The primary locus of compliance is in the academic and administrative units throughout the college where the responsibility for policy development and compliance reside. Ultimately, an effective compliance program incorporates adequate controls to reduce regulatory risks throughout the College and provides to senior leadership reasonable assurance that core compliance management practices are in place across the College.
Consistent with an effective compliance program under the Federal Sentencing Guidelines, the College’s Compliance Program includes the following elements:
- Standards and procedures that promote effective compliance initiatives and prevent and detect violations of law;
- Personnel assigned with overall responsibility for compliance that are provided with the appropriate resources and authority, including the authority for personal communications to the governing body or a subgroup;
- A governing body that is knowledgeable about the Compliance Program and exercises reasonable oversight with respect to the implementation and effectiveness of the Compliance Program;
- Personnel with substantial authority for the Compliance Program that are of high integrity and chosen with due diligence;
- Effective training programs that include a system for disseminating compliance information to employees;
- A system that monitors, audits and evaluates compliance activities, has reporting mechanisms for concerns about unlawful conduct that are well publicized, and follows up and investigates reports of unlawful conduct in an effective and timely manner;
- Standards that are consistently enforced through appropriate incentives and discipline; and
- Responses for violations of law that are appropriate and effective, including making any necessary modifications to the Compliance Program.
II. Compliance Program Implementation
Executive Vice President. The Executive Vice President will serve as the coordinator of the Compliance Program and a resource for all College personnel engaged in compliance activities. The Executive Vice President will oversee the College’s compliance activities and programs to ensure they are reasonably designed, implemented, documented, and enforced; advise the College’s administrative and academic units on compliance matters; promote communication and coordination regarding compliance throughout the College; and take or recommend actions to promote an organizational culture that encourages a commitment to compliance and ethical conduct. In fulfilling these responsibilities, the Executive Vice President, or designee, will, among other things:
- Develop standards and a compliance framework to assess, monitor and report on the progress of implementing the Compliance Program;
- Establish clear compliance roles and responsibilities across the College and exercise due care in delegating authority;
- Meet periodically (at least annually) with Vice Presidents and Compliance Administrators assigned with compliance tasks to provide an orientation to the Compliance Program structure, roles, operation, and resources, and to monitor the status of compliance initiatives;
- Determine whether individuals responsible for compliance have adequate resources, authority, and competencies to carry out their responsibilities and recommend to the College’s senior leadership appropriate steps needed to remedy any deficiencies in these areas;
- Promote and evaluate the College’s culture of integrity and compliance, including: (a) conducting periodic surveys designed to assess the culture of compliance; and (b) assuring that compliance standards, procedures and expectations, including the Code of Conduct, are effectively communicated through education and training programs, publications, and other appropriate means;
- Implement an effective mechanism for employees and agents to report or seek guidance regarding potential or actual wrongdoing, including mechanisms to: (a) allow for anonymous reporting and appropriate safeguards to protect against potential retaliation; and (b) ensure that the College investigates and takes appropriate follow-up action regarding potential incidents of non-compliance, including reporting to governmental or accreditation agencies, where appropriate;
- Assist the College’s senior leadership in promoting and enforcing compliance through appropriate incentives and disciplinary measures, including: (a) imposing sanctions for violations and, if warranted, for failing to reasonably detect offenses; and (b) taking appropriate actions to prevent similar future offenses, including recommending any necessary modifications to the Compliance Program;
- Implement written policies, procedures, and standards of conduct, in furtherance of the College’s compliance responsibilities and reasonably designed to reduce misconduct;
- Coordinate the College’s response to any adverse notice or report issued by an outside regulator or accreditor;
- Address any significant regulatory compliance concerns identified during an internal or external audit; and
- Brief the President and President’s Cabinet periodically (at least annually), the Audit Committee of the Board of Trustees at each meeting of the Committee or more often, and the full Board, or other Board committees, as appropriate, on compliance initiatives and obligations, institutional compliance matters, reports of alleged compliance violations and any related investigations, and proposed new and revised compliance policies.
Vice Presidents. In furtherance of the Compliance Program, the Vice Presidents will, among other things, oversee policies relevant to their compliance areas; monitor compliance efforts by their respective Compliance Administrators; receive periodic reports (not less than annually) on compliance initiatives and new compliance obligations; oversee follow-up and response measures to reports of potential violations of law or other standards in their compliance areas; and provide leadership for coordination of compliance activities with the Executive Vice President and their Compliance Administrators. Vice Presidents have express authority to communicate personally with the Chair of the Audit Committee regarding the Compliance Program and/or possible conduct that could expose the College to liability.
Compliance Administrator. A Compliance Administrator is a College employee responsible for the day-to-day functional compliance activities relevant to an assigned compliance area, whether that involves the Compliance Administrator personally performing such obligations or seeing to the assignment of compliance activities by others and confirming that the activities have been appropriately performed, all in a timely fashion. The Compliance Administrator will:
- Be knowledgeable about the content and operation of the Compliance Program;
- Design and maintain programs for the respective compliance functions based on the policies, procedures and standards of the Compliance Program;
- Establish roles and responsibilities, track compliance implementation, identify gaps and trends in compliance efforts, and report progress to the Vice Presidents and Executive Vice President;
- Coordinate and collaborate with the Executive Vice President on ongoing compliance matters and on the status of compliance initiatives in the respective compliance areas; and
- Brief the Compliance Administrator’s Vice President periodically (at least annually) on compliance initiatives and new compliance obligations.
All Compliance Administrators have express authority to communicate personally with the Chair of the Board’s Audit Committee on the Compliance Program and/or possible conduct that could expose the College to liability.
Board of Trustees. The Audit Committee of the Board of Trustees will exercise reasonable oversight of the Compliance Program and provide timely reports on the Compliance Program and particular compliance matters to the full Board of Trustees.