Management Manual

Table of Contents

RESOLUTION OF THE BOARD OF REGENTS

MANAGEMENT MANUAL

I. HISTORY OF COMPLIANCE PROGRAMS

II. PURPOSE

III. SCOPE AND RESPONSIBLE PARTIES

A. University Personnel

B. Affiliated Individuals and Entities

C. Vendors

D. Management Team

E. Corporate Compliance Officer

F. Corporate Compliance Committee

G. UC Executive Leadership

H. Annual Report

IV. COMMUNICATING QUESTIONS AND CONCERNS

V. CAMPUS COMPLIANCE OFFICIALS AND PHONE NUMBERS

VI. REPORTING POTENTIAL ERRORS OR SUSPECTED VIOLATIONS

VII. COORDINATION WITH ESTABLISHED POLICIES AND PROCEDURES FOR INVESTIGATIONS AND AUDITS UNDER CURRENT UNIVERSITY POLICY G-29

VIII. INTERNAL CONTROLS, AUDITS AND MONITORING

IX. REMEDIAL ACTIONS

X. CORRECTIVE OR DISCIPLINARY ACTIONS

XI COORDINATION OF CORRECTIVE AND DISCIPLINARY ACTIONS WITH EXISTING UNIVERSITY POLICY

XII. EXCLUSION OF INDIVIDUALS AND ENTITIES FROM PARTICIPATION IN MEDICARE, MEDICAID, AND OTHER STATE HEALTH PROGRAMS

XIII. RESPONSE TO GOVERNMENT INVESTIGATIONS

A. Types of Government Agencies that may Investigate Health Care Providers

B. Procedures

C. Interviews

D. Searches

E. Administrative Issues

F. Media Contacts

APPENDICES

Appendix A: Standards of Business Conduct (Code of Conduct Handbook)

Appendix B: Standard Vendor Agreement for Professional Services

Appendix C: Associated Compliance Documents, Policies, and Web Sites

Appendix D: Principles of Community

RESOLUTION OF THE UNIVERSITY OF CALIFORNIA BOARD OF REGENTS

As a leading provider of clinical services, education, and research, the University of California (University) Academic Health Centers should meet high standards for ethical and legal conduct. The University’s reputation for quality, integrity, respect, and honesty in all activities have been the foundation for its success, and the University’s future depends on maintaining and demonstrating a conscious dedication to the values, ethical and legal principles of the University’s Health Sciences Clinical Enterprise Corporate Compliance Program (Program). This Program deals with conduct specific to the health sciences clinical enterprise. It recognizes the increasingly complex and rapidly changing dynamic of today’s health care environment and the need to support the University’s employees in their commitment to ethical and legal conduct in all matters pertaining to the activities of the clinical enterprise. The University’s officers, directors, and individual employees should not take actions which undermine the University’s tripartite mission and values or violate legal requirements.

It is unrealistic for any single employee to know every rule and regulation that exists for the clinical enterprise; however, each University employee should know the policies, laws, and procedures that apply to his or her job. This Program is just one of a number of resources available to us. While the Program does not answer every question or concern, it provides general standards of conduct that guide employees in discerning the appropriate and correct action to take. It is important that every employee, regardless of position, follow the basic principles outlined in the University’s Program and each academic health center’s specific Health Sciences Clinical Enterprise Corporate Compliance Program.

All employees of the University of California’s Health Sciences Clinical Enterprise have an obligation to act in a way that merits the trust, confidence, and respect of the public and other health care professionals. The Regents encourage all employees to engage in open discussion with peers and managers regarding the principles of the Program. Such open discussion is particularly called for when questions or concerns arise regarding specific issues as to what is the appropriate and legal standard. The University will not tolerate retaliation against any employee who, in good faith, reports an ethical or legal concern or raises questions regarding the appropriate behavior.

The Board of Regents of the University of California recognizes and appreciates the significant efforts of the members of the University-wide Clinical Enterprise Corporate Compliance Committee in working with campus leadership and staff in developing this Program. The Regents congratulate all employees of the clinical enterprise for their demonstrated commitment to quality and ethical behavior and support their ongoing efforts to enhance and maintain the University’s meritorious reputation for preeminence in care, education, and research.

UNIVERSITY OF CALIFORNIA, SAN DIEGO
HEALTH SCIENCES
CORPORATE COMPLIANCE PROGRAM
MANAGEMENT MANUAL

I. HISTORY OF COMPLIANCE PROGRAMS

Fraud and Abuse in the Defense Industry

While compliance programs are a relatively new development in the health care industry, they have been common in the defense and financial services industries for many years. Compliance programs were originally imposed by the government on corporations that had defrauded the government. Requiring all companies in the defense industry to initiate compliance programs was a logical requirement because the massive expenditures by the federal government creates a high potential for fraud and abuse. Since the government believes compliance programs are effective in reducing fraud and abuse in the defense industry, it is not surprising that the same rationale is spreading to other industries that receive large amounts of federal funding.

Fraud, Abuse and Compliance in the Health Care Industry

Over the past several years there has been an enormous increase in federal enforcement of criminal and civil fraud statues against health care organizations. Academic medical enterprises have come under recent scrutiny with repayment settlements in excess of $20 million announced by several major universities. The University of California (University) is committed to providing quality health care services, health professional training, and biomedical and behavioral research in compliance with all laws and regulations. Over the years, the University’s health sciences clinical enterprise has implemented a number of policies and procedures to provide guidance regarding federal and state laws. However, only in very recent years has the federal government required hospitals and academic medical centers to implement compliance programs in order to reduce fraud and abuse in today’s complex and highly regulated health care environment. In 1998 the Department of Health and Human Services and the Office of the Inspector General issued the Compliance Program Guidance for Hospitals and strongly encouraged all corporations in the health care industry to implement effective corporate compliance programs.

Effect of the Federal Sentencing Guidelines

The Federal Sentencing Guidelines, adopted in 1991, created another reason for corporations in all industries to adopt and implement effective compliance programs. Prior to 1991, federal judges had wide discretion when sentencing convicted felons. The Guidelines were adopted to limit the variability in sentencing imposed on individuals and organizations found guilty of federal criminal violations (such as Medicare false claims). The Guidelines also provide incentives for organizations to adopt programs designed to eliminate violations of federal law. Corporations and their agents receive lesser sentences and fines if their corporations had implemented effective compliance programs. (In fact, if the programs are truly effective, violations should not occur.) Even if the program was implemented after the violation, most federal prosecutors and judges will look favorably on an organization that has implemented an effective program.¹

Elements of an Effective Compliance Program

The Guidelines indicate that an effective compliance program is one that has been reasonably designed, implemented and enforced so as to be effective in preventing and detecting criminal conduct. This does not mean that the program must be foolproof. Rather, it means that we must be able to show efforts to prevent and detect wrongdoing. According to the Guidelines, an effective program must, at the very least, meet the following standards:

Compliance Standards and Procedures.
The organization must have established compliance standards and procedures to be followed by its employees and other agents that are reasonably capable of reducing the prospect of criminal conduct.

Oversight Responsibilities.
Specific individual(s) within high levels of the organization must have been assigned overall responsibility to oversee compliance with such standards and procedures.

Exercise of Diligence.
The organization must have used due care not to delegate substantial discretionary authority to individuals whom the organization knew or should have known, through the exercise of due diligence, had a propensity to engage in illegal activities.

Employee Training.
The organization must have taken steps to communicate effectively its standards and procedures to all employees and other agents, e.g., by requiring participation in training programs or by disseminating publications that explain in a practical manner what is required.

Monitoring and Auditing.
The organization must have taken reasonable steps to ensure compliance with its standards, e.g., by utilizing monitoring and auditing systems reasonably designed to detect criminal conduct by its employees and other agents, and by having in place and publicizing a reporting system whereby employees and other agents could report criminal conduct by others within the organization without fear of retribution.

Enforcement and Discipline.
The standards must have been consistently enforced through appropriate disciplinary mechanisms, including, as appropriate, discipline of individuals responsible for the failure to detect an offense. Adequate discipline of individuals responsible for an offense is a necessary component of enforcement; however, the form of discipline will be case-specific.

Response and Prevention.
After an offense has been detected, the organization must have taken all reasonable steps to respond appropriately to the offense and to prevent further similar offenses – including any necessary modifications to its programs to prevent and detect violations of the law.

¹ The fines for criminal conduct, not to mention the effects of possible exclusion from the Medicare program, can be significant. The Federal False Claims Act provides for a civil penalty of between $5,000 to $10,000 per claim, plus treble damages. The Guidelines provide for significantly higher fines depending on the "culpability" of the organization. " Culpability" in turn hinges on the extent to which the organization actively or passively (through tolerance or a failure to reasonably investigate) condoned the "criminal" activity (filing a false claim can be viewed as "criminal").

Medicare Conditions of Participation Regarding Patient Rights

On August 2, 1999 the Health Care Financing Administration finalized regulations introducing a new Patients Rights section to the Conditions of Participation. The rule sets forth six standards intended to protect each patient’s physical and emotional health and safety:

• The right of each patient to be notified of his/her rights, in advance of furnishing or discontinuing care.
• The right to participate in the development and implementation of his/her plan of care.
• The right to personal privacy, to receive care in a safe setting and to be free from all forms of abuse or harassment.
• The right to confidentiality of clinical records and to access information contained in the records.
• The right to be free from restraints used in the provision of acute medical and surgical care unless clinically necessary.
• The right to be free from seclusion or restraints used in behavior management, unless clinically necessary.

II. PURPOSE OF THE UCSD HEALTH SCIENCES CORPORATE COMPLIANCE PROGRAM UCSD

UCSD Health Sciences Corporate Compliance Program (the Program) is based on a University of California Compliance Program and seeks to:

• Maintain and enhance quality of care;
• Demonstrate sincere, ongoing efforts to comply with all applicable laws;
• Revise and clarify policies and procedures to enhance compliance;
• Enhance communications with governmental entities with respect to compliance activities;
• Empower all responsible parties to prevent, detect, respond to, report and resolve conduct that does not conform with applicable laws, regulations and the University of California Code of Conduct and the UCSD Program, and;
• Establish mechanisms for employees to raise questions and concerns about compliance issues and ensure those concerns are appropriately addressed.

A copy of the full description of the Program is available in the business office of every department, in the UCSD Health Sciences Corporate Compliance Office, the UC Office of the General Counsel and the UC Office of Clinical Services Development in the University Office of the President. In addition, other compliance documents, such as the Professional Fee Billing Guidelines, Clinical Laboratory Compliance Guidelines, and Health Plan Compliance Guidelines are available through the compliance office.

III. UCSD HEALTH SCIENCES CORPORATE COMPLIANCE PROGRAM SCOPE AND RESPONSIBLE PARTIES

The Program applies to all University Health Sciences Personnel. The University expects that all outside entities doing business with the clinical enterprise are operating under an appropriate compliance program and are aware that University personnel are expected to comply with the University's Program.

A. University Personnel

University personnel covered by this program include all administrators, directors, managers, faculty, physicians, graduate health professions students and other health care professionals and staff in the University’s health sciences programs who are responsible for:

• The direct provision of patient clinical care services; or
• The provision of clinical support services including staff, business, administrative, or patient care support services.

All personnel are required to follow all University of California and UCSD policies and the Program, as well as any other relevant policies of UCSD Health Sciences and their departments, divisions, or programs. All personnel of UCSD Health Sciences should conduct themselves in a manner that at all times demonstrates a sincere and conscious effort to comply with promulgated state and federal standards and by so doing, carry out the University's mission of quality care, state-of-the-art health sciences education, and leading edge research. The individual must take responsibility for ensuring that he/she is knowledgeable about and capable of carrying out all compliance policies and procedures relevant to their job description and area of responsibility and for complying with all standards established by the UCSD Program. Personnel should insist that effective education and training are made available to them.

The standards of conduct expected of all personnel are defined by the UCSD Health Sciences’ Corporate Compliance Program "Code of Conduct" which has been incorporated into this Program. This document addresses the areas considered to be at high risk for error or abuse. The Program requires that this Code of Conduct be distributed to and comprehensible by all employees and regularly updated as state and federal standards are changed. (See Appendix A: Standards of Business Conduct).

B. Affiliated Individuals and Entities

The Program provides that all outside entities doing business with the Clinical Enterprise through a contractual agreement are aware that all UCSD personnel are expected to comply with the UCSD Program when working in an outside facility. In addition, if the affiliated institution has a compliance program and UCSD personnel have received a copy of the compliance program, UCSD personnel should also adhere to the respective affiliate's compliance program. UCSD affiliation agreements should contain language that informs affiliated entities and individuals about the Program and the expectation of UCSD that all parties to an affiliation agreement will comply with applicable ethical and legal standards.

In the case of entities doing business at either University-owned or leased facilities, the UCSD personnel who are responsible for negotiating and managing affiliation agreements and provider contracts must inform those entities and individuals about the University's Program.

As of June 1, 1999, UCSD affiliation agreements will contain language that informs affiliated entities and individuals about the UCSD Program and the expectation that all parties to an affiliation agreement will comply with applicable ethical and legal standards. (See Appendix B: Standard Billing Vendor Agreement).

C. Vendors Providing Goods or Services to the University

In the case of an outside entity doing business with UCSD though a contractual agreement, UCSD personnel who negotiate and/or manage the contract shall inform the vendor of the Program.

D. Management Team

The Chancellor has overall responsibility for compliance activities, appoints the Corporate Compliance Officer (CCO) and approves all appointees to the UCSD Compliance Committee. The Corporate Compliance Officer should provide the Chancellor with an annual report describing the status of the UCSD Compliance Program for review and approval prior to submission of the report to the Office of the President and the Privilege and Tenure Committee of the Academic Senate. The CCO will be responsible for regularly updating the UCSD Health Sciences management team, to include the Health Sciences Vice Chancellor, School of Medicine Deans, Chief Financial Officer (CFO), Corporate Compliance Officer, and Senior Medical Directors to ensure that: procedures are maintained, reviewed, and updated; systems are in place to respond to employee questions and concerns; action is taken on recommendations to prevent and reduce errors; and, when necessary, appropriate remedial, corrective and disciplinary action are taken. Management is responsible for ensuring that appropriate education and training are available.

Administrators are expected to demonstrate through their professional behavior the highest ethical standards of job performance. Compliance with the Program must be part of the job performance evaluation of managers, supervisors and employees.

UCSD management and administration will cooperate and collaborate with the CCO, as well as the Compliance Committee established according to the Corporate Compliance Program, in the development, implementation, and monitoring of the specific policies and procedures of the Program.

E. Corporate Compliance Officer (CCO)

The UCSD Chancellor shall designate a single individual to serve as the Health Sciences Corporate Compliance Officer and specify that individual's title and job description. The UCSD Health Sciences CFO shall not serve as CCO. The CCO shall report to the highest level of the clinical enterprise and have direct access to the clinical enterprise's governing body. The CCO shall be a senior executive with the background, status and time to carry out the responsibilities described here. The CCO should not have any actual or potential conflicts of interest. The CCO must have access to all documents and other information relevant to compliance activities and have sufficient staff and funding to carry out the following primary responsibilities:

1. Develop and maintain the Program and oversee and monitor its implementation. Ensure that policies and procedures are maintained, reviewed, and updated.
2. Report on a regular basis to UCSD Health Sciences senior executives, faculty, Group Practice governing body, and the Corporate Compliance Committee (Committee), the Office of the General Counsel and the Office of Clinical Services Development on the progress of implementation of the Program.
3. Periodically revise the Program in light of changes in the laws, policies, and procedures of government and private payer health plans, fraud and abuse alerts and other developments and/or needs of the clinical enterprise.
4. Facilitate education for all employees about compliance issues. Develop, coordinate, and participate in a multi-faceted educational and training program that focuses on the elements of the Program and seeks to ensure that all appropriate management, faculty and personnel are knowledgeable of and comply with pertinent federal and state standards. An Employee Handbook shall be published and periodically revised. It will be used in the training of all personnel.
5. Ensure that independent contractors, vendors, and others who furnish services to the health sciences clinical enterprise are aware of and operate according to standards at least as stringent as those in the Program
6. Coordinate personnel issues with the medical staff and, where necessary, other health sciences departments, to ensure that the National Practitioner Data Bank and Office of Inspector General (OIG) Cumulative Sanction Report have been checked with respect to all personnel, medical staff, and independent contractors who conduct business with the health sciences enterprise to include, but not be limited to, all vendors, labs, pharmacies and other providers.
7. Work with the financial management of the UCSD School of Medicine, Hospital, Group Practice and other elements of UCSD Healthcare to ensure that each financial unit coordinates with internal compliance reviews and follows monitoring activities, including annual or periodic reviews of departments.
8. Develop, implement, and maintain a well-publicized process through which personnel can raise questions and receive appropriate guidance concerning compliance. Respond to employee’s questions and concerns.
9. Investigate any compliance problems, and where necessary take remedial, corrective and disciplinary actions in accordance with University policy. Examine potential and/or actual areas of non-conformance and recommend, develop and ensure remedial or corrective action or sanctions designed to address areas of actual or potential noncompliance. Provide for controls and procedures to prevent and reduce errors and identify wrong-doing. The Program explains how moneys are refunded when necessary, fines paid and how needed remedial, corrective and disciplinary actions are taken.
10. Determine, in conjunction with University General Counsel, whether to commence an investigation and if so, develop an appropriate response in coordination with current University policies and procedures, including those of the UCSD Medical Center Medical Staff.
11. When necessary, take or recommend appropriate disciplinary actions, within the limits of other University policies, against individuals in appropriate circumstances.
12. Coordinate with UCSD senior management personnel who are responsible for regulatory compliance and other campus policies and procedures that affect and ensure health sciences corporate compliance, to minimize duplication of effort while ensuring adequacy of coverage. Such coordination may include, but not be limited to: Professional Fee Billing, Clinical Laboratory and other component compliance programs, Risk Management, Medical Staff Administrative Services, Medical Group Management, Faculty Council, Medical Staff Governance, Institutional Review Board (IRB), Audit and Management Advisory Services and Campus Controller.

F. UCSD Health Sciences Corporate Compliance Committee

The UCSD Health Sciences Vice Chancellor, in consultation with the Chancellor, shall establish a UCSD Corporate Compliance Committee (Committee) whose members may include the CCO, Compliance Manager, the IRB Director, Hospital CFO, Audit and Management Advisory Services Director, Campus Controller, Risk Manager, Director of Administrative Service Operations, Medical Director, Director of Nursing, selected School of Medicine faculty and Departmental Business Officers and others as deemed appropriate. The CCO shall serve as the Chair of the Committee. The Committee's functions shall include the following activities:

1. Support the CCO and Compliance Manager in the execution of his or her responsibilities;
2. Analyze the organization's health care compliance environment, the legal requirements with which it must comply, and specific risk areas;
3. Assess policies and procedures that address these areas for possible incorporation into the Program;
4. Work with appropriate departments to develop and then review control systems and standards of conduct to promote compliance;
5. Determine the appropriate strategy/approach to promote compliance with the Program;
6. Maintain systems to solicit, evaluate, and respond to complaints and problems; and
7. Participate in the investigation of Program violations, endorsing, when appropriate, that a violation has likely occurred.

G. University of California Executive Leadership

University leadership with overall delegated responsibility and authority for compliance activities, include the University of California President, UCSD Chancellor and Vice Chancellors, Vice Presidents of Clinical Services Development, Business and Finance, and Health Affairs, General Counsel and the University Auditor. These officers are responsible for ensuring that all members of the health sciences clinical enterprise carry out their individual and corporate responsibility to comply with all federal and state requirements and to provide periodic reports to The Regents on compliance with the Code and Programs. At UCSD Health Sciences, the Chancellor has overall responsibility for compliance activities.

H. Annual Report

On an annual basis the CCO will report on the status of the UCSD Compliance Program to the Vice Chancellor, Health Sciences, UCSD Chancellor, Academic Senate and to the Office of Clinical Services Development. A copy of this report will also be provided to the appropriate division Privilege and Tenure Committee for review. The Office of Clinical Services Development, in coordination with the University Auditor and General Counsel, will report annually to The Regents and the President on the monitoring of health sciences clinical enterprise corporate compliance activities. This annual report should summarize the status of all aspects of the program, including reporting on individuals excluded from participation in federal health care programs.

IV. COMMUNICATING QUESTIONS AND CONCERNS

The opportunity for UCSD personnel to ask questions and raise concerns is a cornerstone of a successful corporate compliance program. UCSD supports open discussion of ethical and legal questions regarding compliance issues. UCSD will not tolerate retaliation against any individual who, in good faith, raises questions or reports suspected violations.

The current health care environment is very complex, with many complicated regulations that dictate how the University must conduct its health care business. The purpose of a compliance program is to establish standards and policies that clearly communicate appropriate ethical and legal behavior. However, questions may arise. It is better for an individual to raise a question than to be concerned about the legality or ethics of his or her actions or those of a coworker. It is better to ask a question than to do something wrong.

When UCSD personnel have a question regarding what should be the legal or ethical action, a number of options are available, including the following:

1. Communicate with an immediate supervisor or manager
   The individual can discuss the issue with his or her supervisor, area manager, or team leader because these individuals should be the most familiar with the particular job requirements and business practices. The supervisor should provide a timely response to the individual or work with him or her to seek alternative solutions. Alternatively, UCSD Healthcare employees may complete a Quality Variance Report (QVR).
2. Talk with higher level management
   If an individual is not comfortable speaking with a direct supervisor or manager, he or she can contact a higher level manager in the department, the academic health center or campus.
3. Contact the UCSD Health Sciences Corporate Compliance Officer (CCO)
   At UCSD, the Chancellor has designated the CCO as the individual with lead responsibility for health science clinical enterprise compliance issues. The CCO reports directly to executive leadership (see Section III. E. Corporate Compliance Officer responsibilities). At any time, an individual can bring a question or concern to the CCO or staff within the Compliance Office. This would include situations where the individual believes that he or she has not received an appropriate, timely or ethical response from a supervisor.
4. Obtain help from other University resources
   University personnel can contact UCSD management in other administrative or academic departments, or the University of California - Office of the President. There are many resources within the University that are available to help, including the UCSD corporate compliance office, human resources, the UCSD Division Academic Senate Chair, Audit Management Advisory Services, and University of California general counsel and, where appropriate, UCSD general counsel.
5. Call the UCSD Confidential Message Reporting Line (Hotline) or the Compliance Helpline
   UCSD has established a confidential toll-free campus Hotline and a Helpline for use by University personnel. At any point, an individual can contact the Hotline / Helpline to raise questions, clarify issues or report suspected violations. Reports will be investigated or referred to appropriate personnel for resolution. University personnel who contact the Hotline / Helpline may choose to remain anonymous. University personnel may want to maintain a personal record of any communications or questions raised.

V. CAMPUS COMPLIANCE OFFICIALS AND PHONE NUMBERS:

UCSD Health Sciences Compliance Officials and Telephone Numbers

Name	Title	Telephone
Lee Giddings, M.D.	Corporate Compliance & Privacy Officer; UCSD Health Sciences and Medical Director, Clinical Resource Management , UCSD Medical Center	(619) 471-9028
Kathleen Naughton	Director, UCSD Health Sciences Corporate Compliance/Privacy Program	(619) 471-9152
David Brenner, M.D.	Vice Chancellor for Health Sciences and Dean, UCSD School of Medicine	(858) 534-1501
Thomas McAfee, M.D.	Physician In Chief, UCSD Healthcare	(619) 543-5338
David Sakai	Chief Financial Officer, UCSD Health Sciences (CFO)	(619) 543-6610
Richard Leikweg	Chief Executive Officer,  UCSD Medical Center	(619) 543-6802
Robert Hogan	Chief Financial Officer, UCSD Medical Center	(619) 543-6060
Scott Hofferber	Chief Operating Officer, UCSD Medical Group (COO)	(619) 543-7985
Tia Goodrich	Director of Business Services, UCSD Medical Group	(619) 543-1835
Paul Craig, R.N. J.D.	Director, Patient Safety, Clinical Quality and Risk Management, UCSD Healthcare	(619) 543-6630
Ann Rearden, M.D.	Chief Compliance Officer, UCSD Medical Center Clinical Laboratory Services	(858) 534-0978
Ann Skinner	Director, Human Resources Operations, UCSD Healthcare	(619) 220-5089
Michelle Rubin, Ph.D.	Director, Administrative Services, UCSD Healthcare	(619) 543-5223
Stephanie Burke	Director, Audit & Management Advisory Services, UCSD	(858) 534-3617
Valerie McFarland	Interim Director, Conflict of Interest Office	(858) 534-7321
Michael Caligiuri	Director, Clinical Research Protections Prog. (CRESP)	(858) 455-5050
Coding Help Line		(858) 534-3344 or (619) 471-9150

University of California (UC) - Office of the President

William Gurtner	University of California Vice President, Clinical Services Department	(510) 987-9071
Rory Jaffe, M.D.	University of California, Director, Medical Services, Compliance/Privacy Officer	(510) 987-9406
Andrea Resnick	University of California General Counsel	(510) 987-9749

UCSD Confidential Message Line (Toll Free)

Should all the sources fail to resolve an issue, we have established the toll-free UCSD CONFIDENTIAL MESSAGE LINE 1-877-319-0265.

This is a service provided for us by an outside company so that you will feel free to use it without fear of retaliation. Your call can be anonymous and will not be traced. You do not have to give your name, but you will be given a number so that if you want follow-up information you can check back with the Compliance Office. The concerns or issues you report to the Message Line will be investigated by the Compliance Office and acted upon.

Do you have questions or concerns?

Ask your supervisor or someone higher in the organization.

Call the toll free Confidential Message Line

1-877-319-0265

Keep asking until you are satisfied.

VI. REPORTING POTENTIAL ERRORS OR SUSPECTED VIOLATIONS

All University personnel are strongly encouraged to report issues, concerns or suspected violations related to the University's Program. The University's Business and Finance Bulletin G-29, Procedures for Investigating Misuse of University Resources, requires reporting and describes the responsibilities and procedures for reporting and investigating known or suspected misuse of University resources by University personnel.

The UCSD Chancellor is responsible for implementing the provisions of G-29 and has designated the Director of Audit Management Advisory Services as the individual responsible for implementation of local procedures and for general oversight of investigation activities. University policy G-29 addresses procedures that University personnel should follow to report suspected misuse, including the following:

"instances of suspected misuse that come to the attention of University employees as part of the performance of their job responsibilities, for example, through the performance of routine control procedures or as a result of evidence disclosed during the course of an audit, shall be immediately reported to either the Chancellor’s designee in accordance with campus procedures or to the person appointed to receive whistleblower reports."

The University’s Policy and Procedures for Reporting Improper Governmental Activities and Protection Against Retaliation for Reporting Improper Activities affirms that the University does not tolerate retaliation against University personnel who report suspected violations.

For additional information regarding the University’s G-29 policy or other University policies, University personnel can contact the Corporate Compliance Office or Audit Management Advisory Services.

VII. COORDINATION WITH ESTABLISHED POLICIES AND PROCEDURES FOR INVESTIGATIONS AND AUDITS UNDER CURRENT UNIVERSITY POLICY G-29

UC Business and Finance Bulletin G-29 describes the responsibilities and procedures for investigating known or suspected misuse of resources by University personnel, regardless of the type of position held (staff, management, faculty, student employee, or other). The CCO for the academic health center in collaboration with the Director of Audit Management Advisory Services will be responsible for establishing local policies and procedures that integrate corporate compliance activities with the provisions and enforcement of G-29. Procedures should define implementation to include the following:

The Chancellor shall designate a Corporate Compliance Officer for all matters relating to corporate compliance in Health Sciences. The CCO should serve as the corporate compliance liaison to all appropriate Internal Audit and Investigation Committees including Academic Senate committees, and be responsible for ensuring that there is adequate coordination and reporting among those entities responsible for investigations.

The CCO, in collaboration with the Internal Audit and Investigation Committees, campus Corporate Compliance Committee, the Academic Senate, the general counsel and others, will:

• Develop specific procedures for internal reporting of suspected violations of the University's policy on corporate compliance;
• Define how investigations of reports of suspected violations are conducted and who is the responsible for conducting an investigation;
• Ensure that all procedures developed are consistent with the provisions of related University of California policies and procedures, including the University Policy and Procedures for Reporting Improper Governmental Activities and Protection Against Retaliation for Reporting Improper Activities and related local implementing procedures;
• Implement procedures to facilitate communications and enhance cooperation between the campus corporate compliance office, Audit Management Advisory Services, department chairs, dean, the Academic Senate, Office of the Chancellor, and other applicable entities and individuals; and
• Ensure that Campus Compliance Handbooks clearly communicate to University personnel the manner in which instances of known or suspected misuse are to be reported.
• The CCO shall maintain a complete and accurate record of each investigation including findings, conclusions, and recommendations for the period prescribed by federal regulations.
• In the case of possible criminal activity, the Office of the General Counsel or resident campus counsel and campus police shall be consulted to determine appropriate actions with regard to the investigation and legal proceedings.
• The CCO will report findings, conclusions and recommendations regarding any and all investigations to the Corporate Compliance Committee. A summary of these findings and investigations will be provided to the Chancellor in the Campus Compliance Program Annual Report. Where required, reports will be made to external agencies having jurisdiction pursuant to Business and Finance Bulletin G-29. When it is determined that a crime probably has been committed, the results of investigative work shall be reported to the District Attorney or other appropriate law enforcement agencies.

VIII. INTERNAL CONTROLS, AUDITS, AND MONITORING

All UCSD Health Sciences Departments shall develop and implement appropriate internal controls to guard against compliance problems. These controls will be reviewed in the compliance review and audit processes, including monitoring activities. All internal control activities will be coordinated with both the UCSD Department of Audit Management Advisory Services and UCSD Campus Controller, and through them to the University Auditor in the Office of the President.

Effective tools to prevent and detect unintentional errors and unethical, or illegal behavior, as well as to promote compliance, include periodic compliance reviews and audits based on assessments of risk. These should be conducted by either internal or external auditors with expertise in federal and state health care statutes and regulations. Compliance reviews and audits should be performed at appropriate intervals and may involve on-site visits, interviews with key physicians, records staff, and finance and billing personnel. Reviews and audits may address all levels of compliance, including surveys and trend analyses, and a review of financial records and source documents.

IX. REMEDIAL ACTIONS

Remedial actions are not disciplinary but are done to correct mistakes, and enhance compliance with the Program, and state and federal regulations. In most cases, remedial actions are designed to improve the performance of University personnel. The exact nature of and need for remedial action will be identified by supervisors within departments in collaboration with the CCO and will involve department chairs, deans and the Academic Senate as appropriate. Upon investigating what appears to be behavior requiring remedial actions, the CCO, the executive management team at the campus or, where appropriate, the designated Vice Presidents or General Counsel in the Office of the President, will clarify policies, and will review, and revise if necessary, administrative procedures in order to prevent future errors. If remedial action is deemed necessary, an affected individual will be notified, informed of the concerns regarding their performance, and made aware, if applicable, of the right to grieve.

Examples of behaviors on the part of individuals that could require remedial actions might include the following:

1. Failure of an individual to understand and carry out required procedures and policies;
2. Inappropriate or improper implementation of the procedures and policies of the University’s Program or campus specific corporate compliance policies and procedures;
3. Ambiguous communications regarding job performance expectations; or
4. Negligent behavior.

The CCO is responsible for ensuring that remedial actions have been implemented in a timely manner. The CCO may work with management or others responsible for the individual or operational area under review in order to reduce the likelihood of future errors. The CCO will consult with the campus Corporate Compliance Committee during these actions.

In accordance with the provisions of the applicable personnel policies and collective bargaining agreements, remedial actions may include, among others, the following:

1. The individual or individuals will be required to take part in an education program focused on the problem area;
2. Future billings may be handled in a designated manner, including a third party review of all bills and the temporary suspension or delay of some or all billing to allow for quality review prior to the distribution of bills to third parties;
3. The individual may be reassigned or there may be a change of duty until remediation has successfully corrected the errors; and
4. In the case of an over-payment to a provider, there may be an adjustment from the appropriate source in order to refund the payer or pay any fines and penalties.

INVESTIGATORY LEAVE

An employee may be placed on an investigatory leave, with or without notice, to permit the University to review or investigate actions that would warrant removing the employee from the work site.

X. CORRECTIVE OR DISCIPLINARY ACTIONS

In cases of intentional misconduct, repeated violations, or after documented remedial actions have failed to correct the problem, UCSD will initiate corrective or disciplinary actions where necessary. The initiation of corrective or disciplinary action by UCSD does not preclude or replace any criminal proceedings that may be taken by the district attorney.

Should UCSD initiate corrective or disciplinary action it must do so in accordance with the rules set forth in the Faculty Code of Conduct, the Medical Staff Bylaws, Rules and Regulations, as well as any other existing and applicable personnel policies, collective bargaining agreements, or UCSD policies. The CCO, a supervisor, human resources, labor relations, deans of health science schools, department chairs when appropriate, or University General Counsel can provide additional information regarding those types of activities and behavior that may be subject to corrective and disciplinary actions.

UCSD personnel subject to corrective or disciplinary action have due process rights under applicable existing UCSD personnel policy, Academic Senate Bylaws or collective bargaining agreements. These policies should be followed during any corrective or disciplinary process.

The disciplinary action imposed will depend on the nature, severity, and frequency of the violation, and may include one or more of the following:

1. Verbal and/or written warnings, followed by a written reprimand;
2. The placement of the individual in a different position if the individual is determined to be qualified to perform the essential functions of a different position within the same job classification;
3. Reduction of pay;
4. Suspension;
5. Termination of Medical Staff appointment (pending impact on faculty status), including physicians, nurse practitioners, physician assistants, etc.;
6. Termination of employment; or
7. Other disciplinary action felt to be appropriate for the specific misconduct.

XI. COORDINATION OF CORRECTIVE AND DISCIPLINARY ACTIONS WITH EXISTING UNIVERSITY POLICY

The following lists existing policies and procedures that address misconduct by University personnel:

Academic Senate Faculty Members

The University Policy on Faculty Conduct and the Administration of Discipline—APM 015-0 Policy and Academic Senate Privilege and Tenure Committee Bylaws 195 & 335.

Academic Senate Bylaw 335 provides for a due process review and or a hearing before the Divisional Committee on Privilege and Tenure in any disciplinary action brought against a faculty member. There may be additional division Academic Senate policies relating to disciplinary matters that must be consulted.

Non-Senate Faculty and Other Non-Senate Appointees

Existing policy for imposing corrective or disciplinary action on non-academic personnel varies by the applicable collective bargaining agreement if the individual is represented by an exclusive representative. If an individual is not represented by an exclusive representative, then the Academic Personnel Manual applies.

Staff and Management Personnel

Existing policy for imposing corrective or disciplinary action on non-academic personnel varies by the applicable collective bargaining agreement if the individual is represented by an exclusive representative. If an individual is not represented by an exclusive representative, then the Personnel Policies for Staff Members applies.

Graduate Health Professions Students

Existing policy for imposing corrective or disciplinary action on graduate health professions students, when within the scope of the University’s Program as defined under "Scope and Responsible Parties," is by a collective bargaining agreement with a new exclusive representative.

XII. EXCLUSION OF INDIVIDUALS AND ENTITIES FROM PARTICIPATION IN MEDICARE, MEDICAID AND OTHER STATE HEALTH PROGRAMS

42 United States Code section 1320a-7 and the Health Insurance Portability Accountability Act of 1996 (HIPAA) provide for mandatory and permissive exclusion of certain individuals and entities from participation in Medicare and state health care programs for conviction of offenses defined therein. Further, the civil monetary penalty law, 42 United States Code section 1320a-7a, excludes from coverage for any state or federal health care program any item or service that has been ordered or furnished by any individual or entity during a time when that individual or entity has been excluded from the program.

Mandatory Exclusions of Entities, Officers or Management Responsible for Sanctioned Individuals or Entities

Specifically, the federal Health Insurance Portability and Accountability Act of 1996 provides for the exclusion of certain individuals and entities from participation in Medicare, Medicaid and other government programs including:

1. Mandatory Exclusion applies to any individual or entity that has been convicted of a criminal offense related to:
   1. The delivery of any Medicare or Medicaid item or service;
   2. Neglect or abuse of patients;
   3. Health care fraud relating to the delivery of any item or service with respect to any program financed in whole or in part by any Federal, state or governmental agency; or
   4. The unlawful manufacture, distribution, prescription or dispensing of a controlled substance (after August 21, 1996).
2. The Secretary may exclude any individual subject to the criteria of Permissive Exclusion, which applies to any individual or entity:
   1. Who has been convicted of a misdemeanor relating to fraud, theft, embezzlement, breach of fiduciary responsibility or other financial misconduct in connection with the delivery of any Medicare or Medicaid item or service;
   2. Who has been convicted of obstruction of an investigation;
   3. Who has been convicted of a misdemeanor relating to a controlled substance;
   4. Whose license has been revoked or suspended by any State licensing authority, including the surrendering of a license when an individual or entity is under investigation for issues related to professional competence, professional performance or financial integrity;
   5. Who has submitted or caused to be submitted claims for excessive charges or unnecessary services or failure to furnish medically necessary services;
   6. Who has committed fraud, received kickbacks or participated in other prohibited activities; or
   7. Who has failed to supply requested information, grant access to federal entities including the OIG, and failed to take required corrective action.

Permissive Exclusion of Entities, Officers or Management Responsible for Sanctioned Individuals or Entities

Federal law states that any entity or individual who is responsible for a sanctioned entity or individual—including officers or managing employees of organizations such as the University of California—may also be subject to permissive exclusion if they know or should know of the actions leading to sanction and do not exclude that individual from performing services. In these cases federal law specifically defines a sanctioned entity or individual as those meeting the criteria of "mandatory exclusion" or those described under section 2a, 2b, and 2c above, all of which involve conviction of certain felonies, misdemeanors or obstruction of investigations.

If UCSD has notice that UCSD personnel or a contractor has become ineligible for participation in a federal or state health care program, UCSD, after appropriate due process rights have been exercised and consistent with any decision related thereto, shall remove such person from responsibility for, or involvement with, UCSD's business operations related to federal or state health care programs, and shall remove such person from any position for which the person's salary, or the items or services rendered, ordered, or prescribed by the person, are paid in whole or part, directly or indirectly, by any state or federal program or from any Federal grants, cooperative agreements, contracts of assistance, loans and loan guarantees, until such person is reinstated into participation in the federal health care program.

UCSD does not knowingly permit any debarred or excluded individual or entity from participating in a federal or state health care program including, but not limited to, activities involving billing, reimbursement and patient care. The CCO is responsible for reporting to his/her chancellor regarding appropriate mechanisms for ensuring that:

• The List of Parties Excluded from federal programs and the HHS/OIG List of Excluded Individual/Entities have been checked with respect to all applicant, trainees, residents, fellows, employees, medical staff and contractors;
• All UCSD personnel, as defined in the University’s program, have executed the "Standards of Business Conduct Acknowledgment Statement of the UCSD Health Sciences Corporate Compliance Program" and have provided a personal attestation in connection with his or her exclusion from a governmental health care program; and
• All independent contractors have provided a representation that no individuals in their employ are excluded from participation by a state or federal health care program.

Disbarment from Grants and Contracts

Executive Orders 12549 and 12689, and Section 2455 of the Federal Acquisition Regulation, are Provided in 45 CFR 76, "Government-wide Debarment and Suspension (Nonprocurement) and Government-wide Requirements for Drug-Free Workplace (Grants)."

Accordingly, before a National Institute of Health (NIH) grant award can be made, the applicant organization must make the following certification: (Refer to Appendix A of the DHHS PHS 398 regulations)

"(1) The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals (including research personnel):

"(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any Federal department or agency;

"(b) Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;

"(c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State, or local) with commission of any of the offenses enumerated in paragraph (1)(b) of this certification; and

"(d) Have not within a three-year period preceding this application/proposal had one or more public transactions (Federal, State, or local) terminated for cause or default.

Annual Report

The CCO will provide an annual report to his or her chancellor, to the Divisional Committee on Privilege and Tenure (with respect to any proposed faculty disciplinary actions) and the University’s General Counsel regarding any such personnel actions taken relative to debarred or excluded individuals. The University’s General Counsel is responsible for providing The Regents with an annual report regarding any actions taken. (Refer to section III.H for further details).

Medical Staff Review

Healthcare Staff and Healthcare Center Bylaws require as a condition of application or continuing privileges at the institution, that an individual who is proposed for exclusion by the OIG or any government health care program immediately notify the UCSD Medical Staff Office and the CCO. When UCSD becomes aware that a UCSD employee has been excluded or proposed for exclusion from governmental health programs, the UCSD Medical Staff Office will be notified. As soon as the Medical Staff Office becomes aware from any source of such exclusion or proposed exclusion, it will immediately seek to clarify the circumstances including obtaining information from the individual, the government or any other appropriate source. The clarification process will not exceed ten days, unless extended by the Chair of the UCSD Medical Staff Executive Committee for good cause.

Under most circumstances, exclusion from participation in federally funded programs will exclude the individual from the participation in patient care and will result in termination of Staff privileges until such exclusion expires, after which time the provider may reapply for Staff privileges. Occasionally the Medical Staff may choose to continue privileges with or without modification despite exclusion from government programs.

XIII. RESPONSE TO GOVERNMENT INVESTIGATIONS

In the unusual event of an investigation by the government, representatives of the government could arrive unannounced at the School of Medicine, Medical Center or at the home of present or former personnel, staff members or contractors (collectively referred to as "personnel"). Generally, these government representatives wish to either conduct interviews or obtain certain documents. The following procedures constitute an orderly response to such government requests and enable UCSD to protect its and its patients’ interests while cooperating with the investigation.

It is the policy of UCSD to comply with all applicable health care laws and regulations and to cooperate with appropriately authorized governmental investigations and audits.

A. Types of government agencies that may investigate health care providers

A variety of federal and state governmental agencies may be involved in investigating health care providers for various reasons. These agencies include, but are not limited to, the Office of Inspector General (OIG), the Health Care Financing Administration (HCFA), the Federal Bureau of Investigation (FBI), the Department of Defense, the United States Attorney’s Office, Medicare Intermediaries, the California Attorney General’s Office and the California Department of Health Services.

B. Procedures

1. When a representative from a federal or state agency contacts UCSD personnel anywhere, such as at home or at the office, for information regarding the Clinical Enterprise or an affiliated health care entity, or any other entity with which UCSD does business, the Dean or Medical Center Director should be contacted immediately. If they are not immediately available, contact should be made with the Risk Management Department, Corporate Compliance Officer or University General Counsel.
2. Instructions will be given on how to proceed.
3. UCSD personnel should ask to see the government representative's identification and business card if the government representative is there in person. Otherwise, the person's name and office, address and telephone number, identification number should be obtained and a call made to the government representative's office to confirm his or her authority.
4. If the government representative wishes to speak with UCSD personnel personally, they should find out why without getting into details. (See Section C, Interviews).
5. If the government representative wants to search any facilities of UCSD Health Sciences or obtain any documents, personnel should ask for legal documents authorizing the search, such as subpoena or a search warrant, and any affidavit supporting the warrant. A copy of this legal documentation should be made (see Section D, Searches) and immediately sent to the Risk Management Department, University General Counsel and the Corporate Compliance Officer. If the government representative has appeared in person, he or she should be escorted to the Dean's or Medical Center Director's office for further assistance. The employee should NOT respond to the request to search the facilities or obtain any documents.
6. If a request is received in person or in the mail from a government representative for documents or a subpoena, this should immediately be given to a supervisor. A copy should be immediately sent to the Campus Custodian of Records, to Medical Records and to the Risk Management Department in accordance with the UCSD’s policies for handling subpoenas. A copy should be sent immediately to the Corporate Compliance Officer. Personnel receiving the request should NOT respond to the request.

C. Interviews

Government representatives may ask to speak with individuals regarding UCSD Health Sciences, the Medical Center or any UCSD-affiliated health care entity or any other entity with which UCSD does business. PERSONNEL ARE NOT REQUIRED TO SPEAK TO A GOVERNMENT REPRESENTATIVE ON THE SPOT. Personnel may either agree to be interviewed or refuse to be interviewed - the government representative does not have the right to insist upon an interview. Personnel may also make an appointment to speak with the government representative at a later date.

If an investigator contacts personnel at home and they wish to submit to an interview, they have the right to insist that the interview take place in a UCSD office during normal business hours.

Personnel are entitled to have someone with them during any interview with a government representative. UCSD will arrange to have an appropriate individual (possibly an attorney) present during the interview. The employee may also consult with an attorney of his or her own choosing at the employee's expense if he or she so desires.

If, during the course of an interview, the investigator asks for copies of any School or hospital records (including, but not limited to, medical records, patient billing, financial, quality assurance or peer review records), the employee should refuse, explaining that such records can only be provided in response to a lawfully issued subpoena or other lawful method. University General Counsel will direct the collection and transfer of records and provide other instructions as necessary to assure that UCSD responds expeditiously and completely to the demands of the subpoena.

If personnel choose to be interviewed by a government representative before calling a UCSD representative as identified above, the UCSD supervisor and/or Corporate Compliance Officer should be contacted as soon as possible after the interview. Personnel are encouraged to make detailed notes during the interview.

An individual's decision to be interviewed or not will not be used in any way against the Employee by UCSD.

During the interview with the government representative, personnel should be aware:

• Always tell the truth. If personnel do not recall something or have no knowledge or insufficient knowledge about the topic they should say so. Personnel should not guess or speculate.
• In talking with the government representative, personnel should be very careful to answer questions completely, accurately and concisely so that there will be no misunderstanding as to what is said. It is important for personnel to make clear to the government representative whether the information he or she is providing is first-hand knowledge, or something that has been heard. DO NOT speculate. DO NOT provide information unless having first-hand knowledge of it.
• The Corporate Compliance Officer should be contacted as soon as possible after the interview.

D. Searches

If the government representative wants to obtain documents or search the Medical Center, the government representative should be escorted to the Office of the Dean or Medical Center Director for assistance. Personnel should remember the following:

1. A "search" occurs any time a government representative enters UCSD premises and begins to look for any documents or asks questions. A search may not be conducted without a legally valid search warrant. However, some government agencies have the authority to assess penalties if representatives of the agency are not granted immediate access upon reasonable request to a health care entity. These agencies include the OIG. Therefore, UCSD personnel should strive to be courteous and helpful to government representatives while following the guidelines set forth in this section.
2. A search warrant is different from a subpoena or a records request. A subpoena or records request requires the production of information but does not allow for a search. Most subpoenas or records requests allow a reasonable time in which to respond. The time frame (typically ranging from 10 to 30 days) will usually be identified on the subpoena itself. In contrast, a search warrant is issued by a magistrate or a judge and allows immediate access to the hospital premises or property which are described in the search warrant.
3. Personnel should request that the investigator wait at the Dean's or Medical Center Director's office until either the Corporate Compliance Officer, Risk Manager or University General Counsel arrives. If the warrant is valid, the employee may not stop the search. However, before permitting the government representative to proceed with a requested search, UCSD should first be allowed to determine the validity of the warrant.
4. The confidentiality of medical records, patient records, and other hospital records must be maintained even when responding to a subpoena, warrant, or other request for document production. The Corporate Compliance Officer, Risk Manager, Medical Records Director and/or University General Counsel will direct the collection and transfer of records and provide other instructions as necessary to assure that UCSD safeguards the confidentiality of these records and responds completely and appropriately to the warrant.
5. The confidentiality of medical records, patient records, and other hospital records must be maintained even when responding to a subpoena, warrant, or other request for document production. The Corporate Compliance Officer, Risk Manager, Medical Records Director and/or University General Counsel will direct the collection and transfer of records and provide other instructions as necessary to assure that UCSD safeguards the confidentiality of these records and responds completely and appropriately to the warrant.

E. Administrative Issues

Once a government contact is initiated, personnel should establish a specific file for communications with legal counsel. The file and all of his or her memos to legal counsel should be captioned with the words "Confidential Attorney-Client Privileged Communication."

Copies should NOT be made other than a file copy. Never distribute confidential communications with legal counsel. Distribution may destroy the privilege of confidentiality.

IF AT ANY TIME, PERSONNEL ARE UNSURE OF WHAT TO DO, THEY SHOULD CONTACT THE ADMINISTRATIVE SERVICES OFFICE, THE RISK MANAGER, THE CORPORATE COMPLIANCE OFFICER OR UNIVERSITY GENERAL COUNSEL IMMEDIATELY. THIS SECTION CONTAINS GENERAL GUIDELINES. AT ALL TIMES, FOLLOW INSTRUCTIONS FROM THE COMPLIANCE OFFICER, RISK MANAGER AND/OR UNIVERSITY GENERAL COUNSEL.

F. Media Contacts

It is important that UCSD personnel not discuss their involvement with an investigation or any issue relating to an inquiry by a government agency with other personnel or with people outside of the Medical Center. If an inquiry from the media or any other outside person is received, personnel should do the following:

If the media representative appears in person:

1. Verify their credentials by asking to see their identification and business card.
2. Politely state that he or she is unable to comment or respond at the present time, but that he or she will pass along their business card to a person with authority to speak on behalf of UCSD.
3. Explain that in order to provide the best UCSD spokesperson, he or she will need to know what information the individual is seeking.
4. UCSD personnel should not answer or respond to any requests for information or provide his or her opinion to any media representative.
5. Contact his or her supervisor/department director immediately or, if the employee's supervisor/department director is unavailable, the employee should contact the Health Sciences Communications office at (619) 543-6163.

If personnel are contacted by telephone:

1. Ask for the person's phone number and affiliation for the purpose of returning their call at a more appropriate time.
2. Determine the purpose of the call. Never provide information, answer questions, or speculate. Statements, when taken out of context, can be misinterpreted. The UCSD Health Sciences Communications Office at (619) 543-6163 will be responsible for coordinating all media contacts.
3. Personnel should contact their supervisor/department director immediately or if the supervisor/department director is unavailable, the employee should contact the UCSD Health Sciences Communications office at (619) 543-6163.

APPENDICES

Appendix A:
UCSD Health Sciences Corporate Compliance Program "Standards of Business Conduct" handbook.

Appendix B:
UCSD Standard Vendor Agreement for Professional Services

Appendix C:
Associated Compliance Documents, Policies, and Web Sites

Appendix D:
UCSD Principles of Community

Acknowledgment Statement

The UCSD Health Sciences

Corporate Compliance Handbook

and

Code of Conduct

My signature on this form acknowledges that I have received and agree to read the UCSD Health Sciences Corporate Compliance Handbook and Code of Conduct.

I confirm that I have not been excluded by the federal government from participation in any governmental program nor, to the best of my knowledge, have I been proposed for exclusion. I agree to notify the Corporate Compliance Officer or the University's Office of the General Counsel immediately upon my receiving written or verbal notification that I am proposed for exclusion from any governmental health care program.

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