Handbook of Operating Procedures

I. POLICY AND GENERAL STATEMENT

The University of Texas Health Science Center at Houston (“University”) is committed to exercising due diligence to prevent and detect unethical behavior and/or violations of applicable laws, regulations and policies by its employees, residents² and vendors (including independent contractors and contractors) which would require exclusion from participation in federal and state health care programs. The University is further committed to exercising due care to avoid delegating substantial discretionary authority to an individual or other entity known to have a propensity to engage in unlawful or unethical activities.

Federal and state agencies have the authority to exclude individuals or entities who have engaged in fraud or abuse from participation in programs the agencies sponsor. Entities that employ or contract with excluded individuals or entities may incur civil monetary penalties or be excluded from participation in federal and state programs.

The University makes a reasonable inquiry into the status of post-offer applicants for employment, applicants for University residency programs, employees, residents currently enrolled in University residency programs, and vendors as described in the Exclusion Check Guidelines. These checks will be conducted prior to the start of employment for post-offer applicants, prior to acceptance of applicants for residency programs, prior to the issuance of a vendor code for a vendor, prior to the set-up of a vendor in the University’s financial system and before the execution of a contract with a vendor.  Checks will also be conducted on a monthly basis for all employees and residents; on a monthly basis for vendors; and prior to the issuance of a purchase order of $25,000 or more by the responsible parties. The responsible parties include Human Resources (“HR”), the School of Dentistry's Office of Student and Academic Affairs (“SDOSAA”), the Office of Graduate Medical Education (“OGME”), and Procurement Services.  Each of these responsible parties must provide the Office of Institutional Compliance ("OIC") with a report, at least quarterly, confirming that the required checks have been completed.  Each of these responsible parties will have the responsibility for confirming any potential matches and notifying OIC as soon as practicable.  OIC will coordinate with the affected departments to ensure adherence to the guidelines.

Failure to adhere to this policy by University personnel could result in disciplinary action, up to and including termination or dismissal.

II. PROCEDURE

A. Exclusion and Debarment Lists

The responsible parties shall check for:

1. Debarment, exclusion, or other ineligibility for participation in federally funded health care programs or receipt of federal funds by querying the List of Excluded Individuals/Entities maintained by the Department of Health and Human Services, Office of the Inspector General;
2. Debarment, exclusion, or other ineligibility for participation in state and federally funded health care programs or receipt of state or federal funds by querying the Medicaid and Title XX Provider Exclusion List maintained by the Texas Health and Human Services Commission; 
3. Debarment, exclusion, or other ineligibility for participation from federal procurement programs by querying the System for Award Management;
4. Designation as a Specialty Designated National by querying the Specially Designated Nationals List maintained by the United States Department of the Treasury, Office of Foreign Assets Control;
5. Good standing with the Texas Comptroller of Public Accounts by querying the Franchise Tax Account Status database maintained by the Texas Comptroller of Public Accounts; and, 
6. Debarment from Texas state procurement programs by querying the Texas Procurement and Support Service's Suspended and Debarred Vendor List.

Post-offer applicants for employment, applicants for residency programs, employees, and residents will be subject to checks of all the above noted exclusion and debarment lists with the exception of those lists named in sections 5 and 6.  Vendors will be subject to checks of all the above noted exclusion and debarment lists.

B. Confirmation of Exclusion, Debarment or Designation

The Exclusion Check Guidelines detail the consequences and procedures if an individual or entity is confirmed as being excluded, debarred, or designated.

C. Reinstatement of Eligibility for Employment, Placement or Business

Upon being removed from an exclusion list, a vendor shall be eligible to do business with the University. The vendor’s eligibility to do business with the University is subject to verification of the vendor’s status by the appropriate responsible party.

Upon being removed from an exclusion list, an individual whose offer of employment or offer of placement in a residency program was rescinded or an employee who was terminated as a result of being excluded is considered eligible to apply for employment or enrollment in a residency program with the University.

D. Reporting of Exclusion or Debarment

Any employee or any resident enrolled in a University residency program who receives notification that he/she has been placed on an exclusion or debarment list as indicated above must inform his/her supervisor and the Chief Compliance Officer immediately.

E. Administrative Error

If an employee, resident enrolled in a University residency program or vendor can provide sufficient documentation to OIC to demonstrate an administrative error and to demonstrate that the individual or vendor has taken prompt action to correct the administrative error, the University will take appropriate corrective action immediately. Employees and residents will be immediately returned to their regular status and pay will be reinstated to them for the period they were placed on leave without pay. Vendors will be returned to regular status within the University’s financial system and will immediately be eligible to do business with the University.

¹ Please note that for purposes of this policy and the accompanying guidelines, the term “residency program” also includes clinical fellowships and research fellowships.

² Please note that for purposes of this policy and the accompanying guidelines, the term “resident” also includes clinical fellows and research fellows.

III. CONTACTS

• • Office of Institutional Compliance
  • 713-500-3294
  • compliance@uth.tmc.edu
  • https://www.uth.edu/compliance/

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