(a) Various sections of this title require an entity to adopt and enforce an internal ethics and compliance program. To comply with that requirement, the entity must certify to the department that the entity:
  (1) has adopted an internal ethics and compliance program that:
    (A) is designed to detect and prevent violations of the law, including regulations, and ethical standards applicable to the entity or its officers or employees; and
    (B) satisfies all requirements of this section; and
  (2) enforces compliance with its internal ethics and compliance program.
(b) An entity's internal ethics and compliance program must be in writing and must provide compliance standards and procedures that the entity's employees and agents are expected to follow. At a minimum, the program must provide that:
  (1) high-level personnel are responsible for oversight of compliance with the standards and procedures;
  (2) appropriate care is being taken to avoid the delegation of substantial discretionary authority to individuals whom the entity knows, or should know, have a propensity to engage in illegal activities;
  (3) compliance standards and procedures are effectively communicated to all of the entity's employees, including members of the governing board if the entity has a governing board, by requiring them to participate in periodic training in ethics and in the requirements of the program;
  (4) compliance standards and procedures are effectively communicated to all of the entity's agents;
  (5) reasonable steps are being taken to achieve compliance with the compliance standards and procedures by:
    (A) using monitoring and auditing systems that are designed to reasonably detect noncompliance; and
    (B) providing and publicizing a system for the entity's employees and agents to report suspected noncompliance without fear of retaliation;
  (6) consistent enforcement of compliance standards and procedures is administered through appropriate disciplinary mechanisms;
  (7) reasonable steps are being taken to respond appropriately to detected offenses and to prevent future similar offenses; and
  (8) the entity has a written employee code of conduct that, at a minimum, addresses:
    (A) record retention;
    (B) fraud;
    (C) equal opportunity employment;
    (D) sexual harassment and sexual misconduct;
    (E) conflicts of interest;
    (F) personal use of the entity's property; and
    (G) gifts and honoraria.
(c) The department may, at its discretion, request that the entity provide the department with written evidence of the entity's internal ethics and compliance program.

Source Note: The provisions of this §10.51 adopted to be effective January 6, 2011, 35 TexReg 11951; amended to be effective July 20, 2011, 36 TexReg 4573