Identifying Number: 2024-005
Finding: Material Weakness: Cash Management
Context: Drawdown on reimbursement requests were submitted to the grantor prior to the System incurring qualifying expenditures.
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. Implementing organizational changes such as updated policies and/or procedures
b. Educating the team(s) and/or Department(s) on internal controls, processes and accuracy best practices during the Grant management process
c. Oversight of drawdwn requests by the Director of Sponsored Programs to ensure accuracy of request
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:
- 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.
- Oversight of all drawdown requests, ensring complete and accurate supporting documentation.
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 team, 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: Implementing 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 processed 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.