Drexel University College of Medicine

DREXEL UNIVERSITY COLLEGE OF MEDICINE
COMPLIANCE AND ETHICS PLAN
COMPLIANCE AND ETHICS PLAN CHARTER

1. STATEMENT OF PURPOSE
   The Philadelphia Health and Education Corporation d/b/a Drexel University College of Medicine and each of its schools, divisions, subsidiaries, and operating or business units (the “University”) operates in a highly competitive environment and under complex and rapidly changing laws and regulations. The University is an educational institution comprised of four Schools: the School of Medicine, the School of Health Professions, the School of Nursing and the School of Public Health.

This Compliance and Ethics Plan was created to define the scope of conduct expected of trustees, officers, faculty, employees, agents and students of the University (hereinafter collectively referred to as “Members of the University Community”). However, compliance with these laws and regulations is challenging because they are complex and are constantly changing. Compliance is also difficult because the laws and regulations frequently do not provide sufficient guidance or answers to specific questions. Therefore, this Compliance and Ethics Plan is not intended to be all-inclusive. The University relies on each individual’s sense of fairness, honesty and integrity to meet the challenges (s)he may face in providing quality health care.

With this Compliance and Ethics Plan, the University intends to promote compliance with the legal duties imposed upon it as a health care entity (in addition to those already contained in University policies), to foster and assure ethical conduct, and to provide guidance to Members of the University Community for their conduct. This Compliance and Ethics Plan has been developed to assist Members of the University Community in complying with all University policies and procedures, including the Compliance and Ethics Plan, and applicable federal, state and local laws and regulations, including Medicare and Medicaid requirements (hereinafter collectively referred to as “Applicable Rules”). In addition, the Compliance and Ethics Plan has been designed to comply with the OIG’s Compliance and Ethics Plan Guidance for Hospitals, which is based on the Federal Sentencing Guidelines.

The Compliance and Ethics Plan has the following components:

1. Establishment of a written Code of Conduct and written policies and procedures that govern the actions of all Members of the University Community.
2. The appointment of a Chief Compliance Officer (“CCO”) and a Compliance Committee, who are charged with the responsibility of directing the University’s compliance efforts, including implementing the Compliance and Ethics Plan.
3. The development and implementation of education and training of all affected Members of the University Community.
4. Maintenance of a process, such as a Hotline, for Members of the University Community to report instances of possible non-compliance with Applicable Rules without fear of retaliation, and the adoption of procedures to protect the anonymity of complainants.
5. The establishment of a system to respond to allegations of improper or illegal activities and the enforcement of appropriate disciplinary action against Members of the University Community who have violated the Applicable Rules.
6. The use of audits or reviews to assess compliance and to assist in the reduction of identified problem areas.
7. The investigation and correction of identified systemic problems, and the development of policies addressing the non-employment or retention of sanctioned individuals.

The Compliance and Ethics Plan is primarily intended to establish a framework for ethical responsibilities and legal compliance by the University. It is not intended to set forth all the substantive Compliance and Ethics Plans and practices of the University that are designed to achieve compliance, nor is it intended to replace the University’s moral commitments and values. The University already maintains various corporate practices which are aimed at monitoring the University’s activities, and those practices will continue to be a part of its overall legal compliance efforts.

2. WRITTEN GUIDELINES, POLICIES AND PROCEDURES
   1. Compliance and Ethics Plan Manual
      1. Compliance and Ethics Plan Charter
         The Compliance and Ethics Plan Charter articulates the purpose of the University’s Compliance and Ethics Plan, describes its scope, and prescribes how it will be implemented.
      2. Code of Conduct
         A Code of Conduct setting forth the principles and standards to which the University employees are expected to adhere is included under Tab “C.” The Code of Conduct contains principles articulating the policy of the organization and standards, which are intended to provide additional guidance to persons functioning in managerial or administrative capacities.
      3. Policies and Procedures
         Integral to the Compliance and Ethics Plan are the Compliance Policies and Procedures (“Policies”). These Policies establish the expected actions or work-related behaviors of all Members of the University Community. These Policies may be updated from time to time as is necessary to reflect new situations or expectations of those providing services for the University, or to reflect changes in the Applicable Rules.
      4. Defined Terms
         All defined terms in either the Compliance and Ethics Plan Charter or the Code of Conduct shall have the associated meaning when used in any of the Policies or in any other document which is incorporated into the Compliance and Ethics Plan Manual.
   2. Bulletins and Notices
      From time to time, as necessary, the University will issue additional bulletins, notices and policies relating to compliance issues. Once these are issued, they will become part of the Compliance and Ethics Plan.
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