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University Compliance Office Gail Huelsmann, University

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Compliance Office Presentation
Washington University in St. Louis
September 5, 2002
Senior Compliance Auditors
Becky Evans 362-4907
Byron Morgan 362-4909
4480 Clayton Avenue
Campus Box 8016
http://universitycompliance.wustl.edu/
University Compliance Office
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Agenda
пЂґ Description and purpose of the
University Compliance Office
пЂґ Typical compliance review process
пЂґ Significant compliance issues noted in
the 5 reviews completed
University Compliance Office
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What is the Washington University
Compliance Program ?
The Washington University
Compliance Program is the expression
of a commitment by Washington
University to carry out its educational,
research, and health care activities in
compliance with all relevant laws and
regulations and with the highest
integrity.
University Compliance Office
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What is the Washington University
Compliance Program?
Cont’d
 Washington University’s Board of Trustees approved the
establishment of the Washington University Compliance
Program and a University Compliance Office in April
2000.
пѓј A Code of Conduct was then developed with input from
many members of the University community, and issued
to University community members in April 2002.
пѓј Three full-time compliance auditors perform proactive and
investigational (as needed) compliance audits. The
results of compliance audits are incorporated in formal
compliance training programs that are being developed or
refined.
University Compliance Office
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Specific Role of the University
Compliance Office
пЂґ Verify that effective compliance is occurring in all
activities governed by federal law and regulation,
and by University policy.
Verification does not mean performing the work of
compliance.
– It means making sure that all relevant activities
have effective compliance organizations.
– It means making sure that these compliance
organizations have effective policies and
procedures, effective training programs, and
effective techniques for monitoring compliance.
University Compliance Office
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Specific Role of the University
Compliance Office
пЂґ
Cont’d
Conduct compliance audits.
Auditing is not the same as monitoring. Auditing and
monitoring are both means of checking to see if compliance
has occurred. However, there are important differences:
a) Monitoring is typically done by the activity that is being
monitored.
b) Monitoring typically occurs much more frequently than
auditing.
c) Monitoring is less formal.
d) Monitoring and auditing should work together.
University Compliance Office
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Specific Role of the University
Compliance Office
Cont’d
пЂґ Develop, revise, and maintain a University Code of
Conduct.
пЂґ Maintain a University compliance hotline for the
reporting of suspected violations or concerns.
пЂґ Maintain effective and ongoing communication with
the University’s senior management and with the
Audit Committee of the Board of Trustees concerning
the state of compliance in University activities that
require compliance.
University Compliance Office
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Typical Compliance Review
пЂґ Based on annual plan & special requests
пЂґ Usually 4 to 8 weeks in length
пЂґ WU Guidelines for Direct-Charging Costs
to Grants (“Blue Book”)
пЂґ OMB Circular A-21 (cost principles)
пЂґ NIH/NSF Guidelines
пЂґ Focus on PARS and Supporting
Documentation for charges to grants
University Compliance Office
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Typical Compliance Review Process
пЂґ Opening Meeting
пЂґ Review samples of supporting documentation
пЂґ Interview sample of PIs and other employees (sourced to
federal funds)
пЂґ Review of grant proposals and award documents as necessary
пЂґ Questions back and forth between department administrator and
compliance auditor (usually by email)
пЂґ Draft report to department head and administrator (includes
opinion on overall compliance and recommendations requiring
action)
пЂґ Department administrator responds to recommendations
пЂґ Final report issued
University Compliance Office
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Significant Issues From Past Reviews
пЂґ PARS and Effort Reporting
пЂґ Direct Charges to Grants
– Documentation
– Justification
– Unallowable & Questionable Costs
пЂґ Proportional Benefit
пЂґ Cost Transfers
пЂґ Animal & Human Subject Protocols
пЂґ Training Grants
University Compliance Office
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PARS
пЂґ Legal Document, Official University System
for Reporting Salary Charges to Grants
пЂґ Completed timely and signed properly
пЂґ Reflect actual effort
пЂґ Administrative Issues
– Administrative Job Codes
– Effort on Grant Proposals and Committees
– Other Administrative Activities
пЂґ Key Personnel & Effort Reporting
University Compliance Office
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PARS-Administrative Issues
Activities generally not direct charged to grants, but recovered
indirectly through Facilities & Administration Rate (F&A)
“The expenses under this heading are those that
have been incurred for administrative and
supporting services that benefit common or joint
departmental activities or objectives in academic
deans' offices, academic departments and
divisions, and research centers." (OMB No. A-21
F.4.a.)
University Compliance Office
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PARS-Administrative Issues
Cont’d
Activities generally not direct charged to grants, but recovered
indirectly via Facilities & Administration Rate (F&A)
Faculty and staff departmental administration duties may include, but are not
limited to:
пЂґ preparation and review of Personnel Activity Reports
пЂґ preparation of departmental budgets and/or payroll
пЂґ review of departmental accounts and financial statements
пЂґ preparation of grant applications
пЂґ planning for building projects and renovations
пЂґ selection and recruitment of faculty
пЂґ selection of graduate students
пЂґ selection and training of staff
пЂґ editing professional journals where the journal provides funds which are
administered by WU or where WU is a sponsor
REF:(http://aladdin.wustl.edu/finance.nsf/) (by function Med School website)
University Compliance Office
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PARS-Administrative Issues
Cont’d
Job titles generally not direct charged to grants, recovered through
indirectly through the F&A Rate.
Administration and clerical titles that are typically
coded as departmental administration may
include, but are not limited to:
пЂґ administrators
пЂґ purchasing assistants
пЂґ accountants
пЂґ payroll assistants
пЂґ bookkeepers
пЂґ secretaries
пЂґ accountants
пЂґ stockroom attendants
пЂґ office managers
University Compliance Office
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Key Personnel & Effort Reporting
пЂґ Does effort in the proposal match actual
effort ?
(salary charged to grant and cost sharing
matched with University payroll system)
пЂґ Who are the key personnel listed in the
proposal ?
пЂґ Per NIH guidelines effort decreases (key
personnel) of 25% or more have to be
reported to the agency. (Does the department
have a system to monitor this ?)
University Compliance Office
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Review of Direct Charges
Non-Personnel
1. Normally Allowable (A-21 F.6.b)
2. NOT Normally Allowable (A-21 F.6.b)
3. Questionable (“Okay, if…” A-21,
BUOB Manual)
4. Unallowable (A-21 J.)
University Compliance Office
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BACK TO
BASICS!
University Compliance Office
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“The Golden Rule”
Direct Costs
 “Direct costs are those costs that can be
identified specifically with a particular
sponsored agreement……or that can be
directly assigned to (such activity)
relatively easily and with a high degree of
accuracy.”
(A-21 D.1.)
University Compliance Office
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Significant & Common
Compliance Issues Noted:
пЂґ Missing or unclear PI or Designee
Approval of Expense
пЂґLack of PI Justification !
пЂґLack of PI Justification !
пЂґLack of PI Justification !
University Compliance Office
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Approvals
 A-21 (B4d) - “….(e.g., signature or
initials of the principal investigator or
designee or use of a password) will
normally be considered sufficient.”
пЂґ WU Policies for Direct-Charging Costs
to Grants (Blue Book) - Designee “is in
the position to know the linkage of the
expense with the funded project is close
and clear.” University Compliance Office
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Approvals
Compliance Problems Noted:
пЂґMissing approvals
(Most common - cost transfers, consortium payments,
modifications)
пЂґ Clarity of approvals
(Whose initials/signature? Which initials/signature?)
пЂґ Appropriateness of designee
University Compliance Office
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Documentation
 “Careful and clear documentation of
actions is proof of the investigator’s
conscientious exercise of the fiduciary
responsibility inherent in the
expenditure of public funds…….
WU “Blue Book”
University Compliance Office
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Documentation
Cont’d
 …...Proper documentation for charges
or cost transfers to a grant should pass
the “stand alone” test. An interested
party, without additional explanation,
must easily understand the paper audit
trail for a charge or transfer.”
WU “Blue Book”
University Compliance Office
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Normally Allowable
Direct Costs
пЂґ Lab Supplies &
пЂґ Animal Expenses
Services
пЂґ Other Expenses
пЂґ Travel
пЂґ Equipment
пЂґ Consortium Costs
пЂґ Consulting Costs
пЂґ Human Subject
(Reminder: Use
Consulting Form)
Expenses
пЂґ PI Approval and
Back-up Still
Required
University Compliance Office
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Normally Allowable
Compliance Issues
Travel
пЂґ Traveler Not Paid From
Fund Charged
пЂґ Absence of Receipts
пЂґ Inappropriate Receipts -
need details
пЂґ Misc. - Question phone
charges, use of meal per
diems, Use TA for >$500
and not CR
University Compliance Office
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Normally Allowable
Compliance Issues
Equipment
пЂґ Lack of Justification for General Purpose
Items (especially small equipment)
пЂґ Purchase of Equipment Within Final 60
Days of Project Period (project not
renewed)
пЂґ $25,000 or more - Screening Certificate,
3 bids - in good shape!
University Compliance Office
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NOT Normally Allowable
Direct Costs - A-21 F.6.b
пЂґ Supplies (3403)
(Can the item be
justified as project
specific?)
пЂґ Phone - Monthly
(3530) - Is it Off
Campus ?
пЂґ DP Line Costs пЂґ Office Supplies
Monthly (3532) (Is
(3411) (Admin Core?)
there a special
circumstance?) (3532)
пЂґ Postage (3512)
пЂґ Laser Printer
Supplies (3455)
пЂґ Dues-Memberships
(3557)
University Compliance Office
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Questionable
Direct Costs
пЂґ Uniforms (3424)
пЂґ Books (3575)
пЂґ Laundry (3537)
пЂґ Subscriptions
пЂґ Advertising (3540)
пЂґ Recruitment (3541)
(3576)
пЂґ Publication of a
Book (3517)
пЂґ Relocation (3552)
University Compliance Office
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REMEMBER!
пЂґ PI MUST JUSTIFY
(Do the costs benefit the project(s) being
charged closely and clearly?)
пЂґ PI MUST APPROVE
пЂґ DOCUMENT! DOCUMENT!
AND…..
 Don’t Assume the need for the expense is
understood!
 Don’t expect SPA to “remember last
month’s justification”.
University Compliance Office
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Unallowable
Direct Costs
(A-21 J., SPA Policy Memo 1/31/02)
пЂґ Legal Fees (3080)
пЂґ Bank Fees (3524)
пЂґ Memorial
пЂґ Entertainment
Contributions
(3443)
пЂґ Supplies (3487)
пЂґ Supplies-Other
(3499)
(3550)
пЂґ Social Expenses
(3553)
пЂґ Prizes/Awards
(3554)
пЂґ Bad Debt Expense
(3560)
пЂґ Financial (3521)
University Compliance Office
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Unallowable
Direct Costs
Cont’d
пЂґ Other Services
пЂґ Gifts (3569)
(3588)
пЂґ Alcohol (3574)
пЂґ Misc. Expenses
пЂґ Other Dues/
Memberships (3587)
(3599)
пЂґ Other Travel-Dues
(3657)
University Compliance Office
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Proportional Benefit
пЂґ
From A-21: "If a cost benefits two or more (grants) in proportions that
can be determined without undue effort or (administrative expense),
the cost should be allocated to the (grants) based on the proportional
benefit." (C4d(3))
пЂґ
The cost in question should be specifically identifiable with the group
of grants relatively easily, and with a high degree of accuracy.
пЂґ
Credible documentation of this identification must be maintained
by the department.
пЂґ
The Principal Investigator must approve the use of proportional
benefit and the method of its use.
пЂґ
Distribution of allowable direct costs by proportional benefit is an automated
feature of FIS. Supporting documentation required.
REF: http://spa.wustl.edu/dircharge/interim.html
University Compliance Office
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Cost Transfers
пЂґ Cost transfers from one grant to another are permitted in order to link a
cost more appropriately with the benefit it is providing. Detailed
explanation required. “To correct an error” is not an acceptable
explanation.
пЂґ Cost transfers from one grant to another are not permitted in order to
solve funding problems or for other reasons of convenience. (C4b)
пЂґ Cost transfers must be submitted within 120 days of the original charge
or within 30 days following the ending date of the grant, whichever is
sooner.
пЂґ Approval by PI.
пЂґ Payroll cost transfer tips from SPA (6/21/02)
REF: SPA Website (direct charges-interim guidelines), Research News
Website (message library-other), General Accounting Manual Chapter 15
University Compliance Office
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Human Subject Protocols
пЂґ IRB Protocol is approved under
PI of grant, has same title as
grant, funding agency matches,
& approval is effective during
grant award period
пЂґ Consent forms signed & dated
by PI & subject, signed during
period of active protocol, and
title on consent form agrees to
approved protocol title
University Compliance Office
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Animal Studies
пЂґ Protocol used for purchases is
approved for use by the PI of the
grant being charged, and the title
and agency also match the grant
пЂґ Date of animal purchases fall within
IACUC approved protocol period
пЂґ Species ordered matches species in
approved protocol
пЂґ PI/designee approved requisition
University Compliance Office
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National Research Service Awards (NRSA)
Ref. NIH GPS Pg. 175
пЂґ Key area of non-compliance for T32s
• Stipends & other allowances paid out
prior to submitting Appointment Form
to NIH (GPS Pg. 206 & NGA
Restrictions)
• Other - wrong insurance charges, wrong
stipend levels, missing amended Appointment
Forms
University Compliance Office
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Resources
 WU Policies for Direct-Charging Costs to Grants (“Blue
Book” ) – SPA Website
– ttp://spa.wustl.edu/direct.html
пЂґ OMB A-21
– http://www.whitehouse.gov/omb/circulars/a021/a021.html
пЂґ NIH Grants Policy Statement
– http://grants.nih.gov/grants/policy/nihgps_2001/nihgps_2001.pdf
пЂґ National Science Foundation Grant Policy Manual
– http://www.nsf.gov/
University Compliance Office
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Resources
Cont’d
пЂґ Washington University Research News
– http://researchnews.wustl.edu/medadmin/rnews.nsf/WSM?O
penView&Count=1000
пЂґ Washington University Policies (Systems & Procedures)
– http://fishelp.wustl.edu/
пЂґ Code of Conduct-http://codeofconduct.wustl.edu/
пЂґ Compliance Office-http://universitycompliance.wustl.edu/
University Compliance Office
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Compliance Definition
 Com-pli-ance - “The act of agreeing
passively to a request, rule, or demand.
The tendency to yield to others.”
пЂґ WU Environment -
- Agreeing passively = a required job
duty for each of us - paid to do it
- Others = mostly government entities
University Compliance Office
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