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Email: hr@wju.edu
Phone: 1-304-243-8152


Compliance: Audits & Corrective Actions


Date approved:
July 2012
Approved by:
 
Date to be reviewed:
July 2015
Reviewed by:
Audit Committee
Date revised:
February 2014
Revision number:
1.2

1.0 PURPOSE

To locate and correct areas of non-compliance through internal or external audits, investigations, or corrective actions initiated by the findings of the Title IX Committee of the University.

2.0 POLICY

2.1 Policy Statement

    1. Allegations of non-compliance:
      • Stakeholders may report allegations of non-compliance through multiple channels.
      • All reported allegations of non-compliance will be logged, assessed, and, if necessary, investigated.
      • Written findings either substantiating or dismissing an allegation must be prepared in response to an investigation.
    2. Incidents of non-compliance:
      • Incidents of non-compliance may be discovered during an audit of the compliance inventory.
      • All incidents of non-compliance will be logged separately within individual audit reports.
      • Written incident reports must be prepared upon discovery during an audit of the compliance inventory.
    3. Corrective actions must be prepared in response to all written findings and incident reports.
    4. Serious allegations / incidents must be reported to the president and the audit committee.
    5. Summaries of logs and audits must be reported annually to the president and the audit committee.

2.2 Definitions

    1. Stakeholders - Employees, students, and individuals associated directly or indirectly with the University.
    2. Allegation of Non-Compliance - An unsubstantiated report of a compliance infraction.
    3. Incident - A written, corroborated, discovery of non-compliance uncovered in an audit.
    4. Finding - A written report either substantiating or dismissing an allegation of non-compliance.
    5. Incident Report - A written report either substantiating or dismissing an incident of non-compliance.
    6. Corrective Action - A written report in response to a prepared finding or incident.
    7. Serious Allegations / Incidents - Reports that jeopardize the reputation or finances of the University.

2.3 Reporting Non-Compliance

    1. Allegations of non-compliance can be reported two (2) ways:
      • In writing or in person per posted University policies.
      • Anonymously via the hotline [refer to the Human Resource Whistleblower Policy].
    2. Incidents may be reported as the result of a formal or informal audit of a compliance area.

2.4 Investigating Non-Compliance

    1. The compliance coordinator will assess each report of alleged non-compliance on a case-by-case basis. Due diligence will be taken and the decision whether or not to contact legal counsel and to conduct an investigation will also be determined on a case-by-case basis.
    2. The compliance coordinator will assess each written incident. Due diligence will be taken and the decision whether or not to contact legal counsel will be determined on a case-by-case basis.

2.5 Tracking Non-Compliance

  1. Reported allegations of non-compliance will be logged by the compliance coordinator by type, date, and location of the file. Information will be protected as "restricted" with attorney-client privilege; only counsel or the Audit Committee may change that designation.
  2. Incidents of non-compliance will be summarized in writing by the compliance team members involved in the audit and presented to the compliance coordinator. Information will be protected as "restricted" with attorney-client privilege; only counsel or the Audit Committee may change that designation.

2.6 Corrective Actions

  1. The compliance coordinator will report findings / incidents substantiating non-compliance to the president.
  2. The president and compliance coordinator will determine who will prepare the corrective action.
  3. Corrective actions must address the specific situation, policy, or individual noted in the findings / incident.
  4. Corrective actions with employees will be according to Human Resource policies; corrective actions with students will be according to the Student Handbook.
  5. Corrective actions with policies will be determined by the appropriate manager, approved by the compliance team, and changed within the compliance inventory.
  6. All corrective actions will be designed to prohibit recurrence of the specific issue or similar issues.

2.7 Cooperation

Employees are expected to cooperate fully with investigations or audits and comply with corrective actions. Employees who fail to cooperate, who knowingly give false information, or who fail to comply with the directives of a corrective action will be disciplined according to the University policy on Employee Corrective Action. Efforts will be made to maintain confidentiality during the investigation process and with the subsequent findings; however, confidentiality cannot be guaranteed.

2.8 Retaliation

The University observes a strict no retaliation policy. Employees who, in good faith, report an alleged instance of non-compliance, discover non-compliance during an audit and document it as a finding, or are questioned as part of an investigation or audit, will not be subjected to retaliation or harassment for their participation in the compliance program. Any and all concerns of retaliation or harassment must be reported to the compliance coordinator. Employees who retaliate against a fellow employee for reporting an allegation or an incident, cooperating with an investigation, participating in an audit, or instituting a corrective action will be disciplined according to the University policy on Employee Corrective Action.

3.0 AUTHORIZATION

The authorization for this policy emanates from the Wheeling Jesuit University Board of Trustees; it cannot be changed or modified absent the express written consent of the Audit Committee.

3.0 ATTACHMENTS

Internal Audit Findings Template
Investigation Findings Template


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