2023-005: Inadequate Internal Controls over Suspension and Debarment Compliance Requirement
U.S. Department of Health and Human Services
Federal Programs: Health Center Program Cluster (ALN numbers 93.224/93.527) (Federal Award Year 2023) and Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023)
Repeat Finding: No
Criteria: 2 CFR 200.303(a) requires that each non-Federal entity must "Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." The Organization does not have effective suspension and debarment controls in place.
31 CFR 19.300 requires that "When you enter into a covered transaction with another person at the next lower tier, you must verify that the person with whom you intend to do business is not excluded or disqualified."
Condition: When the Organization entered into covered transactions, it did not verify that the entity was not suspended or debarred or otherwise excluded. While the Organization does have an internal control policy in place regarding the Simplified Registration Services (SAM) exclusion verifications of suspended or debarred entities, the Organization did not always adhere to the policy when entering into covered transactions. Additionally, the policy is vague and does not include details about maintaining evidence of actions taken to ensure proper suspension and debarment requirements are met.
Cause: The Organization does not have procedures in place to ensure suspension and debarment checks are completed prior to entering into purchase or service agreements with vendors. Evidence of actions taken to ensure proper suspension and debarment requirements were not being maintained by the Organization.
Effect: Failing to have the appropriate controls in place may result in vendors who are suspended or debarred receiving federal funds.
Recommendation: We recommend that management implement controls to ensure suspension and debarment checks are completed and documented prior to entering into purchase or service agreements with vendors.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
2023-005: Inadequate Internal Controls over Suspension and Debarment Compliance Requirement
U.S. Department of Health and Human Services
Federal Programs: Health Center Program Cluster (ALN numbers 93.224/93.527) (Federal Award Year 2023) and Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023)
Repeat Finding: No
Criteria: 2 CFR 200.303(a) requires that each non-Federal entity must "Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." The Organization does not have effective suspension and debarment controls in place.
31 CFR 19.300 requires that "When you enter into a covered transaction with another person at the next lower tier, you must verify that the person with whom you intend to do business is not excluded or disqualified."
Condition: When the Organization entered into covered transactions, it did not verify that the entity was not suspended or debarred or otherwise excluded. While the Organization does have an internal control policy in place regarding the Simplified Registration Services (SAM) exclusion verifications of suspended or debarred entities, the Organization did not always adhere to the policy when entering into covered transactions. Additionally, the policy is vague and does not include details about maintaining evidence of actions taken to ensure proper suspension and debarment requirements are met.
Cause: The Organization does not have procedures in place to ensure suspension and debarment checks are completed prior to entering into purchase or service agreements with vendors. Evidence of actions taken to ensure proper suspension and debarment requirements were not being maintained by the Organization.
Effect: Failing to have the appropriate controls in place may result in vendors who are suspended or debarred receiving federal funds.
Recommendation: We recommend that management implement controls to ensure suspension and debarment checks are completed and documented prior to entering into purchase or service agreements with vendors.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
2023-005: Inadequate Internal Controls over Suspension and Debarment Compliance Requirement
U.S. Department of Health and Human Services
Federal Programs: Health Center Program Cluster (ALN numbers 93.224/93.527) (Federal Award Year 2023) and Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023)
Repeat Finding: No
Criteria: 2 CFR 200.303(a) requires that each non-Federal entity must "Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." The Organization does not have effective suspension and debarment controls in place.
31 CFR 19.300 requires that "When you enter into a covered transaction with another person at the next lower tier, you must verify that the person with whom you intend to do business is not excluded or disqualified."
Condition: When the Organization entered into covered transactions, it did not verify that the entity was not suspended or debarred or otherwise excluded. While the Organization does have an internal control policy in place regarding the Simplified Registration Services (SAM) exclusion verifications of suspended or debarred entities, the Organization did not always adhere to the policy when entering into covered transactions. Additionally, the policy is vague and does not include details about maintaining evidence of actions taken to ensure proper suspension and debarment requirements are met.
Cause: The Organization does not have procedures in place to ensure suspension and debarment checks are completed prior to entering into purchase or service agreements with vendors. Evidence of actions taken to ensure proper suspension and debarment requirements were not being maintained by the Organization.
Effect: Failing to have the appropriate controls in place may result in vendors who are suspended or debarred receiving federal funds.
Recommendation: We recommend that management implement controls to ensure suspension and debarment checks are completed and documented prior to entering into purchase or service agreements with vendors.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
2023-005: Inadequate Internal Controls over Suspension and Debarment Compliance Requirement
U.S. Department of Health and Human Services
Federal Programs: Health Center Program Cluster (ALN numbers 93.224/93.527) (Federal Award Year 2023) and Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023)
Repeat Finding: No
Criteria: 2 CFR 200.303(a) requires that each non-Federal entity must "Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." The Organization does not have effective suspension and debarment controls in place.
31 CFR 19.300 requires that "When you enter into a covered transaction with another person at the next lower tier, you must verify that the person with whom you intend to do business is not excluded or disqualified."
Condition: When the Organization entered into covered transactions, it did not verify that the entity was not suspended or debarred or otherwise excluded. While the Organization does have an internal control policy in place regarding the Simplified Registration Services (SAM) exclusion verifications of suspended or debarred entities, the Organization did not always adhere to the policy when entering into covered transactions. Additionally, the policy is vague and does not include details about maintaining evidence of actions taken to ensure proper suspension and debarment requirements are met.
Cause: The Organization does not have procedures in place to ensure suspension and debarment checks are completed prior to entering into purchase or service agreements with vendors. Evidence of actions taken to ensure proper suspension and debarment requirements were not being maintained by the Organization.
Effect: Failing to have the appropriate controls in place may result in vendors who are suspended or debarred receiving federal funds.
Recommendation: We recommend that management implement controls to ensure suspension and debarment checks are completed and documented prior to entering into purchase or service agreements with vendors.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
Finding 2023-003: Noncompliance with Subrecipient Monitoring
U.S. Department of Health and Human Services
Federal Program: Advanced Nursing Education Workforce Grant Program
Federal Assistance Listing Number: 93.247
Federal Award Year: 2023
Repeat Finding: No
Criteria: In accordance with 2 CFR 200.332(a), pass-through entities must ensure that every subaward is clearly identified to the subrecipient as a subaward and includes the information listed in 2 CFR 200.332(a)(1) at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass-through entity must provide the best information available to describe the Federal award and subaward.
In accordance with 2CFR 200.332(d), pass-through entities must monitor the activities of the subrecipient as necessary to ensure that the subaward is used for authorized purposes, in compliance with Federal statutes, regulations, and the terms and conditions of the subaward; and that subaward performance goals are achieved.
Condition: The Organization had memorandum of understanding agreements with each of its subrecipients. However, these agreements did not contain the information required by 2 CFR 200.332(a)(1). The Organization did not request or review the audits of its subrecipients in order to take timely and appropriate action on deficiencies detected through audits, if applicable. The Organization did not have sufficient documentation that internal controls were in place and operating effectively over risk assessment procedures required by the subrecipient monitoring compliance requirement.
Cause: The Organization did not have adequate internal controls in place to ensure the agreements with its subrecipients included the required information. Additionally, the Organization did not have adequate controls in place to properly monitor the activities of its subrecipients, or perform the necessary risk assessment procedures.
Effect: We tested two out of the four subrecipients the Organization passed funds to under this grant award. Of the two we tested, we noted that the Organization did not have properly executed subrecipient agreements with either subrecipient. We also noted that the Organization did not request the audits of either subrecipient, and did not adequately document its risk assessment.
Recommendation: We recommend the Organization enhance its internal controls over the preparation of subrecipient agreements to ensure all required information is contained in the agreements. We also recommend that management enhance its internal controls over subrecipient monitoring to ensure that its subrecipients are utilizing the funds for authorized purposes, in compliance with Federal statutes, regulations, and the terms and conditions of the subaward.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
2023-005: Inadequate Internal Controls over Suspension and Debarment Compliance Requirement
U.S. Department of Health and Human Services
Federal Programs: Health Center Program Cluster (ALN numbers 93.224/93.527) (Federal Award Year 2023) and Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023)
Repeat Finding: No
Criteria: 2 CFR 200.303(a) requires that each non-Federal entity must "Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." The Organization does not have effective suspension and debarment controls in place.
31 CFR 19.300 requires that "When you enter into a covered transaction with another person at the next lower tier, you must verify that the person with whom you intend to do business is not excluded or disqualified."
Condition: When the Organization entered into covered transactions, it did not verify that the entity was not suspended or debarred or otherwise excluded. While the Organization does have an internal control policy in place regarding the Simplified Registration Services (SAM) exclusion verifications of suspended or debarred entities, the Organization did not always adhere to the policy when entering into covered transactions. Additionally, the policy is vague and does not include details about maintaining evidence of actions taken to ensure proper suspension and debarment requirements are met.
Cause: The Organization does not have procedures in place to ensure suspension and debarment checks are completed prior to entering into purchase or service agreements with vendors. Evidence of actions taken to ensure proper suspension and debarment requirements were not being maintained by the Organization.
Effect: Failing to have the appropriate controls in place may result in vendors who are suspended or debarred receiving federal funds.
Recommendation: We recommend that management implement controls to ensure suspension and debarment checks are completed and documented prior to entering into purchase or service agreements with vendors.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
Finding 2023-004: Inadequate Review of the Schedule of Expenditures of Federal Awards
U.S. Department of Health and Human Services
Federal Programs: Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023), Family Planning Services (ALN number 93.217) (Federal Award Year 2023), and Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) (ALN number 93.323) (Federal Award Year 2023)
Repeat Finding: No
Criteria: In accordance with 2 CFR 200.510, the auditee must prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502.
Condition: During our testing, we identified errors in the Organization’s SEFA for the year ended June 30, 2023. The errors were as follows:
• Total federal expenditures for Assistance Listing Number (ALN) 93.247, Advanced Nursing Education Workforce Grant Program, were understated by $516,141.
• Total federal expenditures for ALN 93.217, Family Planning Services, were overstated by $125,252.
• The federal grantor for amounts passed through the Illinois Department of Public Health for ALN 93.323, Epidemiology and Laboratory Capacity for Infectious Disease (ELC), was incorrectly reported as the U.S. Department of the Treasury and should have been reported as the U.S. Department of Health and Human Services.
Cause: The Organization did not have adequate internal controls in place over the review of the SEFA to ensure the SEFA was complete and accurate.
.
Effect: The errors contained in the SEFA led to inaccurate major program determination. After correcting the errors, an additional major program was identified. The data collection form and reporting package were not received by the Federal Audit Clearinghouse by the prescribed due date.
Recommendation: We recommend the Organization enhance its internal controls over the review of the completeness and accuracy of the SEFA.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
Finding 2023-004: Inadequate Review of the Schedule of Expenditures of Federal Awards
U.S. Department of Health and Human Services
Federal Programs: Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023), Family Planning Services (ALN number 93.217) (Federal Award Year 2023), and Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) (ALN number 93.323) (Federal Award Year 2023)
Repeat Finding: No
Criteria: In accordance with 2 CFR 200.510, the auditee must prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502.
Condition: During our testing, we identified errors in the Organization’s SEFA for the year ended June 30, 2023. The errors were as follows:
• Total federal expenditures for Assistance Listing Number (ALN) 93.247, Advanced Nursing Education Workforce Grant Program, were understated by $516,141.
• Total federal expenditures for ALN 93.217, Family Planning Services, were overstated by $125,252.
• The federal grantor for amounts passed through the Illinois Department of Public Health for ALN 93.323, Epidemiology and Laboratory Capacity for Infectious Disease (ELC), was incorrectly reported as the U.S. Department of the Treasury and should have been reported as the U.S. Department of Health and Human Services.
Cause: The Organization did not have adequate internal controls in place over the review of the SEFA to ensure the SEFA was complete and accurate.
.
Effect: The errors contained in the SEFA led to inaccurate major program determination. After correcting the errors, an additional major program was identified. The data collection form and reporting package were not received by the Federal Audit Clearinghouse by the prescribed due date.
Recommendation: We recommend the Organization enhance its internal controls over the review of the completeness and accuracy of the SEFA.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
Finding 2023-004: Inadequate Review of the Schedule of Expenditures of Federal Awards
U.S. Department of Health and Human Services
Federal Programs: Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023), Family Planning Services (ALN number 93.217) (Federal Award Year 2023), and Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) (ALN number 93.323) (Federal Award Year 2023)
Repeat Finding: No
Criteria: In accordance with 2 CFR 200.510, the auditee must prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502.
Condition: During our testing, we identified errors in the Organization’s SEFA for the year ended June 30, 2023. The errors were as follows:
• Total federal expenditures for Assistance Listing Number (ALN) 93.247, Advanced Nursing Education Workforce Grant Program, were understated by $516,141.
• Total federal expenditures for ALN 93.217, Family Planning Services, were overstated by $125,252.
• The federal grantor for amounts passed through the Illinois Department of Public Health for ALN 93.323, Epidemiology and Laboratory Capacity for Infectious Disease (ELC), was incorrectly reported as the U.S. Department of the Treasury and should have been reported as the U.S. Department of Health and Human Services.
Cause: The Organization did not have adequate internal controls in place over the review of the SEFA to ensure the SEFA was complete and accurate.
.
Effect: The errors contained in the SEFA led to inaccurate major program determination. After correcting the errors, an additional major program was identified. The data collection form and reporting package were not received by the Federal Audit Clearinghouse by the prescribed due date.
Recommendation: We recommend the Organization enhance its internal controls over the review of the completeness and accuracy of the SEFA.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
Finding 2023-002: Timely Submission of the Single Audit Reporting Package
U.S. Department of Health and Human Services
Federal Programs: Health Center Program Cluster (ALN numbers 93.224/93.527) (Federal Award Year 2023) and Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023)
Repeat Finding: No
Criteria: In accordance with 2 CFR 200.512, the audit must be completed, and the data collection form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditor’s report, or nine months after the end of the audit period. Additionally, as part of the data collection, a senior level representative of the auditee must attest that, among other things, the information included in its entirety is accurate and complete.
In accordance with 2 CFR 200.510, the auditee must prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502.
Condition: The data collection form and reporting package were not submitted within nine months after the end of the audit period of June 30, 2023.
Cause: The Organization did not have adequate internal controls in place over the review of the SEFA to ensure the SEFA was complete and accurate. The errors contained in the SEFA led to inaccurate major program determination, which ultimately led to the Organization not submitting the single audit reporting package by the prescribed due date.
Effect: The data collection form and reporting package were not received by the Federal Audit Clearinghouse by the prescribed due date.
Recommendation: We recommend the Organization enhance its internal controls over the review of the completeness and accuracy of the SEFA. We also recommend that management ensure that the data collection form and reporting package are submitted by the prescribed due date.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
Finding 2023-002: Timely Submission of the Single Audit Reporting Package
U.S. Department of Health and Human Services
Federal Programs: Health Center Program Cluster (ALN numbers 93.224/93.527) (Federal Award Year 2023) and Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023)
Repeat Finding: No
Criteria: In accordance with 2 CFR 200.512, the audit must be completed, and the data collection form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditor’s report, or nine months after the end of the audit period. Additionally, as part of the data collection, a senior level representative of the auditee must attest that, among other things, the information included in its entirety is accurate and complete.
In accordance with 2 CFR 200.510, the auditee must prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502.
Condition: The data collection form and reporting package were not submitted within nine months after the end of the audit period of June 30, 2023.
Cause: The Organization did not have adequate internal controls in place over the review of the SEFA to ensure the SEFA was complete and accurate. The errors contained in the SEFA led to inaccurate major program determination, which ultimately led to the Organization not submitting the single audit reporting package by the prescribed due date.
Effect: The data collection form and reporting package were not received by the Federal Audit Clearinghouse by the prescribed due date.
Recommendation: We recommend the Organization enhance its internal controls over the review of the completeness and accuracy of the SEFA. We also recommend that management ensure that the data collection form and reporting package are submitted by the prescribed due date.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
Finding 2023-002: Timely Submission of the Single Audit Reporting Package
U.S. Department of Health and Human Services
Federal Programs: Health Center Program Cluster (ALN numbers 93.224/93.527) (Federal Award Year 2023) and Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023)
Repeat Finding: No
Criteria: In accordance with 2 CFR 200.512, the audit must be completed, and the data collection form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditor’s report, or nine months after the end of the audit period. Additionally, as part of the data collection, a senior level representative of the auditee must attest that, among other things, the information included in its entirety is accurate and complete.
In accordance with 2 CFR 200.510, the auditee must prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502.
Condition: The data collection form and reporting package were not submitted within nine months after the end of the audit period of June 30, 2023.
Cause: The Organization did not have adequate internal controls in place over the review of the SEFA to ensure the SEFA was complete and accurate. The errors contained in the SEFA led to inaccurate major program determination, which ultimately led to the Organization not submitting the single audit reporting package by the prescribed due date.
Effect: The data collection form and reporting package were not received by the Federal Audit Clearinghouse by the prescribed due date.
Recommendation: We recommend the Organization enhance its internal controls over the review of the completeness and accuracy of the SEFA. We also recommend that management ensure that the data collection form and reporting package are submitted by the prescribed due date.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
Finding 2023-002: Timely Submission of the Single Audit Reporting Package
U.S. Department of Health and Human Services
Federal Programs: Health Center Program Cluster (ALN numbers 93.224/93.527) (Federal Award Year 2023) and Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023)
Repeat Finding: No
Criteria: In accordance with 2 CFR 200.512, the audit must be completed, and the data collection form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditor’s report, or nine months after the end of the audit period. Additionally, as part of the data collection, a senior level representative of the auditee must attest that, among other things, the information included in its entirety is accurate and complete.
In accordance with 2 CFR 200.510, the auditee must prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502.
Condition: The data collection form and reporting package were not submitted within nine months after the end of the audit period of June 30, 2023.
Cause: The Organization did not have adequate internal controls in place over the review of the SEFA to ensure the SEFA was complete and accurate. The errors contained in the SEFA led to inaccurate major program determination, which ultimately led to the Organization not submitting the single audit reporting package by the prescribed due date.
Effect: The data collection form and reporting package were not received by the Federal Audit Clearinghouse by the prescribed due date.
Recommendation: We recommend the Organization enhance its internal controls over the review of the completeness and accuracy of the SEFA. We also recommend that management ensure that the data collection form and reporting package are submitted by the prescribed due date.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
Finding 2023-002: Timely Submission of the Single Audit Reporting Package
U.S. Department of Health and Human Services
Federal Programs: Health Center Program Cluster (ALN numbers 93.224/93.527) (Federal Award Year 2023) and Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023)
Repeat Finding: No
Criteria: In accordance with 2 CFR 200.512, the audit must be completed, and the data collection form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditor’s report, or nine months after the end of the audit period. Additionally, as part of the data collection, a senior level representative of the auditee must attest that, among other things, the information included in its entirety is accurate and complete.
In accordance with 2 CFR 200.510, the auditee must prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502.
Condition: The data collection form and reporting package were not submitted within nine months after the end of the audit period of June 30, 2023.
Cause: The Organization did not have adequate internal controls in place over the review of the SEFA to ensure the SEFA was complete and accurate. The errors contained in the SEFA led to inaccurate major program determination, which ultimately led to the Organization not submitting the single audit reporting package by the prescribed due date.
Effect: The data collection form and reporting package were not received by the Federal Audit Clearinghouse by the prescribed due date.
Recommendation: We recommend the Organization enhance its internal controls over the review of the completeness and accuracy of the SEFA. We also recommend that management ensure that the data collection form and reporting package are submitted by the prescribed due date.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
2023-005: Inadequate Internal Controls over Suspension and Debarment Compliance Requirement
U.S. Department of Health and Human Services
Federal Programs: Health Center Program Cluster (ALN numbers 93.224/93.527) (Federal Award Year 2023) and Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023)
Repeat Finding: No
Criteria: 2 CFR 200.303(a) requires that each non-Federal entity must "Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." The Organization does not have effective suspension and debarment controls in place.
31 CFR 19.300 requires that "When you enter into a covered transaction with another person at the next lower tier, you must verify that the person with whom you intend to do business is not excluded or disqualified."
Condition: When the Organization entered into covered transactions, it did not verify that the entity was not suspended or debarred or otherwise excluded. While the Organization does have an internal control policy in place regarding the Simplified Registration Services (SAM) exclusion verifications of suspended or debarred entities, the Organization did not always adhere to the policy when entering into covered transactions. Additionally, the policy is vague and does not include details about maintaining evidence of actions taken to ensure proper suspension and debarment requirements are met.
Cause: The Organization does not have procedures in place to ensure suspension and debarment checks are completed prior to entering into purchase or service agreements with vendors. Evidence of actions taken to ensure proper suspension and debarment requirements were not being maintained by the Organization.
Effect: Failing to have the appropriate controls in place may result in vendors who are suspended or debarred receiving federal funds.
Recommendation: We recommend that management implement controls to ensure suspension and debarment checks are completed and documented prior to entering into purchase or service agreements with vendors.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
2023-005: Inadequate Internal Controls over Suspension and Debarment Compliance Requirement
U.S. Department of Health and Human Services
Federal Programs: Health Center Program Cluster (ALN numbers 93.224/93.527) (Federal Award Year 2023) and Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023)
Repeat Finding: No
Criteria: 2 CFR 200.303(a) requires that each non-Federal entity must "Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." The Organization does not have effective suspension and debarment controls in place.
31 CFR 19.300 requires that "When you enter into a covered transaction with another person at the next lower tier, you must verify that the person with whom you intend to do business is not excluded or disqualified."
Condition: When the Organization entered into covered transactions, it did not verify that the entity was not suspended or debarred or otherwise excluded. While the Organization does have an internal control policy in place regarding the Simplified Registration Services (SAM) exclusion verifications of suspended or debarred entities, the Organization did not always adhere to the policy when entering into covered transactions. Additionally, the policy is vague and does not include details about maintaining evidence of actions taken to ensure proper suspension and debarment requirements are met.
Cause: The Organization does not have procedures in place to ensure suspension and debarment checks are completed prior to entering into purchase or service agreements with vendors. Evidence of actions taken to ensure proper suspension and debarment requirements were not being maintained by the Organization.
Effect: Failing to have the appropriate controls in place may result in vendors who are suspended or debarred receiving federal funds.
Recommendation: We recommend that management implement controls to ensure suspension and debarment checks are completed and documented prior to entering into purchase or service agreements with vendors.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
2023-005: Inadequate Internal Controls over Suspension and Debarment Compliance Requirement
U.S. Department of Health and Human Services
Federal Programs: Health Center Program Cluster (ALN numbers 93.224/93.527) (Federal Award Year 2023) and Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023)
Repeat Finding: No
Criteria: 2 CFR 200.303(a) requires that each non-Federal entity must "Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." The Organization does not have effective suspension and debarment controls in place.
31 CFR 19.300 requires that "When you enter into a covered transaction with another person at the next lower tier, you must verify that the person with whom you intend to do business is not excluded or disqualified."
Condition: When the Organization entered into covered transactions, it did not verify that the entity was not suspended or debarred or otherwise excluded. While the Organization does have an internal control policy in place regarding the Simplified Registration Services (SAM) exclusion verifications of suspended or debarred entities, the Organization did not always adhere to the policy when entering into covered transactions. Additionally, the policy is vague and does not include details about maintaining evidence of actions taken to ensure proper suspension and debarment requirements are met.
Cause: The Organization does not have procedures in place to ensure suspension and debarment checks are completed prior to entering into purchase or service agreements with vendors. Evidence of actions taken to ensure proper suspension and debarment requirements were not being maintained by the Organization.
Effect: Failing to have the appropriate controls in place may result in vendors who are suspended or debarred receiving federal funds.
Recommendation: We recommend that management implement controls to ensure suspension and debarment checks are completed and documented prior to entering into purchase or service agreements with vendors.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
2023-005: Inadequate Internal Controls over Suspension and Debarment Compliance Requirement
U.S. Department of Health and Human Services
Federal Programs: Health Center Program Cluster (ALN numbers 93.224/93.527) (Federal Award Year 2023) and Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023)
Repeat Finding: No
Criteria: 2 CFR 200.303(a) requires that each non-Federal entity must "Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." The Organization does not have effective suspension and debarment controls in place.
31 CFR 19.300 requires that "When you enter into a covered transaction with another person at the next lower tier, you must verify that the person with whom you intend to do business is not excluded or disqualified."
Condition: When the Organization entered into covered transactions, it did not verify that the entity was not suspended or debarred or otherwise excluded. While the Organization does have an internal control policy in place regarding the Simplified Registration Services (SAM) exclusion verifications of suspended or debarred entities, the Organization did not always adhere to the policy when entering into covered transactions. Additionally, the policy is vague and does not include details about maintaining evidence of actions taken to ensure proper suspension and debarment requirements are met.
Cause: The Organization does not have procedures in place to ensure suspension and debarment checks are completed prior to entering into purchase or service agreements with vendors. Evidence of actions taken to ensure proper suspension and debarment requirements were not being maintained by the Organization.
Effect: Failing to have the appropriate controls in place may result in vendors who are suspended or debarred receiving federal funds.
Recommendation: We recommend that management implement controls to ensure suspension and debarment checks are completed and documented prior to entering into purchase or service agreements with vendors.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
Finding 2023-003: Noncompliance with Subrecipient Monitoring
U.S. Department of Health and Human Services
Federal Program: Advanced Nursing Education Workforce Grant Program
Federal Assistance Listing Number: 93.247
Federal Award Year: 2023
Repeat Finding: No
Criteria: In accordance with 2 CFR 200.332(a), pass-through entities must ensure that every subaward is clearly identified to the subrecipient as a subaward and includes the information listed in 2 CFR 200.332(a)(1) at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass-through entity must provide the best information available to describe the Federal award and subaward.
In accordance with 2CFR 200.332(d), pass-through entities must monitor the activities of the subrecipient as necessary to ensure that the subaward is used for authorized purposes, in compliance with Federal statutes, regulations, and the terms and conditions of the subaward; and that subaward performance goals are achieved.
Condition: The Organization had memorandum of understanding agreements with each of its subrecipients. However, these agreements did not contain the information required by 2 CFR 200.332(a)(1). The Organization did not request or review the audits of its subrecipients in order to take timely and appropriate action on deficiencies detected through audits, if applicable. The Organization did not have sufficient documentation that internal controls were in place and operating effectively over risk assessment procedures required by the subrecipient monitoring compliance requirement.
Cause: The Organization did not have adequate internal controls in place to ensure the agreements with its subrecipients included the required information. Additionally, the Organization did not have adequate controls in place to properly monitor the activities of its subrecipients, or perform the necessary risk assessment procedures.
Effect: We tested two out of the four subrecipients the Organization passed funds to under this grant award. Of the two we tested, we noted that the Organization did not have properly executed subrecipient agreements with either subrecipient. We also noted that the Organization did not request the audits of either subrecipient, and did not adequately document its risk assessment.
Recommendation: We recommend the Organization enhance its internal controls over the preparation of subrecipient agreements to ensure all required information is contained in the agreements. We also recommend that management enhance its internal controls over subrecipient monitoring to ensure that its subrecipients are utilizing the funds for authorized purposes, in compliance with Federal statutes, regulations, and the terms and conditions of the subaward.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
2023-005: Inadequate Internal Controls over Suspension and Debarment Compliance Requirement
U.S. Department of Health and Human Services
Federal Programs: Health Center Program Cluster (ALN numbers 93.224/93.527) (Federal Award Year 2023) and Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023)
Repeat Finding: No
Criteria: 2 CFR 200.303(a) requires that each non-Federal entity must "Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award." The Organization does not have effective suspension and debarment controls in place.
31 CFR 19.300 requires that "When you enter into a covered transaction with another person at the next lower tier, you must verify that the person with whom you intend to do business is not excluded or disqualified."
Condition: When the Organization entered into covered transactions, it did not verify that the entity was not suspended or debarred or otherwise excluded. While the Organization does have an internal control policy in place regarding the Simplified Registration Services (SAM) exclusion verifications of suspended or debarred entities, the Organization did not always adhere to the policy when entering into covered transactions. Additionally, the policy is vague and does not include details about maintaining evidence of actions taken to ensure proper suspension and debarment requirements are met.
Cause: The Organization does not have procedures in place to ensure suspension and debarment checks are completed prior to entering into purchase or service agreements with vendors. Evidence of actions taken to ensure proper suspension and debarment requirements were not being maintained by the Organization.
Effect: Failing to have the appropriate controls in place may result in vendors who are suspended or debarred receiving federal funds.
Recommendation: We recommend that management implement controls to ensure suspension and debarment checks are completed and documented prior to entering into purchase or service agreements with vendors.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
Finding 2023-004: Inadequate Review of the Schedule of Expenditures of Federal Awards
U.S. Department of Health and Human Services
Federal Programs: Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023), Family Planning Services (ALN number 93.217) (Federal Award Year 2023), and Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) (ALN number 93.323) (Federal Award Year 2023)
Repeat Finding: No
Criteria: In accordance with 2 CFR 200.510, the auditee must prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502.
Condition: During our testing, we identified errors in the Organization’s SEFA for the year ended June 30, 2023. The errors were as follows:
• Total federal expenditures for Assistance Listing Number (ALN) 93.247, Advanced Nursing Education Workforce Grant Program, were understated by $516,141.
• Total federal expenditures for ALN 93.217, Family Planning Services, were overstated by $125,252.
• The federal grantor for amounts passed through the Illinois Department of Public Health for ALN 93.323, Epidemiology and Laboratory Capacity for Infectious Disease (ELC), was incorrectly reported as the U.S. Department of the Treasury and should have been reported as the U.S. Department of Health and Human Services.
Cause: The Organization did not have adequate internal controls in place over the review of the SEFA to ensure the SEFA was complete and accurate.
.
Effect: The errors contained in the SEFA led to inaccurate major program determination. After correcting the errors, an additional major program was identified. The data collection form and reporting package were not received by the Federal Audit Clearinghouse by the prescribed due date.
Recommendation: We recommend the Organization enhance its internal controls over the review of the completeness and accuracy of the SEFA.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
Finding 2023-004: Inadequate Review of the Schedule of Expenditures of Federal Awards
U.S. Department of Health and Human Services
Federal Programs: Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023), Family Planning Services (ALN number 93.217) (Federal Award Year 2023), and Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) (ALN number 93.323) (Federal Award Year 2023)
Repeat Finding: No
Criteria: In accordance with 2 CFR 200.510, the auditee must prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502.
Condition: During our testing, we identified errors in the Organization’s SEFA for the year ended June 30, 2023. The errors were as follows:
• Total federal expenditures for Assistance Listing Number (ALN) 93.247, Advanced Nursing Education Workforce Grant Program, were understated by $516,141.
• Total federal expenditures for ALN 93.217, Family Planning Services, were overstated by $125,252.
• The federal grantor for amounts passed through the Illinois Department of Public Health for ALN 93.323, Epidemiology and Laboratory Capacity for Infectious Disease (ELC), was incorrectly reported as the U.S. Department of the Treasury and should have been reported as the U.S. Department of Health and Human Services.
Cause: The Organization did not have adequate internal controls in place over the review of the SEFA to ensure the SEFA was complete and accurate.
.
Effect: The errors contained in the SEFA led to inaccurate major program determination. After correcting the errors, an additional major program was identified. The data collection form and reporting package were not received by the Federal Audit Clearinghouse by the prescribed due date.
Recommendation: We recommend the Organization enhance its internal controls over the review of the completeness and accuracy of the SEFA.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
Finding 2023-004: Inadequate Review of the Schedule of Expenditures of Federal Awards
U.S. Department of Health and Human Services
Federal Programs: Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023), Family Planning Services (ALN number 93.217) (Federal Award Year 2023), and Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) (ALN number 93.323) (Federal Award Year 2023)
Repeat Finding: No
Criteria: In accordance with 2 CFR 200.510, the auditee must prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502.
Condition: During our testing, we identified errors in the Organization’s SEFA for the year ended June 30, 2023. The errors were as follows:
• Total federal expenditures for Assistance Listing Number (ALN) 93.247, Advanced Nursing Education Workforce Grant Program, were understated by $516,141.
• Total federal expenditures for ALN 93.217, Family Planning Services, were overstated by $125,252.
• The federal grantor for amounts passed through the Illinois Department of Public Health for ALN 93.323, Epidemiology and Laboratory Capacity for Infectious Disease (ELC), was incorrectly reported as the U.S. Department of the Treasury and should have been reported as the U.S. Department of Health and Human Services.
Cause: The Organization did not have adequate internal controls in place over the review of the SEFA to ensure the SEFA was complete and accurate.
.
Effect: The errors contained in the SEFA led to inaccurate major program determination. After correcting the errors, an additional major program was identified. The data collection form and reporting package were not received by the Federal Audit Clearinghouse by the prescribed due date.
Recommendation: We recommend the Organization enhance its internal controls over the review of the completeness and accuracy of the SEFA.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
Finding 2023-002: Timely Submission of the Single Audit Reporting Package
U.S. Department of Health and Human Services
Federal Programs: Health Center Program Cluster (ALN numbers 93.224/93.527) (Federal Award Year 2023) and Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023)
Repeat Finding: No
Criteria: In accordance with 2 CFR 200.512, the audit must be completed, and the data collection form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditor’s report, or nine months after the end of the audit period. Additionally, as part of the data collection, a senior level representative of the auditee must attest that, among other things, the information included in its entirety is accurate and complete.
In accordance with 2 CFR 200.510, the auditee must prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502.
Condition: The data collection form and reporting package were not submitted within nine months after the end of the audit period of June 30, 2023.
Cause: The Organization did not have adequate internal controls in place over the review of the SEFA to ensure the SEFA was complete and accurate. The errors contained in the SEFA led to inaccurate major program determination, which ultimately led to the Organization not submitting the single audit reporting package by the prescribed due date.
Effect: The data collection form and reporting package were not received by the Federal Audit Clearinghouse by the prescribed due date.
Recommendation: We recommend the Organization enhance its internal controls over the review of the completeness and accuracy of the SEFA. We also recommend that management ensure that the data collection form and reporting package are submitted by the prescribed due date.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
Finding 2023-002: Timely Submission of the Single Audit Reporting Package
U.S. Department of Health and Human Services
Federal Programs: Health Center Program Cluster (ALN numbers 93.224/93.527) (Federal Award Year 2023) and Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023)
Repeat Finding: No
Criteria: In accordance with 2 CFR 200.512, the audit must be completed, and the data collection form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditor’s report, or nine months after the end of the audit period. Additionally, as part of the data collection, a senior level representative of the auditee must attest that, among other things, the information included in its entirety is accurate and complete.
In accordance with 2 CFR 200.510, the auditee must prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502.
Condition: The data collection form and reporting package were not submitted within nine months after the end of the audit period of June 30, 2023.
Cause: The Organization did not have adequate internal controls in place over the review of the SEFA to ensure the SEFA was complete and accurate. The errors contained in the SEFA led to inaccurate major program determination, which ultimately led to the Organization not submitting the single audit reporting package by the prescribed due date.
Effect: The data collection form and reporting package were not received by the Federal Audit Clearinghouse by the prescribed due date.
Recommendation: We recommend the Organization enhance its internal controls over the review of the completeness and accuracy of the SEFA. We also recommend that management ensure that the data collection form and reporting package are submitted by the prescribed due date.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
Finding 2023-002: Timely Submission of the Single Audit Reporting Package
U.S. Department of Health and Human Services
Federal Programs: Health Center Program Cluster (ALN numbers 93.224/93.527) (Federal Award Year 2023) and Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023)
Repeat Finding: No
Criteria: In accordance with 2 CFR 200.512, the audit must be completed, and the data collection form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditor’s report, or nine months after the end of the audit period. Additionally, as part of the data collection, a senior level representative of the auditee must attest that, among other things, the information included in its entirety is accurate and complete.
In accordance with 2 CFR 200.510, the auditee must prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502.
Condition: The data collection form and reporting package were not submitted within nine months after the end of the audit period of June 30, 2023.
Cause: The Organization did not have adequate internal controls in place over the review of the SEFA to ensure the SEFA was complete and accurate. The errors contained in the SEFA led to inaccurate major program determination, which ultimately led to the Organization not submitting the single audit reporting package by the prescribed due date.
Effect: The data collection form and reporting package were not received by the Federal Audit Clearinghouse by the prescribed due date.
Recommendation: We recommend the Organization enhance its internal controls over the review of the completeness and accuracy of the SEFA. We also recommend that management ensure that the data collection form and reporting package are submitted by the prescribed due date.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
Finding 2023-002: Timely Submission of the Single Audit Reporting Package
U.S. Department of Health and Human Services
Federal Programs: Health Center Program Cluster (ALN numbers 93.224/93.527) (Federal Award Year 2023) and Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023)
Repeat Finding: No
Criteria: In accordance with 2 CFR 200.512, the audit must be completed, and the data collection form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditor’s report, or nine months after the end of the audit period. Additionally, as part of the data collection, a senior level representative of the auditee must attest that, among other things, the information included in its entirety is accurate and complete.
In accordance with 2 CFR 200.510, the auditee must prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502.
Condition: The data collection form and reporting package were not submitted within nine months after the end of the audit period of June 30, 2023.
Cause: The Organization did not have adequate internal controls in place over the review of the SEFA to ensure the SEFA was complete and accurate. The errors contained in the SEFA led to inaccurate major program determination, which ultimately led to the Organization not submitting the single audit reporting package by the prescribed due date.
Effect: The data collection form and reporting package were not received by the Federal Audit Clearinghouse by the prescribed due date.
Recommendation: We recommend the Organization enhance its internal controls over the review of the completeness and accuracy of the SEFA. We also recommend that management ensure that the data collection form and reporting package are submitted by the prescribed due date.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.
Finding 2023-002: Timely Submission of the Single Audit Reporting Package
U.S. Department of Health and Human Services
Federal Programs: Health Center Program Cluster (ALN numbers 93.224/93.527) (Federal Award Year 2023) and Advanced Nursing Education Workforce Grant Program (ALN number 93.247) (Federal Award Year 2023)
Repeat Finding: No
Criteria: In accordance with 2 CFR 200.512, the audit must be completed, and the data collection form and reporting package must be submitted within the earlier of 30 calendar days after receipt of the auditor’s report, or nine months after the end of the audit period. Additionally, as part of the data collection, a senior level representative of the auditee must attest that, among other things, the information included in its entirety is accurate and complete.
In accordance with 2 CFR 200.510, the auditee must prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period covered by the auditee’s financial statements which must include the total Federal awards expended as determined in accordance with 2 CFR 200.502.
Condition: The data collection form and reporting package were not submitted within nine months after the end of the audit period of June 30, 2023.
Cause: The Organization did not have adequate internal controls in place over the review of the SEFA to ensure the SEFA was complete and accurate. The errors contained in the SEFA led to inaccurate major program determination, which ultimately led to the Organization not submitting the single audit reporting package by the prescribed due date.
Effect: The data collection form and reporting package were not received by the Federal Audit Clearinghouse by the prescribed due date.
Recommendation: We recommend the Organization enhance its internal controls over the review of the completeness and accuracy of the SEFA. We also recommend that management ensure that the data collection form and reporting package are submitted by the prescribed due date.
View of responsible officials of the auditee: Management agrees with the finding and recommendation.