GOV-003: University Corporate Compliance Program for Adherence to Federal, State, and Other Regulations

Date: 06/21/2010 Status: Final
Last Revised: 01/18/2017
Policy Type: University
Contact Office: Compliance Office
Oversight Executive: Executive Vice President and Chief Operating Officer
Applies To: Academic Division, the Medical Center, and the College at Wise.
Reason for Policy:

The University exercises due diligence to comply with federal, state, and other regulations related to its operations. The University has established standards for its compliance programs and identified the responsibilities of senior leaders, compliance officers, and operational managers to promote greater coordination of and consistency among individual University compliance programs.

Definition of Terms in Statement:
  • Corporate Compliance Program:

    A formal program that supports the University’s commitment to following policies and standards of conduct to assist in its compliance with applicable federal, state, and other regulations.

Policy Statement:

The University will comply with federal, state, and other regulations. The Executive Vice President & Chief Operating Officer (EVP&COO) is the University’s Corporate Compliance Officer.

The University’s corporate compliance program provides oversight of individual compliance programs in specific functions of the University, e.g., human resources/equal employment opportunity/Department of Labor, protection of research subjects, research costs, medical reimbursements, tax and other financial issues, environmental and employee health and safety, integrity and ethical conduct, records management, NCAA, etc. Vice Presidents and equivalent officers are responsible for establishing and overseeing compliance programs within their functional areas, and reporting significant issues to the EVP&COO and the Assistant Vice President for Compliance. The University’s compliance efforts will be evaluated through the services of external and internal auditors, the Office of University Counsel, as well as periodic assessments by management.

  1. Compliance Program Standards:
    The University has established standards for individual compliance programs, based on the criteria used in the Federal Sentencing Guidelines, the current version of which includes the following:
    1. Compliance standards and procedures to prevent and detect criminal activity;
    2. Oversight by high-level personnel, with periodic reporting to the board from individuals with operational responsibility;
    3. Due care in delegating substantial discretionary authority;
    4. Effective communication and training to all levels of employees;
    5. Systems for monitoring, auditing, and reporting suspected wrong-doing without fear of reprisal and for periodically evaluating the effectiveness of the compliance program;
    6. Consistent enforcement of compliance standards including disciplinary mechanisms and appropriate incentives to perform in accordance with the compliance program; and
    7. Reasonable steps to respond to and prevent further similar offenses upon detection of a violation.
  2. Responsibilities:
    1. The Executive Vice President & Chief Operating Officer will:
      • Approve compliance policies, upon recommendation by the University’s Policy Review Committee and the Assistant Vice President for Compliance.
    2. The Assistant Vice President for Compliance will:
      • Oversee all compliance functions, including but not limited to:
        • Confirming that the university maintains compliance programs across the University that address applicable laws, meet University standards and are consistently managed and documented;
        • Coordinating communication and monitoring activities in connection with the corporate compliance program; and
        • Overseeing the implementation of corrective actions to be taken when deemed necessary.
      • Provide reports on compliance matters to the Board of Visitors.
    3. The Vice Presidents (and Equivalent Officers) will:
      • Oversee compliance in their specific functional areas;
      • Designate individuals within their units as compliance officers who will be responsible for compliance activities;
      • Adhere to the University compliance program standards outlined in Section 1, Compliance Program Standards, above;
      • Implement or recommend corrective action as necessary; and
      • Provide reports on significant compliance issues to the University’s EVP&COO.
    4. Compliance Officers will:
      • Report to the Vice President of their unit regarding both operational and compliance matters;
      • With guidance from the Vice President to whom they report:
        • develop appropriate policies and procedures to enable compliance with rules and regulations;
        • train and communicate on compliance issues;
        • maintain required documentation (e.g., of training completed); and
        • use feedback (including detected violations) to make improvements.
      • Recommend corrective action as appropriate; and
      • Report to and consult with the Assistant Vice President for Compliance and the EVP&COO on significant compliance issues, reporting requirements, and external compliance reviews.
    5. Operational Managers will:
      • Implement policies and procedures to enable compliance with rules and regulations;
      • Implement corrective actions when necessary; and
      • Provide reports to the relevant compliance officer or Vice President about compliance issues requiring attention.
Related Information:

Code of Ethics
Compliance Matrix

Major Category: Governance
Next Scheduled Review: 01/18/2020
Approved by, Date: Executive Vice President and Chief Operating Officer, 06/21/2010
Revision History: Updated on 1/18/17.