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Office of Compliance Programs

Compliance Update - Basic

Revised: November 7, 2017


What is a Compliance Program?

A compliance program is a voluntary undertaking by a health care entity (like LSUHSC-NO) to ensure compliance with all federal and state laws and regulations. The Patient Protection and Affordable Care Act (Obamacare) requires that all healthcare providers that bill Medicare and Medicaid have an effective compliance program in place.

Laws, Regulations and Policies That Affect LSUHSC-NO

LSUHSC-NO is subject to numerous laws, regulations and policies. Some examples include but are not limited to:

History of the LSUHSC-NO Compliance Program

Compliance Program Elements

The Department of Health and Human Services, Office of Inspector General, in its Compliance Program Guidance for Recipients of PHS Research Awards, lists the following elements of an effective compliance program:

  1. Implementing written policies and procedures including a Code of Conduct.
  2. Designating a compliance officer to oversee the day-to-day operations of the compliance program.
  3. Conducting effective training and education.
  4. Developing effective lines of communication including one or more methods of reporting complaints anonymously.
  5. Conducting internal monitoring and auditing.
  6. Enforcing standards through well publicized disciplinary guidelines
  7. Responding promptly to detected problems and undertaking corrective action.
  8. Clearly defining roles and responsibilities and assigning oversight responsibility.

Compliance Staff

Faculty and Staff Responsibilities

In order for a compliance program to be successful, everyone must take responsibility for ensuring that all university activities comply with applicable laws, regulations and policies. Some of the things you can do personally to ensure the university's compliance are:

Compliance Hotline

To report instances of non-compliance you can:

All reports will be kept in the strictest confidence in accordance with Federal and State laws and LSUHSC-NO whistleblower policy. (CM-53 Section E)

Additional Hotlines

Other agencies provide hotlines to report fraud waste and abuse in their areas of jurisdiction. A complete list can be found here.

Consequences of Non-Compliance

The consequences are not limited to those who are not compliant. Non-compliance affects everyone at LSUHSC-NO.

Examples of Settlements Associated with Noncompliance

Permanent Memorandum (PM) #11- Outside Employment of University Employees

PM-11 Establishes policies and procedures for LSU employees requiring any outside employment be disclosed and submitted for administrative review and approval. It applies to all full-time LSU employees including faculty, unclassified and classified employees.

Outside Employment is defined as any non-University activity for which economic benefit is received, including but not limited to:

Economic benefits include cash payments (e.g. honorariums) or such other non-cash economic benefit (e.g. trips, stock options, equity participation, etc.)

Outside employment shall be performed only outside of assigned working hours and shall not conflict, delay or interfere with an employee’s obligation to LSU.

In accordance with the Academic Affairs Policy on Outside Employment, in order to qualify for outside employment:

YOUR Responsibilities Under PM-11


Because activities conducted under PM-11 are by definition outside the course and scope of an individual's employment with the University:

Chancellor's Memorandum (CM) #52 - Official Business Before Elected Officials

CM-52 establishes a policy and procedure regarding conducting official business before elected officials. Louisiana Revised Statute 24:56F prohibits university employees from lobbying the Legislature in their official capacity or on behalf of LSUHSC-NO. This provision does not prohibit university employees from giving factual information to the Legislature.

To ensure compliance with state statutes, any communications with elected officials, whether federal, state or local, must be coordinated with the Office of External Relations. They can be reach by phone at (504) 568-8976 or via email. This includes any situations where you may be contacted directly by an elected official.

Nothing in the statute or the policy is intended to prevent employees from expressing themselves on matters of personal concern in their individual capacity. However, when doing so, employees:

Document Retention Policy

Louisiana’s Public Records Act (LA R.S. 44.1 et seq.) requires that “...a statewide system of managing and preserving government records which will meet informational requirements and serve the rights and interest of government and its citizens...” be developed. This system is administered through the Louisiana Division of Archives, Records Management and History located in the Secretary of State’s Office (State Archives).

The law requires that each state agency designate a Records Officer to work with State Archives regarding that agency's records management needs.

LSUHSC-NO’s Records Officer is designated by the Chancellor annually.

What is Considered a Record?

Louisiana Revised Statutes 44:402 defines a Record as “all documents, papers, letters, books, drawings, maps, plates, photographs, magnetic or optical media, microfilm, microphotograph, motion picture film, or other document or any other material regardless of physical form or characteristic, generated or received under law or in connection with the transaction of official business, or preserved by an agency or political subdivision because of other informational or legal value.” The content, or what the record is about, controls the length of time that the records must be maintained. For example, emails regarding patient care should be maintained for the same retention period as the retention period of paper patient care records.

LSUHSC-NO’s Records Retention Policy and Schedule

In order to comply with the legal retention requirements, the University has created the LSUHSC-NO Records Retention and Disposition Policy and Records Retention Schedule.

The Retention Period is the amount of time that a record must be retained prior to its destruction. This is usually expressed in terms of the number of years after the record is actively referenced.

Destruction of Records

Once the Retention Period for a set of records has expired, LSUHSC-NO may request permission from State Archives to destroy the records. The process for obtaining permission to destroy records is as follows:

Step 1: Identification of Retention Period of the Records to be Destroyed

Step 2: Obtain Approval from State Archives

Step 3: Disposal of Records-Paper

Disposal of Records--Electronic

Permission to destroy electronic records must be obtained as described above for paper records. Electronic records that contain Protected or Restricted information (as defined by PM-36) must be disposed of in accordance with PM-36.

Consequences of Failure to Comply with the Record Retention Policy

Failure to comply with the LSUHSC-NO Records Retention policy may place the University at risk of liability.

State law defines “injuring of public records” as the intentional removal, mutilation, destruction or alteration, falsification or concealment of any record, document, or other thing filed or deposited… in any public office or with any public officer.”

Violations of the law are punishable by as long as five years in prison and fines of as much as $5,000. (Note: Each record can be considered a separate violation.)

Signatures on Agreements

An agreement is any legal document which obligates the university to take certain actions or limits the actions the university may take. Examples of agreements include but are not limited to the following:

ALL agreements must be signed by the Chancellor or an Authorized Representative. Department Heads, Business Managers, Principal Investigators (PI’s), the Dean’s office, etc. DO NOT have the authority to obligate LSUHSC-NO by themselves (sign an agreement) unless they have been authorized in writing by the Chancellor to be an Authorized Representative of the university.

Attendance and Leave

All employees shall:

In addition:

Faculty/Unclassified Employees

Louisiana Revised Statute 17:3311A(3) requires that daily leave and attendance records for unclassified employees must be maintained.

On June 23, 2000, then LSU President William Jenkins worked out an arrangement with the Legislative Auditor regarding the documentation LSU campuses needed to maintain in order to comply with this statute.This documentation consists of:

  1. Application for Leave (SF-6) which documents the permission (or lack thereof) of LSUHSC-NO management for an employee to be absent from work. There must be at least one application for leave, approved by the employee's supervisor, on file for each contiguous absence from work within a pay period.
  2. Certification of Attendance to which the unclassified employee attests each pay period. This certification takes the place of a sign-in sheet or other methods of recording attendance. There must be one certification, approved by the employee's supervisor, on file for each pay period.

LSUHSC-NO has an online system for submitting the application for leave and the certification of attendance for unclassified employees. All unclassified employees should complete their certification of attendance by the tenth (10th) day of the month following the pay period for which they are certifying.

Faculty/Unclassified Employees’ Responsibilities:

  1. To report leave, unclassified employees must request leave (i.e. Annual, Sick, Leave without Pay, Funeral, Educational, Military, and Civil) by submitting, in advance, a completed University approved Application for Leave request via the online system  to the immediate supervisor. In situations in which prior notification is not possible (e.g. unplanned sick leave), complete the Application for Leave request immediately upon return to work.
  2. In situations where an employee took a different amount of leave than on the original leave request, a new leave request with the correct amount shall be submitted and the original leave slip should be deleted.
  3. LSUHSC-NO’s online Application for Leave request must be used.
  4. Leave can only be taken in an initial half hour increments, with all subsequent time taken in quarter hour increments.
  5. Enter all leave for the pay period (month) on or before the fifth (5th) day of the month following the pay period in which the leave was taken.
  6. Attest to their presence at work by submitting the monthly Time and Attendance Certification online on or before the tenth (10th) day of the month following the month being certified.

Classified Employees

Classified Employees’ Responsibilities:

  1. Classified Employees shall report their leave by submitting a completed University approved Application for Leave Form for all types of leave (i.e. Annual, Sick, Leave without Pay, Funeral, Educational, Military, and Civil) to their immediate supervisor, in advance. In situations in which prior notification is not possible (e.g. unplanned sick leave), employees must complete the Application for Leave immediately upon return to work. The LSUHSC-NO Application for Leave Form, on the Human Resource Management's webpage is required.
  2. In situations where an employee took a different amount of leave than on the original leave slip either a new leave slip with the correct amount with both the employee’s and supervisor’s signature should be created or the original leave slip should be amended and the employee and supervisor should initial the corrections. If the incorrect leave amount has been submitted on the monthly Attendance and Leave Voucher a corrected leave voucher should be submitted to Human Resource Management.
  3. Classified employees are responsible for certifying the accuracy of their hours worked and leave taken by signing a Time Detail Report at the end of each pay period. Supervisors are responsible for reviewing the reports and ensuring they are completed, signed, and accurate. Actual employee and supervisor signatures must be present on all Time Detail Reports generated from PeopleSoft.
  4. Ensure leave is charged in increments of one-tenth hour (6 minutes) Civil Service Rule 11.7(c).
  5. An individual's available leave balance is the ending balance from the previous pay period. Questions related to an individual leave balance should be directed to the timekeeper.


Timekeeper Responsibilities:

  1. Enter all “Applications for Leave” into Monitor Absence in PeopleSoft on a timely basis for unclassified employees.  All “Applications for Leave” for a pay period must be entered between by the day before Payroll starts the subsequent monthly payroll process.  See the “Calendar of Payroll Schedule” on the Office of Payroll webpage for the specific dates.
  1. Reconcile all employees’ “Applications for Leave” to PeopleSoft by the tenth of the month subsequent to the month of leave taken. (The reconciliation of leave taken in September would be reconciled by October 10th)
  2. Ensure a Per-3 is completed and forwarded to Human Resource Management for all instances of LWOP for more than 30 consecutive calendar days. 
  1. Ensure all part-time employees’ actual work schedule is listed on, or attached to, all LWOP leave slips and/or Per-3s to for Human Resource Management to verify the dollar amount of LWOP.
  2. Maintain all original “Applications for Leave” and monthly reconciliations in the department for audit purposes in accordance with the University’s retention schedule.
  3. Ensure leave is reported in an initial half hour increment and all subsequent time is reported in quarter hour increments.

Getting Help

If you have any questions, please contact the Office of Compliance Programs by: