Finding 2023‐001—Significant Deficiency in Internal Controls over Compliance: Research and Development
Cluster
Contact Person: Melissa Quintero, Director, Sponsored Programs Administraon and Peter D. Friedmann, Chief
Research Officer, Baystate Health.
Views of Responsible Officials:
Management agre...
Finding 2023‐001—Significant Deficiency in Internal Controls over Compliance: Research and Development
Cluster
Contact Person: Melissa Quintero, Director, Sponsored Programs Administraon and Peter D. Friedmann, Chief
Research Officer, Baystate Health.
Views of Responsible Officials:
Management agrees and acknowledges that well‐defined roles, responsibilies, processes, and monitoring are
necessary. Management wishes to highlight that no unallowable charges were incurred as a result of the
idenfied deficiencies.
Correcve Acon Plan and Expected Compleon Date
Roles and Responsibilies—Management has engaged Huron Consulng Group (Huron) to review roles and
responsibilies across Sponsored Programs Administraon (SPA), Research Accounng and other affected
areas to ensure adequate definions and clarity across control owners. Huron’s recommendaons should be
available by April 11, 2024. Once Huron’s recommendaons are received and reviewed by management,
posion descripons will be revised, new posions created, and training implemented to ensure personnel
understand their role and responsibilies related to internal controls, including controls over compliance and
documentaon requirements.
Policies and Procedures—Management maintains policies and procedures that govern the conduct of grantrelated
acvies. Policies and procedures will be updated following Huron’s review of the roles and
responsibilies, and management will connue to make addional updates as necessary. Personnel will be
trained on relevant updated policies and procedures.
Documentaon and Document Maintenance—Management has iniated implementaon of ServiceNow to
improve the consistency and accessibility of documentaon evidencing review over research and development
(R&D) compliance requirements and performance of internal control procedures. ServiceNow is a cloud‐based
plaorm that will allow for the operaon of cket‐based help desk funconality for SPA. This system will
replace the large volume of email communicaons that currently documents a significant proporon of
internal control acvity and solve the problem of such emails lost to incomplete archiving and Baystate’s email
retenon policy. SPA has a Microso Teams central repository for all award‐related documents, as well as any
legacy email and other documentaon related to compliance requirements and internal controls over
compliance.
Salary Cap—Management will re‐emphasize to end‐users via wrien communicaon that the quarterly Excel
summary report of salary cap is a courtesy report only, and that end‐users should rely on Infor Lawson as the
system of record and its (1) Labor Cost by Acvity report for labor cost and (2) Acve 10.2 report for salary cap
distribuon and validaon. Prior to the quarterly meengs with the Departments and Service Lines to review
award acvity and expenditures, SPA and Research Accounng will compare the Excel summary with the two
Infor Lawson reports for accuracy, invesgate and resolve differences in a mely manner, and document
evidence of review in SPA’s Microso Teams site.
Indirect Cost and Fringe Benefit Review—Due to the manual nature of entering and maintaining award data in
the financial system, complete accuracy in data capture connues to be an ongoing goal and objecve. Management will develop and implement a checklist to enhance the review of internal controls associated
with the SPA form maintained in IRBNet prior to submission to Finance. Documentaon of this review will be
maintained in the Microso Teams central repository. SPA has acvated in IRBNet a system‐generated email
alert that will be sent to Research Accounng on the compleon of the SPA form to enable the account set up
step to be iniated or revised, as required.
SEFA Review—An enhanced monthly Infor Lawson report and a quarterly schedule of expenditures of federal
awards (SEFA) report from Research Accounng has been added to the SPA’s quality assurance process to
ensure mely review of the SEFA data to improve accuracy. All quality assurance reports are available monthly
aer the month end close. These reports will be reviewed by SPA and Research Accounng for accuracy and
retained in SPA’s Microso Teams site with evidence of review.
Management expects to complete the above acons by December 31, 2024.