Compliance and Audit Oversight Committee Charter

I. Mission:

In keeping with SUNY Downstate Health Sciences University’s (Downstate) 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 an 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 of Compliance and Audit shall be the Committee Chairperson.
  2. The Committee membership shall include:                              
    1. President, Downstate

    2. Dean, College of Medicine

    3. Associate Dean, College of Medicine

    4. Chief Executive Officer, University Hospital at Downstate

    5. Senior VP Operations, University Hospital at Downstate

    6. Chief Administrative Officer, Downstate

    7. Senior VP for Research, Downstate

    8. Chairperson, CPMP/DHP

    9. Executive Director, CPMP/DHP

    10. Chief Financial Officer, CPMP/ DHP

    11. Chief Financial Officer, Downstate

    12. Chief Information Officer, Downstate

    13. Assistant Vice President for Finance, University Hospital at Downstate

    14. Chief Medical Officer, University Hospital at Downstate

    15. Chief Medical Information Officer, University Hospital at Downstate

    16. Chief Quality Officer, University Hospital at Downstate
    17. Senior Associate VP for HR
    18. Senior Associate VP of Finance & Deputy CFO, Downstate
    19. Counsel, Downstate

    20. Vice President for Compliance and Audit and Chief Compliance Officer, Downstate

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 annually and more often if necessary
  2. Where possible, the agenda will be distributed in advance
  3. Minutes will be documented and distributed following the 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 and approve the Annual Work Plan.  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 Chief Compliance Officer, the committee will take action, as appropriate, to strengthen the Compliance and Audit programs.