Identifying Number: 2024-001
Finding: Allowable Costs/Cost Principles
Context: The System received funding that was not net of appliccable credits. The funding received from the grantor was the full invoice amount, howver, the actual expenditure was net of applicable credits ($6,945).
Corrective Actions Taken or Planned:
The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-value expenditures. This checklist will require all Sponsored Programs analysts to submit complete documentation with expense reports and proof of payment and have their respective immediate supervisor/manager review for compliance before final approval by the Director.
a. Correcting the gaps between invoicing processes and collecting the Departments/AP proof of payment
b. Returning overpayments, if applicable
c. Implementing organizational changes such as updated policies and/or procedures
d. Educating the team(s) and/or Department(s) on internal controls, processes and accuracy best practices during the Grant management process
Planning Process
Compliance with Regulations: The Director and Manager from Sponsored Programs will ensure the corrective actions align with applicable federal grant regulations and guidelines. We will create:
- Processes in which we will adopt verification procedures for invoices and collections.
- Create/update Standard Operating Procedures (SOPs).
- Provide our team with updated training material (working pratice guidelines -WPGs), so they have clear expectations and understand our compliance mechanism.
- Implement internal controls, with the Director and Manager from Sponsored Programs developing checks and balances at the end of each month to ensure compliance in all the grant's portfolio.
Communication: The Director and Manager from Sponsored Programs will communicate the corrective action plan to all relevant staff and stakeholders.
Follow-up: The Director and Manager from Sponsored Programs will regularly monitor progress and adjust to resolve any inefficiencies.
Training: The Director and Manager from Sponsored Programs will work on the development and delivery of mandatory training sessions for all Sponsored Programs relevant staff. This will include (not limited to):
- Retrain on updated policies and procedures (OSP tean, Departments and stakeholders, if applicable)
- Retrain on workflows and system (OSP team, Departments and stakeholders, if applicable)
- Retrain on process improvement (OSP team, Departments and stakeholders, if applicable)
Policy Updates: Revision of existing policies or creation of new ones to clarify procedures.
System Enhacements: Implemeting new software/program that improves data accuracy and compliance in all Federal/State and Local Grants throughout Nicklaus Children's Hospital.
Monitoring and Oversight: The Director and Manager from the Sponsored Programs will monitor transactions and reporting processes more frequently.
Deadline for Implementation:
Immediate action: The Director of Sponsored Programs transitioned the staff member responsible for the findings to an area where their expertise is most valuable.
This CAPA will take effect immediately and be fully implemented within six weeks by April 07, 2025, allowing time to create/revise SOPs, Working Practice Guidelines (WPGs). Checklists and training/retraining sessions for stakeholders and OSP team members.