Department of Internal Audit and Compliance

The Compass March 2025 Vol. 21, no. 1

Guidance for University leaders on governance topics facing UToledo and our peer institutions

THOUGHT FOR THE DAY

"Every desk of card has a pair of jokers."

- - Pete Seeger (portrayed by Edward Norton in the film "A Complete Unknown")

 

(Unsolicited) Advice from the Auditors for 2025

Internal Audit has been publishing The Compass for about five years now, and is believes The Compass has become a publication that can give anyone a sense of the current risks in healthcare and higher education regardless of their role. I recently asked my colleagues to share their one piece of relevant advice for a successful 2025, which I summarize/paraphrase below.

    1. Prioritize communication and build strong relationships to foster a culture of good governance. Leaders should engage with their teams to communicate the importance of adhering to university policies, completing mandatory training, and submitting required conflict of interest/commitment disclosures. While email and virtual meetings can be effective, face-to-face communication remains the most impactful way to connect with faculty, staff, and administrators and convey the significance of good governance. By focusing on relationship building, we can create a more collaborative and supportive environment that encourages everyone to prioritize good governance.
    2. Building a solid sense of community is one of our best defenses against potential threats. Get to know your peers, support one another, and cultivate an atmosphere of respect and trust. When we look out for each other, we create a safer campus for all.
    3. Put controls at the front and center. We live in a world where risks are changing at an incredible pace; let these developments be a strong reminder that we should continually reassess risks and the controls in place to mitigate risks.

This is good advice from exceptionally talented people with important roles at the University of Toledo. I would echo the key point on the rapid pace of change. You can get a solid overview of current events in the governance area by reviewing the stories from the past month below.

David L. Cutri, CPA, CISA, CIA

Chief Compliance Officer and Chief Audit Executive

Internal Audit

 

Recognition

Sara Soper, Office of Accessibility and Disability Resources

Jaclyn Tadlock, Student in UToledo College of Law and MBA Program

In this issue of The Compass, we would like to recognize two members of the University community that are doing remarkable things in terms of promoting good governance – Sara Soper and Jaclyn Tadlock.

Sara is an Accessibility Specialist in the Office of Accessibility and Disability Resources, tasked with ensuring that our students with disabilities receive accommodations that allow them to maximize their success in the classroom. Recently, Sara lent her talents to the film Disability Download: The Human Perspective, which presents guidelines for interacting with individuals with disabilities. The film begins at the 10:00 mark of this video, which can be found on YouTube. Sara is the person in the video’s thumbnail. Sara is a terrific advocate for her students and does such a wonderful job in the film. While it is not an Academy Award, we hope that Sara will gladly accept our The Compass Award for all her efforts.

Jaclyn, in addition to concurrently pursuing two academic programs at UToledo, is also serving both the Internal Audit department and the Office of Research and Sponsored Programs in concurrent externships. The common theme of both externships is export control, which is a system of federal laws and regulations that limit the transfer of goods, technology, and services to other countries. The goal of export control is to protect United States (U.S.) national security, foreign policy, and economic interests. In an externship with us last year, Jaci completed a very thorough export control assessment, which she successfully presented to the UToledo President’s Cabinet. In her current externship, Jaci is helping flesh out our current export control processes with an eye toward alignment with recently passed research security legislation. In gratitude for all her hard work, we present Jaci with The Compass Award.

If you see someone doing the right thing, write to us and tell us about it using The Compass Nomination Form on our website. Who knows? We may feature them in our next The Compass edition.

 

This section of The Compass proactively shares key risks and emerging trends with stakeholders in regular interactions (e.g., emerging trends and key risks in the news) and explicitly discusses Internal Audit’s work within this context. The Fiscal Year 2025 Internal Plan addresses each of these topic areas. Feel free to reach out to David Cutri to learn more.

OFAC Record Retention Requirement

We wanted to bring to your attention the recent Office of Foreign Assets Control (OFAC) record retention requirement update, which takes effect on March 12, 2025. OFAC is a financial intelligence and enforcement agency of the U.S. Treasury Department. It administers and enforces economic and trade sanctions in support of U.S. national security and foreign policy objectives Previously, OFAC required maintenance of records for five years, but the new regulation extends this period to ten years from the date of the relevant payment. 

We wanted to ensure everyone was aware of this update given its potential impact. Beyond research administration compliance, this change may affect other operational units. This includes records related to the disclosure of endowments or donations, gifts or contracts with foreign individuals or entities of concern, and international travel. Compliance with this new requirement will require updates to institutional policies and procedures, as well as a review of how this change intersects with other legal obligations and statutes of limitations. Additionally, with the increased federal scrutiny of higher education institutions, as seen in recent False Claims Act enforcement actions, ensuring compliance with this change is critical to mitigating legal and compliance risks. 

To proactively align with the updated requirement, process owners may want to consider the following:

    • Engaging with other impacted University departments to ensure institution-wide compliance.
    • Reviewing/Updating relevant policies and procedures
    • Confirming that our current record retention system can maintain and secure records for the extended period.
    • Implementing training/awareness initiatives for relevant personnel

Please read the article below from the Federal Register on reporting, procedures, and penalties to learn more.

OFAC Record Retention Requirement

 

Disability Loan Fraud Scheme

The U.S. Attorney for the Southern District of New York announced that a U.S. District Judge sentenced a nurse practitioner who stole the identities of twelve medical doctors and orchestrated an $11.2 million disability loan fraud scheme, in early February to five years in prison. Please read this article from the Justice Department to learn more.

Disability Loan Fraud Scheme

 

Oversight of Reporting of Foreign Gifts and Contracts

Congress enacted section 117 of the Higher Education Act, as amended, (Section 117) mandating financial transparency of institutions of higher education (institution) through required reporting of gifts from and contracts with a foreign source. Applicable institutions must file a disclosure report by one of the two annual reporting deadlines, January 31 or July 31, whichever is sooner. Section 117 helps to raise awareness of potential foreign influence on college campuses which could help stakeholders assess, detect, and respond to potential threats to U.S. academic and research pursuits, free speech on campuses, and national security. Click on the link below from the Office of Inspector General’s webpage to learn more.

Oversight of Reporting of Foreign Gifts and Contracts

 

Data Breach

Indiana University Health (IU Health) has reported a data breach affecting a limited number of individuals, potentially compromising Social Security Numbers and other sensitive personal information. The breach, first detected on November 8, 2024, impacted specific patient and employee data, and IU Health notified those affected on January 2, 2025. According to IU Health, the breach may have included personal details such as addresses, ages, medical record numbers, diagnoses, and other treatment-related information. While the breach primarily impacted a limited group of individuals, the affected data included Social Security Numbers. The breach occurred due to unauthorized access to an IU Health team member’s email account, compromised between August 27, 2024, and October 2, 2024.

Data Breach

 

Ransomware

The Texas Tech University Health Sciences Center and its El Paso counterpart suffered a cyberattack that disrupted computer systems and applications, potentially exposing the data of 1.4 million patients. The organization is a public, academic health institution that is part of the Texas Tech University System, which educates and trains healthcare professionals, conducts medical research, and provides patient care services. The organization announced that, in September 2024, it suffered a cyberattack involving sensitive data theft. In a filing with the U.S. Department of Health and Human Services Office for Civil Rights (OCR), the Texas Tech University Health Sciences Center reports that the breach exposed the combined data of 1,465,000 people.

Ransomware

 

Free Speech Settlement

A month after a Doctor of Pharmacy student enrolled at the University of Tennessee, the college’s professional conduct committee received an anonymous complaint about her posts on social media. The college reviewed her posts, which included racy rap lyrics and tight dresses, and concluded that they were vulgar and unprofessional. It threatened to expel her. For the last four years, the student has been fighting the school in court, arguing that the posts were fun and sex-positive, and unconnected to a status as a student. Now the student has won a settlement: In late-January, receiving a check for $250,000 -- both vindication and relief, the student said.

Free Speech Settlement

 

Shared Ancestry

The U.S. Department of Education’s OCR on January 6th announced that Johns Hopkins University in Maryland has entered into a resolution agreement to ensure alignment with Title VI of the Civil Rights Act of 1964 (Title VI) when responding to allegations of harassment based on shared ancestry (a common heritage that a group of people share, including cultural practices, languages, and traditions). OCR’s investigation confirmed multiple important steps taken by the university to fulfill its Title VI obligations with respect to shared ancestry. Nonetheless, OCR identified a Title VI concern that, although the university received ninety-nine complaints of harassment based on shared ancestry from October 2023 through May 2024, the records do not reflect university consideration of whether these and other incidents individually and cumulatively created a hostile environment for students.

Title VI

 

Drug Use

Health officials warn the increased use of nitrous oxide, an inhalant commonly used by healthcare providers as a sedative, is causing an influx in throat and mouth injuries among college students. Commonly referred to as laughing gas, nitrous oxide is an odorless gas used for sedation and pain relief as it slows down the nervous system by restricting oxygen flow to the brain, producing a high. For months now, social media has amplified the trend as people film themselves or their friends’ doing whippets. Experts say as young people continue to struggle with their mental health, the increase in social media posts about huffing have contributed to its normalization.

Drug Use

 

If you have any suggestions, questions or feedback, please e-mail david.cutri@utoledo.edu, including suggestions for items to include in future newsletters Feel free to forward this email to your colleagues, employees. Back issues of this newsletter are available on the Internal Audit and Compliance website.

Redistribution of this newsletter, with or without modification, is permitted provided University of Toledo Internal Audit Department is listed as the source.

Last Updated: 3/4/25