1. ABC Organization will conduct an annual review of its Compliance Program elements as
well as an assessment of the overall success of the program. The following
Compliance Program elements will be individually reviewed and evaluated:
a) Designation of a Compliance Officer and Compliance Committee. This aspect
involves review of the ABC Organization “structure” to conduct compliance
activities, reporting relationships and interpersonal relationships among ABC
Organization’s personnel with compliance responsibilities, and among the
Compliance Committee and Compliance Officer and the Board of Trustees.
b) Development of Compliance Policies and Procedures, including Standards of
Conduct. This includes a review of policies and procedures for accuracy,
readability and updating plus an evaluation of policy and standards’ knowledge
and compliance.
Review of this element also includes the development and use of a risk assessment
c) Developing Open Lines of Communication. Evaluation here requires an assessment
of reporting line effectiveness and use, review of investigations and reports of
investigations and review and evaluation of methods for conveying ongoing
compliance information within the organization.
d) Appropriate Training and Education. Current compliance training offered to
employers, contractors and agents of the ABC Organization should be
inventoried, both general and specific to individual roles and duties; evaluate
and update content; review personnel evaluations of training programs; review
compliance with education requirements and assess compliance education
provided to the Board of Trustees.
e) Internal Monitoring and Auditing. Plans for programs should be reviewed and
monitoring and auditing results and reports evaluated, including evaluation of
the use of external auditors. Trends in error rates should be assessed.
f) Response to Detected Deficiencies. Review ABC Organizations’ response to
deficiencies detected through audits or other means in terms of timeliness of
investigation and correction, the quality and effectiveness of corrective action
plans and the results of monitoring to determine whether corrective action was
g) Enforcement of Disciplinary Standards. Review the consistency of required
background education and disciplinary standards pertinent to compliance.
Consider whether ABC Organization’s employees, contractors and agents are
notified and periodically reminded of the standards of conduct and disciplinary
consequences for infractions.
2. Annual reviewed of Compliance Program elements and overall effectiveness will be
initiated and planned by the Compliance Officer working with the Compliance
Committee, Legal Counsel and technical consultants as appropriate. The evaluation
process needs not be highly technical or performed by external consultants. However,
it will be planned and conducted in a manner designed to gather objective information
and to detect areas requiring correction, improvement and/or further development.
3. Following review of all Compliance Program elements and overall effectiveness, the
Compliance Officer, with the assistance of the Compliance Committee, will develop
goals and improvement plans for the Compliance Program that respond to the findings
and conclusion of the review.
4. Results of the annual review of the Compliance Program, along with goals and
improvement plans, will be reported to the Board of Trustees.