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 3364-15-05 - Protected disclosures through the anonymous reporting line

Universal Citation: OH Admin Code 3364-15-05

Current through all regulations passed and filed through September 16, 2024

(A) Policy statement

According to federal sentencing guidelines, the university of Toledo ("UToledo") provides procedures for employees to report, in good faith, suspected violations of UToledo policies and federal, state, or local laws and regulations.

(B) Purpose of policy

The purpose of this policy is to provide anonymous reporting line procedures for reporting any activity or conduct that are suspected violations of UToledo's policies and procedures, and/or federal, state, or local laws and regulations. For other methods to report see rule 3364-15-03 of the Administrative Code (compliance incident reporting).

(C) Definitions

(1) Protected disclosure: reports about actual or suspected wrongful conduct engaged in by a UToledo employee, student, volunteer, agent or contractor (who is not the disclosing individual) based on a good faith and a reasonable belief that the conduct has both occurred and is wrongful under applicable law and/or UToledo policy.

(2) Wrongful conduct: a serious violation of UToledo policy; a violation of applicable state and federal laws; or the use of UT property, resources or authority for personal gain or other non-university-related purposes except as provided under UToledo policy.

(3) Retaliation: disciplinary or adverse action taken against an individual because she or he has made a protected disclosure or has participated in an investigation, proceeding, or hearing involving a protected disclosure.

(4) Anonymous reporting line: the anonymous reporting line is an external service provider that collects and documents information provided on the call. It operates seven days a week, twenty-four hours a day, and three hundred sixty-five days a year.

(D) Procedures

Individuals who report using the anonymous reporting line should follow the procedures outlined in this paragraph.

(1) Anonymous reporting line:
(a) Either call 1-888-416-1308 go to: www.mycompliancereport.com Or follow the link on: http://www.utoledo.edu/offices/compliance/reporting.html

(b) If calling, after the operator answers and provides a greeting, discuss in detail the issue or concern, ask questions, and answer questions the operator may have. The operator will reinforce that the caller does not need to identify him or herself. If online, follow the prompts.

(c) Record your password for future reference, and

(d) Access the site with your password within ten days to receive an update, answer questions from the investigator, or obtain a report on actions taken to date. At this time, the investigator can let you know if they need additional time to fully investigate.

(2) The executive director of internal audit and chief compliance officer and the director of the university of Toledo medical center ("UTMC") compliance will receive the anonymous reporting line report and review to determine the appropriate department for investigation.

(3) Upon receiving a report, the individual will receive a response, acknowledging receipt of the report.

(4) An investigation can take more than ten days but will be completed within forty five days of the receipt the report unless more time is necessary to thoroughly investigate.

(5) Upon completion of an investigation, UToledo will take appropriate disciplinary action based on the results of the investigation, up to and including termination.

(6) The reporter will be notified through the anonymous reporting line database that the investigation has been concluded, but will not be notified of the discipline to any employees involved in the investigation.

(E) Compliance

All UToledo employees, students, volunteers, agents or contractors are expected to understand and follow UToledo policies and/or federal, state, and local laws and regulations. Individuals are encouraged to report compliance concerns to maintain the mission of UToledo.

UToledo, in compliance with section 4113.52 of the Revised Code, is committed to protecting individuals from interference with making a protected disclosure and from retaliation for having made a protected disclosure. See rule 3364-15-04 of the Administrative Code (non-retaliation).

Replaces: 3364-15-05

Disclaimer: These regulations may not be the most recent version. Ohio may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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