2022-001: First tier subawards were not reported on the Federal Funding Accountability and Transparency Act Subaward Reporting System (?FSRS?)Cluster: Not applicableFederal Granting Agency: Health Resources and Services Administration (?HRSA?)Award Name: Coordinated Services and Access to Research for Women, Infants, Children, and Youth (?Ryan White Part D Program?)Award #: 7 H12HA45378-01-00; 2 H12HA45378-02-00Assistance Listing #: 93.153Award Year: Fiscal year 2022Pass-through entity: N/ACondition:As part of PwC?s testing over the reporting requirements related to the Ryan White Part D Program, we identified a first tier subaward to Duke University in the amount of $128,218 during fiscal year 2022, and this subaward was not reported within the FSRS system, as required.Criteria:The Federal Funding Accountability and Transparency Act (?FFATA?) of 2006 requires full disclosure of all entities and organizations receiving federal funds, including grants, contracts, loans, and other assistance and payments. Prime Grant Recipients awarded a new Federal grant greater than or equal to $30,000 as of October 1, 2010 are subject to FFATA sub-award reporting requirements as outlined in the Office of Management and Budgets guidance issued August 27, 2010. The prime awardee is required to file a FFATA sub-award report in the FSRS system by the end of the month following the month in which the prime recipient awards any sub-grant greater than or equal to $30,000.Cause:Management did not perform a thorough review of the contract, which noted the FSRS reporting requirement related to subawards that was relevant to the Company and as such, they failed to file the required notification of subaward within the FSRS system for Duke University, a first tier subrecipient under the Ryan White Part D Program.Effect:The appropriate report was not filed and as such, the FSRS system did not appropriately include the first tier subaward from Novant Health to Duke University under the Ryan White Part D Program for fiscal year 2022.Recommendation:We recommend the Company implement a contract summarization control whereby the grant accountant (or designee) summarize all relevant aspects of the contract(s) for the fiscal year. This summary should then be reviewed by the grant/program coordinator prior to the start of the contract to ensure that all relevant requirements are included within the summary and to discuss with the appropriate individuals the plan to execute on each requirement.Management?s Views and Corrective Action Plan:Management?s views and corrective action plan is included at the end of this report after the summary schedule of prior audit findings and status.
2022-001: First tier subawards were not reported on the Federal Funding Accountability and Transparency Act Subaward Reporting System (?FSRS?)Cluster: Not applicableFederal Granting Agency: Health Resources and Services Administration (?HRSA?)Award Name: Coordinated Services and Access to Research for Women, Infants, Children, and Youth (?Ryan White Part D Program?)Award #: 7 H12HA45378-01-00; 2 H12HA45378-02-00Assistance Listing #: 93.153Award Year: Fiscal year 2022Pass-through entity: N/ACondition:As part of PwC?s testing over the reporting requirements related to the Ryan White Part D Program, we identified a first tier subaward to Duke University in the amount of $128,218 during fiscal year 2022, and this subaward was not reported within the FSRS system, as required.Criteria:The Federal Funding Accountability and Transparency Act (?FFATA?) of 2006 requires full disclosure of all entities and organizations receiving federal funds, including grants, contracts, loans, and other assistance and payments. Prime Grant Recipients awarded a new Federal grant greater than or equal to $30,000 as of October 1, 2010 are subject to FFATA sub-award reporting requirements as outlined in the Office of Management and Budgets guidance issued August 27, 2010. The prime awardee is required to file a FFATA sub-award report in the FSRS system by the end of the month following the month in which the prime recipient awards any sub-grant greater than or equal to $30,000.Cause:Management did not perform a thorough review of the contract, which noted the FSRS reporting requirement related to subawards that was relevant to the Company and as such, they failed to file the required notification of subaward within the FSRS system for Duke University, a first tier subrecipient under the Ryan White Part D Program.Effect:The appropriate report was not filed and as such, the FSRS system did not appropriately include the first tier subaward from Novant Health to Duke University under the Ryan White Part D Program for fiscal year 2022.Recommendation:We recommend the Company implement a contract summarization control whereby the grant accountant (or designee) summarize all relevant aspects of the contract(s) for the fiscal year. This summary should then be reviewed by the grant/program coordinator prior to the start of the contract to ensure that all relevant requirements are included within the summary and to discuss with the appropriate individuals the plan to execute on each requirement.Management?s Views and Corrective Action Plan:Management?s views and corrective action plan is included at the end of this report after the summary schedule of prior audit findings and status.
2022-002: Evidence of vendor suspension and debarment checks for vendors was not retained ? Significant deficiencyCluster: Not applicableFederal Granting Agency: Health Resources and Services Administration (?HRSA?)Award Name: COVID-19 National Bioterrorism Hospital Preparedness Program (?Bioterrorism Program?)Assistance Listing #: 93.889Award Year: Fiscal year 2022Pass-through entity: N/ACondition:The Company has a policy by which all new vendors are required to be checked against the SAM.gov database by the Risk Management department prior to being entered into the accounts payable system regardless of the dollar value of the transaction. Through inquiry with the Company, they indicated that while these checks are performed, evidence of the checks is not retained. Additionally, of the 179 unique vendors used during fiscal year 2022 related to the Bioterrorism Program, PwC was unable to obtain information regarding how many were new vendors and thus subject to this check. For context, however, if the Company used the federal threshold of $25k for completing the SAM.gov checks, there were 4 transactions totaling approximately $420k above this threshold.Criteria:Non-federal entities are prohibited from contracting with or making subawards under covered transactionsto parties that are suspended or debarred. When a non-federal entity enters into a covered transactionwith an entity at a lower tier, the nonfederal entity must verify that the entity, as defined in 2 CFR section180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded fromparticipating in the transaction. This verification may be accomplished by (1) checking the System forAward Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting acertification from the entity, or (3) adding a clause or condition to the covered transaction with that entity(2 CFR section 180.300).Cause:Management?s process and controls did not include the applicable requirement of retaining history or evidence of SAM.gov vendor checks for vendors utilized by the program. As such, no single individual within the Risk Management department at the Company was retaining history or evidence of this step in the Company?s procurement and vendor setup process.Effect:The Company may do business with a vendor that is suspended or debarred if timely checks are not performed.Recommendation:We recommend the Company enhance its controls and revise its procedures surrounding vendor suspension and debarment to include a requirement that evidence is appropriately maintained of SAM.gov vendor checks for each vendor (e.g. screenshots, a checklist including this procedure that is signed, etc.).Management?s Views and Corrective Action Plan:Management?s views and corrective action plan is included at the end of this report after the summary schedule of prior audit findings and status.
2022-002: Evidence of vendor suspension and debarment checks for vendors was not retained ? Significant deficiencyCluster: Not applicableFederal Granting Agency: Health Resources and Services Administration (?HRSA?)Award Name: COVID-19 National Bioterrorism Hospital Preparedness Program (?Bioterrorism Program?)Assistance Listing #: 93.889Award Year: Fiscal year 2022Pass-through entity: N/ACondition:The Company has a policy by which all new vendors are required to be checked against the SAM.gov database by the Risk Management department prior to being entered into the accounts payable system regardless of the dollar value of the transaction. Through inquiry with the Company, they indicated that while these checks are performed, evidence of the checks is not retained. Additionally, of the 179 unique vendors used during fiscal year 2022 related to the Bioterrorism Program, PwC was unable to obtain information regarding how many were new vendors and thus subject to this check. For context, however, if the Company used the federal threshold of $25k for completing the SAM.gov checks, there were 4 transactions totaling approximately $420k above this threshold.Criteria:Non-federal entities are prohibited from contracting with or making subawards under covered transactionsto parties that are suspended or debarred. When a non-federal entity enters into a covered transactionwith an entity at a lower tier, the nonfederal entity must verify that the entity, as defined in 2 CFR section180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded fromparticipating in the transaction. This verification may be accomplished by (1) checking the System forAward Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting acertification from the entity, or (3) adding a clause or condition to the covered transaction with that entity(2 CFR section 180.300).Cause:Management?s process and controls did not include the applicable requirement of retaining history or evidence of SAM.gov vendor checks for vendors utilized by the program. As such, no single individual within the Risk Management department at the Company was retaining history or evidence of this step in the Company?s procurement and vendor setup process.Effect:The Company may do business with a vendor that is suspended or debarred if timely checks are not performed.Recommendation:We recommend the Company enhance its controls and revise its procedures surrounding vendor suspension and debarment to include a requirement that evidence is appropriately maintained of SAM.gov vendor checks for each vendor (e.g. screenshots, a checklist including this procedure that is signed, etc.).Management?s Views and Corrective Action Plan:Management?s views and corrective action plan is included at the end of this report after the summary schedule of prior audit findings and status.
2022-002: Evidence of vendor suspension and debarment checks for vendors was not retained ? Significant deficiencyCluster: Not applicableFederal Granting Agency: Health Resources and Services Administration (?HRSA?)Award Name: COVID-19 National Bioterrorism Hospital Preparedness Program (?Bioterrorism Program?)Assistance Listing #: 93.889Award Year: Fiscal year 2022Pass-through entity: N/ACondition:The Company has a policy by which all new vendors are required to be checked against the SAM.gov database by the Risk Management department prior to being entered into the accounts payable system regardless of the dollar value of the transaction. Through inquiry with the Company, they indicated that while these checks are performed, evidence of the checks is not retained. Additionally, of the 179 unique vendors used during fiscal year 2022 related to the Bioterrorism Program, PwC was unable to obtain information regarding how many were new vendors and thus subject to this check. For context, however, if the Company used the federal threshold of $25k for completing the SAM.gov checks, there were 4 transactions totaling approximately $420k above this threshold.Criteria:Non-federal entities are prohibited from contracting with or making subawards under covered transactionsto parties that are suspended or debarred. When a non-federal entity enters into a covered transactionwith an entity at a lower tier, the nonfederal entity must verify that the entity, as defined in 2 CFR section180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded fromparticipating in the transaction. This verification may be accomplished by (1) checking the System forAward Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting acertification from the entity, or (3) adding a clause or condition to the covered transaction with that entity(2 CFR section 180.300).Cause:Management?s process and controls did not include the applicable requirement of retaining history or evidence of SAM.gov vendor checks for vendors utilized by the program. As such, no single individual within the Risk Management department at the Company was retaining history or evidence of this step in the Company?s procurement and vendor setup process.Effect:The Company may do business with a vendor that is suspended or debarred if timely checks are not performed.Recommendation:We recommend the Company enhance its controls and revise its procedures surrounding vendor suspension and debarment to include a requirement that evidence is appropriately maintained of SAM.gov vendor checks for each vendor (e.g. screenshots, a checklist including this procedure that is signed, etc.).Management?s Views and Corrective Action Plan:Management?s views and corrective action plan is included at the end of this report after the summary schedule of prior audit findings and status.
2022-003: Evidence of physical inspection of equipment purchased with federal funds was not maintained ? Significant deficiencyCluster: Not applicableFederal Granting Agency: Health Resources and Services Administration (?HRSA?)Award Name: COVID-19 National Bioterrorism Hospital Preparedness Program (?Bioterrorism Program?)Award #: N/AAssistance Listing #: 93.889Award Year: Fiscal year 2022Pass-through entity: North Carolina Healthcare Foundation; North Carolina Department of Health and Human Services ? Division of Health Service Regulation, Office of Emergency Medical ServicesPass-through award #: U3REP 200659; 42705; 44024Condition:As part of our testing over the equipment compliance requirements related to the Bioterrorism Program, we noted no physical inventory of equipment performed by management that was purchased with federal funds since the inception of the grants in July 2019. Management has noted that routine maintenance checks are performed periodically on all equipment, however, we were unable to obtain management?s evidence of these checks for our 25 selections. At the end of the fiscal year, there were approximately 225 pieces of equipment with a value of approximately $800,000.Criteria:2 CFR 200.313 d(2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years.Cause:Management?s process and controls do not include performing a formal physical inventory of federal equipment and retaining evidence of this process at least once every two years and management was not aware of this requirement.Effect:The Company may not maintain complete and accurate property records or safeguard equipment appropriately.Recommendation:We recommend the Company create a control and revise its process surrounding physical inventories of equipment to include a requirement that the inventory is completed in accordance with the criteria noted above. Additionally, a full inventory of all equipment should be performed as soon as practical.Management?s Views and Corrective Action Plan:Management?s views and corrective action plan is included at the end of this report after the summary schedule of prior audit findings and status.
2022-003: Evidence of physical inspection of equipment purchased with federal funds was not maintained ? Significant deficiencyCluster: Not applicableFederal Granting Agency: Health Resources and Services Administration (?HRSA?)Award Name: COVID-19 National Bioterrorism Hospital Preparedness Program (?Bioterrorism Program?)Award #: N/AAssistance Listing #: 93.889Award Year: Fiscal year 2022Pass-through entity: North Carolina Healthcare Foundation; North Carolina Department of Health and Human Services ? Division of Health Service Regulation, Office of Emergency Medical ServicesPass-through award #: U3REP 200659; 42705; 44024Condition:As part of our testing over the equipment compliance requirements related to the Bioterrorism Program, we noted no physical inventory of equipment performed by management that was purchased with federal funds since the inception of the grants in July 2019. Management has noted that routine maintenance checks are performed periodically on all equipment, however, we were unable to obtain management?s evidence of these checks for our 25 selections. At the end of the fiscal year, there were approximately 225 pieces of equipment with a value of approximately $800,000.Criteria:2 CFR 200.313 d(2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years.Cause:Management?s process and controls do not include performing a formal physical inventory of federal equipment and retaining evidence of this process at least once every two years and management was not aware of this requirement.Effect:The Company may not maintain complete and accurate property records or safeguard equipment appropriately.Recommendation:We recommend the Company create a control and revise its process surrounding physical inventories of equipment to include a requirement that the inventory is completed in accordance with the criteria noted above. Additionally, a full inventory of all equipment should be performed as soon as practical.Management?s Views and Corrective Action Plan:Management?s views and corrective action plan is included at the end of this report after the summary schedule of prior audit findings and status.
2022-003: Evidence of physical inspection of equipment purchased with federal funds was not maintained ? Significant deficiencyCluster: Not applicableFederal Granting Agency: Health Resources and Services Administration (?HRSA?)Award Name: COVID-19 National Bioterrorism Hospital Preparedness Program (?Bioterrorism Program?)Award #: N/AAssistance Listing #: 93.889Award Year: Fiscal year 2022Pass-through entity: North Carolina Healthcare Foundation; North Carolina Department of Health and Human Services ? Division of Health Service Regulation, Office of Emergency Medical ServicesPass-through award #: U3REP 200659; 42705; 44024Condition:As part of our testing over the equipment compliance requirements related to the Bioterrorism Program, we noted no physical inventory of equipment performed by management that was purchased with federal funds since the inception of the grants in July 2019. Management has noted that routine maintenance checks are performed periodically on all equipment, however, we were unable to obtain management?s evidence of these checks for our 25 selections. At the end of the fiscal year, there were approximately 225 pieces of equipment with a value of approximately $800,000.Criteria:2 CFR 200.313 d(2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years.Cause:Management?s process and controls do not include performing a formal physical inventory of federal equipment and retaining evidence of this process at least once every two years and management was not aware of this requirement.Effect:The Company may not maintain complete and accurate property records or safeguard equipment appropriately.Recommendation:We recommend the Company create a control and revise its process surrounding physical inventories of equipment to include a requirement that the inventory is completed in accordance with the criteria noted above. Additionally, a full inventory of all equipment should be performed as soon as practical.Management?s Views and Corrective Action Plan:Management?s views and corrective action plan is included at the end of this report after the summary schedule of prior audit findings and status.
2022-001: First tier subawards were not reported on the Federal Funding Accountability and Transparency Act Subaward Reporting System (?FSRS?)Cluster: Not applicableFederal Granting Agency: Health Resources and Services Administration (?HRSA?)Award Name: Coordinated Services and Access to Research for Women, Infants, Children, and Youth (?Ryan White Part D Program?)Award #: 7 H12HA45378-01-00; 2 H12HA45378-02-00Assistance Listing #: 93.153Award Year: Fiscal year 2022Pass-through entity: N/ACondition:As part of PwC?s testing over the reporting requirements related to the Ryan White Part D Program, we identified a first tier subaward to Duke University in the amount of $128,218 during fiscal year 2022, and this subaward was not reported within the FSRS system, as required.Criteria:The Federal Funding Accountability and Transparency Act (?FFATA?) of 2006 requires full disclosure of all entities and organizations receiving federal funds, including grants, contracts, loans, and other assistance and payments. Prime Grant Recipients awarded a new Federal grant greater than or equal to $30,000 as of October 1, 2010 are subject to FFATA sub-award reporting requirements as outlined in the Office of Management and Budgets guidance issued August 27, 2010. The prime awardee is required to file a FFATA sub-award report in the FSRS system by the end of the month following the month in which the prime recipient awards any sub-grant greater than or equal to $30,000.Cause:Management did not perform a thorough review of the contract, which noted the FSRS reporting requirement related to subawards that was relevant to the Company and as such, they failed to file the required notification of subaward within the FSRS system for Duke University, a first tier subrecipient under the Ryan White Part D Program.Effect:The appropriate report was not filed and as such, the FSRS system did not appropriately include the first tier subaward from Novant Health to Duke University under the Ryan White Part D Program for fiscal year 2022.Recommendation:We recommend the Company implement a contract summarization control whereby the grant accountant (or designee) summarize all relevant aspects of the contract(s) for the fiscal year. This summary should then be reviewed by the grant/program coordinator prior to the start of the contract to ensure that all relevant requirements are included within the summary and to discuss with the appropriate individuals the plan to execute on each requirement.Management?s Views and Corrective Action Plan:Management?s views and corrective action plan is included at the end of this report after the summary schedule of prior audit findings and status.
2022-001: First tier subawards were not reported on the Federal Funding Accountability and Transparency Act Subaward Reporting System (?FSRS?)Cluster: Not applicableFederal Granting Agency: Health Resources and Services Administration (?HRSA?)Award Name: Coordinated Services and Access to Research for Women, Infants, Children, and Youth (?Ryan White Part D Program?)Award #: 7 H12HA45378-01-00; 2 H12HA45378-02-00Assistance Listing #: 93.153Award Year: Fiscal year 2022Pass-through entity: N/ACondition:As part of PwC?s testing over the reporting requirements related to the Ryan White Part D Program, we identified a first tier subaward to Duke University in the amount of $128,218 during fiscal year 2022, and this subaward was not reported within the FSRS system, as required.Criteria:The Federal Funding Accountability and Transparency Act (?FFATA?) of 2006 requires full disclosure of all entities and organizations receiving federal funds, including grants, contracts, loans, and other assistance and payments. Prime Grant Recipients awarded a new Federal grant greater than or equal to $30,000 as of October 1, 2010 are subject to FFATA sub-award reporting requirements as outlined in the Office of Management and Budgets guidance issued August 27, 2010. The prime awardee is required to file a FFATA sub-award report in the FSRS system by the end of the month following the month in which the prime recipient awards any sub-grant greater than or equal to $30,000.Cause:Management did not perform a thorough review of the contract, which noted the FSRS reporting requirement related to subawards that was relevant to the Company and as such, they failed to file the required notification of subaward within the FSRS system for Duke University, a first tier subrecipient under the Ryan White Part D Program.Effect:The appropriate report was not filed and as such, the FSRS system did not appropriately include the first tier subaward from Novant Health to Duke University under the Ryan White Part D Program for fiscal year 2022.Recommendation:We recommend the Company implement a contract summarization control whereby the grant accountant (or designee) summarize all relevant aspects of the contract(s) for the fiscal year. This summary should then be reviewed by the grant/program coordinator prior to the start of the contract to ensure that all relevant requirements are included within the summary and to discuss with the appropriate individuals the plan to execute on each requirement.Management?s Views and Corrective Action Plan:Management?s views and corrective action plan is included at the end of this report after the summary schedule of prior audit findings and status.
2022-002: Evidence of vendor suspension and debarment checks for vendors was not retained ? Significant deficiencyCluster: Not applicableFederal Granting Agency: Health Resources and Services Administration (?HRSA?)Award Name: COVID-19 National Bioterrorism Hospital Preparedness Program (?Bioterrorism Program?)Assistance Listing #: 93.889Award Year: Fiscal year 2022Pass-through entity: N/ACondition:The Company has a policy by which all new vendors are required to be checked against the SAM.gov database by the Risk Management department prior to being entered into the accounts payable system regardless of the dollar value of the transaction. Through inquiry with the Company, they indicated that while these checks are performed, evidence of the checks is not retained. Additionally, of the 179 unique vendors used during fiscal year 2022 related to the Bioterrorism Program, PwC was unable to obtain information regarding how many were new vendors and thus subject to this check. For context, however, if the Company used the federal threshold of $25k for completing the SAM.gov checks, there were 4 transactions totaling approximately $420k above this threshold.Criteria:Non-federal entities are prohibited from contracting with or making subawards under covered transactionsto parties that are suspended or debarred. When a non-federal entity enters into a covered transactionwith an entity at a lower tier, the nonfederal entity must verify that the entity, as defined in 2 CFR section180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded fromparticipating in the transaction. This verification may be accomplished by (1) checking the System forAward Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting acertification from the entity, or (3) adding a clause or condition to the covered transaction with that entity(2 CFR section 180.300).Cause:Management?s process and controls did not include the applicable requirement of retaining history or evidence of SAM.gov vendor checks for vendors utilized by the program. As such, no single individual within the Risk Management department at the Company was retaining history or evidence of this step in the Company?s procurement and vendor setup process.Effect:The Company may do business with a vendor that is suspended or debarred if timely checks are not performed.Recommendation:We recommend the Company enhance its controls and revise its procedures surrounding vendor suspension and debarment to include a requirement that evidence is appropriately maintained of SAM.gov vendor checks for each vendor (e.g. screenshots, a checklist including this procedure that is signed, etc.).Management?s Views and Corrective Action Plan:Management?s views and corrective action plan is included at the end of this report after the summary schedule of prior audit findings and status.
2022-002: Evidence of vendor suspension and debarment checks for vendors was not retained ? Significant deficiencyCluster: Not applicableFederal Granting Agency: Health Resources and Services Administration (?HRSA?)Award Name: COVID-19 National Bioterrorism Hospital Preparedness Program (?Bioterrorism Program?)Assistance Listing #: 93.889Award Year: Fiscal year 2022Pass-through entity: N/ACondition:The Company has a policy by which all new vendors are required to be checked against the SAM.gov database by the Risk Management department prior to being entered into the accounts payable system regardless of the dollar value of the transaction. Through inquiry with the Company, they indicated that while these checks are performed, evidence of the checks is not retained. Additionally, of the 179 unique vendors used during fiscal year 2022 related to the Bioterrorism Program, PwC was unable to obtain information regarding how many were new vendors and thus subject to this check. For context, however, if the Company used the federal threshold of $25k for completing the SAM.gov checks, there were 4 transactions totaling approximately $420k above this threshold.Criteria:Non-federal entities are prohibited from contracting with or making subawards under covered transactionsto parties that are suspended or debarred. When a non-federal entity enters into a covered transactionwith an entity at a lower tier, the nonfederal entity must verify that the entity, as defined in 2 CFR section180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded fromparticipating in the transaction. This verification may be accomplished by (1) checking the System forAward Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting acertification from the entity, or (3) adding a clause or condition to the covered transaction with that entity(2 CFR section 180.300).Cause:Management?s process and controls did not include the applicable requirement of retaining history or evidence of SAM.gov vendor checks for vendors utilized by the program. As such, no single individual within the Risk Management department at the Company was retaining history or evidence of this step in the Company?s procurement and vendor setup process.Effect:The Company may do business with a vendor that is suspended or debarred if timely checks are not performed.Recommendation:We recommend the Company enhance its controls and revise its procedures surrounding vendor suspension and debarment to include a requirement that evidence is appropriately maintained of SAM.gov vendor checks for each vendor (e.g. screenshots, a checklist including this procedure that is signed, etc.).Management?s Views and Corrective Action Plan:Management?s views and corrective action plan is included at the end of this report after the summary schedule of prior audit findings and status.
2022-002: Evidence of vendor suspension and debarment checks for vendors was not retained ? Significant deficiencyCluster: Not applicableFederal Granting Agency: Health Resources and Services Administration (?HRSA?)Award Name: COVID-19 National Bioterrorism Hospital Preparedness Program (?Bioterrorism Program?)Assistance Listing #: 93.889Award Year: Fiscal year 2022Pass-through entity: N/ACondition:The Company has a policy by which all new vendors are required to be checked against the SAM.gov database by the Risk Management department prior to being entered into the accounts payable system regardless of the dollar value of the transaction. Through inquiry with the Company, they indicated that while these checks are performed, evidence of the checks is not retained. Additionally, of the 179 unique vendors used during fiscal year 2022 related to the Bioterrorism Program, PwC was unable to obtain information regarding how many were new vendors and thus subject to this check. For context, however, if the Company used the federal threshold of $25k for completing the SAM.gov checks, there were 4 transactions totaling approximately $420k above this threshold.Criteria:Non-federal entities are prohibited from contracting with or making subawards under covered transactionsto parties that are suspended or debarred. When a non-federal entity enters into a covered transactionwith an entity at a lower tier, the nonfederal entity must verify that the entity, as defined in 2 CFR section180.995 and agency adopting regulations, is not suspended or debarred or otherwise excluded fromparticipating in the transaction. This verification may be accomplished by (1) checking the System forAward Management (SAM) Exclusions maintained by the General Services Administration, (2) collecting acertification from the entity, or (3) adding a clause or condition to the covered transaction with that entity(2 CFR section 180.300).Cause:Management?s process and controls did not include the applicable requirement of retaining history or evidence of SAM.gov vendor checks for vendors utilized by the program. As such, no single individual within the Risk Management department at the Company was retaining history or evidence of this step in the Company?s procurement and vendor setup process.Effect:The Company may do business with a vendor that is suspended or debarred if timely checks are not performed.Recommendation:We recommend the Company enhance its controls and revise its procedures surrounding vendor suspension and debarment to include a requirement that evidence is appropriately maintained of SAM.gov vendor checks for each vendor (e.g. screenshots, a checklist including this procedure that is signed, etc.).Management?s Views and Corrective Action Plan:Management?s views and corrective action plan is included at the end of this report after the summary schedule of prior audit findings and status.
2022-003: Evidence of physical inspection of equipment purchased with federal funds was not maintained ? Significant deficiencyCluster: Not applicableFederal Granting Agency: Health Resources and Services Administration (?HRSA?)Award Name: COVID-19 National Bioterrorism Hospital Preparedness Program (?Bioterrorism Program?)Award #: N/AAssistance Listing #: 93.889Award Year: Fiscal year 2022Pass-through entity: North Carolina Healthcare Foundation; North Carolina Department of Health and Human Services ? Division of Health Service Regulation, Office of Emergency Medical ServicesPass-through award #: U3REP 200659; 42705; 44024Condition:As part of our testing over the equipment compliance requirements related to the Bioterrorism Program, we noted no physical inventory of equipment performed by management that was purchased with federal funds since the inception of the grants in July 2019. Management has noted that routine maintenance checks are performed periodically on all equipment, however, we were unable to obtain management?s evidence of these checks for our 25 selections. At the end of the fiscal year, there were approximately 225 pieces of equipment with a value of approximately $800,000.Criteria:2 CFR 200.313 d(2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years.Cause:Management?s process and controls do not include performing a formal physical inventory of federal equipment and retaining evidence of this process at least once every two years and management was not aware of this requirement.Effect:The Company may not maintain complete and accurate property records or safeguard equipment appropriately.Recommendation:We recommend the Company create a control and revise its process surrounding physical inventories of equipment to include a requirement that the inventory is completed in accordance with the criteria noted above. Additionally, a full inventory of all equipment should be performed as soon as practical.Management?s Views and Corrective Action Plan:Management?s views and corrective action plan is included at the end of this report after the summary schedule of prior audit findings and status.
2022-003: Evidence of physical inspection of equipment purchased with federal funds was not maintained ? Significant deficiencyCluster: Not applicableFederal Granting Agency: Health Resources and Services Administration (?HRSA?)Award Name: COVID-19 National Bioterrorism Hospital Preparedness Program (?Bioterrorism Program?)Award #: N/AAssistance Listing #: 93.889Award Year: Fiscal year 2022Pass-through entity: North Carolina Healthcare Foundation; North Carolina Department of Health and Human Services ? Division of Health Service Regulation, Office of Emergency Medical ServicesPass-through award #: U3REP 200659; 42705; 44024Condition:As part of our testing over the equipment compliance requirements related to the Bioterrorism Program, we noted no physical inventory of equipment performed by management that was purchased with federal funds since the inception of the grants in July 2019. Management has noted that routine maintenance checks are performed periodically on all equipment, however, we were unable to obtain management?s evidence of these checks for our 25 selections. At the end of the fiscal year, there were approximately 225 pieces of equipment with a value of approximately $800,000.Criteria:2 CFR 200.313 d(2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years.Cause:Management?s process and controls do not include performing a formal physical inventory of federal equipment and retaining evidence of this process at least once every two years and management was not aware of this requirement.Effect:The Company may not maintain complete and accurate property records or safeguard equipment appropriately.Recommendation:We recommend the Company create a control and revise its process surrounding physical inventories of equipment to include a requirement that the inventory is completed in accordance with the criteria noted above. Additionally, a full inventory of all equipment should be performed as soon as practical.Management?s Views and Corrective Action Plan:Management?s views and corrective action plan is included at the end of this report after the summary schedule of prior audit findings and status.
2022-003: Evidence of physical inspection of equipment purchased with federal funds was not maintained ? Significant deficiencyCluster: Not applicableFederal Granting Agency: Health Resources and Services Administration (?HRSA?)Award Name: COVID-19 National Bioterrorism Hospital Preparedness Program (?Bioterrorism Program?)Award #: N/AAssistance Listing #: 93.889Award Year: Fiscal year 2022Pass-through entity: North Carolina Healthcare Foundation; North Carolina Department of Health and Human Services ? Division of Health Service Regulation, Office of Emergency Medical ServicesPass-through award #: U3REP 200659; 42705; 44024Condition:As part of our testing over the equipment compliance requirements related to the Bioterrorism Program, we noted no physical inventory of equipment performed by management that was purchased with federal funds since the inception of the grants in July 2019. Management has noted that routine maintenance checks are performed periodically on all equipment, however, we were unable to obtain management?s evidence of these checks for our 25 selections. At the end of the fiscal year, there were approximately 225 pieces of equipment with a value of approximately $800,000.Criteria:2 CFR 200.313 d(2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years.Cause:Management?s process and controls do not include performing a formal physical inventory of federal equipment and retaining evidence of this process at least once every two years and management was not aware of this requirement.Effect:The Company may not maintain complete and accurate property records or safeguard equipment appropriately.Recommendation:We recommend the Company create a control and revise its process surrounding physical inventories of equipment to include a requirement that the inventory is completed in accordance with the criteria noted above. Additionally, a full inventory of all equipment should be performed as soon as practical.Management?s Views and Corrective Action Plan:Management?s views and corrective action plan is included at the end of this report after the summary schedule of prior audit findings and status.