Office of Compliance Programs
Compliance Update - Basic
Revised: November 7, 2017
- Introduction to the LSUHSC-NO Compliance Program
- Permanent Memorandum (PM) #11- Outside Employment of University
- Chancellor's Memorandum (CM) #52 - Official Business Before
- Document Retention Policy
- Signatures on Agreements
- Attendance and Leave
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:
- Federal Laws and Regulations
- Clery Act
- State Laws and Regulations
- Public Records Law
- Ethics Code
- Civil Service Rules
- LSU Regulations and Policies
- Bylaws and Regulations
- Permanent Memoranda (PMs)
- LSUHSC-NO Policies
- Chancellor's Memoranda (CMs)
- Department Policies
History of the LSUHSC-NO Compliance Program
- December 1998 - A resolution is passed by the LSU Board of
Supervisors requiring all LSU medical campuses to have compliance
programs in place. Individual LSUHSC-NO schools name compliance
- January 2001 - A report by an ad hoc committee appointed by the
establishment of central compliance office. The Office of Compliance
Programs (OCP) was created.
- Current - OCP reports to the Chancellor.
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:
- Implementing written policies and
procedures including a Code of Conduct.
- Designating a compliance officer to oversee the day-to-day
operations of the compliance program.
- Conducting effective training and
- Developing effective lines of
communication including one or more methods of reporting complaints
- Conducting internal monitoring
- Enforcing standards through well publicized
- Responding promptly to detected
problems and undertaking corrective
- Clearly defining roles and responsibilities
and assigning oversight responsibility.
- Lori Ferro, CIA, CRMA, CISA, CRISC, Compliance Internal Auditor
- Roy Clay, Compliance Officer/Privacy Officer
- Kelly Guth, CHC, Compliance Educator
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:
- Familiarize yourself with the University’s Code of Conduct and
all policies and procedures that apply to your duties. Note: The
easiest way to do this is by completing your compliance training.
- Complete all recurring compliance training within 30 days of
- Report any instance of non-compliance to your supervisor or the
Office of Compliance Programs.
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)
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.
- Fines and penalties (including imprisonment)
- Additional oversight/monitoring by the government
- Potential reduction or elimination of Federal funding
- Adverse publicity and loss of confidence of the community we serve
- Suspension, debarment, and exclusion of individuals or the
institution as a whole
Examples of Settlements Associated with Noncompliance
- In 2012, Tenet Healthcare agreed to pay $42.8 million to settle
allegations it overcharged Medicare from 2005 to 2007 by moving
patients from ordinary hospitals into more costly facilities intended
for those who need intensive follow-up treatment after undergoing
- In 2015, the Medical Center of Central Georgia paid the federal
government $20 million to settle allegations it billed Medicare for
more expensive inpatient services instead of the less costly outpatient
observation services it provided.
- In 2015, medical device manufacturer, Medtronics, agreed to pay
the U.S. government $4.4 million to settle a qui tam suit for violating
the Trade Agreements Act.
Permanent Memorandum (PM) #11- Outside Employment of University
PM-11 Establishes policies and procedures for LSU
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:
- Employment with a non-University employer
- Contract to provide consulting, personal or professional services
to non-University individuals or entities
- Self-employment or operation of a business
Economic benefits include cash payments (e.g. honorariums) or
such other non-cash economic benefit (e.g. trips, stock options, equity
Outside employment shall be performed only outside of assigned
working hours and shall not conflict, delay or interfere with an
obligation to LSU.
In accordance with the Academic Affairs Policy on Outside Employment, in order to qualify
for outside employment:
- The proposed activity would not be more appropriately
accomplished by a contract through the University; and
- The legal entity for which the outside employment is proposed
not have a substantial economic interest which may be affected by the
way in which the employee performs his or her duties and
responsibilities as a University employee; and
- The activity is approved for conduct outside the University;
YOUR Responsibilities Under PM-11
- Disclose any outside employment to the University
- Submit a list of all contracts or other agreements between the
University and the outside employer
- Provide notification to the outside employer accepting employment
as an individual not as a representative of the University
- Comply with the all other provisions of PM-11
Because activities conducted under PM-11 are by definition outside
the course and scope of an individual's employment with the University:
- University resources (e.g. personnel, supplies, facilities,
network, etc.) may not be used in support of the outside activity
- Leave must be taken if any time and effort in support of the
outside activity occurs during working hours.
- Outside activities are NOT covered by University insurance
coverage (e.g. liability, malpractice, etc.)
Chancellor's Memorandum (CM) #52 - Official Business Before
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
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:
- Shall clearly state that the opinions expressed are their own and
do not represent the official position of LSUHSC-NO.
- Shall not use their lsuhsc.edu email address for email
communications regarding matters of personal concern.
- Shall not use official LSUHSC-NO stationery for any mailings or
other hardcopy correspondence.
- Shall not use their official LSUHSC-NO title (e.g. "Department
Head", "Associate Professor", etc.) in any such communications.
- Shall not wear or carry anything with official LSUHSC-NO insignia
to a face-to-face meeting with any elected officials that might lead
those officials to assume this was an official LSUHSC-NO meeting.
- Shall take annual leave if any such face-to-face meeting occurs
during normal working hours.
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
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,
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
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
Step 1: Identification of Retention Period of the Records to be
- Once the major category of records has been identified, consult
the LSUHSC-NO Records Retention Schedule.
- Under the major category designations, there are subcategories
which determine the retention period for those types of records.
- According to the Louisiana Public Records Act, all records the
University maintains must be kept for the current year plus three
years. However, longer federal or contractual retention periods may
- If you are unsure what major category or subcategory to which a
particular record set belongs, contact the Office of Compliance
Programs or LSUHSC-NO Records Officer.
- In accordance with R.S. 44:411, written approval shall be
obtained from the State Archivist (or his designee) prior to the
disposing of any records of the agency.
- If records you wish to destroy do not fall under any category on
LSUHSC-NO’s Document Retention Schedule, contact the Office of
Compliance Programs to initiate the process to add line items of record
types prior to destroying the documents.
Step 2: Obtain Approval from State Archives
- Complete Form SS ARC 930. If there is a small number
of items to be destroyed you can list them directly on the form. When
destroying several different types of records you can attach a
spreadsheet of the items for sections #6 and #7 on the form.
- See examples of completed spreadsheets on the Office of
Compliance Programs website. (insert links)
- Send a scanned copy of the completed form with the attached
listing (if necessary) to email@example.com.
- Once the documents are ready, OCP will forward the documents to
LSUHSC-NO’s Records Officer for submission to State Archives. Note:
LSUHSC-NO’s Records Officer will sign and date the form as the
- You will be notified by email when written approval for the
destruction of the records from State Archives has been received.
Step 3: Disposal of Records-Paper
- The acceptable methods of destruction will be included on the
- Complete the Certificate of Destruction Form SS ARC 933 to
document the date of destruction. In the event that a third party
shredding company is used for destruction, the date the records are
transferred to the shredding company will constitute the destruction
- You must document the destruction of the records by maintaining
Certificate of Destruction form (SS ARC 933) along with the approved
request for destruction received back from State Archives (SS ARC 930).
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
take certain actions or limits the actions the university may take.
Examples of agreements include but are not limited to the following:
- Professional services contracts
- Medical directorship contracts
- Affiliation agreements
- Resident supervision contracts
- Clinical Trial Agreements
- Research Agreements
- Grant Award Agreements
- Confidentiality Disclosure Agreements
- Material Transfer Agreements
ALL agreements must be signed by the Chancellor or an Authorized
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:
- Report your
to your supervisor on or before the 5th day of the month following the
month the leave was taken in
order to be considered timely.
- Monitor your leave balances to ensure
accuracy. Leave cannot be taken in advance, so employees must
ensure they have enough leave in the system prior to submitting a
request. Leave balances can be viewed in Employee
- Report all instances of military deployment to your Department
Head and Human Resource Management’s Employee Relations Manager, to
ensure compliance with applicable federal law and university policy.
This would apply to the usual annual active duty requirement as well as
activation for any other reasons and includes any absence for military
reasons, whether it is charged to military leave, annual leave, or
leave without pay.
- If an employee transfers to another department of the University,
all original attendance and leave records, including but not limited to
Application for Leave forms, should be maintained in the original
department in accordance with the University’s retention policy.
- If an employee transfers to another State agency, it is the
employee’s responsibility to provide Human Resource Management the name
of the new agency in order to facilitate the proper transfer of
individual leave balances.
- Any employee who does not follow the University’s policies and
procedures may be subject to disciplinary action.
Louisiana Revised Statute 17:3311A(3) requires that daily leave and attendance records for unclassified
employees must be
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:
- Application for Leave (SF-6) which documents the permission
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.
- Certification of Attendance to which the unclassified employee
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
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
which they are certifying.
Faculty/Unclassified Employees’ Responsibilities:
- To report leave, unclassified employees must request leave (i.e.
Annual, Sick, Leave without Pay,
Educational, Military, and Civil) by submitting, in advance, a
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.
- In situations where an employee took a different amount of
than on the original leave request, a new leave request with the
correct amount shall be submitted and the original leave slip should be
- LSUHSC-NO’s online Application for Leave request must be used.
- Leave can only be taken in an initial half hour increments,
all subsequent time taken in quarter hour increments.
- 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
- 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
Classified Employees’ Responsibilities:
- Classified Employees shall report their leave by submitting a
completed University approved
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
- In situations where an employee took a different amount of
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
- Classified employees are responsible for certifying the
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.
- Ensure leave is charged in increments of one-tenth hour (6
Civil Service Rule 11.7(c).
- 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.
- 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.
- Ensure all “Applications for Leave” are signed by the employee
and their supervisor. If incomplete, return the form to the
- Ensure the employee has enough leave to take the requested
before entering it into PeopleSoft. Leave cannot be taken in
advance. If the balance is not sufficient return the leave form
to the employee’s supervisor for correction or rejection.
- 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
- Ensure a Per-3 is completed and forwarded to Human Resource
Management for all instances of LWOP for more than 30 consecutive
- For LWOP that involves a partial day, the specific hours must
noted and highlighted in the comment section.
- Ensure all part-time employees’ actual work schedule is listed
or attached to, all LWOP leave slips and/or Per-3s to for Human
Management to verify the dollar amount of LWOP.
- Maintain all original “Applications for Leave” and monthly
reconciliations in the department for audit purposes in accordance with
the University’s retention schedule.
- Ensure leave is reported in an initial half hour increment and
all subsequent time is reported in quarter hour increments.
If you have
any questions, please contact the Office of