Ohio Admin. Code 3364-15-03

Current through all regulations passed and filed through August 12, 2024
Section 3364-15-03 - Compliance incident reporting
(A) Policy statement

The university of Toledo ("UToledo") strives to comply with all federal, state, and local statutes. This policy sets forth the procedures that UToledo will use to respond to reports by institutional members or others regarding possible violations of UToledo policies and procedures or a possible violation of applicable state and federal laws.

(B) Purpose of policy

This policy establishes UToledo's response in situations where UToledo policies, rules and standards, state and federal regulations have been violated either inadvertently or knowingly. Corrective action or procedure are necessary to ensure compliance. It is necessary to protect UToledo in the event of civil or criminal enforcement actions.

(C) Scope

All UToledo campuses.

(D) Definitions

"Institutional members" Any person who participates in university activities, or has an affiliation with UToledo, including but not limited to staff, faculty, providers of medical services, contractors, vendors, students, alumni and volunteers, whether or not they are paid by UToledo.

(E) Procedures
(1) Institutional member duty.

Institutional members have a duty to ask questions regarding potential issues and to report potential concerns. If any institutional member knows of or suspects a violation, they are to report it immediately without fear of retaliation. At no time will any retaliatory action be taken against any individual who files a good faith complaint. Please refer to rule 3364-15-04 of the Administrative Code (non-retaliation).

(2) Students and student employees seeking to raise concerns should speak directly with the responsible UToledo office/student conduct office. Student employees who have concerns regarding their UToledo job can use this policy.
(3) Reporting methods.

Institutional members may report in good faith incidents or suspicious activities in the manner listed in this rule. Information received will be maintained confidentially to the extent the law permits.

(a) Local resolution.

The recommended method to raise a concern begins with your own college, department or unit through supervisory channels or you may report to:

(b) Central offices.

Due to the subject matter, work or personal relationship, it may be best to raise questions through a specialized central office. Examples include:

(i) Human resources or the office of diversity and inclusion for employment concerns, discrimination or sexual harassment.
(ii) The office of athletics compliance for possible national collegiate athletic association ("NCAA") violations.
(iii) The office of research and sponsored programs for research concerns.
(c) Department of internal audit and compliance.

If the institutional member is uncomfortable with addressing concerns at the local level or through a central office, needs advice on how to handle an issue, or issues have not been resolved satisfactorily, the institutional member can call and report directly to the department of internal audit and compliance. Institutional members may also submit a written report to the department of internal audit and compliance.

(d) Anonymous reporting line.

UToledo has an anonymous reporting line to report any situation without using any personally identifiable information (888-416-1308). Refer to rule 3364-15-05 of the Administrative Code (protected disclosures and anonymous reporting line policy).

(e) Direct reporting.

Should institutional members feel that the issues or concerns are not being addressed by administration; the institutional member may file a complaint directly to the government or supporting agency.

(4) Investigations are conducted in compliance with procedures set within the internal audit and compliance department.
(5) Training

All institutional members are provided training on how to report suspected violations of UToledo policies, state and federal regulations.

(F) Enforcement

The failure of any institutional member to perform any obligation required of this policy or applicable local, state, and federal laws or regulations is subject to established UToledo disciplinary actions and/or prosecution by state or federal authorities.

(G) List of critical areas of compliance concern (not all inclusive)
(1) Fraud, waste and abuse
(2) False claims
(3) Medicare and medicaid anti-kickback statutes/stark laws
(4) Improper claims for clinical trials
(5) Research
(6) Provider based clinics
(7) Organ acquisition
(8) Direct graduate medical education/indirect medical education ("DGME/IME") reimbursement
(9) Emergency medical treatment and active labor act ("EMTALA")
(10) Medicare art D
(11) Joint commission
(12) University and medical center policies
(13) Family Educational Rights and Pprivacy Act ("FERPA")
(14) Health Insurance Portability and Accountability Act ("HIPAA")
(15) Construction
(16) National collegiate athletic association ("NCAA")
(17) Record industry association of America ("RIAA")
(18) Public records laws
(19) Ohio ethics laws
(20) Discrimination laws
(21) Federal financial aid
(22) Part 2 ("SAMHSA")

Replaces: 3364-15-03

Ohio Admin. Code 3364-15-03

Effective: 4/2/2020
Promulgated Under: 111.15
Statutory Authority: 3364
Rule Amplifies: 3364
Prior effective dates: 6/1/2016