Open Recommendations

The Lieutenant Colonel Charles S. Kettles VA Medical Center Director ensures that operative documentation is completed per facility policy, reviews the methodology for monitoring operative documentation compliance, and takes action as necessary.

The Lieutenant Colonel Charles S. Kettles VA Medical Center Director reviews and monitors staff and health professional trainee compliance with the rules of behavior as it applies to authorized access to all VA computer programs including clinical applications.

The Under Secretary for Health evaluates the process for granting authorized access to VA computer systems for health profession trainees and takes steps to ensure access is provided by the start of trainee rotations at VA facilities.

The VA Healthcare System Serving Ohio, Indiana, and Michigan Network Director ensures the corrective actions developed by facility leaders to address surgical intensive care unit patient safety concerns are completed and evaluated for effectiveness.

Resolve the $388,319 in questioned salary costs and direct Columbia to repay or otherwise remove the sustained questioned costs from its NSF awards.

Direct Columbia to provide documentation supporting it has repaid or otherwise credited the $48,706 in questioned unsupported subaward and relocation expenses for which it has agreed to reimburse NSF.

Direct Columbia to strengthen its policies, procedures, and internal controls around subrecipient monitoring to ensure subawardees comply with federal and NSF requirements when incurring expenses under NSF awards. This could include implementing additional procedures that require Columbia to verify that subawardees maintain adequate documentation to support expenses and submit invoices based on actual expenses incurred and not based on the award budget.

Direct Columbia to implement additional procedures that require it—or its subawardees—to perform periodic reconciliations to ensure that expenses paid to its subawardees are supported by the subawardees’ financial records.

Direct Columbia to develop additional resources that provide guidance to subawardees on the types of documentation they are required to retain in order to support the allowability of salary and relocation expenses charged to NSF awards. These resources should also address ensuring fringe benefit rates are not applied to non-salary expenses.

Resolve the $200,726 in questioned costs and direct Columbia to repay or otherwise remove the sustained questioned costs from its NSF awards.

Direct Columbia to provide documentation supporting it has repaid or otherwise credited the $14,161 in questioned unallowable fringe benefit, subaward, and travel expenses for which it has agreed to reimburse NSF.

Direct Columbia to strengthen its policies, procedures, and internal controls around subrecipient monitoring to ensure subawardees comply with federal and NSF requirements when incurring expenses under NSF awards. This could include developing additional resources for subawardees that provide guidance regarding the allowable charging of expenses—including salary, bonus, fringe benefit, visa, and travel expenses—consistent with federal and NSF regulations.

Direct Columbia to strengthen its internal controls and processes for obtaining NSF approval for subawards. This could include:
• Requiring Sponsored Projects Administration to verify whether a subaward is explicitly identified within the award budget approved by NSF or written approval is obtained from the NSF Grants Officer before establishing the subaward.
• Requiring periodic training for Principal Investigators and other personnel responsible for identifying subaward agreements under NSF awards.

Direct Columbia to strengthen its procedures and internal controls around invoice processing to ensure duplicate payments are not made to subawardees.

Direct Columbia to provide documentation supporting it has repaid or otherwise credited the $9,441 in questioned indirect cost expenses for which it has agreed to reimburse NSF.

Direct Columbia to strengthen its policies, procedures, and internal control processes for ensuring its subawardees appropriately apply either their federally negotiated indirect cost rates or the de minimis rate to NSF awards. These updated procedures could include:
• Requiring personnel responsible for approving invoices to perform a calculation in order to determine whether the indirect costs invoiced are appropriate based on the direct costs invoiced and the rate identified in the subawardee’s Negotiated Indirect Cost Rate Agreement (or the de minimis rate when the subawardee does not have a federally negotiated rate).
• Developing resources that provide guidance on appropriately…

Direct Columbia to strengthen its subaward monitoring procedures to ensure that it verifies whether its subawardees apply the appropriate fringe benefit rates included within their Negotiated Indirect Cost Rate Agreements.

Direct Columbia to establish and implement policies and procedures or internal controls for executing subaward modifications to extend the subaward period of performance prior to paying invoices under an expired subaward.

Direct Columbia to develop resources that provide its subawardees with guidance on how to perform—and document performance of—risk assessments prior to issuing subawards.

Direct Columbia to develop resources that provide its subawardees with guidance on the types of policies and procedures and financial accounting system records necessary to demonstrate compliance with federal financial management systems requirements.

Direct Columbia to establish and implement policies and procedures or internal controls for ensuring that invoices are processed and paid within the 30-day time limit.

Direct Columbia to update its invoice review procedures to ensure that subawardee invoices include all of the data elements required per the subaward terms and conditions.

Direct Columbia to develop additional resources for subawardees that provide guidance on how to ensure they appropriately account for and invoice expenses on a cost-reimbursement basis consistent with subaward terms and conditions.

Direct Columbia to implement additional policies or procedures to ensure that subawardees complete and submit any progress, technical, or other reports that Columbia requires per the subaward terms and conditions.

Direct Columbia to implement internal controls to ensure that all required subawardee documentation is appropriately completed and provided to Columbia’s Sponsored Projects Administration prior to subaward issuance.