Ohio Administrative Code
Title 3364 - University of Toledo
Chapter 3364-15 - HIPAA Organizational Structure; Fraud, Waste and Abuse; Compliance and Confidentiality of Patient Information
Section 3364-15-03 - Compliance incident reporting
Current through all regulations passed and filed through September 16, 2024
(A) Policy statement
The university of Toledo ("UToledo") strives to comply with all federal, state, and local statutes. This policy sets forth the procedures that UToledo will use to respond to reports by institutional members or others regarding possible violations of UToledo policies and procedures or a possible violation of applicable state and federal laws.
(B) Purpose of policy
This policy establishes UToledo's response in situations where UToledo policies, rules and standards, state and federal regulations have been violated either inadvertently or knowingly. Corrective action or procedure are necessary to ensure compliance. It is necessary to protect UToledo in the event of civil or criminal enforcement actions.
(C) Scope
All UToledo campuses.
(D) Definitions
"Institutional members" Any person who participates in university activities, or has an affiliation with UToledo, including but not limited to staff, faculty, providers of medical services, contractors, vendors, students, alumni and volunteers, whether or not they are paid by UToledo.
(E) Procedures
Institutional members have a duty to ask questions regarding potential issues and to report potential concerns. If any institutional member knows of or suspects a violation, they are to report it immediately without fear of retaliation. At no time will any retaliatory action be taken against any individual who files a good faith complaint. Please refer to rule 3364-15-04 of the Administrative Code (non-retaliation).
Institutional members may report in good faith incidents or suspicious activities in the manner listed in this rule. Information received will be maintained confidentially to the extent the law permits.
The recommended method to raise a concern begins with your own college, department or unit through supervisory channels or you may report to:
Due to the subject matter, work or personal relationship, it may be best to raise questions through a specialized central office. Examples include:
If the institutional member is uncomfortable with addressing concerns at the local level or through a central office, needs advice on how to handle an issue, or issues have not been resolved satisfactorily, the institutional member can call and report directly to the department of internal audit and compliance. Institutional members may also submit a written report to the department of internal audit and compliance.
UToledo has an anonymous reporting line to report any situation without using any personally identifiable information (888-416-1308). Refer to rule 3364-15-05 of the Administrative Code (protected disclosures and anonymous reporting line policy).
Should institutional members feel that the issues or concerns are not being addressed by administration; the institutional member may file a complaint directly to the government or supporting agency.
All institutional members are provided training on how to report suspected violations of UToledo policies, state and federal regulations.
(F) Enforcement
The failure of any institutional member to perform any obligation required of this policy or applicable local, state, and federal laws or regulations is subject to established UToledo disciplinary actions and/or prosecution by state or federal authorities.
(G) List of critical areas of compliance concern (not all inclusive)
Replaces: 3364-15-03
