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ROWAN UNIVERSITY POLICY 

Title: Reporting Compliance & Ethics Concerns ("Whistleblower Policy")
Subject: Ethics
Policy No: ELO:2014:01
Issuing Authority: Rowan President
Responsible Authority: Executive Vice President for Administration & Strategic Advancement
Adopted: August 21, 2014
Reviewed: August 21, 2014
Last Revision:

I. PURPOSE

Rowan University is committed to ethical conduct in all of its operations. At the very minimum, all employees, contractors, representatives or agents are responsible to ensure that their activities on behalf of the University, and those of their colleagues, comply with all applicable federal and state laws and Rowan University policies. To that end, all employees have a responsibility and an affirmative duty to report actual or suspected wrongful conduct, and the University has a responsibility to make sure that they can do so without fear of retaliation or reprisal. All Such reports that are filed in good faith shall be accepted, kept confidential to the extent possible in conformance with applicable laws, regulations and University policies and procedures, evaluated fairly and addressed promptly and appropriately.

II. ACCOUNTABILITY

This policy applies to and should be read by all employees, students employed by the university, contractors, representatives or agents of the schools, departments and units that are a part of Rowan University as to their duty to report suspected wrongdoing, the methods they may use to meet their reporting requirements and the protections in place for individuals who provide reports of suspected wrongdoing in good faith.
This policy can be found on the University website as follows: www.rowan.edu/compliance /reporting.

III. APPLICABILITY

It is the policy of Rowan University that employees, students employed by the university, contractors, representatives or agents have a duty to report suspected wrongful conduct and they should be able to meet this duty without the fear of retaliation or reprisal. This policy gives everyone the opportunity to help Rowan achieve its mission.

IV. REFERENCES

  1. Corporate Integrity Agreement between the Office of Inspector General of the Department of Health and Human Services and the University of Medicine and Dentistry of New Jersey, September 25, 2009 to September 25, 2014, as amended by a Letter Agreement, UMDNJ-RowanSOM dated 5/1/2013.
  2. The Medicare and Medicaid Patient Protection Act of 1987, as amended, 42 U.S.C. §1320a- 7b (the "Anti-kickback Statute"),
  3. Stark Law, 42 CFR §§ 411.350 – 411.389.
  4. New Jersey's Conscientious Employee Protection Act (N.J.S.A. 34.19-1 et seq., also known as the "Whistleblower Act").
  5. Sarbanes-Oxley not only prohibits retaliating against whistleblowers (SOX section 806), it also affirmatively requires companies to set up hotlines or other "procedures" for the "confidential, anonymous submission of employee complaints and concerns" about audit/accounting fraud (SOX section 301).

V. POLICY

All employees have a responsibility and an affirmative duty to report actual or suspected wrongful conduct, and the University has a responsibility to make sure that they can do so without fear of retaliation or reprisal.

  1. Reporting Policy Violations & Crime

    1. Employees, students employed by the university and even contractors occasionally violate university policy or even commit crimes. Unfortunately, there are times when these behaviors go unreported because people fear reprisal or retribution from those who are committing the acts. 

    2. Rowan University prohibits retaliation, harassment, intimidation or discrimination against any individual who makes a good faith report of suspected wrongdoing. If something seems wrong, it may be, so employees are encouraged to report it.

  2. Reporting compliance and ethics concerns

    1. As always, report immediate threats or danger by calling 911. Other University contacts include: 

      1. University Ethics Liaison Officer (ELO), established under Executive Order 24 (Christie). The University's ELO is Robert Zazzali who is located on the Glassboro Campus at Bole Hall. He can be reached at 856-256-4110. The Deputy ELO is Ray Braeunig who is located on the Stratford Campus in the University Education Center (UEC-1034). He can be reached at 856-566-6136. 

      2. University Chief Compliance & Privacy Officer, Ray Braeunig . As Compliance Officer, he is obligated by law to report any violations of any Federal Health Care program requirements or of Rowan's own Policies & Procedures to the Office of Inspector General (OIG). While his Compliance duties relate primarily to Federal Health Care program requirements, his duties as Privacy Officer extend across all campuses.

      3. University Equity and Diversity Office. Johanna Velez-Yelin is Assistant Vice President Equity and Diversity and can be reached at the Glassboro Campus in Linden Hall. She can be reached at 856-256-5440. The Office of Equity and Diversity oversees compliance with policies that include but are not limited to: The NJ Policy Prohibiting Discrimination in the Workplace, Americans with Disabilities Act, Title IX Compliance, Rowan University Workplace Violence Policy, and EEO Compliant Search Practices.

    2. The obligations and authority of these offices overlap in some measure, but their jurisdictions and authority are different. Calls to them are confidential, and they will direct you to the right area based on the issue or registered concern.

    3. The university also maintains a confidential hotline It is the Rowan University Integrity Hotline; available 24 hours a day/7days a week, via a toll free phone number, 1 855-431-9967, and via a website: http://rowan.edu/integrityline.

    4. The schools, departments and units that are a part of Rowan University have established, and shall continue to maintain, effective and confidential means for individuals to report allegations or concerns that include actual or suspected violations of law, violations of Rowan University policies or procedures, or any other type of wrongful conduct. Individuals will be permitted to make such reports anonymously if they so desire, and their anonymity will be protected to the extent possible and as permitted by law.

    5. To make a report, individuals may contact their direct manager or other members of their management team. In addition, individuals may call the units Compliance Office, General Counsel; Ethics Liaison Officers; or they may call the Rowan University Integrity Line.

  3. Integrity hotline: 855-431-9967

    1. New in 2014, Rowan has created a phone hotline for those who want to report issues confidentially (to the extent possible) to an outside agency. The hotline, (855) 431-9967, is managed by Global Compliance, an independent organization that provides a secure and confidential means to file a report 24 hours a day, seven days a week. The system accommodates callers in 150 languages as well as callers with special needs.

    2. Global Compliance logs each and every report. Whether you use the Integrity Hotline Phone number or website the Rowan University-Integrity Hotline allows you to report issues and concerns you may have (regarding but not limited to), unethical behavior, inappropriate conduct, bullying, harassment, and any other violation to Rowan University policies. This reporting process is secure and confidential. The organization prioritizes the speed with which reports must be addressed as follows:

      Priority A – Immediate
      Priority B – Moderate
      Priority C – Standard

    3. A committee of two University employees reviews each and every report. Should they believe the report involves factors that require greater perspective and independence they have access to outside investigators.

    4. Visit www.rowan.edu/compliance to learn more about Rowan's policy on Reporting Compliance and Ethics Concerns, the protection afforded to employees who report violations and rights of individuals accused of wrongdoing.

  4. Protection from reprisal or retaliation

    1. Rowan University policy prohibits retaliation, harassment, intimidation or discrimination against individuals who make good faith reports of suspected wrongdoing. Any employee found to have retaliated against anyone who has made a good faith report shall be subject to appropriate disciplinary action up to and including termination of employment. Good faith reports that are not substantiated are protected under this policy.

    2. Complaints made in bad faith using falsified information is contrary to the intent and spirit of this policy, and may subject the reporter to disciplinary action up to and including termination.

    3. To make reports of immediate threats or danger, call 911. The Rowan University Alert Line should not be used for emergencies. There are other reporting methods for concerns which are summarized in Attachment 2.

  5. Retaliation & Whistleblower Protection

    1. Reporting and Investigating Retaliation Allegations:

      1. Reporting: Anyone who has provided information who believes he or she is the subject of retaliation should report the facts supporting the allegations of retaliation to the Chief Compliance Officer; Assistant Vice President Equity and Diversity; General Counsel, Ethics Liaison Officers (ELO) or the Alert Line.

        1. All investigations of alleged retaliation will be conducted as sensitively and expeditiously as possible. Due consideration will be given to existing grievance procedures under applicable collective bargaining agreements.

      2. Should an investigation lead the appropriate Rowan University authority to conclude that retaliation has been substantiated; the individual(s) responsible for committing the retaliation, in addition to any civil or criminal proceedings, shall be subject to disciplinary action up to and including termination.

      3. In accordance with New Jersey's Conscientious Employee Protection Act (N.J.S.A. 34.19-1 et seq., also known as the "Whistleblower Act"), Rowan University shall take no retaliatory action against an employee as identified in Attachment 1.

    2. The Conscientious Employee Protection Act Annual Notice is Attachment 1.

  6. Sanctions

    Failure to comply with this policy may result in sanctions up to, and including, termination of employment or termination of a contractor's agreement.

  7. Communications

    As Rowan University grows it is important to have process in place to ensure concerns are addressed in a timely and a efficient basis. Effective communication is necessary for a University to swiftly communicate information to personal that are a part of Rowan University to report Non-compliant activities. The document below provides a mechanism for anonymous and confidential reporting without any form of retaliation. It also provides a wide array of direction for all Rowan personal to address concerns. Please read and keep this information available to you.

    Notices: Posters will be placed in each Human Resource site for each Rowan University unit/school. See below Attachment 1 – Annual Notice.

    Email: An email will be sent in the second week of the fall, spring and summer terms of each year to all faculty, staff, students employed by the university and Trustees.

VI. ATTACHMENTS 

  1. Attachment 1 - Annual Notice
  2. Attachment 2 - Type of Issue
  3. Attachment 3 - Integrity Hotline Investigation Process


ATTACHMENT 1 

 Annual Notice

...

CONSCIENTIOUS EMPLOYEE PROTECTION ACT
"WHISTLEBLOWER ACT"

Employer retaliatory action; protected employee actions; employee responsibilities

...

Este aviso se debe exponer a la vista de todos.
Una vez por año, los empleadores deben de distribuir un aviso de esta ley a sus empleados. Si necesita este documento en algún otro idioma que no sea inglés o español, sírvase llamar al (609) 292-7832. Posiblemente, una carga nominal puede ser cobrada.

 

 

ATTACHMENT 2

...

TYPE of

...

ISSUE

 

Where to go for support/direction and how to report an issue

...

    1. In an emergency, or if you experience or witness imminent or actual violence involving weapons or potential injuries, call 911.
    2. Any person who is the subject of, or witness to, a suspected violation of this policy should report the incident to his or her supervisor or, in lieu thereof, to the appropriate Designated University Representative.

 

 

 

ATTACHMENT 3

INTEGRITY HOTLINE INVESTIGATION PROCESS

 

NOTE:  These investigative processes are general guidelines. Depending on the policy being investigated, the investigation process may be different.  The Integrity Hotline can be used by employees and students as well as external visitors, and vendors.  The following investigation process guidelines do not apply to students. For information on student–on-student case please visit the Student Handbook at:

http://www.rowan.edu/studentaffairs/main_office/publications/Handbook_Planner.cfm

 

  1. Hotline Reports
    1. A committee of Rowan University employees reviews each and every Hotline report. Once the report has been reviewed, the case is assigned to an investigator. 
    2. The objective of the investigation is to determine the credibility of the Reporter (employee who notified the Hotline) and reported allegation. If the Reporter has revealed his/her identity, the Investigator will contact the Reporter via telephone or email. The Investigator will ask the Reporter for available dates and times to schedule an interview to acquire more information about the reported allegation.
    3. It is the interviewed employee’s responsibility to notify his/her superiors of the interview date and time. The Investigator will attempt to conduct the interview at a Rowan University location that will allow the employee to be relaxed and forthcoming.
    4. If the Reporter did not reveal their identity, the Investigator will attempt to communicate with the anonymous Reporter, utilizing the Rowan University Integrity Hotline website: www.rowan.edu/integrityline.
  2. Communication with Reporter 
    1. To effectively conduct an investigation, it is crucial for the anonymous Reporter to maintain communication with the case Investigator by utilizing the Communication with Reporter section of the website. The Reporter will need to know the case number and PIN for his/her case to continue communications with the Investigator.  Without key information, it may be very difficult to effectively investigate the credibility of the allegation and may result in the allegation being classified as “unsubstantiated”.
    2. It is very important to note, that any case may be re-opened, if additional information is provided.
    3. At the inception of an investigation, when appropriate, the assigned Investigator may notify the Vice President that oversees the area under investigation.
  3. Internal Investigation Interview(s)
    1. Internal Interview Introduction (information provided below is for guidance purposes only and specific questions and areas of inquiry may vary based on the subject matter of the allegation and the specific policy involved)
      • The Investigator will send a request to the employee to be interviewed labeled “CONFIDENTIAL INTERVIEW”. The employee will be requested to provide times they will be available for the interview. The employee will be requested to notify their department supervisor about the interview request. If the employee does not feel comfortable notifying their department supervisor, they may elect to notify the individual their supervisor reports to, or ask the Investigator to notify departmental management. The Investigator will attach the Investigation process to the CONFIDENTIAL INTERVIEW invitation to provide the employee the opportunity to review.   
      • The Interviewed employee will be provided with the New Jersey State Policy Prohibiting Discrimination in the Workplace as well as Rowan University Workplace Violence Policy or any other policy related to the complaint, which includes instructions regarding the Confidentiality, Prohibition against Retaliation of the information discussed during the interview and the employee’s Weingarten Rights (for union employees).  Employees who are members of the union may request union representation during the interview.
      • The Interviewed employee will be asked to read and sign the confidentiality form.
      • The Investigator’s role will be explained to the employee.
      • Interview ground rules will be explained, including, but not limited to answering the questions to the best of the interviewed employee’s ability. Please note that it is acceptable if the employee does not remember or does not know the answer to the question but inform the investigator of that.
      • The Investigator will determine the value of information reported by third parties, depending upon the allegation and how it relates to the case.   
    2. Overview of the Allegation
      • The allegations will be reviewed with the reporter  and the Investigator will ask  for more in depth information regarding the allegation.
      • The Investigator will request any evidence associated with the allegation from any involved employee or department.
      • The Reporter will be asked; what are your expectations or desired outcome to resolve this allegation.
    3. Interview Conclusion
      • The Investigator will ask the employee if he/she has witnessed or has knowledge of, any other unethical, fraudulent, discriminatory or criminal behaviors during his/her employment at Rowan University.
      • The Investigator will review the Confidentiality statement and the No Retaliation Policy with the employee. The employee will be given the Investigator’s contact information, in case the employee remembers additional information related to the case or if he/she feels that he or she is experiencing adverse employment consequences based upon involvement in the investigation.
    4. The Investigator will interview employees who witnessed the incident or may have additional foundational knowledge related to the allegation. The allegation will not necessarily be disclosed during interviews performed to acquire foundational knowledge; only relevant information to that witness will be shared.
    5. The investigator will meet with the respondent/accused and review and discuss the allegations. A statement will be taken and incorporated into the investigative report.
  4. Investigation Analysis
      • The Investigator will review all of the information provided in the interviews and related evidence to determine if the allegation violates Rowan University Policy, New Jersey State and/or federal laws or regulations.
      • If the facts of the case reveal a violation, then the allegation is considered substantiated.
      • If the facts of the case reveal there has not been a violation, the allegation is considered unsubstantiated.
      • If the facts of the case, do not allow the Investigator to determine the credibility of the allegation, it is considered inconclusive.
  5. Investigation Conclusion
      • Depending under what policy the investigation is taking place, the Investigator will discuss the Investigational conclusion(s) on allegations that have been substantiated only with the department management or director. The Investigator may provide recommendations to the department management. The Office of Compliance & Corporate Integrity will request a Corrective Action Plan (CAP) from the involved department and may audit the effectiveness of the CAP, after it has been implemented.  (Please note this does not always apply to Discrimination, Workplace Violence, or Title IX investigations.).
      • The Investigator will communicate to the Reporter, thanking them for being forthcoming and that the investigation has been closed.   
      • The Investigator may also be required/requested to notify Rowan’s Office of General Counsel, Labor Relations Office, the Dean, President and/or Rowan University Board of Trustees Audit Committee, when appropriate.
      • If criminal behavior has been substantiated, the Investigator will notify the Office of General Counsel and/or law enforcement (when appropriate).
      • If the allegation has been determined to be inconclusive or unsubstantiated, the case will be closed. If in the future, additional information is provided relating to the allegation, the case may be re-opened.  Please note that in cases of inconclusive or unsubstantiated determinations concerns may be identified relating to process or procedure.  In such cases, the investigator will alert appropriate university administrators of such concerns.  Further, at the conclusion of the investigation, the Investigator will alert the department Vice President or other appropriate administrator that the matter has been concluded.
      • In order to preserve the integrity of the investigation, only the Executive Vice President and Rowan General Counsel’s Office will have access to the full report of findings.
  6. Participation in an Internal Investigation
      1. Noted previously, employees are obligated to report concerns relating to illegal and unethical conduct as well as potential policy violations.  Such information is vital in ensuring that Rowan operates in a way that is compliant with applicable law and satisfies its mission.
      2. As such, Rowan University expects all employees to cooperate fully with internal investigations. If the employee refuses to   cooperate with internal investigations, the employee may be subject to disciplinary actions, up to and including termination in accordance with applicable policies.  
  7. Protection from Reprisal or Retaliation
    1. Rowan University prohibits retaliation, harassment, intimidation or discrimination against individuals who make good faith reports of suspected wrongdoing.  Any employee found to have retaliated against anyone who has made a good faith report shall be subject to appropriate disciplinary action up to and including termination of employment. Good faith reports that are not substantiated are protected under this policy.
    2. Complaints made in bad faith using falsified information are contrary to the intent and spirit of this policy, and may subject the reporter to disciplinary action up to and including termination.
    3. To make reports of immediate threats or danger, call 911.  The Rowan University Alert Line should not be used for emergencies.
  8. Retaliation & Whistleblower Protection
    1. Reporting and Investigating Retaliation Allegations:
      1. Reporting: Anyone who has provided information who believes he or she is the subject of retaliation should report the facts supporting the allegations of retaliation to the Chief Compliance Officer; Assistant Vice President Equity and Diversity; General Counsel, Ethics Liaison Officers (ELO) or the Alert Line.
      2. All investigations of alleged retaliation will be conducted as sensitively and expeditiously as possible. Due consideration will be given to existing grievance procedures under applicable collective bargaining agreements.
      3. Should an investigation lead the appropriate Rowan University authority to conclude that retaliation has been substantiated; the individual(s) responsible for committing the retaliation, shall be subject to disciplinary action up to and including termination and may be subject to other civil or criminal proceedings under applicable law.
    2. Rowan University forbids retaliation in accordance with New Jersey’s Conscientious Employee Protection Act (N.J.S.A. 34.19-1 et seq., also known as the “Whistleblower Act”).  Rowan University shall not engage in conduct prohibited by the act and employees who violate the provisions shall be subject to disciplinary action.
  9. Corrective Action Plan (CAP)
    1. Depending upon the sensitivity of the substantiated allegation finding, the involved employees/department/unit may be requested to create a CAP (when appropriate) to resolve the allegation and provide an implementation date. The Investigator will receive a copy of the CAP and implementation date.
    2. The Investigator may perform a follow up assessment of the effectiveness of the CAP. If the CAP has been determined to be ineffective to resolve the allegation, the Investigator follow up assessment may be discussed with the involved employees/departments/units to determine if there are additional possible processes that will resolve the allegation.
  10. Frequently Asked Questions:
    1. How does the Anonymous Reporter, continue to communicate with the Investigator and still be anonymous?
      • The Rowan Integrity Hotline website (Communication with the Reporter section) provides an area for the Reporter to communicate with the Investigator anonymously. When the Reporter submits a case, they are provided a case number and PIN, which allows them access to this area. The Reporter will be required to use the case number and PIN to access the case in the future. It is very important to maintain this communication, if the Reporter wants to see resolution to their allegation. Investigators will always have more questions.
    2. How does the Reporter know about the investigational findings?
      • If the allegation has been substantiated, the Reporter should notice changes within their department and may be requested to assist to resolve the allegation.
      • If the allegation has been unsubstantiated or inconclusive, the Reporter may not notice any changes within their department. 
      • It is important to note that unsubstantiated and inconclusive cases may be closed, but have potential to be reopened, if additional information is provided. To maintain the confidentiality, Investigators consider these cases as having the potential to be re-opened.
    3. Will management be notified about the allegation or investigational finding?
      • The Investigator will notify the departmental vice president or other appropriate administrator of a pending investigation unless doing so will impact the integrity of the investigation.  Further, to avoid being disruptive to the department workflow, we welcome discussion with management about appropriate time to schedule an interview with the employee. To maintain the confidentiality of the investigation, management will not be notified about investigational findings, unless they will need to be involved in the Corrective Action Plan.
    4. Can the interviewed employee bring union or legal representatives to the internal investigation interview?
      • Yes. However, since the interviews are part of the administrative internal investigation and not considered a judicial proceeding, representatives may not participate in the interview questioning or answers. Union and legal representatives will be required to sign a Rowan University Confidentiality form and will not be allowed to take notes of the interview.
    5. How long does an investigation take?
      • The length of time for an investigation varies greatly and is dependent upon the nature of the allegation, the Investigator’s case load and the amount of time needed to analyze evidence provided.  However, Rowan will attempt to resolve investigations in a timely manner.
    6. Do I have to be interviewed on my own time?
      • Interviews will be scheduled during work time to encourage cooperation.  However, employees are encouraged to consider departmental needs when scheduling time for interviews.   
    7. Can we meet in a neutral location?
      • Yes.  The Investigator will meet with the employee in a neutral, relaxing environment where the employee feels comfortable being forthcoming with appropriate information related to the allegation.
    8. What happens if I lose my case number and/or PIN?
    9. Can the Reporter receive a copy of the case report?
      • Rowan University Internal investigation reports are confidential and are only provided to the Executive Vice President and Office of General Counsel unless otherwise required by law.  
    10. Should I report Human Resources or Labor Relations issues to Rowan University Hotline?
      • Rowan University recommends that employees utilize their department “chain of command” or the Human Resources office to report Human Resources issues. If the employee is a union employee, the employee may utilize his/her union contract process to report Labor Relation issues. After the employee utilizes the established processes mentioned above and he/she has not received a satisfactory response, he/she may decide to notify the Rowan University Integrity Hotline.