Pennsylvania State System of Higher Education
Procedures and Standards for University Operations
Procedure/Standard Number 2013-17
Conducting Investigations Received through
PASSHE’s Incident Reporting System

Approved by:

Date:

August 7, 2013

Chancellor

History: Procedure/Standard 2013-17
Revised:replaces Administrative Directive 1991-06.01,
Procedures for Conducting Investigations
Additional History:
Related Policies, Procedures or Standards:
Board of Governors' Policy 1991-06-A: State System Audit PolicyBoard of Governors'Policy 2010-01-A: Expenditures of Public Funds; Board of Governors' Policy 2012-01:
Conflict of Interest; PASSHE Procedures and Standards for University Operations, PASSHE
Procedures and Standards for University Operations, Procedure/Standard Number 201107, Expenditures of Public Funds Guidelines, Standards, and Limits
Additional References: State Public Official and Employee Ethics Act (Ethics Act) at 65
Pa. C.S.§§ 1101 et.seq.

I.

Introduction
The purpose of this procedure is to communicate the Pennsylvania State System ofHigher Education (PASSHE) responsibilities for the investigation of alleged
fraudulent or irregular activities and provide specific instructions regarding
appropriate action in cases of suspected improprieties received through thePASSHE Fraud/Waste/Abuse Incident Reporting System (Incident ReportingSystem).
The procedure covers reports received through the Incident Reporting System andwill ensure investigations are conducted in a fair manner, both to PASSHE and theemployee; actions taken are consistent from case-to-case; investigations arecompleted and actions are timely; and appropriate personnel are adequately
informed about the status of ongoing investigations.
Use of the Incident Reporting System is not intended to take the place of existing
reporting mechanisms and processes established at each university, for concerns
related to:• academic matters such as grade appeals, curriculum structure, andteaching effectiveness, which shall be addressed through the proper
academic process;1•••II.

employment disputes, such as those governed under collective bargaining
agreements, which shall be addressed through human resources offices;
reporting of crimes on campus, which shall be made directly to university
police departments; and,matters dealing with harassment, sexual harassment, and discrimination,
which shall be addressed pursuant to Board of Governors’ Policy 2009-03:
Social Equity.

Definitions
A. Fraud/Waste/Abuse: Fraudulent or irregular activities represent instances wherea PASSHE employee intentionally uses or abuses their position to obtain orwithhold property of the Commonwealth, PASSHE, or an affiliated organization.
Examples include, but are not limited to: misappropriation of funds, theft orembezzlement of cash, equipment or supplies; falsification of official records
such as time sheets, travel expense reports, student records; performing or
directing employees to perform non-PASSHE work during work hours; and using
PASSHE facilities or property for personal gain or any unauthorized use, orotherwise inappropriate use of public funds.
B. PASSHE Entity: A university of the Pennsylvania State System of Higher Educationor the Office of the Chancellor.
C. Public Funds: All monies received by a PASSHE entity are public funds including,but not limited to, state appropriations, tuition, room, board, and other student
fees; restricted and unrestricted gifts and gifts-in-kind; restricted andunrestricted grants; ticket sales from athletic, cultural, or other events; revenue
from athletic camps and conferences; corporate sponsorships; and investment
income.

III.

Responsibility
A. PASSHE employees are responsible for safeguarding PASSHE resources by (1)establishing and maintaining sound business controls designed to deter anddetect potential fraud, waste, or abuse; (2) taking action to minimize financial
loss when fraud, waste, or abuse occurs; and (3) correcting fraud, waste, orabuse. Each employee should be familiar with different types of possible fraud,
waste, or abuse, and be alert for any indication that a fraud, waste, or abuse isor was in existence in their area.
B. PASSHE shall maintain an Incident Reporting System operated by an externalvendor to provide independent collection of information related to suspectedfraud, waste, or abuse. PASSHE’s Incident Reporting System protocol isprovided in Appendix A.
The Office of Internal Audit and Risk Assessment (OIARA), in consultation with
PASSHE’s Office of Chief Counsel, shall be responsible for the administration ofthe Incident Reporting System.

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1. Each president and the chancellor shall appoint an Incident Reporting
System liaison (“PASSHE entity liaison” or “liaison”) to coordinate with theOIARA and be responsible for management of incident reports received fortheir PASSHE entity.
2. All alleged incidents of fraud, waste, or abuse that are brought to theattention of a PASSHE entity’s administration must be reported to the OIARA
Director who will enter it into the Incident Reporting System.
3. The OIARA director will ensure the Incident Reporting System is kept current
and will provide quarterly updates to the chancellor and Board ofGovernors’ Audit Committee on all activity.
C. All information contained in the Incident Reporting System and resulting fromany subsequent investigation is confidential to the extent possible under thelaw and relevant collective bargaining agreements, including the identity of
the reporter (if known), individuals who are subject to the investigation or party
to the allegations, and any private information disclosed within the allegation.
D. Retaliation against anyone who reports in good faith potential fraud, waste, orabuse is prohibited. Allegations of retaliation shall be investigated and, iffounded, discipline may result.
IV.

Initial Review and Determination
A. Incident reports submitted through the Incident Reporting System will beassessed timely, discretely, and in an appropriate manner. OIARA, in concert
with PASSHE’s Office of Chief Counsel, will determine (1) if the report involves
fraud, waste, or abuse, (2) if an investigation is warranted, (3) if theinvestigation will be handled by the OIARA, the Office of Chief Counsel, or thePASSHE entity involved, and (4) make the necessary referral as appropriate.
Situations where the investigation will be conducted by the OIARA and/orOffice of Chief Counsel may include, but are not limited to, conflicts of interestat the campus level and matters which could bring ill repute upon PASSHE.
Notifications to governing bodies or external agencies will be made by theOIARA director or chief counsel in the following circumstances:
1. If the chancellor is the subject of an investigation, the OIARA director, inconsultation with chief counsel, will notify the Board of Governors’ Audit
Committee chairperson and chairperson of the Board of Governors.
2. If a university president is the subject of an investigation, the OIARA director,
in consultation with chief counsel, will report the matter to the Council ofTrustees’ chairperson, chancellor, Board of Governors’ Audit Committee
chairperson, and chairperson of the Board of Governors.

33. If an employee of the OIARA is the subject of an investigation, the Office ofChief Counsel will notify the Board of Governors’ Audit Committee
chairperson and chairperson of the Board of Governors.
4. If an attorney other than the chief counsel is the subject of an investigation,
the OIARA director will notify the chief counsel. If the chief counsel is thesubject of an investigation, the OIARA director will notify the chancellor whowill refer the matter to the Office of General Counsel, Commonwealth ofPennsylvania.
5. If member(s) of PASSHE’s Board of Governors, university councils of trustees,or external board or personnel of affiliated organizations who are not
employees of PASSHE are the subject of an investigation, the chief counsel
shall refer the matter for investigation to the appropriate external agency.
B. Once the OIARA, in concert with PASSHE’s Office of Chief Counsel, determines
an investigation is warranted and makes referral to the appropriate PASSHE
entity, the respective PASSHE entity liaison will have access to reports assigned
to them through the Incident Reporting System for review and appropriateaction. The liaison is responsible for communicating the complaint to theuniversity president or designee; in cases involving Office of the Chancellor
personnel, to the chancellor or designee.
C. The university president or chancellor may place an employee(s) involved inknown or suspected misuse of PASSHE resources on appropriate leave under
the terms of the applicable collective bargaining agreement or Board ofGovernors’ policy during the investigation. Placing an employee on leave may
be proper when there is evidence he/she is responsible for misuse of resources
and his/her continued presence at work may interfere with the investigation or
further expose PASSHE property to loss through possible misuse.
D. In instances of external inquiries, which may include the media, the response
will be developed by the Office of the Chancellor’s Office of External Relations,in consultation with the public relations representative(s) of the PASSHE entity
investigating the alleged incident.
V.

Investigation Procedures
A. Conduct of Investigation: Investigations shall be conducted and reported in amanner that:•••••

fulfills PASSHE’s legal and fiduciary responsibilities;
minimizes loss and promotes recovery of PASSHE resources;
identifies controls that should be strengthened to reduce future vulnerability
regarding misuse of PASSHE resources;
protects the rights of the accused, the interests of those making allegations,and the public trust;provides confidentiality compatible with an effective response andapplicable reporting requirements; and,4

•

guards against real or apparent conflicts of interest.

B. Assignment of Investigation and Notification Process: Once assigned, thePASSHE entity liaison shall review the report in the Incident Reporting Systemand provide notifications as follows.
Within two business days – Notify the PASSHE entity leader, or designee, of thereported incident and of the entity’s responsibility to conduct the investigation.
Within five business days – An initial response to the reporter should be made by
the liaison through the Incident Reporting System indicating the complaint has
been received and the matter is being reviewed.
Within five to ten business days – If an initial response to the reporter is notmade within five business days by the liaison, the OIARA director will follow-up
with the liaison to determine the status. If the liaison is out of the office and/or
unable to respond, then OIARA will make the initial response.
Eleventh business day – If an initial response to the reporter is not made by theliaison within ten business days, the report will be sent to the university president
by the OIARA director for direction.
C. Determination of Appropriate Investigator(s): The PASSHE entity leader, or theirdesignee, assigns the investigator or the investigative team responsible forhandling the investigation. The investigator or the investigative team may
include, but not be limited to, representatives from the following areas oranalogous positions on a university campus:
••
•
•
•
•

OIARA;
university legal counsel and/or PASSHE special investigator;social equity coordinator;
financial officer (reports alleging financial improprieties/fraud);
human resources and labor relations;
university/office of the chancellor experts (e.g., public safety) and/orexternal experts.

D. Responsibility of Investigative Team: The investigator or the investigative teamwill conduct timely and thorough investigations, which should include thefollowing:
1. Determine if adequate information was provided in the incident report toconduct a review/investigation. If not, request the liaison notify the reporter
through the Incident Reporting System that additional information isrequired.
2. Develop an investigation strategy: Determine the scope of theinvestigation, responsibilities of parties, interviews to be conducted, records
to be reviewed, and appropriate offices/personnel to be involved.

53. When appropriate, take immediate action to secure and protect fromdestruction or alteration all pertinent records.
4. Identify potential reporting obligations and make recommendations
regarding the need to notify external entities (e.g., federal granting
agencies, NCAA, law enforcement, etc.), when notification should occur
and report made, and how this responsibility will be fulfilled.
5. Define communication process: Determine when to inform parties affectedby the allegation/investigation and best method of communication.
6. Maintain appropriate records documenting the allegation, the investigative
process, outcomes, and corrective actions.
7. Provide updates regarding the status of the investigation to the PASSHE
entity liaison. The liaison is responsible for providing the status of ongoinginvestigations to OIARA, when requested.
E. Actions: Investigative outcomes should determine if any appropriate corrective
actions are necessary, including recommendation of referral to an external
agency. The process should include determination if a systemic problem exists
and whether adequate internal controls (policies, practices, guidelines, etc.)
exist to prevent future occurrences.

F. Conclude Investigation: Upon conclusion of the investigation, the liaison should
document the status of investigative outcomes in the Incident Reporting
System. Where the situation warrants, the OIARA may notify the reporter
through the Incident Reporting System regarding the status of the investigation.

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Appendix A
Pennsylvania State System of Higher Education
Incident Reporting System

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