Office of Compliance and Audit Services

I. Mission:

In keeping with Downstate Medical Center's ("DMC") commitment to conduct its business in an ethical and sound manner, in compliance with applicable regulations, policies and procedures, the Compliance and Audit Oversight Committee ("CAOC") has been established. The CAOC is a matrix executive committee with a mission to guide the compliance and audit activities of the Campus and to proactively strengthen the internal control environment.

II. Committee Composition:

1. The Vice President for Compliance and Audit Services shall be the Committee Chairperson.
2. The Committee membership shall include:
   1. President, DMC
   2. Chief Operating Officer and Executive Vice President, DMC
   3. Chief Executive Officer and Senior Vice President for Clinical Affairs, DMC
   4. Senior Vice President and Chief Financial Officer, DMC
   5. Chief Administrative Officer, University Hospital
   6. Assistant Vice President Finance, University Hospital
   7. Vice-President, Human Resources, DMC
   8. Associate Dean for Administration College of Medicine
   9. Assistant Vice-President, Scientific Affairs
   10. Chief Medical Officer, University Hospital
   11. Chairperson, CPMP/UPB
   12. Executive Director and CEO, CPMP/UPB
   13. Legal Counsel, DMC

III. Committee Members Attributes:

1. Committee members should collectively possess the following:
   1. Knowledge of Downstate's mission
   2. Independence and objectivity
   3. Sufficient time to serve
   4. Operational expertise
   5. Financial and health care reimbursement expertise
   6. Clinical expertise
   7. Regulatory expertise
   8. Internal control expertise
   9. Legal expertise
   10. Working knowledge of Federal Sentencing Guidelines (i.e., education, training, auditing, monitoring and corrective action)

IV. Meeting Requirements:

1. The Committee will meet at least four times per year
2. Where possible, the Agenda will be distributed in advance
3. Minutes will be documented and distributed prior to the following meeting

V. Committee's Primary Responsibilities:

The committee will review the overall regulatory, risk, and internal control environment in order to provide reasonable assurance of compliance with Federal and State laws, policies and procedures. To that end, the Office of Compliance and Audit Services ("OCAS") will develop a Compliance and Audit Annual Work Plan, (hereafter "Annual Work Plan") which will be submitted to the CAOC at the beginning of each fiscal year. The CAOC will review, if necessary revise, and approve the Annual Work Plan. Throughout the fiscal year updates and status of the Annual Work Plan will be provided to the CAOC by the Chair, members of the committee and relevant senior staff of the Campus. The committee will assess the effectiveness of the Compliance and Audit Programs that support the Campus activities including, but not limited to; education/training, assessments/auditing, corrective action, and monitoring. Under the general direction of the President and the OCAS Vice President, the committee will take action as appropriate to strengthen the Compliance and Audit programs.