University of Houston-Victoria Institutional Compliance Report 2009

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					UHV Compliance Report – Calendar Period Ending 2/28/09                                                          Page 1 of 4

                                                University of Houston-Victoria
                                               Institutional Compliance Report
                                    2009 Calendar Year – Two Month Period Ending 2/28/09

I. Committee Meetings/Other Organization Matters
    1. Quarterly campus Compliance Committee Meeting held January 21, 2009. Minutes posted online at

II. Compliance Audits/Reviews/Surveys
      1. Facilities Services –
            a. Institutional Facilities Inventory Coordinating Board Peer Review Team Audit conducted on-site Jan 13-
                  14th. Texas Education Code 61.0583 requires the CB to periodically conduct audits of all educational and
                  general facilities on the campuses of public senior colleges and universities to determine whether
                  selected institutions of higher education are accurately reporting their facilities data to the Board (as
                  reported via CB 11-14 reports). Management Action Plan sent to CB in response to recommendations.

     2.   Finance –
              a. Texas Higher Education Coordinating Board completed Accuracy Review of FY06, 07, 08 appropriation
                 formula funding Cost Study. Found information to be accurate.
              b. Provided payroll information requested by State Office of Risk Management for determination of campus
                 workers’ compensation cost allocation assessment for FY10.

     3.   Information Technology – Preliminary findings from May 20-22, 2008 UHS Internal Auditing review of IT
          Department compliance with Texas Administrative Code (TAC) 202, Information Security Standards were
          received. Some policies and business contingency plan required changes. Also questions regarding wireless
          security. Final report is expected by March 31st.

     4.   Safety and Risk Management – The biennial Alcohol and Other Drug (AOD) Review for the two year period
          ending 12/31/08 was finalized January 7th. The Drug-Free Schools and Communities Act requires campuses to
          certify that they have adopted and implemented programming to prevent the unlawful possession, use, or
          distribution of illicit drugs and alcohol by students and employees. The report was presented to the President’s
          Cabinet on February 11th and is posted on the campus safety website.

III. Hot Line and Other Fraud Reports
      1. Number of Reports Received this Quarter:             1
      2. Reports resolved during Quarter:                     1*
      3. Unresolved Reports as of 2/28/09 :                   0

          *Bank, J.P. Morgan Chase, reported possible compromise of certain credit card account information at a 3rd party
          location. As a precaution, 15 campus cards were cancelled and reissued. No fraudulent use occurred.

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

V. Risk Assessments Updated this Quarter
    1. None

VI. Risk Mitigation Implemented This Quarter

A. Policies, Procedures and Other Actions:
    1. New or Updated Institutional policies this quarter: (
            a. A-11, Memberships
            b. A-17, Assignment and Use of University Space
            c. B-3, Service Department Billing
            d. B-7, Change Funds
            e. B-14, Sales and Use Taxes
            f. F-1, Reimbursement for Travel and Other Expenses

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              g.   F-4, Meal Expenses for One Day Trips
              h.   F-5, Travel Reservations
              i.   F-6, Registration Fees
              j.   F-7, Prospective State Employees
              k.   F-8, Foreign Travel Policy
              l.   Athletic Drug and Alcohol Policy (In Athletic Handbook)

    2. Athletics –
          a. Athlete Drug Education and Drug Testing Program policy and procedures reviewed by Office of General
               Counsel and approved for use. Policy will be available for review on Athletic Department website by
               March 31, 2009 and incorporated into Athletes Handbook by July 1st. Initial testing scheduled to begin
               spring 2009. (NAIA compliance issue)
          b. Upgraded Athletic Department website in January 2009 to properly report statistics of team and individual
               athletes. (NAIA compliance issue)
          c. Athletics Department completed written PCI Policy and Procedures Guide. Required of Merchants
               accepting credit or debit payment cards, 2/17/09. (PCI compliance issue)

    3. Facilities Services –
          a. Departmental procedures written or updated include:
                     1. Compliance with Hazardous and Industrial Solid Waste regulations
                     2. Recycling and Pollution and Prevention efforts for Compliance Policy Statement
                     3. Unauthorized discharge of water
                     4. Water pollution prevention practices
                     5. Preventative Maintenance Procedures
                     6. Water Spills procedures
                     7. Departmental Cash Handling
                     8. Pay check pick-up distribution
                     9. Processing invoices and vouchers
          b. Annual Fire Extinguishers test conducted 2/13/09
          c. Fire Suppression System for Computer Server Room tested, 1/9/09

    4. Information Technology –
           a. Submitted DIR Incident Reports for Jan, Feb in accordance with TAC 202, Information Security

    5. Safety and Risk –
          a. Monthly Fire Extinguisher inspections, including correction of deficiencies, conducted at UHV for months
               of January and February.

    6. School of Nursing -
          a. Student Handbook – reviewed, revised and published online at
              Safety and compliance policies within the handbook include:
                     1. Blood, body fluid and hazardous exposure protocol
                     2. Calculations Proficiency Test
                     3. Cardiopulmonary Resuscitation (CPR) Course Completion
                     4. Clinical Agency Policies and Procedures
                     5. Clinical Performance Evaluation
                     6. Confidentiality Statement
                     7. Criminal Background Checks
                     8. Physical Examination/Immunization Requirements
          b. MySafeCampus link posted on School of Nursing web pages

B. Training Activities

  1. Facilities Services Training
           a. SORM MSDS (Material Safety Data Sheet) training completed by all maintenance staff, 1/29-2/3/09

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              b. Methicillin Resistant Staphylococcus Aureus (MRSA) infection awareness training completed by all full
                 and part-time custodial staff, 2/24/09
              c. Table Saw safety training completed by all maintenance staff, 1/29/09
              d. Industrial Ergonomics training completed by all custodial staff, 2/2/09

  2. Finance Department PeopleSoft Training
          a. Training, one-on-one, for 16 employees in select areas. Individualized compliance related training
              included Purchase Requisitions, Smart Data Online (SDOL), Budget Journal Entry, Travel Vouchers,
              General Ledger Journal Entry, Electronic Approval and Monthly Verification.

  3. Human Resources –
         a. New Employee Orientation conducted February 19th – 10 employees attended. Orientation addresses
            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), Mandatory Training Program and PIER communications.
         b. Conducted five ePar training sessions with 24 employees attending. PeopleSoft ePar is the method used
            to process all personnel changes.
         c. Training and Continuing Education Office completed written PCI Policy and Procedures Guide. Required
            of Merchants accepting credit or debit payment cards, 2/19/09. (PCI compliance issue)

  4. Provost’s Office (Academic Affairs)
          a. Consultant Marilee Bresciani conducted two workshops with faculty and staff to review institutional
              academic program assessment processes. Intent is to help insure that the review process used by the
              University is effective in evaluating the performance of academic programs in preparation for SACS
              accreditation review and VSA reporting. (Voluntary System of Accountability, which all UHS components are
                   required to participate in.)

  5. School of Nursing
         a. Hospital Orientation Training – Training includes site specific safety concepts for each hospital.
                   i. NUR 4421 – 20 RN-BSN students attended hospital orientation in January at one or more of the
                      following hospitals based on clinical assignments: Oak Bend; Memorial Hermann Sugar Land;
                      The Methodist Hospital Sugar Land, Richmond State School, Fort Bend ISD.
                  ii. 2nd Degree BSN – 18 students attended safety training at The Methodist Hospital Sugar Land in
         b. Simulation Safety Modules – The nursing skills lab for NUR 3734 conducted simulation modules focusing
              on one or more of the following safety topics: Error Prevention; Injury Prevention; Safety Devices;
              Standard/transmission-based Precautions; Safe Use of Equipment. Modules offered 1/23, 1/30, 2/20.

  6. Student Solutions and Safety and Risk Management
          a. Risk Manager presented annual Risk Management Program for members and advisors of student organizations as
                   required by Texas Education Code, Section 51.9361 (Senate Bill 1138) on February 4, 2009.

  7. Various Departments
           a. Employees from Safety and Risk, Financial Aid, Registrar, Finance, Bursar’s Office attended a webinar on
               compliance issues associated with the recently passed 2008 Higher Education Reauthorization Act which
               became law August, 2008. 14 employees attended the January 13th seminar.
           b. Bursar, Registrar, Director of Financial Aid and Compliance Officer attended a Red Flag compliance workshop
                   sponsored by UHS on February 26 in Houston. May 1, 2009 is deadline for implementing procedures required by
                   FACT act to prevent identity theft.

Reporting Note:

This report provides a summary of compliance related activities reported by departments serving on the campus IC Committee. These departments
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.

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Report Compiled by: Gregory Fanelli, UHV Compliance Officer.
Report Completed: March 5th, 2009

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