ROWAN UNIVERSITY POLICY
Title: Reporting Compliance & Ethics Concerns
Subject: Office of Compliance & Corporate Integrity (OCCI)
Policy No: OCCI: 2013: C01
Applies: RowanSOM
Issuing Authority: President
Responsible Authority: RowanSOM Dean, RowanSOM Chief Compliance & Privacy Officer
Adopted: 1/16/2007
Reviewed: 3/15/2011
Amended: 7/1/2013
I. PURPOSE
The Rowan School of Osteopathic Medicine (RowanSOM) departments and units that bill federal or state programs for the provision of healthcare-related goods and services (“Related Healthcare Entity or “Related Healthcare Entities”) are committed to the highest possible standards of ethical business conduct and to the proposition that, not only that employees have a responsibility and an affirmative duty to report actual or suspected wrongful conduct, but also that they should be able to do so without fear of reprisal. Such reports shall be accepted willingly, kept confidential to the extent possible in conformance with applicable laws, regulations and other procedures, and addressed promptly and appropriately. All employees and faculty of the Related Healthcare Entities are responsible to ensure that their activities on behalf of the Related Healthcare Entity, and those of their colleagues, comply with all applicable federal and state laws, Rowan University policies and RowanSOM policies.
II. ACCOUNTABILITY
This policy applies to and should be read by all employees, contractors or agents of the schools, departments and units that are a part of RowanSOM units and departments that bill federal or state programs for healthcare-related goods or services (“Related Healthcare Entity” or “Related Healthcare Entities”) as to their duty to report suspected wrongdoing, the methods they may use to meet their reporting requirements and the protections in place for individuals who may reports of suspected wrongdoing in good faith. Other employees of RowanSOM departments that support the Related Healthcare Entities in their operations, including but not limited to Rowan University Procurement Services, The Office of General Counsel and RowanSOM University Finance should also read this policy.
III. APPLICABILITY
This policy is intended for all faculty members, employees, students and independent contractors of RowanSOM departments and units that bill federal or state programs for the provision of healthcare-related goods and services (“Related Healthcare Entity” or “Related Healthcare Entities”). These faculty members, employees, students and independent contractors have a duty to report suspected wrongful conduct and that they should be able to meet this duty without the fear of reprisal.
IV. REFERENCES
A. Voluntary Compliance Plan effective September 26, 2014
B. The Medicare and Medicaid Patient Protection Act of 1987, as amended, 42 U.S.C. §1320a-7b (the "Antikickback Statute")
C. Stark Law, 42 CFR §§ 411.350 – 411.389
V. POLICY
A. Reporting Compliance and Ethics Concerns
- The schools, departments and units that are a part of RowanSOM departments and units that bill federal or state programs for the provision of healthcare-related goods or services (“Related Healthcare Entity” or “Related Healthcare Entities”) have established, and shall continue to maintain, effective and confidential means for individuals to report allegations or concerns that include actual or suspected violations of law, violations of Rowan University or RowanSOM policies or procedures, or any other type of wrongful conduct. Individuals will be permitted to make such reports anonymously if they so desire, and their anonymity will be protected to the extent possible and as permitted by law.
- To make a report, individuals may contact their direct manager or other members of their management team. In addition, individuals may call the RowanSOM Office of Compliance and Corporate Integrity at 856-566-6136, Rowan SOM Chief Compliance & Privacy Officer, General Counsel; Ethics Liaison Officers; or they may call the RowanSOM Compliance Hotline 1 855-431-9967.
- The RowanSOM Compliance Hotline is available 24 hours a day/7days a week, via a toll free phone number, 1 855-431-9967. The RowanSOM Compliance Hotline accommodates 150 languages and includes special handling for challenged callers.
- RowanSOM policy prohibits retaliation, harassment, intimidation or discrimination against individuals who make reports of suspected wrongdoing in good faith. Any employee found to have retaliated against another employee who reported actual or suspected wrongful conduct shall be subject to appropriate disciplinary action up to and including termination. The making of false, frivolous, or bad faith reports by an employee is contrary to the intent and spirit of this policy, and may subject the reporter to disciplinary action.
- To make reports of immediate threats or danger, call 911.The RowanSOM Compliance Hotline should not be used for emergencies. There are other reporting methods for concerns which are summarized in attachment A.
B. Retaliation
- Reporting and Investigating Retaliation Allegations:
- Reporting: Anyone who has provided information who believes he or she is the subject of retaliation should report the facts supporting the allegations of retaliation to the Chief Compliance & Privacy Officer; General Counsel or Ethics Liaison Officers (ELO).
- All investigations of alleged retaliation will be conducted as sensitively and expeditiously as possible. Due consideration will be given to existing grievance procedures under applicable collective bargaining agreements.
- Should an investigation lead the appropriate RowanSOM authority to conclude that retaliation has been substantiated; the individual(s) responsible for committing the retaliation, in addition to any civil or criminal proceedings, shall be subject to disciplinary action up to and including termination.
C. Sanctions
Failure to comply with this policy may result in sanctions up to, and including, termination of employment or termination of a contractor’s agreement.
VI. ATTACHMENTS
A. Attachment 1, Where to Go For Support/Direction and How to Report an Issue
By Direction of the President:
Signature on file
RowanSOM Chief Compliance & Privacy Officer
ATTACHMENT 1
WHERE TO GO FOR SUPPORT/DIRECTION AND HOW TO REPORT AN ISSUE BY TYPE OF ISSUE
- Abuse/neglect of minors
- Anyone who suspects that a minor has been subject to abuse or neglect must immediately notify the RowanSOM Police Department (RUPD) at 856-757-7777.
- New Jersey law (NJSA 9:6-8.10) requires all persons who have reasonable cause to believe that a minor has been subject to abuse or neglect to report it to the New Jersey Division of Child Protection and Permanency, formerly the Division of Youth and Family Services (DYFS) at 1-877-NJABUSE (1-877-652- 2873).
- Website Page – www.rowan.edu/compliance
- Protection of Minors Policy - http://catalog.proemags.com/publication/cc2384ea#/cc2384ea/94
- Accident/Injury
- In an Emergency, call 911
- Job-related injury reporting- http://www.rowan.edu/hr/pension/workerscomp.html
- Injury Reporting Form for Student or the Public - http://www.rowan.edu/open/studentaffairs2/healthcenter/confidentiality.html
- Alcohol and Drug Use; Alcohol on Campus
- The resources available to employees and supervisors relating to alcohol and drug use/abuse may be accessed in RowanSOM Policy- http://www.rowan.edu/studentaffairs/main_office/files/aodguide.pdf
- Employees are encouraged to seek assistance through the Faculty and Staff Assistance Program if they believe they may have an alcohol or other drug abuse problem- http://www.rowan.edu/studentaffairs/main_office/files/aodguide.pdf
http://www.rowan.edu/som/hr/documents/orientation.pdf - Animal Research Violations of NIH, USDA, AAALAC Regulations- http://www.rowan.edu/open/provost/research
http://srintra.rowan.edu/viv/links.cfm - animal welfare regulations- The Office of Research and Sponsored Programs provides information relating to the use of animal in research. To contact the Office of Research and Sponsored Programs staff, please follow this link:
http://www.rowan.edu/provost/research/Integrity_and_compliance/Integrity_and_compliance.cfm
- The Office of Research and Sponsored Programs provides information relating to the use of animal in research. To contact the Office of Research and Sponsored Programs staff, please follow this link:
- Conflict of Interest violation of DHHS, FDA, NSF or other Federal Agency Regulations
- Contact the Office of the Vice President of Research and Economic Development.
http://www.rowan.edu/open/provost/research/Integrity_and_compliance/Integrity_and_compliance.cfm
http://www.rowan.edu/som/research/admin.html
- Contact the Office of the Vice President of Research and Economic Development.
Critical information system being hacked or compromised (Oracle, PeopleSoft, Banner, e-mail)
http://www.rowan.edu/som/ist/index.html- Disability: Americans with Disabilities Act (faculty-related)- http://www.rowan.edu/som/about/docs/ADANoticeRowan.pdf
- Academic Labor Relations- contact Robert Zazzali @ 856-256-4110 or zazzali@rowan.edu
Disability: Americans with Disabilities Act (staff-related)
Disability: Americans with Disabilities Act (student-related)
- Office of Disability Services for Students - http://www.rowan.edu/studentaffairs/asc
- The Office of Student Affairs Compliance - http://www.rowan.edu/som/education/student_affairs/index.html
Discrimination
- Policy Prohibiting Discrimination and Harassment-
http://www.rowan.edu/hr/affirm/pdfs/StatePolicy2007.pdf
http://www.rowan.edu/som/hr/documents/orientation.pdf - Office of Employment Equity - http://www.rowan.edu/equity
- Code of Student Conduct- http://www.rowan.edu/som/education/student_affairs/documents/SOMStudentHonorCode-Final.pdf
- Office of Student - handles complaints against students arising out of their conduct as students - http://www.rowan.edu/som/education/student_affairs/documents/SOMStudentHonorCode-Final.pdf
- Policy Prohibiting Discrimination and Harassment-
Export Controls (Research)- www.rowan.edu/compliance, click research tab
- RowanSOM Export Control Officer - http://www.rowan.edu/som/research/admin.html
- The Office of the Vice President of Research and Economic Development Export Control Guidelines - http://www.rowan.edu/som/research/admin.html
Fair Labor Standards Act and Overtime Provisions
- UHR Policies and Resources - http://www.rowan.edu/som/hr/documents/orientation.pdf
- Office of Labor Relations - contact Robert Zazzali @ 856-256-4110 or zazzali@rowan.edu
- UHR Compensation - http://www.rowan.edu/som/hr/documents/orientation.pdf
Fraud (Financial)
- Internal Audit Department
Harassment
- Policy Prohibiting Discrimination and Harassment - http://www.rowan.edu/hr/affirm/pdfs/StatePolicy2007.pdf
- Office of Employment Equity: http://www.rowan.edu/equity
- Harassment: A Guide for Faculty- http://www.rowan.edu/som/hr/documents/orientation.pdf
- Harassment: A Guide for Staff- http://www.rowan.edu/som/hr/documents
Student Sexual Misconduct and Harassment Policy-
http://www.rowan.edu/equity/documents/TITLEIXCOMPLAINTFORM_004.pdf
http://www.rowan.edu/som/hr/documents/orientation.pdf- Code of Student Conduct- http://www.rowan.edu/som/education/student_affairs/documents/SOMStudentHonorCode-Final.pdf
- Office of Student Conduct -handles complaints against students arising out of their conduct as students- http://www.rowan.edu/som/education/student_affairs/documents/SOMStudentHonorCode-Final.pdf
Healthcare Compliance
- The RowanSOM Office of Compliance and Corporate Integrity- www.rowan.edu/compliance or call 856-566-6136
Human Subject Research Violations of DHHS/OHRP, FDA and other Federal Regulations pertaining to human subject research
- The Office of the Vice President of Research and Economic Development IRB and Compliance Administrator - http://www.rowan.edu/som/research/admin.html
Improper accounting and costing on sponsored projects
- Division of Grant and Contract Accounting- http://www.rowan.edu/som/research/admin.html
- Internal Audit Department
Improper document of or billing for healthcare goods or services
- RowanSOM Office of Compliance and Corporate Integrity (856-566-6136)
Laboratory Safety Violations
- RowanSOM Environment Health and Safety http://www.rowan.edu/adminfinance/facilities/ehs/TrainingResourcesforSupervisors.php
Misconduct in Research including Falsification of Documents/Records
- University Policy for Dealing with Allegations of Misconduct in Research – http://www.rowan.edu/compliance, click research tab
Open Public Meetings Act –
- Office of the Secretary of the University – http://www.rowan.edu/president/board/tentativeagenda.html
Open Public Records Act –
- Office of the Secretary of the University – http://www.rowan.edu/president/board/tentativeagenda.html
Radiation Safety Violation of NRC or DCRA Regulations
- Laboratory Safety and Environmental Programs Radiation Safety Group - http://srintra.rowan.edu/RadSafety.cfm
Records Management (e.g. document retention schedules, archiving documents)
www.rowan.edu/compliance - Policies- Records Management- Division of Administration and Public Safety- http://www.rowan.edu/safety
Records: Loss of records; inability to find records; improper release, disclosure or access to records
http://www.rowan.edu/adminfinance/records
http://www.rowan.edu/som/hr/documents/orientation.pdf- Depending on the type of records, you may contact the following offices:
- RowanSOM Business or Financial Information: Office of the Secretary of the University, Custodian of Records
Student Information: The Office of Student Affairs Compliance - http://www.rowan.edu/som/education/student_affairs/contact.html
http://www.rowan.edu/equity/titleixPatient Information - RowanSOM Chief Compliance & Privacy Officer (856-566-6136) or
HOTLINE 1-855-431-9967, www.rowan.edu/complianceNon-public personal information of any individual, including credit card information, social security numbers, driver’s license numbers, etc. – Compliance HOTLINE-1-855-431-9967.
Director of Information Protection and Security or go to the Information Protection and Security website Research Compliance- http://www.rowan.edu/som/ist/index.html
- Office of the Vice President of Research and Economic Development Director of Regulatory Affairs -
http://www.rowan.edu/som/research/admin.html
- Office of the Vice President of Research and Economic Development Director of Regulatory Affairs -
Research: Sponsored Project Billing and Reporting
- Division of Grant and Contract Accounting- http://www.rowan.edu/som/research/admin.html
- Internal Audit Department
RowanSOM Biomedical and Health Sciences Compliance Issues
• The RowanSOM Office of Compliance and Corporate Integrity- www.rowan.edu/compliance or call (856) 566-6136Sexual Harassment
- Policy Prohibiting Discrimination and Harassment - http://www.rowan.edu/equity, or http://www.rowan.edu/som/hr/documents/orientation.pdf
- Office of Employment Equity: http://www.rowan.edu/equity
- Harassment: A Guide for Faculty- http://www.rowan.edu/som/hr/documents/orientation.pdf
- Harassment: A Guide for Staff- http://www.rowan.edu/som/hr/documents/orientation.pdf
- Harassment: A Guide for Students- http://www.rowan.edu/equity/documents/StudentSexualPolicy7-25-12_002.pdf
- Code of Student Conduct (also see school-specific Codes of Student Conduct on the school’s website) http://www.rowan.edu/som/education/student_affairs/documents/SOMStudentHonorCode-Final.pdf
- Office of Student Conduct handles complaints against students arising out of their conduct as students- http://www.rowan.edu/som/education/student_affairs/documents/SOMStudentHonorCode-Final.pdf
Student Billings
- RowanSOM Office of Student Accounting, Billing and Cashiering - http://www.rowan.edu/adminfinance/policies_procedures/chap07/BURSAR%20Chapter%207%20OCT%2007%20%282%29.032808.pdf
http://www.rowan.edu/som/education/student_affairs/index.html
- RowanSOM Office of Student Accounting, Billing and Cashiering - http://www.rowan.edu/adminfinance/policies_procedures/chap07/BURSAR%20Chapter%207%20OCT%2007%20%282%29.032808.pdf
Student Loan Abuses
- RowanSOM Office of Financial Aid- http://www.rowan.edu/som/financialaid/Apply_JUMP.htm
University Property: Loss or Theft
- If the loss or theft involves the loss of records or information, see Records (link to the Records, Loss of Records below.)- http://www.rowan.edu/safety/lostandfound/index.php
Victim Assistance (and violence prevention)
- In an emergency, dial 911.
- Violence Prevention and Victim Assistance
- Violation of OSHA, HFPA, BOCA, NRC, and FDA regulations
- RowanSOM Environment Health and Safety- http://www.state.nj.us/dep
http://srintra.rowan.edu/RadSafety.cfm
- RowanSOM Environment Health and Safety- http://www.state.nj.us/dep
- Violation of System Security
- Director of Information Protection and Security or go to the Information Protection and Security website (http://www.rowan.edu/som/ist/index.html
- Violations of EPA regulations and Hazardous material releases- http://www.state.nj.us/dep
- Emergency call 911
- Worker's Compensation Laws
- New Jersey Department of Labor- http://lwd.state.nj.us/labor/index.html
- Workplace Violence- http://lwd.state.nj.us/labor/index.html
- In an emergency, or if you experience or witness imminent or actual violence involving weapons or potential injuries, call 911.
- Any person who is the subject of, or witness to, a suspected violation of this policy should report the incident to his or her supervisor or, in lieu thereof, to the appropriate Designated University Representative listed below:
- RowanSOM Workplace Violence Policy - http://www.rowan.edu/som/hr/documents/orientation.pdf
All regulations and procedures are subject to amendment.