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Compliance Plan


The University maintains an “open door” policy with respect to information of suspected violations of compliance. To achieve the goals of this Plan,, employees are required to report any activity which they believe is in violation of this plan or any legal requirements to one or more of the following persons: the Unit Compliance Officer, the Chief Compliance Officer, the Dean of each School, the President of each Clinical Unit, a department’s physician or administrator responsible for compliance, and/or the UMNDJ General Counsel. Failure to report knowledge of wrongdoing may itself result in disciplinary action. Any manager or supervisor receiving a report of possible misconduct must immediately advise the Unit Compliance Officer.

The Chief Compliance Officer will publicize the Ethics Helpline that may be used to report compliance issues or possible violations.

The Ethics Helpline is maintained by the UMDNJ Office of Ethics, Compliance and Corporate Integrity. To the extent possible, calls to the “helpline” will remain confidential and anonymous as required by policy # 00-01015-55:00 “Reporting Compliance and Ethics Concerns”. The “helpline” will be operated in a manner designed to encourage complete disclosure by the callerof information such as a particular description of the activity in question, the department in which it has taken place, and the identity of the people who may have knowledge of the relevant facts. A record will be maintained of any reports. Each complaint will be investigated. After a review and investigation, which may include assistance from the University Investigations Group,, the Office of Ethics, Compliance and Corporate Integrity prepares a written report of findings and, after consultation with the Dean of the School or the President of a Clinical Unit, the Unit then proceeds with any corrective action that is required, in accordance with the “Policy on Reporting Compliance and Ethics Concerns.”

In accordance with this policy, the University will not tolerate retaliation against any individual who reports actual or suspected violations of the laws, regulations, or policies. All reported violations will be handled with the utmost integrity and confidentiality to keep the identity (if and when known) of the reporting individual,, and the identity of the person or persons involved in the suspected violation is only given to those persons with an absolute need to know.

Whenever a compliance issue has been identified, the Unit Compliance Officer shall obtain advice and guidance, as needed, from the UMDNJ Office of the General Counsel and the Chief Compliance Officer. There may also be consultation with the Dean, the President of a Clinical Unit, appropriate department chairpersons and appropriate clinical, research and billing personnel. The Chief Compliance Officer, in collaboration with the appropriate senior leadership of the Unit, shall make any necessary reports to the President and to the UMDNJ Board of Trustees through the Audit Committee.

Corrective action plans shall be designed to ensure not only that the specific issue is addressed, but also that similar problems do not occur in other areas or departments.


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