REORGANIZATION OF THE OFFICE OF AUDIT, COMPLIANCE & ETHICS (OACE)
ABOUT THE REORGANIZATION President’s JACC Office What it was? OACE Reported functionally to Chair Compliance function oversaw of JACC and administratively Privacy, Policy Management, to the President’s Office Minor Protection, as well as Clinical Compliance & Privacy at Audit function oversaw UConn Health efforts to identify institutional risks, perform audits, and Separate Ethics Liaisons at provide independent, UConn & UConn Health objective, assurance and consulting services Separate management of Reportline & investigations REORGANIZATION OF THE OFFICE OF AUDIT, COMPLIANCE & ETHICS (OACE)
ABOUT THE REORGANIZATION The Three Lines of Defense Model in Effective Risk Management and Control Governing Body / Board / Audit Committee Senior Management External Audit 1 st Line of Defense 2nd Line of Defense 3rd Line of Defense Regulator University Compliance Privacy Internal Management Audit Healthcare & Regulatory Research Compliance Effective risk management requires the coordination of activities between the various lines of defense. REORGANIZATION OF Adapted from ECIIA/FERMA Guidance on the 8th EU Company Law Directive, article 41 THE OFFICE OF AUDIT, COMPLIANCE & ETHICS (OACE)
ABOUT THE REORGANIZATION President’s CEO of UConn JACC Office Health What’s Changed? Office of University Compliance Kimberly Fearney 860-486-6195 (UConn) Interim Chief 860-679-1802 (UConn Health) Compliance Officer Office of Healthcare and Regulatory Compliance OACE Debra Abromaitis 860-679-7015 Interim Compliance Officer OACE Office of Privacy Protection & Management Rachel Rudnick 860-486-5256 (UConn) Chief Privacy Officer 860-679-7334 (UConn Health) Office of Audit & Management Advisory Services Cheryl Chiaputti 860-486-2749 (UConn) Chief Audit Executive 860-679-4735 (UConn Health) REORGANIZATION OF THE OFFICE OF AUDIT, COMPLIANCE & ETHICS (OACE)
ABOUT THE REORGANIZATION Office of University Office of Healthcare and Office of Privacy Protection & Office of Audit and Compliance Management Management Advisory Services Regulatory Compliance Serves as a central resource for Provides independent Promotes a University-wide Serves as a central privacy matters University-wide objective assurance & culture of compliance and resource for consulting services designed ethics healthcare regulatory to add value & improve compliance preparedness Advises & assists regarding the operations Provides educational reporting and response proper access, use, training & resources, assists management, protection & Enhances & protects decentralized compliance disclosure of confidential organizational value by Provides enterprise areas with monitoring information via education, providing risk-based risk management efforts outreach & guidance assessments, advice & insight assessments, guidance and Manages confidential monitoring & offers Helps the University Reportline Monitors compliance and healthcare compliance accomplish its objectives by investigates privacy concerns education & training to the bringing a systematic, Ensures coordination & healthcare domain disciplined approach to consistency among individual evaluate & improve the Manages response to data compliance units effectiveness of governance, incidents (e.g. breaches) and risk management & control identity theft concerns processes REORGANIZATION OF THE OFFICE OF AUDIT, COMPLIANCE & ETHICS (OACE)
OFFICE OF UNIVERSITY COMPLIANCE What we do? Responsible for annual Responsible for institution-wide Manages the anonymous REPORTLINE compliance training operation of the compliance and ethics program Provides updates to the Includes role of Ethics Liaison Monitors key compliance Joint Audit and areas Compliance Committee Promotes the University’s Supports University-wide Commitment to Compliance Manages Compliance compliance initiatives & Ethics Committees https://compliance.uconn.edu/ REORGANIZATION OF THE OFFICE OF AUDIT, COMPLIANCE & ETHICS (OACE)
OFFICE OF UNIVERSITY COMPLIANCE President JACC Interim Associate Vice President & Chief Compliance Officer Kimberly Fearney Executive Assistant Liz Vitullo Associate Compliance Officer Omar Andujar Associate Compliance Officer Bruce Gelston Associate Compliance Officer Vacant https://compliance.uconn.edu/ REORGANIZATION OF THE OFFICE OF AUDIT, COMPLIANCE & ETHICS (OACE)
OFFICE OF HEALTHCARE AND REGULATORY COMPLIANCE What we do? Coordinates healthcare Works with healthcare program Investigates healthcare concerns regulatory surveys design and modifications Proactively provides enterprise Coordinates, implements and Works with physicians to risk management assessments, monitors action plans after establish relationships educating advice and monitoring regulatory surveys and monitoring physician billing requirements Provides healthcare and Reports adverse events regulatory new employee Collaborates with management Provides updates to UConn orientation and annual on compliance with changing Health Senior Team compliance training laws, regulations and statutes Prepares healthcare areas Guides healthcare operational Chairs/member on appropriate for regulatory surveys practices and assists with committees to support decision making Healthcare and Regulatory Compliance https://health.uconn.edu/healthcare-regulatory-compliance/ REORGANIZATION OF THE OFFICE OF AUDIT, COMPLIANCE & ETHICS (OACE)
OFFICE OF HEALTHCARE AND REGULATORY COMPLIANCE CEO of UConn Health Interim Compliance Officer Debra Abromaitis Administrative Administrative Officer Program Coordinator Shannon Kelmelis Michelle Mendocha Associate Regulatory Associate Education Associate Clinical Associate Finance Compliance Officer Compliance Officer Compliance Officer Compliance Officer Joanna Mackie Vacant Rikel Lightner Kimberly Bailot Administrative Program Coordinator Kaitlyn Rewenko https://health.uconn.edu/healthcare-regulatory-compliance/ REORGANIZATION OF THE OFFICE OF AUDIT, COMPLIANCE & ETHICS (OACE)
OFFICE OF PRIVACY PROTECTION & MANAGEMENT What we do? Promotes the University’s commitment to protect Responsible for integrated, University- privacy rights of patients, students, employees, wide Privacy program research subjects, and other constituents through education, outreach and advice Conducts investigations into privacy concerns, identity theft, data compromises Conducts periodic monitoring and reviews of privacy and inappropriate access to confidential obligations and access to confidential and protected and protected information data Coordinates management of, and response to, data Collaborates with information incidents including breaches technology, clinical and operational areas to promote “Privacy By Design” Chairs/serves as member on appropriate campus- approach towards management of specific and University-wide committees confidential and protected data https://privacy.uconn.edu/ REORGANIZATION OF THE OFFICE OF AUDIT, COMPLIANCE & ETHICS (OACE)
OFFICE OF PRIVACY PROTECTION & MANAGEMENT President Associate Vice President & Chief Privacy Officer Rachel Rudnick Executive Assistant (Vacant) Health Privacy University Privacy Manager (Vacant) Specialist (Vacant) Health Privacy Specialist University Privacy Analyst Susan Kerr Laurie Neal Health Privacy Specialist Priscilla Fretz Health Privacy Analyst (Vacant) https://privacy.uconn.edu/ REORGANIZATION OF THE OFFICE OF AUDIT, COMPLIANCE & ETHICS (OACE)
OFFICE OF AUDIT AND MANAGEMENT ADVISORY SERVICES What we do? The scope of audit activities encompasses all controls, reports and operations and the evaluation of a broad range of objectives including: Efficiencies and effectiveness of Compliance with laws, Effectiveness of risk operations regulations, policies, management and control framework and processes procedures and contracts Safeguarding of assets How we do it? Performs risk based financial, Performs consulting services Performs investigations related operational, compliance and IT including advisory and related to suspected fraud and fiscal activities in order to mitigate audits – results are formally irregularities - results may be communicated to the JACC risk and improve business communicated to the JACC and operations – results may be other external entities Acts as liaison to external auditors communicated to the JACC including the state auditors https://audit.uconn.edu/ REORGANIZATION OF THE OFFICE OF AUDIT, COMPLIANCE & ETHICS (OACE)
OFFICE OF AUDIT AND MANAGEMENT ADVISORY SERVICES Board of Trustees Board of Directors JACC President Executive Assistant Chief Audit Executive Angela Marsh Cheryl Chiaputti Audit Director Audit Assistant IT Audit Director Audit Director Audit Assistant UConn UConn / UConn Health UConn Health UConn UConn Health Gregory Perrotti Heather Hildebrandt Elaine Zincavage Karen Violette Melanie Hufschmied Senior Auditor Internal Auditor IT Auditor Katherine Goss Libby Gallo Tom Dyer Senior Auditor Internal Auditor Angelo Quaresima Claire Murray Construction Auditor Medical Auditor Vacant David Hook https://audit.uconn.edu/ REORGANIZATION OF THE OFFICE OF AUDIT, COMPLIANCE & ETHICS (OACE)
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