Ohio Administrative Code › Title 3364 - University of Toledo › Chapter 3364-15 - HIPAA Organizational Structure; Fraud, Waste and Abuse; Compliance and Confidentiality of Patient Information › Section 3364-15-03 - Compliance incident reporting

Current through all regulations passed and filed through July 1, 2024
(A)
								Policy
			 statement
The university of Toledo ("UToledo")
				strives to comply with all federal, state, and local statutes. This policy sets
				forth the procedures that UToledo will use to respond to reports by
				institutional members or others regarding possible violations of UToledo
				policies and procedures or a possible violation of applicable state and federal
				laws.
(B)
								Purpose of policy
This policy establishes UToledo's
				response in situations where UToledo policies, rules and standards, state and
				federal regulations have been violated either inadvertently or knowingly.
				Corrective action or procedure are necessary to ensure compliance. It is
				necessary to protect UToledo in the event of civil or criminal enforcement
				actions.
(C)
								Scope
All UToledo
				campuses.
(D)
								Definitions
"Institutional members" Any person who
				participates in university activities, or has an affiliation with UToledo,
				including but not limited to staff, faculty, providers of medical services,
				contractors, vendors, students, alumni and volunteers, whether or not they are
				paid by UToledo.
(E)
								Procedures
(1)
									Institutional member duty.
Institutional members have a duty to
				ask questions regarding potential issues and to report potential concerns. If
				any institutional member knows of or suspects a violation, they are to report
				it immediately without fear of retaliation. At no time will any retaliatory
				action be taken against any individual who files a good faith complaint. Please
				refer to rule
				3364-15-04
				of the Administrative Code (non-retaliation).
(2)
									Students and
			 student employees seeking to raise concerns should speak directly with the
			 responsible UToledo office/student conduct office. Student employees who have
			 concerns regarding their UToledo job can use this policy.
(3)
									Reporting
			 methods.
Institutional members may report in
				good faith incidents or suspicious activities in the manner listed in this
				rule. Information received will be maintained confidentially to the extent the
				law permits.
(a)
										Local resolution.
The recommended method to raise a
				concern begins with your own college, department or unit through supervisory
				channels or you may report to:
(b)
										Central
			 offices.
Due to the subject matter, work or
				personal relationship, it may be best to raise questions through a specialized
				central office. Examples include:
(i)
											Human resources
			 or the office of diversity and inclusion for employment concerns,
			 discrimination or sexual harassment.
(ii)
											The office of
			 athletics compliance for possible national collegiate athletic association
			 ("NCAA") violations.
(iii)
											The office of research and sponsored programs for
			 research concerns.
(c)
										Department of
			 internal audit and compliance.
If the institutional member is
				uncomfortable with addressing concerns at the local level or through a central
				office, needs advice on how to handle an issue, or issues have not been
				resolved satisfactorily, the institutional member can call and report directly
				to the department of internal audit and compliance. Institutional members may
				also submit a written report to the department of internal audit and
				compliance.
(d)
										 Anonymous reporting line.
UToledo has an anonymous reporting line
				to report any situation without using any personally identifiable information
				(888-416-1308). Refer to rule
				3364-15-05
				of the Administrative Code (protected disclosures and anonymous reporting line
				policy).
(e)
										Direct reporting.
Should institutional members feel that
				the issues or concerns are not being addressed by administration; the
				institutional member may file a complaint directly to the government or
				supporting agency.
(4)
									Investigations
			 are conducted in compliance with procedures set within the internal audit and
			 compliance department.
(5)
									Training
All institutional members are provided
				training on how to report suspected violations of UToledo policies, state and
				federal regulations.