URMC Compliance Program Policy Manual:
Regulations

The URMC entities operate in a highly regulated industry, and must monitor compliance with a great variety of highly complex regulatory schemes. The cooperation is needed of employees and professional staff members in complying with these regulations and brining lapses or violations to light. While the regulatory schemes may not carry criminal penalties, they control the licenses and certifications that allow the system to deliver care to its patients. The system's continued ability to operate and serve the community depends upon each employee's help in regulatory compliance.

Some of the regulatory programs which employees may deal with in the course of their duties include the following:

  • New York State licensure
  • JCAHO accreditation
  • Medicare certification and conditions of participation
  • Certificate of Need
  • Controlled substance registration
  • Pharmacy licensure and registration
  • Clinical laboratory licensure and regulation
  • Union rules and collective bargaining agreements
  • Occupational Safety and Health regulation
  • Building, safety, food service and fire codes
  • Nurse Practice Act

The Compliance Officer can provide employees with information on these rules, and can direct questions or concerns to the proper person.