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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 [i] .
B. The Medicare and Medicaid Patient Protection Act of 1987, as amended, 42 U.S.C. §1320a-7b (the "Antikickback Statute") [ii] ,
C. Stark Law, 42 CFR §§ 411.350 – 411.389 [iii]

V. POLICY

A. Reporting Compliance and Ethics Concerns

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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

  1. Reporting and Investigating Retaliation Allegations:
    1. 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).
    2. 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.
    3. 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

B. Attachment 2, Hyperlinks

 

 

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

  1. 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
  2. Accident/Injury
  3. Alcohol and Drug Use; Alcohol on Campus
  4. 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
  5. 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
  6. Conflict of Interest violation of DHHS, FDA, NSF or other Federal Agency Regulations

  7. Critical information system being hacked or compromised (Oracle, PeopleSoft, Banner, e-mail)
    http://www.rowan.edu/som/ist/index.html

  8. Disability: Americans with Disabilities Act (staff-related)

  9. Disability: Americans with Disabilities Act (student-related)

  10. Discrimination

  11. Export Controls (Research)- www.rowan.edu/compliance, click research tab

  12. Fair Labor Standards Act and Overtime Provisions

  13. Fraud (Financial)

    • Internal Audit Department

  14. Harassment

  15. Student Sexual Misconduct and Harassment Policy- 

    http://www.rowan.edu/equity/documents/TITLEIXCOMPLAINTFORM_004.pdf
    http://www.rowan.edu/som/hr/documents/orientation.pdf

  16. Healthcare Compliance

  17. Human Subject Research Violations of DHHS/OHRP, FDA and other Federal Regulations pertaining to human subject research

  18. Improper accounting and costing on sponsored projects

  19. Improper document of or billing for healthcare goods or services

    • RowanSOM Office of Compliance and Corporate Integrity (856-566-6136)

  20. Laboratory Safety Violations

  21. Misconduct in Research including Falsification of Documents/Records

  22. Open Public Meetings Act –

  23. Open Public Records Act –

  24. Radiation Safety Violation of NRC or DCRA Regulations

  25. Records Management (e.g. document retention schedules, archiving documents)
    www.rowan.edu/compliance - Policies- Records Management

  26. 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/titleix

    • Patient Information - RowanSOM Chief Compliance & Privacy Officer (856-566-6136) or
      HOTLINE 1-855-431-9967, www.rowan.edu/compliance

    • Non-public personal information of any individual, including credit card information, social security numbers, driver’s license numbers, etc. – Compliance HOTLINE-1-855-431-9967.

  27. 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

  28. Research: Sponsored Project Billing and Reporting

  29. RowanSOM Biomedical and Health Sciences Compliance Issues
    • The RowanSOM Office of Compliance and Corporate Integrity- www.rowan.edu/compliance or call (856) 566-6136

  30. Sexual Harassment

  31. Student Billings

  32. Student Loan Abuses

  33. University Property: Loss or Theft

  34. Victim Assistance (and violence prevention)

    • In an emergency, dial 911.
    • Violence Prevention and Victim Assistance
  35. Violation of OSHA, HFPA, BOCA, NRC, and FDA regulations
  36. Violation of System Security
  37. Violations of EPA regulations and Hazardous material releases- http://www.state.nj.us/dep
    • Emergency call 911
  38. Worker's Compensation Laws
  39. 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.

Voluntary Complance Plan effective September 26, 2014.
The Medicare and Medicaid Patient Protection Act of 1987, as amended, 42 U.S.C. §1320a-7b (the "Anti-kickback Statute")
Stark Law, 42 CFR §§ 411.350 – 411.389


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