annual-csueb-risk-management-report-2019-for-2018

RISK MANAGEMENT DEPARTMENT 2018 ANNUAL REPORT RISK CONSULTATIONS Business Continuity Planning - Special Events - Training - Incident Response COMPLIANCE & INTERNAL CONTROL Audits - Spec

RISK MANAGEMENT DEPARTMENT

2018 ANNUAL REPORT

RISK CONSULTATIONS

Business Continuity Planning - Special Events -

Training - Incident Response

COMPLIANCE & INTERNAL CONTROL

Audits - Special Projects - Whistleblower

Complaints

COMMUNITY WELFARE & COVERAGE

Insurance Services - Workers’ Compensation - Employee Disabilities - Ergonomics

ENVIRONMENTAL HEALTH & SAFETY

Work Safety - Lab Safety - Hazardous Materials -

Regulatory Compliance

TITLE IX & INVESTIGATIONS

Discrimination, Harassment and Retaliation - Sexual

Misconduct - Referrals and Training

The Risk Management Department works collaboratively to assist the University community

in fulfilling their missions by identifying, assessing, and mitigating the risks that threaten

students, employees, and guests

Table of Contents

Risk Management’s Role within the University 1

Risk Management’s Programs and Staffing 2

Mission and Objectives of the Risk Management Department 2

Risk Management’s Responsibility 3

Department Highlights in 2018 4

2018 Highlights of Risk Management’s Four Offices 5

Compliance & Internal Control 6

Liaison with the Chancellor’s Office of Audit & Advisory Services 6

Internal Audits, Assessments, and Reviews 7

Investigations 7

Community Welfare and Coverage 9

Workers’ Compensation 11

Environmental Health & Safety 14

2018 Accomplishments for Environmental Health & Safety 14

Environmental Health & Safety Activities 15

Injuries and Illnesses 16

Title IX and Investigations 17

Discrimination, Harassment, and Retaliation Cases 17

Sexual Misconduct Training 17

Title IX and Investigations Accomplishments 18

Looking Forward to 2019 and Beyond 19

Business Continuity Planning 19

Compliance & Internal Control 19

Community Welfare and Coverage 19

Environmental Health & Safety 20

Title IX & Investigations 20

Cal State East Bay Risk Management ● Annual Report for 2018

Risk Management Department Overview

Risk Management’s Role within the University

Cal State East Bay is organized by four distinct divisions The Risk Management Department resides within the Division of Administration & Finance

Exhibit 1: General Campuswide Organizational Chart

Cal State East Bay Risk Management ● Annual Report for 2018

Risk Management Department Overview

Risk Management’s Programs and Staffing

The organizational chart below identifies the professional staff members and reporting

structures within department

Exhibit 2: Departmental Organizational Chart showing Risk Management’s Staff

Members at the end of Calendar Year 2018

Mission and Objectives of the Risk Management Department

The mission of the Risk Management Department is to assist Cal State East Bay and its

auxiliaries in fulfilling their missions by identifying, assessing, and mitigating the risks that

threaten students, employees, and guests Specifically, the department:

 Protects the University’s interests and resources

 Promotes the well-being of the campus community (students, faculty members, staff

members, contractors, and visitors)

 Promotes compliance with federal and State laws and regulations, and system rules

Cal State East Bay Risk Management ● Annual Report for 2018

Risk Management Department Overview

Risk Management’s Responsibility

Every day, the Risk Management Department works to protect the University’s interests and resources, promote the well-being of the campus community, and promote compliance with federal and state laws and regulations, and system rules The following are specific responsibilities of the department:

 Review trends to ensure appropriate policy or guidance is in place on matters of significant risk (e.g business continuity, minors on campus, special events, using valuable items on campus, etc.) Develop plans to mitigate threats as needed

 Assist in the planning and preparation of departmental and campuswide events and initiatives

 Advise members of the campus community on operational matters, and compliance requirements

 Identify, compile, and develop training resources for students, faculty members, staff members, and contractors

 Facilitate the mitigation of environmental and safety hazards

 Receive, settle, and refer claims related to administrative matters, bodily injury, and employment practices

 Advise students, faculty, and staff with information about their rights and responsibilities related to federal, state, and system laws and rules

 Investigate matters of inappropriate conduct, non-compliance, fraud, waste, or abuse

 Facilitate the issuance of benefits and payments to employees who suffer illnesses and injuries caused by work

 Ensure the campus’ compliance with environmental ordinances and regulations

 Enforce student and employee compliance with state ethics requirements

Cal State East Bay Risk Management ● Annual Report for 2018

Risk Management Department Overview

Department Highlights in 2018

As in previous years, Risk Management engaged in numerous ongoing and one-time activities that served the entire campus community

Business Continuity Planning (BCP) In accordance with Executive Order 1014,

Risk Management led a campuswide business continuity planning effort As part of this, Risk Management provided customized training to 37 campus stakeholders, identified campuswide mission-critical functions and information systems, facilitated the completion of business impact analyses for mission-critical functions and information systems, and identified recovery time objectives for various business recovery strategies In addition, Risk Management ensured the testing of major critical functions, and ensured that BCP efforts were publicized to the campus community through a campuswide email, and the creation of a BCP webpage:

www.csueastbay.edu/riskmanagement/business-continuity.html

Website Redesign. In alignment with the campuswide website conversion, Risk Management underwent a complete reorganization of its website and pages In addition to including new content and eliminating out of date content, the new website is more accessible, and formatted to be more compatible with mobile browsers

Wildfire Response. Risk Management worked with other campus departments to respond to the California wildfires in November 2018[DC1] Among other things, Risk Management facilitated the availability of masks for students and staff members seeking relief from the poor air quality caused by the fires In addition, Risk Management was involved in deciding to close the campus when air quality reached unhealthy levels, and participated in debriefs to identify future planning needs

Resources for Pregnant Students and New Parents. As a result of a directive

from the Department of Education’s Office of Civil Rights, Risk Management led a joint effort with the campus’ Accessibility Services and Academic Affairs Division to provide resources to improve accessibility for pregnant students and those

recovering from childbirth Risk Management assisted in training Academic Affairs staff members, wrote memos to campus management employees, faculty members, and students, and created/published a webpage with useful information for

students regarding pregnancy and childbirth:

[DC2]http://www.csueastbay.edu/riskmanagement/pregnancy-childbirth.html

Emergency Management Risk Management facilitates the Volunteer Team Leaders (VTL) program through which campus employees are trained to respond to emergency situations The department also provides areas of specialized training

on various subjects including fire extinguisher use, building evacuation, radio communications, and evacuation chair training VTLs are also offered training on first aid, cardio-pulmonary resuscitation (CPR), and the use of automated external

Cal State East Bay Risk Management ● Annual Report for 2018

Risk Management Department Overview

defibrillators The department also provides the general campus community

informational resources to help the campus community respond to emergency events

Protection of Minors. Risk Management drafted a protection of minors (POM)

program and guidelines designed to promote a culture of awareness among

employees, students, and volunteers who work with minors on campus A Minors on

Campus committee was initiated to assist with development and implementation

Settlements. Claims against the university arose from incidents involving

administrative appeals, bodily injury, and disability accommodation The campus

settled four claims Payments associated with these claims were just under $10,000

2018 Highlights of Risk Management’s Four Offices

The remainder of this report highlights the work of the department’s four offices – Community Welfare & Coverage, Compliance & Internal Control, Environmental Health & Safety, and Title IX & Investigations Where meaningful and available, data of service outputs and outcomes are included to show the effect of services provided These data can provide insight on how well the four offices and the Risk Management Department as a

whole, is achieving its goals and objectives.

Cal State East Bay Risk Management ● Annual Report for 2018

Compliance & Internal Control

Compliance & Internal Control

Compliance & Internal Control pursues more effective, efficient, and accountable University programs

Liaison with the Chancellor’s Office of Audit & Advisory Services

Like in previous years, 2018 saw the majority of Compliance & Internal Control’s efforts dedicated to facilitating audits by the Chancellor’s Office of Audit and Advisory Services (AAS) Compliance & Internal Control responded to requests for information and documents arising from AAS audits, and fostered collaboration between the respective staff members

of the Chancellor’s Office and the University After the audits, Compliance & Internal Control worked with University staff and management to formally respond to audits, and implement recommendations timely

Exhibit 3: Compliance & Internal Control’s Work with the Chancellor’s Office

Information security Construction

Emergency management Cashiering Sponsored programs

International activities Cloud computing

Construction (9)

Emergency management (8)

Cashiering (5)

International activities (6) Cloud computing (3)

# of

recommendations

closed

Clery Act (3) Information security (9)

Clery Act (3) Information security (9) Information technology procurement (3)

Construction (9)

Emergency management (7)

Cashiering (4)

International activities (6) Sponsored programs (5)

Cal State East Bay Risk Management ● Annual Report for 2018

Compliance & Internal Control

Internal Audits, Assessments, and Reviews

The Office uses a systematic approach to identify ways to improve processes, and accordingly recommend improvements to University management In 2018, the Office completed multiple internal reviews of programs of the University and its auxiliary organizations

 Pursuant to requirements of the U.S Department of Education, the Office conducted a

“due diligence review” of the services offered to students by campus’ contracted banking services provider The objective of the review was to ensure that accounts marketed and offered to Cal State East Bay students support the financial interests of the students opening them

 The Office conducted a performance audit related to the aforementioned due diligence review That audit sought to determine if the contract between Cal State East Bay and its contracted bank, served the interests of accountholders, students, and the campus community; and to assess how the arrangement between Cal State East Bay and the bank served the interests of the University

 Compliance & Internal Control partnered with the University Police Department and Facilities Development & Operations on a comprehensive assessment of campus security This review is expected to be completed in 2019

Reports summarizing results of the Office of Compliance & Internal Control’s reviews are issued internally to University leadership, and are generally not made public Just as it does for outside audits, the Office follows-up with relevant University staff to ensure that internal findings are addressed, and recommendations are implemented

Investigations

The Office maintains a process to receive anonymous inquiries and complaints, consider allegations, conduct preliminary reviews of complaints, and if necessary, plan and perform comprehensive independent and confidential investigations

Fiscal Improprieties. The Office is the designated repository for suspected "fiscal improprieties." Pursuant to Executive Order 1104, the Office provides timely notifications to the Chancellor’s Office about potential improprieties involving dollar amounts exceeding $5,000, and notifies the State Auditor and the Department of Finance about incidents involving amounts exceeding $50,000 In 2018, Compliance &

Cal State East Bay Risk Management ● Annual Report for 2018

Compliance & Internal Control

facilitates "whistleblower complaints" about potential waste, fraud, and abuse of State resources This responsibility is codified by the State's Whistleblower Protection Act and the California State University Executive Orders 1115 and 1116 During calendar year

2018, the office fielded numerous inquiries from members of the campus community, and completed 2 investigations One involving claimed retaliation based on protected disclosures was not sustained Another involving claims of conflict of interest was also not sustained Through bulletin postings and email communique, the Office will encourage people to come forward with complaints, and advertise the protections provided by the California Whistleblower Protection Act

Internal investigations At the request of University leadership, over a three-month period in 2018, the Office led an investigation around suspicious p-card transactions and fiscal mismanagement within a University Program The work resulted in an investigation report containing specific findings, observations, recommendations, and exhibits The employee at the center of this investigation, as well as a manager tasked with monitoring the employee have separated from the campus Because the incident involved a campus employee, and significant monetary value, the Office notified the Chancellor’s Office, the state Department of Finance and the State Auditor (pursuant to the aforementioned Executive Order 1104) T