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 Institutional Compliance

University of Houston-Victoria
Institutional Compliance Quarterly Report
2007 Calendar Year – 3rd Quarter Ending 9/30/07

1. Committee Meetings/Other Organization Matters
1. Quarterly campus Compliance Committee Meeting held 7/31/07. Minutes posted on the UHV IC website (http://www.uhv.edu/compliance/meetings.asp)
2. Membership Changes:
   • Tong-Ai Zhang, representing the Provost’s Office, stepped down. Karen Boldt will fill that role.
   • The Directors of Sugar Land and Cinco Ranch will serve on the committee in an ex-official capacity since compliance issues for Sugar Land and Cinco Ranch sites are addressed by other departments. Directors will continue to kept informed, notified of meetings, but not required to submit reports.


2. Compliance Audits/Reviews Conducted/Status Reports
1. Financial Aid - Texas Veterans Commission Audit conducted 9/26/07. No findings reported.
2. Financial Aid - Texas State F/Aid Limited Scope on-site audit concluded late August. Awaiting report.
3. Financial Aid - Scholarship Audit conducted by Internal Auditing concluded. Awaiting report.


3. Hot Line and Other Fraud Reports
1. Number of Reports Received this Quarter: 0
2. Number of Bonafide reports: 0
3. Number of Reports Resolved: 0


4. New Risk Assessments (RA) Completed this Quarter
1. None.


5. Risk Assessments Updated this Quarter
1. Annual Risk Matrix review began during the quarter. Submitted information is still being reviewed.
2. SACs Assessment Updated by Provost’s Office.


6. Risk Mitigation Implemented This Quarter
1. Policies, Procedures and Other Actions:
1. Initiated, Reviewed, and/or Updated the following institutional policies ( http://www.uhv.edu/fin/policy/Policies_Procedures.htm ) during this quarter:
• F-4 Travel - Meal Expenses for One Day Trips
2. Safety and Risk - Conducted quarterly campus Safety and Risk Advisory Committee meeting on 8/14/07, as part of campus Safety and Risk Mgmt Program and SORM recommended practices. 16 attended including UHSSL/UHSCR participants via ITV.
3. Safety and Risk - Monthly Fire Extinguisher inspections conducted at UHV and Sugar Land.
4. Safety and Risk - Campus Business Continuity Plan approved by President’s Cabinet 7/11/07. Posted on line and hardcopies distributed to President’s Cabinet and Emergency Response Team.
5. Safety and Risk - Reviewed and updated Campus Crime Log procedures to comply with Clery Act recommendations, 9/07.
6. Safety and Risk - Distributed Clery Act Annual Security Report electronically to all employees and students on 9/28/07. Locked data for required crime statistics reporting with DOE, 9/26/07.
7. International Programs – Reviewed departmental procedures with Vice President Administration and Finance and Finance employees to assure receipt of student participation funds prior to the student’s departure on Study Abroad programs.
8. Office of Research - Updated External Grant Routing review sheet to insure that new grant proposals are seen by the Research Administrator as part of the application process.
9. Information Technology - Submitted DIR Incident Reports for July, August, Sept in accordance with TAC 202, Information Security Standards, as required.
10. Facilities Services - Conducted the following inspections and tests during the quarter at UHV: Bi-annual boiler inspection completed 9/16/07.
11. Safety and Risk - Created Lab Use Authorization form for students doing independent research and requesting unsupervised use of BioLab after hours. Procedure to be incorporated within Lab Safety Manual. Approval requires both Department and Dean’s authorization and Safety Office notification.
12. Training/CE and Campus Compliance Office - Formally introduced mandatory training program at UHV, effective 9/1/07 which incorporates UHS mandatory training sessions and certain other UHV role based training. Joint effort between UHS, UHV Training/CE and Campus Compliance Office.
13. Financial Aid and Campus Compliance Office - Introduced new Financial Aid Employee Standards of Conduct/Conflict of Interest Certification requirement. Each FA employee annually acknowledges in writing specific activities that must be refrained from as well as responsibility to promptly report any real or apparent conflicts of interest, violations of laws or regulations, fraud, theft or other financial aid irregularities. (8/07)
14. Campus Compliance Office - Submitted FY08 Annual Campus Compliance Plan of proposed activities to UH System (7/07)

 

2. Training Activities
1. Business Services - Coordinated on-site Insurance Workshop presentation provided by UHS on 9/20/07. 22 employees representing key areas attended.
2. Business Services - Introduced WebCT based ProCard training 8/15/07. Online training/testing will be mandatory for all new cardholders and those renewing cards. This replaces live orientation.
3. Provost’s Office - New employee orientation for incoming faculty held 9/7/07 in Sugar Land. Five new faculty participated.
4. Human Resources - New employee orientation conducted 9/13/07, 11 attended. Orientation addresses EEO and Sexual Harassment training, Campus Safety, Governor’s Program on Fraud Prevention including briefing on MySafeCampus confidential reporting, campus Institutional Compliance Program FERPA and Mandatory Training Program.
5. Training and CE - Responsibility Redefined. Two sessions 7/26, 7/27. 105 total employees attended including 46 UHS employees participating in HR Day.
6. Safety and Risk - Safety and Risk Manager attended two day workshop on Clery Act compliance and reporting requirements.
7. Training and CE (EAP Program) - Civility in the Workplace, 8/14/07. 13 attended.
8. Training and CE - Stepping Up to Supervisor Program began 9/18/07. 14 employees participating.
9. Finance - Travel Procedure Training, two sessions 9/20/07. 29 employees attended.
10. Finance - Held 8 individual one-on-one 4 hour sessions with new hires on PS and Monthly Verifications.
11. Facilities Services - Coordinated Blood Borne Pathogen and Personal Protective Gear (PPG) training for all Facilities personnel (20 individuals), 7/07.
12. BioLab - Biotechnology lab safety training given to 17 students: 9 students at UHV; 8 students at UHSSL.

 

7. Status of Pending Compliance Activities:
1. Athletics Department - (1) Finalize Athletic Program Handbook, addressing NAIA bylaw requirements. Submit to UHS Risk Management for review. Complete Risk Assessments for external compliance issues. (2) Develop written protocol for athletic injuries during training or games. Status: In Progress
2. School of Nursing - Complete risk assessment(s) and identify external compliance issues associated with new Nursing Program. Develop written policies and procedures as required. Status: Pending
3. International Programs - Finalize written policies and procedures for traveling abroad upon OGC review Develop a monitoring plan to insure compliance. Finalize Risk Assessments all external compliance issues. Status: In Progress.
4. Human Resources - Employee Background Checks - Develop formal campus policy and procedures. Identify “security sensitive” positions. Status: In Progress
5. Facilities Services - Disposal of State Property - Updating of campus policy in progress. Formal Risk assessment is pending from Facilities Services. Status: In Progress
6. Business Services - Placing Students on Hold With the State - Finalize in-house procedures once Legal responds to pending Request for Advice. Status: In Progress
7. Research Administrator - Implement consistent use of Annual Certificate of Compliance/Conflict of Interest for Academic Staff. 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. Update existing Risk Assessments. Status: In Progress.
8. Office of University Advancement - 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. Complete Risk Assessment of all external compliance issues. Status: In Progress.
9. 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. (2) Incorporate procedures for unsupervised use of labs into Lab Safety Manual. Status: In Progress
10. Safety and Risk Management - Develop campus and off-site plans meeting state requirements, including monthly and annual inspections, and periodic refresher training for all AED devices. Complete Risk Assessment. Status: In Progress
11. Safety and Risk Management - In coordination with UHDPS, develop procedures to insure monthly inspections of Fire Extinguisher units at Cinco Ranch location. Status: Pending

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 Institutional Compliance Officer.
Source of Information: Campus IC Committee Members and Compliance Officer
Date Report Completed: October 5, 2007