#2 I. SANCTION CHECK PROCEDURES OVERVIEW The Institutional Compliance Office (ICO) is responsible for the coordination of University sanction check procedures with various departments and administrative offices in accordance with ICO Policy #ICO-002 Sanction Checks. University employees, vendors, affiliated research personnel, and affiliated physician practice group employees will be checked against the following federal exclusion/debarment/suspension lists to ensure eligibility for hire and/or to participate in University programs: U.S. Department of Health and Human Services, Office of Inspector General s (OIG) List of Excluded Individuals/Entities (LEIE) General Services Administration s (GSA) Excluded Parties List System (EPLS) U.S. Food and Drug Administration s (FDA) Debarment List and Disqualified/Totally Restricted List for Clinical Investigators U.S. Department of the Treasury, Office of Foreign Asset Control s (OFAC) Specially Designated Nationals List (SDN) U.S. Department of Commerce (DOC), Bureau of Industry and Security s (BIS) Denied Persons List, Entity List, and Unverified List U.S. Department of State s (DOS), Directorate of Defense Trade Control s List of Statutorily Debarred Parties and List of Administratively Debarred Parties ORGANIZATIONAL RESPONSIBILITIES The following Departments and Administrative Offices are responsible throughout the University community for implementation of these procedures as follows: Institutional Compliance Office (ICO) Responsible for oversight of University sanction check process, including the following: Administration of vendor contract for an online searchable database system (VOD), Development of departmental user instructions for VOD, Execution of semi-annual sanction check for University employees, Execution of annual sanction check for University vendors, Verification of potential matches of new University employees, vendors, and affiliate researchers identified by supporting University compliance departments in ongoing sanction check processes, and Reporting of verified matches to University officials for appropriate action. Subject: Sanction Check Procedures Procedure #ICO-PR002 Page 1 of 6
Human Resources Department (HR) Responsible for sanction check of new University employees via VOD for identification of potential matches to applicable federal exclusion/debarment/suspension lists. HR reports all potential matches to the Institutional Compliance Office for verification/approval procedures prior to hire. HR is also responsible for supplying the ICO with a current list of all University employees to the ICO for semi-annual sanction check procedures. Purchasing Department Responsible for sanction check of new University contractors via VOD for identification of potential matches to federal exclusion/debarment/suspension lists prior to contract award. The Purchasing Department reports all potential matches to the Institutional Compliance Office for verification/approval procedures prior to contract award. See Purchasing Department Policy #35.00 Federal Debarment. In addition, the Purchasing Department is responsible for supplying the ICO with a list of Procurement Card (ProCard) vendors/merchants with annual expenditures of $1,000 or greater for annual vendor sanction check procedures. Financial Services Department Responsible for supplying the ICO with a list of all active University vendors with annual expenditures of $1,000 or greater for annual vendor sanction check procedures. HSC Office of Compliance Office Responsible for oversight of sanction check process for affiliated physician practice group employees, including semi-annual affiliate employee sanction check procedures via VOD. In addition, the Health Sciences Center (HSC) Office of Compliance will obtain annual attestations from affiliated physician practice groups that the practice is aware of its responsibility to ensure its employees and vendors are not excluded/disbarred/suspended on applicable federal lists and that it is not aware of any current exclusion/disbarment/suspension activity for any of its active employees or vendors. See HSC Office of Compliance Policy #INT019REP Medicare Sanction Checks. Office of Research Integrity (ORI) Responsible for oversight of sanction check process for affiliated research personnel. Responsibilities include semi-annual sanction check procedures via VOD as addressed in ORI Standard Operating Procedures Manual #RI-050. II. DETAILED PROCEDURES BY DEPARTMENT /ADMINISTRATIVE OFFICE A. ICO CHECKS - UNIVERSITY EMPLOYEES & VENDORS 1. UNIVERSITY EMPLOYEES - SEMI-ANNUAL CHECKS: a. The ICO will obtain electronic lists of all current University employees from the Human Resources Department (HR) for completion of semi-annual sanction check procedures in February and September. Subject: ICO Sanction Check Procedures Procedure #ICO-PR002 Page 2 of 6
b. The ICO will submit the University employee list to VOD for identification of potential matches to federal exclusion/debarment/suspension lists. The ICO will maintain an electronic log of all semi-annual sanction checks for audit trail purposes. See VOD User Instructions for ICO (Attachment C). c. The ICO will request additional employee information as considered necessary from HR for all potential matches identified by VOD, including, but not limited to, Social Security Numbers (SSN). This information will be used by the ICO for verification purposes with applicable federal agency exclusion/debarment/suspension list(s) resources as considered necessary to confirm if a potential match identified by VOD is a positive match. Supporting documentation for verification of potential matches will be filed by batch number and individual name in the ICO. See Potential Match Verification Procedures for Employees/Affiliated Individuals (Attachment A). d. The Associate Compliance Officer will report all positive matches to the University Compliance Officer and other applicable University Compliance Officials and/or Administration for appropriate action. 2. UNIVERSITY VENDORS ANNUAL CHECK: a. The ICO will obtain electronic lists of all active Accounts Payable (A/P) vendors and Procurement Card (ProCard) vendors/merchants with annual expenditures of $1,000 or greater from the Financial Services and Purchasing Departments, respectively, for completion of an annual vendor sanction check procedures in July. b. The ICO will submit the list of A/P & ProCard vendors with annual expenditures of $1,000 or greater to VOD for identification of potential matches to Federal exclusion/debarment/suspension lists. The ICO will maintain an electronic log of all annual sanction checks for audit trail purposes. See VOD User Instructions for ICO (Attachment C). c. The ICO will request additional A/P and ProCard vendor information as considered necessary from the Financial Services and Purchasing Departments, respectively, for all potential matches identified by VOD, including, but not limited to Taxpayer Identification Numbers (TIN). This information will be used by the ICO for verification purposes with applicable federal agency exclusion/debarment/suspension list(s) resources as considered necessary to confirm if a potential match identified by VOD is a positive match. All supporting documentation for verification of potential matches will be filed by batch number and vendor name in the ICO. See Potential Match Verification Procedures for Vendors (Attachment B). d. The Associate Compliance Officer will report all positive matches to the University Compliance Officer and other applicable University Compliance Officials and/or Administration for appropriate action. Subject: ICO Sanction Check Procedures Procedure #ICO-PR002 Page 3 of 6
B. HR CHECK OF NEW UNIVERSITY EMPLOYEES 1. HR will submit new University employees for sanction check via VOD prior to hire. HR will maintain an electronic log of all new employee sanction checks, including batch search number, for audit trail purposes. See VOD User Instructions for Human Resources Department (Attachment D). 2. HR will report any potential matches, including the VOD batch search number, to the ICO for verification/approval procedures prior to hire. HR will supply additional information including, but not limited to, SSN s to the ICO to use for verification purposes with applicable federal agency exclusion/debarment/suspension list(s) resources as considered necessary to confirm if a potential match identified by VOD is a positive match. 3. The ICO will complete verification procedures within three (3) business days of receipt of potential match information. All supporting documentation for verification of potential matches will be filed by batch number and individual name in the ICO. See Potential Match Verification Procedures for Employees/Affiliated Individuals (Attachment A). 4. The ICO will clear any individuals in the VOD system that are confirmed not to be a positive match, indicating to HR that the individuals have been approved for hire in regards to sanction check requirements. 5. The Associate Compliance Officer will report all positive matches to the University Compliance Officer and AVP Human Resources for appropriate action. C. PURCHASING DEPT CHECK OF NEW CONTRACTORS 1. The University Purchasing Department (Purchasing) will submit new contractors, including subcontractors, for sanction check via VOD prior to contract award. Purchasing will maintain an electronic log of all new contractor sanction checks, including batch search number, for audit trail purposes. See VOD User Instructions for Purchasing Dept (Attachment E). 2. Purchasing will report any potential matches, including the VOD batch search number, to the ICO for verification/approval procedures. Purchasing will supply additional information including, but not limited to, TIN s to the ICO to use for verification purposes with applicable federal agency exclusion/debarment/suspension list(s) resources as necessary to confirm if a potential match identified by VOD is a positive match. 3. The ICO will complete verification procedures within three (3) business days of receipt of potential match information. All supporting documentation for verification of potential matches will be filed by batch number and contactor name in the ICO. See Potential Match Verification Procedures for Vendors (Attachment B). Subject: ICO Sanction Check Procedures Procedure #ICO-PR002 Page 4 of 6
4. The ICO will clear contractors in the VOD system that are confirmed not to be a positive match, indicating to Purchasing that the contractors have been approved for contract award in regards to sanction check requirements. 5. The Associate Compliance Officer will report all positive matches to the University Compliance Officer and Director of Purchasing for appropriate action. D. HSC SEMI-ANNUAL CHECK AFFILIATE MEDICAL PRACTICE EMPLOYEES 1. The University s Health Sciences Center (HSC) Office of Compliance (OOC) will work with the ICO to obtain an electronic list of all current University affiliated physician practice group employees for HSC OOC completion of semi-annual sanction check procedures. The HSC Deputy Compliance Officer (DCO) or designee will submit an electronic list of HSC employees, including affiliated physician practice group employees, to the ICO. The ICO will utilize audit software to eliminate University employees from the HSC OOC s list for which semi-annual sanction check procedures will be performed by the ICO (see II A above). The remaining affiliate physician practice group employees list will be generated by the ICO and returned to the HSC DCO for completion of semi-annual sanction check procedures in February and September. 2. The HSC DCO or designee will submit the affiliate physician practice group employee list to VOD for identification of potential matches to applicable federal exclusion/debarment/suspension lists. The HSC OOC will maintain an electronic log of all sanction checks, including batch search number, for audit trail purposes. All supporting documentation will be filed by individual name in the HSC DCO's office. See VOD User Instructions for HSC OOC (Attachment F). 3. The HSC DCO or designee will request additional employee information as considered necessary from affiliate physician practice groups for all potential matches identified by VOD, including, but not limited to, Social Security Numbers (SSN). This information will be used by the HSC DCO or designee for verification purposes with applicable federal agency exclusion/debarment/suspension list(s) resources as necessary to confirm if a potential match identified by VOD is a positive match. All supporting documentation for verification of potential matches will be filed by batch number and individual/business name in the HSC-OOC. See Potential Match Verification Procedures for Employees/Affiliated Individuals (Attachment A). 4. The HSC DCO will report all positive matches to the AVP for Health Affairs/Compliance and the University Compliance Officer. The AVP will discuss with University Legal Counsel and the departmental entity to determine the appropriate action. Subject: ICO Sanction Check Procedures Procedure #ICO-PR002 Page 5 of 6
5. The HSC-OOC will also obtain annual attestations from affiliated physician practice groups that the practice is aware of its responsibility to ensure its employees and vendors are not excluded/disbarred/suspended on applicable federal lists and that it is not aware of any current exclusion/disbarment/suspension activity for any of its active employees or vendors. See HSC OOC Policy #INT019REP Medicare Sanction Checks. E. ORI SEMI-ANNUAL CHECK NON-EMPLOYEES INVOLVED IN RESEARCH 1. The University Office of Research Integrity (ORI) will submit an electronic list of affiliated research personnel to VOD for identification of potential matches to applicable federal exclusion/debarment/suspension lists. The ORI will maintain an electronic log of all sanction checks, including batch search number, for audit trail purposes. See VOD User Instructions for ORI (Attachment G). 2. The ORI will report any potential matches, including the VOD batch search number, to the ICO for verification/approval procedures. The ORI will supply additional information including, but not limited to, SSN s to the ICO to use for verification purposes with applicable federal agency exclusion/debarment/suspension list(s) resources as necessary to confirm if a potential match identified by VOD is a positive match. See Potential Match Verification Procedures for Employees/Affiliated Individuals (Attachment A). 3. The ICO will clear any affiliated research personnel in the VOD system that are confirmed not to be a positive match. 4. The Associate Compliance Officer will report all verified positive matches to the University Compliance Officer and Director of Research Integrity for appropriate action. III. DEFINITIONS FOR PROCEDURE 1. Contractor means any individual or other legal entity that: a. Directly or indirectly submits offers for or is awarded, or reasonably may be expected to submit offers for or be awarded, a University contract, or a subcontract under a university contract; or b. Conducts business, or reasonably may be expected to conduct business, with the university as an agent or representative of another contractor. 2. Affiliated Research Personnel means any Non-University employed individuals involved in University research. Subject: ICO Sanction Check Procedures Procedure #ICO-PR002 Page 6 of 6