Financial Aid - Texas State F/Aid Limited Scope final report received. Four (4) findings noted. Financial Aid has changed processes/procedures and will provide evidence of compliance with UHS IA.
Financial Aid – Final audit report still pending on Scholarship Audit conducted by UH Internal Auditing.
Information Technology – Began self-assessment phase of UHS Internal Audit to determine compliance with Texas Administrative Code (TAC) 202- Information Security Standards. Ongoing.
Business Services – PCI Compliance Review. All UHV Credit Card Merchants completed questionnaires to determine what corrective actions, if any, may need to be implemented to achieve PCI compliance. This is the 1st phase of the review process with the goal of System-wide compliance by June, 2008. (PCI : Payment Card Industry).
Safety and Risk – Completed chemical inventory audit for annual Texas Tier II Report of hazardous chemicals in the workplace. Signed, updated chemical inventory spreadsheets are on file in Business Services, Campus Safety and Risk office. (2/19)
Safety and Risk – Completed required Department of Homeland Security audit of “Chemicals of Interest” in accordance with 6 CFR Part 27. UHV did not possess any chemicals in quantities at or above the specified screening threshold quantity and therefore was not required to submit any “Top-Screen reports. Review completed 3/19 and on file in Business Services, Campus Safety & Risk office.
Hot Line and Other Fraud Reports
Number of Reports Received this Quarter: 3
Reports resolved during Quarter: 2
Unresolved Reports as of March 31, 2008: 1
Notes: (1) No Hotline. Two bank reports of suspicious P-Card activity. (No employee involvement) Accts were closed w/no loss. Third report remains open and under review.
New Risk Assessments (RA) Completed this Quarter
Facilities Services – Disposal of State Property, 3/08. Risk After Controls: Low
Student Services- Risk Management Program for Registered School Organizations, 3/08. Risk After Controls: Medium
New Policy A-7, Reporting Indebtedness to the State
Updated Policy C-16, Drug and Alcohol Abuse Program
Athletic Department – Submitted draft Athletic Injury Protocol for review by Safety and Risk Manager and campus Compliance Officer in late March. Protocol should be finalized in April.
BioLab – Drs. Gunasekera and Somasundaram reported updating of NIH guidelines for recombinant DNA usage at Biology Labs at Victoria and Sugar Land campuses.
BioLab - Added authorization form in Lab Safety Manual to be used when Graduate students require working in a lab on weekends.
Finance – To improve state contract rental car compliance added new reference tool in the departmental General Operating Procedure Guide (GOP) for the “Do’s and Don’ts when Renting Vehicles”. Website: http: //www.sorm.state.tx.us/Publications/risk_tex-8Dec/rental.
Financial Aid – Updated National Student Loan Data System (NSLDS) reporting procedures to improve internal monitoring of student loan activity and to keep current on student loan defaults.
Information Technology – Submitted DIR Incident Reports for January and February in accordance with TAC 202, Information Security Standards. March report to be filed in April.
Institutional Research – Reviewed guidelines for door prizes, contest entry and winner awards for Math and Computer Science fairs funded by grant funds.
Provost’s Office – Reviewed and revised Faculty Manual, Section G 2.7, eliminating requirement for travel reports associated with Faculty
Development Grants.
Safety and Risk – Held quarterly campus Safety and Risk Advisory Committee meeting on 1/24/08. This is part of campus Safety and Risk Mgmt Program and SORM recommended practices. UHSSL/UHSCR members participate via ITV.
Financial Aid – Director and Accountant reviewed risks and compliance issues associated with acceptance of federal funds and created audit worksheets. Accountant now samples students monthly through PeopleSoft for federal compliance.
Training/CE and Campus Compliance Office – The UHS mandatory training program for FY08 ended March 31st.
Training Activities
BioLab – Conducted Lab Safety training for students at Sugar Land and Victoria Campuses: Sugar Land- Immunohistochemistry Lab safety, 8 students; Victoria- Biochemistry Lab safety, 10 students.
Facilities Services – Safety Training for Maintenance staff via SORM DVD presentations: 2/27/08 – MSDS and Personal Protective Equipment Training, 4 attended each session; 3/4/08 - Indoor Air Quality review, 4 attended.
Finance – Conducted 3 Travel Processes sessions during quarter on 1/10, 2/19 and 2/20 (78 attended)
Finance – Conducted PeopleSoft Electronic Approval training on 3/18 (3 attended); also one-on-one PeopleSoft New Hire training for two employees.
Finance –
Conducted two GL Journal Workflow Training sessions on 1/29 and 3/4/08 (49
attended)
Human Resources – New employee orientation held 2/21/08, 12 employees attended. Orientation addressed EEO and Sexual Harassment training (Human Resources), Campus Safety and Clery Act Report (Safety and Risk), Governor’s Program on Fraud Prevention including briefing on MySafeCampus confidential reporting, campus Institutional Compliance Program (Campus Compliance)FERPA and PeopleSoft Security Access (Admissions and Records), and Mandatory Training Program.
Provost – Presented three informational sessions at Cinco ranch, Sugar Land and Victoria (March 3,14,24) for all non-tenure track faculty, providing information on what faculty need to do to prepare for promotion and tenure. (19 attended).
Status of Pending Compliance Activities
(Refer to Attachment A for most recent status report.)
Reporting Note:
This report provides a summary of compliance related activities reported by
departments serving on the campus IC Committee. These departments generally
represent areas of highest risk exposure to UHV. Reporting departments include:
Financial Aid, Human Resources, Finance, Facilities Services, Safety and Risk
Management, Information Technology, BioLab, Business Services, Student
Relations, Admissions, Institutional Research, Community/Alumni Relations,
International and Special Projects, Nursing and Sponsored Research, and
Athletics.
Report Compiled by: Gregory Fanelli, UHV Compliance Officer. Source of Information: Campus IC Committee Members and Compliance Officer Date Report Completed: April 7, 2008
Attachment A
Status of Pending Compliance Activities as of 3/31/08
Athletics Department- (1) Develop written protocol for athletic injuries during
training or games. Status:
Draft written protocol for handling athletic injuries submitted to Compliance Officer for
review late March. (2) Complete Risk Assessments for external compliance issues –
Status:
Incomplete (3) make Athletic Handbook readily available to athletes and departments by posting
on Athletic website. Status: New
Business Services – Reporting Indebtedness to the State – Status:
Closed: Policy A-7 approved by President and Cabinet on 3/24/08.
Facilities Services – (1) Updating of Disposal of State Property Policy H-6. Policy and procedural changes need to address disposal of
non-tagged property, procedures for disposal of IT equipment, among other things. Status: Remains
incomplete. (2) Develop compliance risk assessment. Status: Completed March 08. (Refer to Section
IV in this report).
Human Resources - Employee Background Checks – Develop formal campus policy and procedures. Identify “security sensitive” positions.
Current Status: Policy and Procedures Under Development.
International Programs and Special Projects– (1) Finalize written policies and procedures for traveling abroad upon OGC review
Develop a monitoring plan to insure compliance Status: (1) Department submitted written policies/procedures and forwarded to OGC (Contract Administration)
for review several months ago. After several follow-ups, OGC, Contracts Administration, said they did not have. Business Services resubmitted late March.
(2)
Develop protocols to be followed in the event of specific events which might occur in any International Program. Protocols will prescribe specific actions
in the event of death, serious injury, kidnapping, terrorism or other specific “trigger” events involving UHV students abroad.
Status: Incomplete - Pending – Protocols have not been finalized; Director targets completion by 6/30th.
(3) Other: Intl Education Committee has been reorganized as the Provost’s Advisory Committee on International Programs and Activities (4) Procedures are being discussed with Finance for the issuance of emergency credit cards to faculty who are leasing student groups abroad with credit limit sufficient to purchase return fares (3/08) (5) Insurance Requirements and Intl Identify Cards are being reviewed to insure adequate without duplication of other coverage
Office of University Advancement – (1) Develop a monitoring plan to insure endowment compliance and proper stewardship of donor funds, avoiding non-compliance with donor restrictions and/or inappropriate use of endowment funds and Complete Risk Assessment of all external compliance issues.
Status: Draft Compliance Risk Assessment reviewed with Compliance Officer in March. Status: Pending finalization.
Research Administrator – – (1) Implement consistent use of Annual Certificate of Compliance/Conflict of Interest for Academic Staff
Status: Unknown. (2) Develop a monitoring plan to insure contract/grant compliance, including compliance with OBM Rules, Principle Investigator’s acknowledgement of responsibilities and time and effort reporting.
Status: Unknown
Safety and Risk Management – (1) Develop campus and off-site plans meeting state requirements, including monthly and annual inspections, and periodic refresher training for all AED devices. Status: Incomplete – Pending (2) Finalize Compliance Risk Assessment for AEDs.
Status: Incomplete - Pending
Safety and Risk Management – (1) In coordination with UHDPS, develop procedures to insure monthly inspections of Fire Extinguisher units at Cinco Ranch location.
Current Status: Incomplete – Incomplete - Pending
Safety and Risk Management – Complete update of campus wide Fire Preparedness Plan and Emergency Evacuation Plans.
Status: Incomplete. Draft update has been created but never finalized. Director of Business Services is working to finalize and implement by June 30, 2008.
School of Arts and Sciences – UHV and UHSSL Biolabs – (1) Complete a Risk
Assessment form for handling and reporting of lab related accidents. Submit to Safety and Risk Officer
for review/comment. Include protocol in Lab Safety Manual. Status: Remains incomplete. (2) Incorporate
procedures for unsupervised use of labs into Lab Safety Manual. Status: Complete. Authorization form
incorporated into Lab
Safety Manual to be used when Graduate students require working in a lab on weekends.
School of Nursing – (1) Complete risk assessment(s) and identify external compliance issues associated with new Nursing Program.
Status: Remains incomplete. (2) Develop written policies, procedures/protocols for program as required. Status: Second draft Blood/Body Fluid Exposure Protocol submitted to Compliance Officer for review/comment in March. Review not finalized,
Student Services – (1) Implement “Risk Management Program for Members and Advisors of Student Organizations”, in compliance with SB 1138, 80th Regular Session, effective 9/1/07.
Status: Completed. Refer to Section lV of this report.
