1.0 PURPOSE

The Wheeling Jesuit University Compliance program is established in support of the Jesuit Mission and Identity, the University’s Code of Ethics and Conduct, the draft Office of the Inspector General (“OIG”) Guidelines, the U.S. Sentencing Guidelines (“USSG”) and the regulatory, policy or organizational requirements of the various compliance areas.

The draft OIG guidelines describe eight basic elements necessary for a comprehensive compliance program:

1. The development and distribution of written standards of conduct as well as written policies and procedures that reflect the institutions commitment to compliance;
2. The designation of a Compliance Officer and a Compliance Committee charged with the responsibility for developing, operating and monitoring a compliance program with authority to report directly to the head of the organization (the President) and / or the Board of Directors;
3. The development and implementation of a regular, effective, training program for all employees;
• The creation and maintenance of an effective line of communications between the Compliance Officer and the employees including a process to receive complaints with procedures to protect the anonymity of complainants and whistleblowers from retaliation;
4. Clear definitions of roles and responsibilities within the organization to insure oversight responsibilities;
5. The use of audits and risk evaluation techniques to monitor compliance and identify problems;
6. The enforcement of appropriate disciplinary action against employees or contractors who have violated institutional policies and applicable Federal requirements coupled with incentives for compliance; and
7. The development of policies and procedures for the investigation of alleged instances of non-compliance or misconduct with appropriate corrective action and preventative measures.

In addition, the section of the USSG entitled “Effective Compliance and Ethics Programs” identifies seven (7) core elements which it deems minimally necessary to ensure that the organization has met its obligations to , “exercise due diligence to prevent and detect criminal conduct and otherwise promote an organizational culture that encourages ethical conduct and a commitment to compliance with the law.” Those seven (7) elements are:

1. Adequate compliance standards and procedures;
2. Effective compliance oversight;
3. Careful delegation and due care in hiring / screening employees;
4. Effective training and education for roles and responsibilities;
5. Monitoring, auditing and hot lines;
6. Enforcement for violations; and
7. Corrective action.   

2.0 POLICY

2.1 Board Audit Committee Charter

In keeping with the Purpose delineated above, the Wheeling Jesuit University Board of Directors has charged the Board Audit Committee with compliance oversight accountability and reporting requirements as stated in the Audit Committee Charter as follows:

The primary purpose of the Audit Committee is to assist the Board of the University in fulfilling its responsibility to oversee management’s conduct of the University’s financial reporting process including: (i) overseeing the integrity of the University’s financial statements; (ii) compliance with legal and regulatory requirements; (iii) independent auditor’s qualifications and independence; and (iv) performance of independent auditors and financial management; (v) managements standards of conduct; and (vi) ensuring adherence to the institutions conflict-of-interest policy.

In addition, the “Key Responsibilities” of the Audit Committee as defined by the Charter include:

• Reviewing with management, the independent auditor and if appropriate the internal auditors the University’s accounting and financial reporting processes, financial operations, internal control systems, compliance with laws regulations, and related matters.
• Evaluating the University’s policies with respect to risk assessment and risk management, and reviewing contingent liabilities and risks that may be material to the University and major legislative and regulatory developments that could materially impact the University’s contingent liabilities and risks.
• Reviewing (a) the status of the University’s compliance with laws, regulations, and internal procedures, and (b) the scope and status of systems designed to promote the University’s compliance with laws, regulations and internal procedures, through receiving reports from management, legal counsel and third parties, as determined by the Audit Committee.
• Establishing procedures for the confidential and anonymous receipt, retention and treatment of complaints regarding the University’s accounting, internal controls and auditing matters.
• Assisting the Board in fulfilling their oversight responsibilities for legal compliance.

2.2 Compliance Coordinator/Team Mission Statement 

To assist with compliance oversight accountability, the Audit Committee establishes a position of Compliance Coordinator, assisted by a Compliance Team, and delegates responsibility as follows:

The mission of the Wheeling Jesuit University Compliance Team is to identify, inventory, assess and prioritize risks which may adversely affect the University with the stated goals of continuous improvement and mitigation though the development of managerial controls, training programs, communications, reporting procedures, investigative techniques, audits and ongoing corrective action. 

2.3 Compliance Coordinator/Team Charter 

1. The Compliance Team, under the direction of and through the Compliance Coordinator, will report directly to the President and the Board Director representing the Audit Committee empowered with immediate oversight responsibilities.
2. The Compliance Coordinator will chair the team and will interact directly with the President and the assigned Board Director on all matters pertaining to the Compliance Program including inventory development, risk assessment, findings, reports and enforcement of corrective action.
3. The Compliance Team will develop and adhere to an approved timeline for program development and subsequent program maintenance including scheduled meetings to review the inventory, complaints, audits, findings and corrective actions; minutes of these meetings will be maintained as a record.
4. The Compliance Team will develop operating policies and procedures to govern Team functions with the inventory, risk assessment, training, communications, audits and corrective actions.
5. The Compliance Team will provide training and communications to all employees on general compliance and to specific employees on the responsibilities for compliance that may be associated with their positions.
6. The Compliance Team will be trained to complete the assigned tasks of inventory and risk assessment, policy development and internal auditing. The Compliance Team will benchmark and endeavor to adhere to best practices in all areas
7. The Compliance Coordinator will develop semi-annual reports for the Board Audit Committee to review including all serious infractions by employees documented in findings, audit findings, charges and litigation.
8. The Compliance Coordinator will review both serious infractions documented in findings and general audit findings with legal counsel before implementing corrective action.
9. The Compliance Team will develop measures of performance to track program effectiveness.
10. The Compliance coordinator and Team will function without fear of retaliation or retribution for any activities associated with the operations of the Program provided such activities are in compliance with this charter and the operating policies, information is maintained as “restricted”, and all reports and findings are unbiased and substantiated with corroborative documentation.  

2.4 Employee Requirements and Responsibilities

As a condition of employment, all members of the University community who are employed by the University, who act on behalf of the University or who work on campus in various capacities as equivalent employees, including faculty, administration, staff and contract employees, as well as Board Members, are expected to conduct their day-to-day operations in accordance with the regulations, policies, procedures, requirements and expectations of the University as a whole as well as the specific requirements defined within their job descriptions, contracts, bylaws or charters . Compliance will be recognized within the performance management process; conversely, noncompliance will be addressed in accordance with University policies on discipline, up to and including termination of employment. Where applicable, issues of noncompliance will be directed to the appropriate external agency for adjudication.

2.5 Authorization

The authorization for this mission and charter emanates from the Wheeling Jesuit University Board of Directors and cannot be modified or deleted except by that Board.