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Policy No: 2172
Responsible Office: Human Resources
Last Review Date: 11/09/2026
Next Required Review: 11/09/2031
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Policy No: 2172
Responsible Office: Human Resources
Last Review Date: 11/09/2026
Next Required Review: 11/09/2031
Regulatory Compliance Requirements
1. Purpose
To outline compliance program requirements for the University, including general guidance on how the University should maintain compliance readiness, and direction for how departments shall identify and assess current and emerging regulations and implement processes and procedures to minimize associated risk.
2. Applicability
This policy applies to all campus divisions, particularly to any office or department whose operations are impacted by, and therefore must ensure compliance with, state or federal laws, statutes and regulations.
3. Definitions
Compliance Committee: Per the Compliance Committee Charter, appointed committee members meet at least semiannually, charged with advising in the development and management of the Campus Compliance Plan. The Compliance Committee assists the senior leadership team in its responsibilities relating to compliance with University policies, applicable legal requirements and sound ethical standards.
Compliance Plan: The Compliance Committee has established and oversees a Compliance Plan whose outline is based on the essential elements of an effective compliance program (as defined by the United States Sentencing Guidelines). The Plan summarizes processes and procedures necessary for ensuring compliance with current and emerging federal and state regulations that impact University operations. The Compliance Committee reviews and approves the Compliance Charter & Plan on a biennial basis.
4. Policy Guidelines
4.1 University Compliance Plan
The University’s Compliance Plan is modeled on the elements of an effective compliance program, as set forth by the U.S. Federal Sentencing Guidelines. The elements are widely referenced in compliance programs of companies and institutions across all U.S. industry.
To demonstrate an effective compliance program, organizations must “exercise due diligence to prevent and detect criminal conduct” and “promote an organizational culture that encourages ethical conduct and a commitment to compliance with the law” (Section §8B2.1, "Effective Compliance and Ethics Program," published by the United States Sentencing Commission). The following summarizes the elements of an effective compliance program (modified for applicability to our University operations).
4.2 Elements of an Effective Compliance Program
4.2.1 Oversight
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- Designate compliance professional(s) to oversee the development and management of the USA Campus Compliance Program;
- Operate objectively, with an arms-length separation from business operations (to a reasonable extent), and with necessary support from leadership.
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4.2.2 Policies and Procedures
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- Develop, review, modify, and publish guiding principles, including the Community Values and Code of Conduct, applicable portions of the Staff Employee Handbook and Faculty Handbook, and compliance-related University Policies;
- Subject matter experts should stay abreast of new state and federal laws, regulations and statutes that impact higher education and the University of South Alabama in particular, and ensure University policies and procedures are updated accordingly.
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4.2.3 Education and Training
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- Develop, implement and maintain an effective training program which ensures employees are aware of applicable policies and procedures;
- Recommend focused, role-based training on identified high-risk topics for applicable employees.
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4.2.4 Open Lines of Communication
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- Ensure the availability of a means by which employees may report potential compliance violations, free of retaliation, and anonymously if desired;
- Assess efficacy of compliance issue reporting processes;
- Foster a culture of ethical conduct and transparency so that employees feel comfortable reporting concerns directly to their supervisors.
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4.2.5 Auditing and Monitoring
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- Compliance audits and surveys should be scheduled routinely to ensure University processes and procedures are compliant with our standards and policies (e.g., the biennial Compliance Risk Assessment);
- Auditing and monitoring findings should be communicated to department or division leadership, with remediation steps and follow-up requirements clearly communicated.
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4.2.6 Response and Prevention
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- Monitor long-term trends of compliance violations and make recommendations for necessary mitigation;
- Recommend areas of concern for targeted risk assessments to the University’s compliance professionals and Internal Audit;
- Corrective actions in the wake of confirmed violations should be addressed to all involved, and leadership should consider sharing lessons learned with others;
- Ensure employee criminal background checks are consistent, effective, and appropriately scaled to the level and type of responsibility of the employee.
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4.2.7 Enforcement and Discipline
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- Ensure that enforcement measures and disciplinary options are reasonably consistent across departments and divisions;
- Develop positive incentives to promote ethical and compliant conduct.
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4.2.8 Compliance Program Evaluation
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- Periodically evaluate the effectiveness of the University’s ethics and compliance program.
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4.3 Participation in the University’s Biennial Compliance Risk Assessment
Campus leaders who are responsible for ensuring their office or department’s compliance with state and federal laws, statutes and regulations will participate in a biennial Compliance Risk Assessment, which functions as a self-assessment, to include, if necessary, the development and management of department processes and procedures which minimize the risk of violation of those laws as pertains to relevant department operations. Applicable offices and departments are identified in Section 7.1.
5. Procedures
5.1 Participation in the Biennial Compliance Risk Assessment.
Offices and Departments identified in Section 7.1 respond to the Compliance Risk Assessment on a biennial basis by self-assessing their compliance with identified state and federal laws, statutes and regulations. The assessment is administered by the Office of Compliance, and subject to periodic monitoring by the University’s Office of Internal Audit.
5.1.1 Federal regulations are published in the Higher Education Compliance Alliance’s “Compliance Matrix,” which features all laws, statutes & regulations that impact higher education-related operations. The Compliance Matrix includes summarized recommendations and references specific to each regulation, based on the functional area to which it applies. Persons responsible for completing their department’s Compliance Risk Assessment rate their compliance with the regulations and cite any challenges needing attention.
On an as-needed basis, department leaders will develop and maintain processes and procedures which ensure risks of violation of the applicable federal regulations are minimized.
5.1.2 State regulations which impact University operations will need to be added to the Compliance Risk Assessment by the Compliance Risk Assessment participants, and these will need to be self-assessed just as with the federal regulations.
On an as-needed basis, department leaders will develop and maintain processes and procedures which ensure risks of violation of the applicable state regulations are minimized.
6. Enforcement
Violations of this policy are grounds for disciplinary action up to, and including, termination of employment. The Office of Compliance and/or Internal Audit will periodically monitor compliance with this policy.