Optional_2023 Board Resources

Title : Compliance: Board Compliance Program Oversight and Resolution Process Number : 4310 Version : 6

cannot reach this conclusion and the steps that will be taken to implement an effective Compliance Program. c. The Audit Committee will submit a resolution or written explanation in the Annual Report to the OIG for each of the five Reporting Periods of the CIA.

B. Information about the Compliance Program. 1. To fulfill its oversight obligation, the Audit Committee will receive quarterly reports on the effectiveness of Banner’s Compliance Program. a. The Chief Compliance Officer will provide these reports, which may include such items as the following: i. A summary of quarterly certifications and Exception Reports submitted by senior management; ii. Minutes/reports of the System Compliance Committee; iii. Completion rates for compliance courses; iv. Results of the risk assessment; v. The compliance audit plan, including a summary of any closed audits and the status of any open audits and their expected completion dates; vi. Information about internal investigations of significant compliance issues; vii. Updates regarding any audits or investigations conducted by government entities or government contractors that resulted in corrective actions plans, litigation, sanctions, or increased government scrutiny; viii. Details about Reportable Events; and ix. Other relevant information about the Compliance Program. b. After providing each quarterly report, the Chief Compliance Officer will confirm that the Audit Committee has concluded, to the best of each member’s knowledge, that Banner’s Compliance Program is effective or, if not, what additional information is required to make that determination. c. The Audit Committee Chair will update the full Board of Directors as necessary on compliance matters. 2. Throughout the year, the Audit Committee may receive additional information from the Chief Compliance Officer regarding compliance or regulatory issues occurring at Banner or within the health care industry. 3. The Audit Committee (as well as the rest of the Board of Directors) will annually complete compliance training that provides an overview of the seven elements of an effective compliance program as well as Banner’s implementation of those elements in its Compliance Program. This training will also address Banner’s CIA requirements and applicable Federal Health Care Program requirements. 4. The Audit Committee will contact the Chief Compliance Officer (or their designee) if it has any questions or concerns regarding Banner’s Compliance Program. The Ethics & Compliance Department will report to the OIG in writing any actions or changes that would affect the Audit Committee’s ability to perform the duties necessary to meet the CIA obligations within 15 days after such a change. IV. Procedure/Interventions: A. During the Reporting Period (Audit Committee) 1. The Audit Committee oversees and monitors Banner’s Compliance Program throughout the Reporting Period, which includes, but is not limited to, the following actions: a. Receiving quarterly reports from the Chief Compliance Officer; b. Completing compliance training; c. Reviewing any materials shared by the Chief Compliance Officer regarding compliance or regulatory issues; and

Page 4 of 5