2017 ANNUAL REPORT - University Of South Florida

2017 ANNUAL REPORTUSF SYSTEM COMPLIANCE ÐICS PROGRAM

TABLE OF CONTENTSUSF System Compliance & Ethics ProgramORGANIZATIONAL CHART. 3ELEMENT 1: GOVERNANCE & HIGH-LEVEL OVERSIGHT. 4A. Board of Trustees Audit and Compliance Committee . 4B. USF System Compliance & Ethics Program . 5C. (High Risk) Compliance Officers Workgroup . 7ELEMENT 2: ESTABLISH STANDARDS OF CONDUCT, POLICIES, & PROCEDURES 10A. Internal Control Policy . 10B. Protection of Minors Policy . 10C. Florida Code of Ethics Policy . 10D. Higher Education Opportunity Act . 11ELEMENTS 3 & 4: CREATE A FAIR AND ETHICAL CULTURE & OPEN LINES OFCOMMUNICATION . 12EthicsPoint . 12ELEMENT 5: EDUCATION AND TRAINING . 14A. Compliance & Ethics Training for New Employees . 14B. Compliance & Ethics Training for Current Employees . 14ELEMENT 6: DETECTION, REMEDIATION, AND ENFORCEMENT . 15A. Protection of Minors on Campus/Summer Programs . 15B. Export Controls/Office of Foreign Assets Control (OFAC) Compliance . 15ELEMENT 7: RISK ASSESSMENT, AUDIT, AND MONITORING . 15A. USF System Enterprise-Wide Risk Assessments . 15B. Audit & Monitoring Risks . 16ELEMENT 8: ASSESSMENT OF EFFECTIVENESS . 18USF System CEP 2017 Annual Report2

USF System Compliance and Ethics ProgramOrganizational ChartBoard of TrusteesAudit & Compliance CommitteeUSF SystemPresidentSenior Vice President& Chief OperatingOfficer Chief Compliance OfficerJeffrey MuirJD, Stetson Univ. College of LawMPA Public Administration, USFBA Political Science, USFSenior Associate Director & SWAIntercollegiate AthleticsDirectorResearch Integrity & ComplianceAdministrative SpecialistJolanda Thompson BSBA ManagementNorthwood University Associate Director of ComplianceDivision of Human ResourcesDirector, Professional IntegrityProgram, USF HealthAssociate Compliance OfficerCaroline Fultz-CarverCertified Compliance & EthicsProfessionalPhD Medical Sciences, USFMHA Health Policy &Management, USFMS Medical Sciences, USFBS Biology, USFUSF System CEP 2017 Annual ReportAssistant Vice PresidentInformation SecurityDirectorEqual Opportunity & ComplianceDirectorEnvironmental Health & Safety3

2017 ANNUAL REPORTUSF System Compliance & Ethics ProgramThe USF Compliance & Ethics Program was created in 2007 as a component of UniversityAudit & Compliance (UAC), with the appointment of a Chief Compliance Officer (CCO)charged by President Genshaft and the USF Board of Trustees (BOT) to create andmaintain an effective compliance and ethics program based on best-practices; to prevent,monitor, detect, and respond to non-compliance; and recommend corrective actions to fullymeet regulatory requirements. In 2017, UAC separated into two entities: USF System Auditand the USF System Compliance & Ethics Program (the “Program”). This separation was inaccordance with Board of Governors (BOG) Regulation 4.003, a regulation based onChapter 8, Part B, Section 2(b) of the Federal Sentencing Guidelines, the Florida Code ofEthics for Public Officers and Employees, and industry best practices.While our reporting relationship and responsibilities have changed under this newregulation, our mission of creating, supporting, and promoting a system-wide culture ofcompliance, ethics, and accountability remains the same. The Program continues toprovide assurance to the BOT that the compliance and ethics activities of the USF Systemare reasonably designed, implemented, enforced, and effective in preventing and detectingviolations of law, regulations, and policies, as well as violations of ethical principles ofconduct.This annual report summarizes the activities of our Program from July 1, 2016, to December31, 2017, unless otherwise indicated. This extended reporting period is due to our transitionfrom fiscal to calendar year for annual reporting to the BOT. This report is organized by the“essential elements” for an effective compliance and ethics program as prescribed by theFederal Sentencing Guidelines and fulfills our annual reporting requirements in accordancewith BOG Regulation 4.003 and the USF System Compliance & Ethics Program Plan.Element 1: Governance & High-Level OversightThe USF System addresses this element through the BOT Audit and ComplianceCommittee, the USF System Compliance & Ethics Program, and the (High-Risk)Compliance Officers Workgroup.A. Board of Trustees Audit and Compliance CommitteeBOG Regulation 4.003 required creation of a BOT committee solely focused on auditand compliance oversight. The BOT Finance and Audit Workgroup was separated intotwo committees: the BOT Finance Committee and the BOT Audit and ComplianceCommittee. The financial oversight responsibilities of the BOT Finance and AuditWorkgroup were retained by the BOT Finance Committee; whereas its audit andcompliance oversight responsibilities were transferred to the newly-created BOT Auditand Compliance Committee (the “Committee”).USF System CEP 2017 Annual Report4

To facilitate this modification in BOT committee structure, USF System Audit and theUSF System Compliance & Ethics Program jointly drafted a BOT Audit & ComplianceCommittee Charter (“Committee Charter”). The Committee Charter was approved by theCommittee at their May 2017 meeting and moved to the BOT (the “Board”) with arecommendation for approval. The Board approved the Committee Charter at their June2017 meeting and a copy was submitted to the BOG pursuant to BOG Regulation 4.003requirements.B. USF System Compliance & Ethics ProgramImplementation of BOG Regulation 4.003 and 4.002, required separation of UAC intotwo units: USF System Audit and the USF System Compliance & Ethics Program, eachreporting directly to the BOT Audit & Compliance Committee and administratively to theUSF System President. Prior to this reporting period, our Program reported to the BOTand President through the Executive Director of UAC.To implement this reorganization, USF System Audit and our Program jointly updatedexisting policies or drafted new USF System policies; and our Program drafted aprogram charter and plan as described below: Updated USF System Policy 0-025: USF System Audit, to include new BOGRegulation 4.002 requirements. This policy addresses the authority of USFSystem Audit for the direction of a broad, comprehensive program of internal auditfor the University of South Florida System. These policy updates wereimplemented in July 2017. Drafted new USF System Policy 0-026: USF System Compliance & EthicsProgram to address the authority of the Program for the coordination andmanagement of all USF System compliance and ethics activities under BOGRegulation 4.003. This newly drafted policy was successfully promulgated andimplemented in August 2017. Drafted new USF System Compliance & Ethics Program Charter (“ProgramCharter”) to identify the purpose, authority, and responsibilities of the USF SystemCompliance & Ethics Program in accordance with BOG Regulation 4.003. TheProgram Charter was reviewed by the Committee at their February 2017 meetingand moved to the Board with a recommendation for approval. The Boardapproved the Program Charter at their March 2017 meeting and a copy wassubmitted to the BOG pursuant to BOG Regulation 4.003.USF System CEP 2017 Annual Report5

Drafted new USF System Compliance & Ethics Program Plan (“Program Plan”) tosummarize the current status of the USF System Compliance & Ethics Program inaccordance with BOG Regulation 4.003. The Program Plan was reviewed by theCommittee at their May 2017 meeting and moved to the Board with arecommendation for approval. The Board approved the Program Plan at theirJune 2017 meeting and a copy was submitted to the BOG pursuant to BOGRegulation 4.003.During this reporting period, the BOG, through their Inspector General and Director ofCompliance, periodically checked with all State University System (SUS) institutionsregarding their progress towards implementing BOG Regulation 4.003. Each SUSinstitution completed a BOG-provided SUS Compliance Program Status Checklistindicating the status of their implementation the BOG regulation. The completedchecklist was submitted to the BOG Inspector General and Director of Compliance andwas summarized for presentation to the BOG. Our Program completed and submitted abaseline checklist in January 2017 and an updated checklist to the BOG in September2017, as requested. Below is a summary of our institution’s implementation of BOGRegulation 4.003 relative to all other SUS institutions, as summarized by the BOG Officeof the Inspector General.COMPLIANCE AND ETHICS PROGRAM STATUS18 Regulatory ElementsAt least half:FAMU, FAU,FGCU, FLPOLY, NCF, UFLess than half:FSU, UWFImplemented:FIU, UCF, UNF,USFUSF System CEP 2017 Annual Report6

C. (High Risk) Compliance Officers WorkgroupThe Compliance Officers Workgroup assists the CCO in maintaining an effective andbroad-based program designed to prevent, monitor, and detect areas of non-complianceand, when necessary, to fully meet compliance requirements and recommend correctiveactions. This workgroup is comprised of senior compliance officers in the following“high-risk” compliance units within the USF System, all of whom have an “accountablereporting” relationship to the CCO: Athletics ComplianceEnvironmental Health & SafetyResearch Integrity & ComplianceDiversity and Equal Opportunity (including Title IX and ADA compliance)Human Resources ComplianceProfessional Integrity Program, USF HealthInformation SecurityBrief descriptions of several of the above-listed “high-risk” compliance units andhighlights from this reporting period are provided below.Athletics ComplianceThe USF Athletics Compliance Office (Athletics Compliance) ensures compliancewith National Collegiate Athletic Association (NCAA) and American AthleticConference rules and associated USF System regulations and policies through itseducation, monitoring, and enforcement efforts. During the 2016-2017 academicyear, Athletics Compliance provided 209 in-person educational sessions. Thesesessions provided athletics compliance education to 745 athletic employees, studentathletes, on-campus constituents, and external constituents (e.g., localestablishments, friends of the program, etc.).Environmental Health & SafetyUSF Environmental Health & Safety (EH&S), a department within the Division ofFacilities Management, ensures potential environmental hazards are properlyremediated in accordance with applicable federal, state, and local requirements; USFSystem policies, procedures, guidelines; and industry best practices. EH&S servesas the liaison between the USF System and external agencies and providesenvironmental health and safety awareness and compliance training. EH&Sadministers multiple programs to achieve this end. Some highlights from FY 20162017 include:USF System CEP 2017 Annual Report7