University Policy 1003

University Responsibility for Compliance

  • Responsible Oversight Executive:ÌýVice President for Strategic Operations and Chief of Staff
  • Date of Current Revision or Creation:ÌýOctober 8, 2024
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¹ÏÉñÍø is committed to fostering an institutional culture of ethical conduct and adherence to compliance requirements by establishing and maintaining an effective university compliance program. Critical to this process is the recognition that the responsibility for upholding ethical standards rests with every individual employee. The purpose of this policy is to establish the University's framework for compliance with applicable laws, rules, regulations, and standards and institutional policies and to define the responsibilities of the Compliance Advisory Committee, Vice Presidents, and individuals in meeting and maintaining compliance requirements.

, grants authority to the Board of Visitors to make rules and policies concerning the institution. Section 7.01(a)(6) of theÌýBoard of Visitors BylawsÌýgrants authority to the President to implement the policies and procedures of the Board relating to University operations.

Ìý- "We will maintain the highest level of ethical standards and comply with all applicable laws and regulations and University policies.

Compliance OwnersÌý- Amy person with assigned or delegated authority over the operational aspects of compliance obligations for a particular unit/division/function of the institution. The compliance owner serves as a central point of contact, coordination, and oversight for the compliance-related matters within the scope of the obligations they own.

Compliance RequirementsÌý- Federal, state, and local laws, rules, regulations, standards, and institutional policies and procedures that University employees, students, volunteers, and vendors are expected to be aware of and adhere to.

University Compliance MatrixÌý- An inventory of complianceÌýrequirements that includes a description of the activity, reporting, and disclosure requirements and applicable deadlines, regulation or other citable reference, responsible executive oversight, responsible office, responsible compliance owner position number and title, and applicable compliance partners.

University Compliance Network – A network established and led by the University Compliance Officer, bringing together operational owners of compliance functions to ensure collaboration and coordination of compliance activities across the institution and in accordance with the University Compliance Program.

University Compliance Officer – A compliance leader responsible for providing direction and centralized oversight of the University Compliance Program.

University Compliance Program – A university-wide program designed to track, monitor, assess, and support compliance with applicable federal, state, and local laws, rules, regulations, and standards and institutional policies and procedures through mechanisms to prevent, detect, and correct violations and misconduct.

This policy applies to all employees, students, volunteers, and vendors. Employees include all staff, administrators, faculty, full- or part-time, and classified or non-classified persons who are paid by the University. Students include all persons admitted to the University who have not completed a program of study for which they were enrolled; student status continues whether or not the University’s programs are in session. Volunteers include individuals who perform services in support of the University’s mission without promise, expectation, or receipt of compensation for services rendered. Vendors are those individuals who have a relationship with the University by virtue of a contract.

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Compliance with laws, rules, and regulations is mandated by several oversight agencies and authorities that impose requirements on the University. The risks of non-compliance can be significant, and may include, but are not limited to, loss of accreditation, reputation, and/or funding, financial and non-financial penalties, and potential criminal prosecution.

This policy outlines the University’s compliance structure and responsibilities in its commitment to fostering an institutional culture of ethical conduct and adherence to compliance requirements. University compliance is a shared responsibility among all employees, students, volunteers, and vendors.

The University adopts the U.S. Federal Sentencing Guidelines, Seven Elements of an Effective Compliance Program framework as a baseline for establishing and maintaining the University Compliance Program.

The role of the University Compliance Officer is to direct and oversee the development and preservation of the University Compliance Program and University Compliance Network.

The role of the University Compliance Network is to promote compliance awareness among the University’s academic and administrative units. These duties include:

  • Collaborating with the University Compliance Officer to perform compliance risk and progrma assessments, and maintenance of the University Compliance Matrix;
  • Promoting effective communication and collaboration among those responsible for compliance;
  • Monitoring emerging compliance trends and disseminating information as needed;
  • Developing, maintaining, and improving compliance related processes;
  • Working with the University's Policy Review Committee to ensure development of policies and procedures required for current or future compliance requirements; and
  • Making recommendations to senior management as to any resources or actions required for University compliance.

Vice Presidents and compliance owners are responsibleÌýfor promoting compliance awareness and responsibilities within their respective areas; maintaining an inventory of all compliance requirements for units within their areas of oversight; developing and implementing applicable policies and procedures, providing compliance training and communications; and developing programs, processes, and internal controls to ensure compliance requirements are met.

All University employees, students, volunteers, and vendors are expected to be aware of and adhere to any compliance requirements that are applicable to their respective status and responsibilities within the University. They are also responsible for being cognizant of any changes in the compliance environment that may impact these responsibilities and, where applicable, cooperating with other affected units of the University to ensure compliance requirements are met for the University as a whole. Additionally, all University employees, students, volunteers, and vendors have a responsibility to report any suspected compliance violations or ethical misconduct.

Failure to comply with the requirements of this policy may result in disciplinary action up to and including termination or expulsion in accordance with relevant University policies. Additionally, non-compliance with federal, state, and other regulations related to operations may result in fines, penalties, and other legal action.

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  1. The University Compliance Officer will establish and maintain a centralized compliance program promoting a culture of ethical conduct and adherence to compliance requirements by enhancing awareness of compliance risks and responsibilities, improving communication and coordination, monitoring and assessing compliance activities, and supporting compliance owners with their responsibilities. The University Compliance Officer will exercise independent oversight of the adequacy of compliance activities, tracking and monitoring compliance statuses for periodic reporting to the Board of Visitors Audit, Compliance, and Human Resources Committee.

  2. The University Compliance Officer, in consultation with the Vice Presidents, will establish a University Compliance Network, comprised of compliance owners and subject-matter experts from the University's major compliance areas. The University Compliance Officer will lead the Network's coordination and assessment of compliance and will determine the scope and frequence of meetings in the fulfillment of its duties as outlined in this policy.

  3. The Vice Presidents, in collaboration with respective compliance owners, will maintain an inventory of all compliance requirements within their areas of oversight. The inventory should include the position number and title of the employee(s)Ìýresponsible for each compliance requirement and any associated reporting requirements. The inventories will be submitted to the University Compliance Officer, as requested, or as changes are made throughout the year. The inventories will be used to establish the comprehensive University Compliance Matrix maintained by the University Compliance Officer. Vice Presidents are responsible for enforcing accountability and should ensure that position descriptions for those employeesÌýwho have been identified as responsible for meeting compliance requirements include compliance as a core responsibility that is evaluated during the annual evaluation period.

  4. Compliance owners are responsible for managing all aspects of adherence to rules and regulations within the scope of their assigned authority, including staying updated on the ever-changing legal landscape, interpreting compliance regulations, documenting and maintaining policies and procedures, promoting accountability for establishing clear objectives and lines of responsibility, providing communication and training, implementing effective strategies and controls, and tracking progress to ensure the organization's activities align with these requirements. Compliance owners shall promptly notify the University Compliance Officer of the results of regulatory findings, external audits (state, federal, or third-party), and external regulatory inspections.

Applicable records must be retained and then destroyed in accordance with theÌý.

University Compliance Officer

Policy History

Policy Formulation Committee (PFC) & Responsible Officer Approval to Proceed:

/s/ÌýChristina Russell


Responsible Officer


October 3, 2024


Date


Policy Review Committee (PRC) Approval to Proceed:

/s/ÌýDonna W. Meeks


Chair, Policy Review Committee (PRC)


June 18, 2024


Date


Executive Policy Review Committee (EPRC) Approval to Proceed:

/s/ÌýAshley L. Schumaker


Responsible Oversight Executive


October 8, 2024


Date


University Counsel Approval to Proceed:

/s/ÌýAllen T. Wilson


University Counsel


October 7, 2024


Date


Presidential Approval:

/s/ÌýBrian O. Hemphill, Ph.D.


President


October 8, 2024


Date

Previous Revisions: May 16, 2013; November 21, 2019; October 8, 2024

Scheduled Review Date: October 8, 2029