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Title: Reporting Compliance & Ethics Concerns
Subject: Compliance and Corporate Integrity
Policy No: OCCI:2014:01
Applies: University-wide
Issuing Authority: Rowan University President 
Responsible Officer: Executive Vice President for Administration & Strategic Advancement 
Adopted: August 21, 2014
Last Revision: August 21, 2014
Last Reviewed: Dec 19, 2014

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:

http://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. Reference

The University complies with the following related documents:

A.    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.
B.    The Medicare and Medicaid Patient Protection Act of 1987, as amended, 42 U.S.C. §1320a- 7b (the "Anti-kickback Statute"),
C.    Stark Law, 42 CFR §§ 411.350 – 411.389
D.    New Jersey's Conscientious Employee Protection Act (N.J.S.A. 34.19-1 et seq., also known as the "Whistleblower Act")
E.    Sarbanes-Oxley Sarbanes-Oxley not only prohibits retaliating against whistle blowers (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

A. 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.

B. 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.

C. 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

D. 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 1
  4. Retaliation & Whistle blower Protection
    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.
      1. 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 "Whistle blower Act"), Rowan University shall take no retaliatory action against an employee as identified in Exhibit A below.
      The Conscientious Employee Protection Act Annual Notice is given in Attachment 2 or Attachment 3 in Spanish
  5. 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. 

  6. Communications
    Notices: Posters will be placed in each Human Resource site for each Rowan University unit/school. See below Attachment 2 or Attachment 3 in Spanish
    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

A. Attachment 1 - Other Reporting Methods for Concerns

B. Attachment 2 - Annual notice, Conscientious Employee, Protection Act "Whistleblower Act"

C. Attachment 3 - Annual notice, Conscientious Employee, Protection Act "Whistleblower Act" (Spanish)

ATTACHMENT 1

Other Reporting Methods for Concerns

 Type of Issue

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

 Abuse/neglect of minors

Accident/Injury

Alcohol and Drug Use; Alcohol on Campus

Employees are encouraged to seek assistance through the Faculty and Staff Assistance Program if they believe they may have an alcohol or other drug abuse problem-  http://www.rowan.edu/studentaffairs/main_office/files/aodguide.pdf 

http://www.rowan.edu/som/hr/documents/orientation.pdf

 Animal Research Violations of NIH, USDA, AAALAC Regulations

http://www.rowan.edu/open/provost/research

http://srintra.rowan.edu/viv/links.cfm - animal welfare regulations 

 Conflict of Interest violation of DHHS, FDA, NSF or other Federal Agency Regulations

Contact the Office of the Vice President of Research and Economic Development.

 http://www.rowan.edu/open/provost/research/Integrity_and_compliance/Integrity_and_compliance.cfm

http://www.rowan.edu/som/research/admin.html

Critical information system being hacked or compromised (Oracle PeopleSoft, Banner, e-mail)

 Disability: Americans with Disabilities Act (staff-related)

Disability: Americans with Disabilities Act (student-related)

Discrimination

Export Controls (Research)-www.rowan.edu/compliance, click research tab

 Fair Labor Standards Act and Overtime Provisions

Fraud (Financial)

  •  Internal Audit Department 

Harassment

Student Sexual Misconduct and Harassment Policy-http://www.rowan.edu/equity/TITLEIX

Employee Sexual Misconduct and Harassment Policy-

www.rowan.edu/equity

Healthcare Compliance

Human Subject Research Violations of DHHS/OHRP, FDA and other Federal Regulations pertaining to human subject research

Improper accounting and costing on sponsored projects

Improper document of or billing for healthcare goods or services

  •  RowanSOM Office of Compliance and Corporate Integrity (856-566-6136)

Laboratory Safety Violations

Misconduct in Research including Falsification of Documents/Records

Open Public Meetings Act –

Open Public Records Act –

Public Safety/Emergency Management

http://www.rowan.edu/safety/

Radiation Safety Violation of NRC or DCRA Regulations

Records Management (e.g. document retention schedules, archiving documents)

 www.rowan.edu/compliance - Policies- Records Management 

Records: Loss of records; inability to find records; improper release, disclosure or access to records

http://www.rowan.edu/adminfinance/records

http://www.rowan.edu/som/hr/documents/orientation.pdf

http://www.rowan.edu/equity/titleix

http://www.rowan.edu/provost/registrar/

 Director of Information Protection and Security or go to the Information Protection and Security website Research Compliance- 

Research: Sponsored Project Billing and Reporting

  • Rowan University Office of Sponsored Program - http://www.rowan.edu/open/provost/grants/
  •  Internal Audit Department – James J. Rowan, Chief Internal Auditor – (856) 256-5110 or rowanj@rowan.edu

RowanSOM Biomedical and Health Sciences Compliance Issues

 Sexual Harassment

Student Billings

http://www.rowan.edu/som/education/student_affairs/index.html\

Student Loan Abuses

University Property: Loss or Theft

Victim Assistance (and violence prevention)

  •  In an emergency, dial 911.
  •  Violence Prevention and Victim Assistance 

 Violation of OSHA, HFPA, BOCA, NRC, and FDA regulations

Violation of System Security

Violations of EPA regulations and Hazardous material releases- http://www.state.nj.us/dep

 Worker's Compensation Laws

Workplace Violence- http://www.rowan.edu/equity


ATTACHMENT 2 – Annual Notice 

Conscientious Employee
Protection Act
"Whistleblower Act"


Employer retaliatory action; protected employee actions; employee responsibilities

  1. New Jersey law prohibits an employer from taking any retaliatory action against an employee because the employee does any of the following:
    1. Discloses, or threatens to disclose, to a supervisor or to a public body an activity, policy or practice of the employer or another employer, with whom there is a business relationship, that the employee reasonably believes is in violation of a law, or a rule or regulation issued under the law, or, in the case of an employee who is a licensed or certified health care professional, reasonably believes constitutes improper quality of patient care;
    2. Provides information to, or testifies before, any public body conducting an investigation, hearing or inquiry into any violation of law, or a rule or regulation issued under the law by the employer or another employer, with whom there is a business relationship, or, in the case of an employee who is a licensed or certified health care professional, provides information to, or testifies before, any public body conducting an investigation, hearing or inquiry into quality of patient care; or
    3. Provides information involving deception of or misrepresentation to, any shareholder, investor, client, patient, customer, employee, former employee, retiree or pensioner of the employer or any governmental entity.
    4. Provides information regarding any perceived criminal or fraudulent activity, policy or practice of deception or misrepresentation which the employee reasonably believes may defraud any shareholder, investor, client, patient, customer, employee, former employee, retiree or pensioner of the employer or any governmental entity.
    5. Objects to, or refuses to participate in, any activity, policy or practice which the employee reasonably believes:
      1. is in violation of a law, or a rule or regulation issued under the law or, if the employee is a licensed or certified health care professional, constitutes improper quality of patient care;
      2. is fraudulent or criminal; or
      3. is incompatible with a clear mandate of public policy concerning the public health, safety or welfare or protection of the environment. N.J.S.A. 34:19-3.
  2. The protection against retaliation, when a disclosure is made to a public body, does not apply unless the employee has brought the activity, policy or practice to the attention of a supervisor of the employee by written notice and given the employer a reasonable opportunity to correct the activity, policy or practice. However, disclosure is not required where the employee reasonably believes that the activity, policy or practice is known to one or more supervisors of the employer or where the employee fears physical harm as a result of the disclosure, provided that the situation is emergency in nature. 

CONTACT INFORMATION
The following contact persons at Rowan University have been designated to answer your questions or provide information regarding your rights and responsibilities under the Whistleblower Act (N.J.S.A. 34:19-4):
*Name: Robert Zazzalli
Address:Bole Hall
Telephone Number: (856) 256-4110

Or

*Name: Rowan University Integrity Line
Telephone Number: 1-855-431-9967
Website Access: http://rowan.edu/integrityline.

This notice must be conspicuously displayed.
Once each year, employers must distribute notice of this law to their employees.
If you need this document in a language other than English
or Spanish, please call (609) 292-7832.

AD-270 (3/06)

ATTACHMENT 3
La Ley de protección al
empleado consciente
"Ley de protección del denunciante"

Acciones de represalia del empleador; protección de las acciones del empleado

  1. La ley de New Jersey prohíbe que los empleadores tomen medidas de represalia contra todo empleado que haga lo siguiente:
    1. Divulgue o amenace con divulgar, ya sea a un supervisor o a una agencia pública toda actividad, directriz o norma del empleador o de cualquier otro empleador con el que exista una relación de negocios y que el empleado tiene motivos fundados para pensar que violan alguna ley, o en el caso de un trabajador licenciado o certificado de la salud y que tiene motivos fundados para pensar que se trata de una manera inadecuada de atención al paciente;
    2. Facilite información o preste testimonio ante cualquier agencia pública que conduzca una investigación, audiencia o indagación sobre la violación de alguna ley, regla o reglamento que el empleador o algún otro empleador con el que exista una relación de negocios; o en el caso de un trabajador licenciado o certificado de la salud que facilite información o preste testimonio ante cualquier agencia pública que conduzca una investigación, audiencia o indagación sobre la calidad de la atención al paciente; o
    3. Ofrece información concerniente al engaño o la tergiversación con accionistas, inversionistas, usuarios, pacientes, clientes, empleados, ex empleados, retirados o pensionados del empleador o de cualquier agencia gubernamental.
    4. Ofrece información '63on respecto a toda actividad que se pueda percibir como delictiva o fraudulenta, toda directiva o práctica engañosa o de tergiversación que el empleado tenga motivos fundados para pensar que pudieran estafar a accionistas, inversionistas, usuarios, pacientes, clientes, empleados, ex empleados, retirados o pensionados del empleador o de cualquier agencia gubernamental.
    5. Se opone o se niega a participar en alguna actividad, directriz o práctica que el empleado tiene motives fundados para pensar que:
      1. viola alguna ley, o regla o reglamento que dicta la ley o en el caso de un empleado licenciado o certificado de la salud que tiene motivos fundados para pensar que se trata de la atención inadecuada al paciente;
      2. es fraudulenta o delictiva; o
      3. es incompatible con algún mandato establecido por las directrices públicas relacionadas con la salud pública, la seguridad o el bienestar o la protección del medio ambiente. Artículo 34:19-3 de las Leyes comentadas de New Jersey de protección del empleado consciente (N.J.S.A., por sus siglas en inglés)
  2. No se puede acoger a la protección contra la represalia, cuando se hace una divulgación a un organismo público, a no ser que el empleado le informe al empleador de tal actividad, política o norma a través de un aviso por escrito y le haya dado al empleador una oportunidad razonable para corregir tal actividad, política o norma. Sin embargo, no es necesaria la divulgación en los casos en que el empleado tenga indicios razonables para creer que un supervisor o más de un supervisor del empleador tienen conocimiento de tal actividad, política o norma o en los casos en los que el empleado teme que tal divulgación pueda traer como consecuencia daños físicos a su persona siempre y cuando la naturaleza de la situación sea la de una situación de emergencia. 

Información del Contacto
La persona siguiente para ha sido designada a contestar sus preguntas
o, proporcionar información adicional relacionada con sus derechos y
responsabilidades según lo indica esta ley (N.J.S.A. 34:19-4):

      • Nombre: Robert Zazzalli
        Dirección: Bole Hall
        Número de teléfono: (856) 256-4110
      • Nombre: Rowan University Integrity Line
        Dirección: 
        Número de teléfono: (855) 431-9967
        Website: http://rowan.edu/integrityline

 

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. 

 

 

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