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Institutional Compliance Committee Charge
Committee Makeup
Cross-functional managers
who have high-risk compliance issues within their area of control.
Committee Charge
The committee is to develop
a compliance plan. The committee will also be responsible for organizing,
directing and controlling compliance activities. This will be an ongoing
working committee that meets at least quarterly (more frequently
initially).
Specifically:
- Each committee member
will conduct a comprehensive risk assessment of compliance issues within
the area represented. This risk assessment will be accomplished through a
smaller working team within the department. Those team members will be
identified on the Risk Assessment for each department.
- Each identified
compliance issue will be evaluated and assigned a level of risk.
- Each committee member
will then assess the current monitoring mechanisms for the high risk areas
that were identified within the department;
- Each committee member
will then identify and implement additional monitoring, training or other
efforts that need to be initiated to mitigate the higher risks
identified. Mitigation efforts include:
- Operating Controls:
Those procedures that are applied to every event/transaction in a
process to ensure compliance with the policies and procedures governing
the process. This includes policies and procedures, segregation of
duties and reconciliations, etc.
- Supervisory Controls:
Those procedures performed immediately thereafter by first line
management, usually on a sample of all events/transactions to determine
if the operating controls have been applied as designed.
- Oversight Controls:
Those procedures applied periodically by senior management to ensure
that supervisory and/or operating controls have been applied as
designed. Examples include: status reports, exception reports, budgeted
versus actual comparisons, etc.
- Internal Auditor
Controls: Those procedures applied periodically by auditors outside the
department to test and evaluate sample populations of events or
transactions for compliance with policies and procedures.
- The committee as a group
will prepare a report of its findings according to the UHS Action Plan and
timeline. Administration will then have an opportunity to review and take
corrective action where appropriate.
- Each committee member
will prepare a periodical report (minimally semi-annually) reporting on
the status of Institutional Compliance efforts within the department.
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