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


Compliance: Program & Plan


Date approved:
July 2012
Approved by:
 WJU Audit Committee
Date to be reviewed:
July 2013
Reviewed by:
Compliance Coordinator/Team
Date revised:
 
Revision number:
1.1

1.0 PURPOSE

The Wheeling Jesuit University compliance program is a proactive approach to insure University-wide compliance with all relevant federal, state and local regulations, internal University policies, and the requirements of the various organizations in which the University voluntarily participates in conformance with U.S. Sentencing Guidelines. Oversight of the program will be conducted by a centralized team of administrators, under the direction of a Compliance Coordinator, with each member of the team representing a specific compliance area within the University. Compliance areas will operate in a de-centralized fashion according to their own approved policies and procedures designed to uphold the University's compliance plan and overall goal of compliance. The University Board of Directors will review the charter of the Compliance Program and maintain ultimate oversight responsibility.

2.0 POLICY

2.1 Policy Statement

The University's Compliance Program is predicated upon the implementation of the following Compliance Plan:

  1. Building the Foundation 
    • Developing the University's philosophy of Compliance with a focus on reducing or eliminating the risks of non-compliance while increasing or enhancing repeatability of complaint behavior.
    • Charter the Compliance effort and specify its mission.
    • Establishing roles and responsibilities for the Compliance Coordinator.
    • Establishing roles and responsibilities for a Compliance Team with members who have functional expertise in:
      • Athletics versed in NCAA regulatory requirements.
      • Sponsored Programs versed in governmental compliance and oversight.
      • Business Office versed in matters of taxation and financial regulations.
      • Facilities versed in Building, grounds, public health, environmental and safety regulations.
      • Student Development versed in matters of student-related regulations.
      • Enrollment versed in matters of financial aid and recruiting.
      • Human Resources versed in matters of Employment.
    • Establishing operating procedures for the various components of the plan.
    • Establishing a methodology to document and elevate findings to the President through the Board of Directors.
    • Establishing the timeline for initial implementation and annual review.
  2. Implementing a Systemic Approach
    1. Assess and Inventory
      • Complete a thorough "risk assessment" that includes:
        • Collecting, assessing and inventorying existing documentation on a spreadsheet
        • Collecting, assessing and inventorying complaints, litigation and claims history on a spreadsheet.
        • Assessing and inventorying Findings and Recommendations from prior internal and external audits.
        • Assessing areas of concern within University operations (third party / vendors, contracts, etc).
        • Inventorying regulations, policies and requirements on a spreadsheet and correlating this documentation to  the information gathered above.
        • Completing a Gap Analysis to determine availability versus requirements; assessing the requirements affecting the Compliance Areas and the assessing the risk of non-compliance.
        • Protecting confidential University information as "restricted" while developing the program for campus-wide distribution.
      • Developing a Compliance Inventory noting, for all areas, applicable regulations, policies and requirements, the risk of non-compliance and the controls necessary to mitigate the risk.
      • Developing an "Action Plan" with measurable policies to bridge the gap between availability and requirements, prioritizing the high risk areas.
    2. Communicate and Train
      • Providing proactive, positive, communications in person and on the website for all stakeholders  informing employees that they can report instances of non-compliance free of retribution, those who are involved in audits or investigations should participate fully absent fear of retaliation and that all  reports will be handled with highest levels of integrity.
      • Training on specific policies, specific compliance - related activities associated with job descriptions,  and University-wide compliance initiatives.
      • Developing written communications to be disseminated throughout the University.
      • Developing positive, proactive, communications for both the campus-community and the public in the  event of an instance of non-compliance.
    3. Audit and Correct
      • Reporting of alleged non-compliant activities may be reported through several channels. The University  will maintain a hotline (callers may remain anonymous) for reporting allegations of non-compliance.  Employees and  students may also use specific University policies and procedures to report allegations of  non-compliance.
      • All reports will be logged, assessed and, if necessary, investigated. Allegations that are  substantiated  will be reported through the Audit Committee to the President.
      • The Compliance Team will conduct reviews of the Compliance Inventory. Audits will be based upon policies noted in the Compliance Inventory.
      • The Compliance Team will be trained to conduct internal audits. For those areas uncovered by an independent, third-party, audit, the University will conduct its own audit.

2.2 Definitions

  1. Risk - The probability that an event may occur and the severity of the potential negative outcomes.
  2. Compliance Area - A specific portion of a department or departments whose compliance with relevant legal,  regulatory and internal policies for which University-wide compliance is mandated by the government,  regulatory agency, association to which the  University belongs.
  3. Compliance Inventory - A comprehensive list of relevant legal, regulatory and internal policies for which  University-wide compliance is mandated by the government, regulatory agency, association to which the  University belongs or the Board of Directors. This Inventory forms the nucleus of the University's compliance efforts in the areas of process improvement, training and assessment.
  4. Compliance Coordinator - Fulfills the following roles and responsibilities:
    • Develops and maintains a compliance program to prevent and correct areas of non-compliance.
    • Establishes and provides on-going training to promote University-wide compliance.
    • Assures that compliance areas develop, maintain and adhere to policies and procedures.
    • Investigates or coordinates investigations of all allegations reported through the University hot-line, employee or student reports, internal or external audits, or proactive compliance checks.
    • Establishes a training program to communicate to University employees' appropriate behavior, roles and responsibilities defined by compliance, and methods for reporting alleged non-compliant activities.
    • Reports all substantiated non-compliant activities to both the highest executive in University administration and the Board director assigned compliance responsibilities.
    • Assesses and implements corrective actions to findings of non-compliant activities.
  5. Compliance Team - Fulfills the following roles and responsibilities:
    • Define the risk in their compliance areas.
    • Oversee the development of policies and procedures within their compliance areas.
    • Oversee implementation and communication of changes within their compliance areas.
    • Coordinate, track and verify training in their compliance areas.
    • Coordinates corrective actions for areas of non-compliance discovered within their compliance areas.
    • Performs internal audits as needed on assigned compliance areas within the University.
  6. Compliance Team - Fulfills the following roles and responsibilities:
    • Define the risk in their compliance areas.
    • Oversee the development of policies and procedures within their compliance areas.
    • Oversee implementation and communication of changes within their compliance areas.
    • Coordinate, track and verify training in their compliance areas.
    • Coordinates corrective actions for areas of non-compliance discovered within their compliance areas.
    • Performs internal audits as needed on assigned compliance areas within the University.

2.3 Program Timeline

  1. The timeline for implementation and follow-up is attached to this policy.
  2. The annual timeline for meetings and audits will be placed on-line as an attachment to this policy.
  3. The strategic timeline for the program will be placed on-line as an attachment to this policy.  

2.4 Program Maintenance/On-Going

The Program will be maintained and improved through the systemic, "closed loop", approach presented above with the steps: 1.) Assess & Inventory; 2.) Communicate & Train; and 3.) Audit & Corrective Action.

2.5 Authorization

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

3.0 ATTACHMENTS

Timeline



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