documented.
The UTMB Human Resources Department maintains training records and
reports detailed training activities for employees. Summary reports
of compliance with education and training requirements are provided
to the ICC.
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VI. Adherence to the Compliance
Program as a Requirement for Promotion for Faculty and as an Element
for Evaluating all Employees
A. Faculty
Adherence to the UTMB Institutional Compliance Program
is a part of each faculty member's annual evaluation and is also used
as a criterion for promotion in academic rank. It is understood that
the Appointment Promotion and Tenure Committee of each UTMB school
should consider participation in compliance training and any involvement
in compliance infractions as a part of the promotion evaluation process.
B. Managers and Supervisors
Managers and supervisors include all individuals who
have as part of their job descriptions the supervision of any UTMB
employee. The promotion of and adherence to the Institutional Compliance
Program by all management and supervisors is considered an integral
part of their job performance. At UTMB, employees' awareness of and
adherence to the Institutional Compliance Program should be used as
an element or measurement tool in the evaluation process for continuing
employment and promotions.
1.
Education and Training
Managers and supervisors are required to ensure and verify that
employees complete all mandatory and elective training assigned
to the employee including compliance training at UTMB. Managers
and supervisors should inform employees that UTMB will take disciplinary
ction for violation of policies, procedures, and regulatory requirements,
or for failure to complete mandatory training requirements. Moreover,
employees are informed that strict adherence to the laws, regulations,
and policies are a condition of employment.
2.
Inform Employees
Managers and supervisors are responsible for informing
employees of compliance policies and procedures specifically related
to their job function and appropriately monitoring employees to
help ensure adherence to policies and procedures.
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VII. Risk Assessment
A. Risk Assessment Profile
The UTMB OIC completes a risk assessment of institutional
compliance issues each fiscal year. The purpose of the risk ssessment
is to:
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identify high-risk compliance issues
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establish a priority for these issues
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establish monitoring activities that review
processes to advance compliance
- prepare the annual work plan for the Office of Institutional
Compliance
The risk assessment process utilizes a variety of
methods to identify institutional compliance risks. The risk assessment
may be a comprehensive risk assessment, a review of prior year's
issues, or a combined risk assessment with UTMB Audit Services Department.
B. Work Plan
In conjunction with the ICC the Office of Institutional
Compliance will create an annual work plan to review high risk items
identified through the risk assessment process. The work plan will
also include other items and/or issues in which the Office of Insitutional
Compliance expects to be involved during the year.
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VIII. Compliance Monitoring
UTMB monitors the implementation of the Institutional
Compliance Plan and the annual work plan. TheOffice of Institutional
Compliance conducts periodic reviews of identified high-risk compliance
areas. These reviews are aimed at ensuring adherence to general compliance
policies and applicable federal and state laws and regulations. Reviews
will include on-site visits; interviews with personnel involved in
administration, operations, billing, reporting, and other related
activities; review of documentation and other written materials; and
trend analysis studies.
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IX. Reporting Violations
or Questionable Conduct
A. Employee's Responsibility
It is every employee's responsibility to report suspected
violations of laws, regulations, policies or questionable conduct.
UTMB has established methods for employees to report, confidentially
and anonymously, any questionable conduct or possible violation(s).
Individual employees may discuss concerns with their supervisor or
directly with the Institutional Compliance Officer.
B. Fraud and Abuse Hotline (1-800-898-7679)
UTMB has established a dedicated Fraud and Abuse Hotline
as an internal reporting mechanism for reporting suspected waste,
abuse, fraud, or other illegal conduct of UTMB employees, students,
vendors, or independent contractors.
C. UTMB Compliance Web Site
A UTMB compliance web site also offers employees another
option for anonymous reporting. The web address is http://www2.utmb.edu/compliance/hotline/hotline_form.htm.
D. Confidential and Anonymous
UTMB will ensure the anonymity, to the extent allowed
by law, for all persons who choose to report violations or questionable
conduct. All allegations or concerns received through reports will
be investigated confidentially.
E. Intentional False
Accusations
UTMB will consider it a serious violation of UTMB policy
for employees to intentionally make false accusations. Such false
accusations may result in disciplinary action, up to and including
termination, against the accuser. All reports to the UTMB OIC should
be made in good faith and with the best of intentions.
F. Non-retaliation
Policy
Employees are encouraged to freely discuss and raise
questions to managers or to any appropriate personnel about situations
they feel are in violation of applicable laws, regulations, rules,
policies, and procedures. Moreover all UTMB employees have a personal
obligation to report any activity that appears to viloate applicable
laws, regulations, rules, policies, and procedures. Employees may
also make reports through the UTMB Fraud and Abuse Hotline (800-898-7679).
UTMB shall not intimidate, threaten, coerce, discriminate against,
or take any retaliatory action against any individuals who in good
faith report sus[ected wrongdoing to their supervisor or through the
UTMB Fraud and Abuse Hotline.
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X. Response to Allegations,
Identified Problems, and Audit Outcomes
A. Investigation
All reports of potential violations of laws, regulations,
policies or questionable conduct, from any source, shall be logged
and presented to the ICO. The ICO will authorize, direct and/or conduct
the investigation. A report of the investigation, including findings
and recommendations, will be created. A summary report of all investigations
will be provided to the ICC periodically. Investigations resulting
in extensive corrective action and/or disciplinary action shall be
reviewed and approved by the ICO prior to implementation. The ICC
will be informed of these actions and following discussion may direct
further action.
B. Recommendations
1.
Corrective Action
When an instance of non-compliance has
been determined and confirmed by the ICO, a corrective action plan
will be submitted to the ICO. The corrective action plan will focus
on implementing changes in internal processes to improve, prevent,
or detect compliance inadequacies. The ICO shall notify and meet with
the department Chair and/or the department compliance representative,
the affected faculty member(s) or employee(s) and explain the corrective
action to be implemented. The corrective action plan may include one
or all of the following elements:
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specific areas requiring compliance
attention
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requirement of additional training
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change in policies and procedures
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further audit and/or investigation
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2.
Disciplinary Action
Disciplinary action may be imposed
as a part of a corrective action plan for all UTMB administration,
faculty, house staff, and employees.
3.
Obligation to Report
a) Reckless Disregard
of Criminal, Civil, or Administrative Law
Reports or allegations that may constitute
intentional violation or reckless disregard of criminal, civil,
or administrative law shall be refered to UTMB legal authorities
for investigation and disposition. If the investigation produces
credible evidence that provides a reasonable basis to conclude that
a violation of law may have occurred, UTMB shall promptly provide
all information to the appropriate legal authorities for a determination
of prosecution.
b) Overpayments Detected through Monitoring
UTMB will refund appropriate overpayments
to payers identified through compliance monitoring activities, investigations,
or other reviews.
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XI. Disciplinary Action and
Appeal
UTMB will impose disciplinary action on employees who
fail to comply with applicable laws, regulations, and policies. The
seriousness of the violation will determine the level of the disciplinary
action.
A. Disciplinary Action
1. Faculty
a) Recommendation
of disciplinary action related to compliance issues
Disciplinary action administered to faculty is in accordance
with the UTMB Faculty Disciplinary Policy. The UTMB ICC may make
recommendations related to disciplinary action of faculty regarding
compliance violations up to and including termination. Disciplinary
action and termination will be conducted according to Rules and
Regulations of the Board of Regents of the University of Texas System.
b)
Recommendation of summary dismissal
Reports or allegations that may constitute
an intentional violation or reckless disregard of criminal, civil,
or administrative law shall be given to UTMB legal authorities for
investigation and disposition. Notwithstanding the foregoing, following
the determination that a reckless disregard or intentional violation
of law has occurred, the Dean of the appropriate school of the faculty
member may recommend to the President to proceed with charges for
termination, depending upon the nature of the conduct. Procedures
for termination shall be according to the Rules and Regulations
of the Board of Regents of the University of Texas System.
2. Non-employee Medical Staff
Disciplinary action administered to non-employee medical
staff will follow the guidelines as outlined in the UTMB Medical
Staff By-laws.
3. House Staff
Disciplinary action administered to house staff is
in accordance with the UTMB Hospitals General Information for House
Staff Policy and the Office of the Associate Dean for Graduate Medical
Education..
4. Administrative and Professional
Staff
Administrative and professional employees are subject
to the same disciplinary process as faculty.
5. Classified Employees
Disciplinary action related to classified employees
will be administered in accordance with the disciplinary action
provided for in Section 3.10.1 of the UTMB Handbook of Operating
Procedures. Any recommendations of disciplinary action shall be
managed pursuant to UTMB's Institutional Handbook of Operating Procedures
(IHOP) and the Rules and Regulations of the University of Texas
Board of Regents.
B. Appeal
1. Faculty
Appeal of a UTMB disciplinary action shall be according
to the appeals procedure in Section 6 of the Rules and Regulations
of the Board of Regents of the University of Texas System. No other
internal appeal process is available to a disciplined faculty other
than as provided by the Regents' Rules.
2. Non-employee Medical Staff
Non-employee Medical Staff are subject to the appeals
procedures outlined in the UTMB Hospitals Medical Staff By-laws.
3. House Staff
Appeals for disciplinary actions administered to house
staff are in accordance with the UTMB Hospitals General Information
for House Staff Policy.
4. Administrative and Professional
Staff
Administrative and professional employees are subject
to the same appeals procedures and corrective actions (where applicable)
as those governing faculty.
5. Classified Employees
Appeal for disciplinary action administered to classified
employees is in accordance with the appeals procedure provided for
in Section 3.10.2 of the UTMB Institutional Handbook of Operating
Procedures.
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XII. Non-employment or Retention
of Sanctioned Employees
UTMB prohibits the employment of the following individuals:
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persons known to be under investigation related
to health care violations
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persons convicted of a criminal offense related
to health care or research
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persons, listed by a federal or state agency as
debarred, excluded, or otherwise ineligible for participation
in federally funded programs
UTMB prohibits the retention of the following individuals:
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persons convicted of a criminal offense related
to health care or research
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persons listed by a federal or state agency as
debarred, exculded, or otherwise ineligible for participation
in federally funded programs
UTMB screens the list of all employees monthly against
the federal and state lists of persons who are debarred, excluded,
or otherwise ineligible for participation in federally funded programs.
UTMB shall check references and verify education and certification
credentials of all new employees prior to employment.
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XIII. Revisions to Compliance
Plan
This compliance plan is intended to be flexible and
readily adaptable to changes in regulatory requirements. The ICC shall
review the plan at least annually to assure that it remains current
and effective. Changes to the plan may be proposed by members of the
ICC, departments, or individual employees. Any recommendations for
changes to the plan must be approved by the ICC. All changes to the
compliance plan must be consistent with the Institutional Handbook
of Operating Procedures and the Rules and Regulations of the Board
of Regents of the University of Texas System.
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