The UTMB
Compliance Program Structure
The UTMB Compliance Program is intended to demonstrate in the
clearest possible terms the absolute commitment of UTMB to the
highest standards of ethics and compliance with all applicable
laws, policies, rules, and regulations. An Institutional Compliance
Committee representing all major compliance areas provides program
direction. Mr. E. J. Pederson, Executive Vice President, is the
UTMB Institutional Compliance Officer. He is responsible for the
execution of the program and for ensuring that the institution
has a risk-based process that (1) builds compliance consciousness
into daily operations, (2) monitors the effectiveness of compliance
activities, and (3) communicates instances of noncompliance to
appropriate administrators for corrective action.
The principal functions of the UTMB Institutional Compliance
Program are as follows:
- To perform a risk assessment of UTMB's compliance issues.
- To monitor the implementation of UTMB's compliance plan.
- To provide education and training regarding the compliance
program and applicable laws and regulations that affect UTMB.
- To communicate instances of noncompliance to the UTMB Institutional
Compliance Officer and Institutional Compliance Committee.
- To follow-up on compliance findings to ensure that appropriate
corrective action has been taken.
- To continuously assess the effectiveness of compliance activities,
including the effectiveness of the committee itself
Compliance Issues
UTMB is committed to providing a hotline as an anonymous way
for employees to report suspected wrongdoing, including waste,
fraud and abuse, and violations of federal and state laws. The
UTMB Fraud and Abuse Hotline is 1 (800) 898-7679. Compliance issues
should be addressed through normal administrative channels. If
you feel you are unable to address the issue through normal administrative
channels you may call the hotline. Calls to the hotline should
be made in good faith and report misconduct rather than employee
dissatisfaction. The hotline is available 24 hours a day to every
employee from any telephone. If you call the hotline, you may
remain completely anonymous, your conversation is never recorded,
and the telephone number that you are calling from is not identified.
It is UTMB policy that you will not be fired or in any other way
retaliated against for reporting information to the hotline in
good faith.
The UTMB Fraud and Abuse Hotline
1 (800) 898-7679
UTMB is committed to investigating all reports promptly. Confidentiality
and anonymity are protected to the extent allowed by law. Results
of the investigation are reported to the Institutional Compliance
Officer and corrective action plans are implemented as soon as
possible.
Education and Training
As an institution of higher education, UTMB is committed to effectively
communicating our standards and procedures to all employees by
providing education and training to develop compliance awareness
and commitment. All administration, faculty, medical staff, employees,
and students must attend both general and specific compliance
training applicable to their job functions at UTMB.
Disciplinary Action for Violation
of the UTMB Standards of Conduct Guide
Any employee who violates the UTMB Standards of Conduct Guide
is subject to disciplinary action. The specific discipline administered
will depend on the nature and severity of the violation, as well
as the consequences to the institution of individual violations.
Disciplinary action may include any of the following actions:
- verbal warning,
- written warning,
- fines,
- suspension, or
- termination.
Actions that constitute an intentional violation or reckless
disregard of criminal, civil, or administrative law may result
in disciplinary action and possible criminal prosecution by the
appropriate state and/or federal agencies. Penalties upon conviction
may include fines and imprisonment.
Compliance Monitoring
UTMB is committed to thorough monitoring of compliance, implementation
of the Institutional Compliance Program, and compliance with the
applicable laws and regulations. The UTMB Compliance Program is
responsible for compliance monitoring activities. The compliance
program may utilize expertise of UTMB staff for auditing as well
as external auditing firms.
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never will come a time when we will have no longer anything more
to learn of Nature, in health or in disease, and just here is
one of the greatest attractions of our profession.'"