Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-016 ? Subrecipient MonitoringIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.853, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s subrecipient monitoring tracking document, while designed appropriately, is not being maintained effectively and includes errors, since line items on the tracking document for several subrecipients appear to be incorrect with regards to audit findings. Findings appear to have been left off of the tracking document or added incorrectly for a particular subrecipient or may not apply to the subrecipient but to a different subrecipient.Cause St. Joseph?s Hospital and Medical Center did not have internal controls and policies and procedures in place to effectively maintain its subrecipient monitoring tracking document.Effect or potential effect If the subrecipient monitoring tracking document includes errors, St. Joseph?s Hospital and Medical Center may not appropriately modify its ongoing monitoring and risk assessment procedures based on any findings noted in a subrecipients report.Questioned costs None.Context St. Joseph?s Hospital and Medical Center?s subrecipient expenditures totaled $4.7 million during the period, which represented 37% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million and 6% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is not a repeat finding.Recommendation We recommend St. Joseph?s Hospital and Medical Center implement controls over the maintenance of the subrecipient monitoring tracking document to ensure the tracking document is accurately representing the findings for each subrecipient so that the subrecipients may be effectively monitored.Views of responsibleofficials Management agrees with the finding and will implement corrective action by June 2023.
Finding 2022-018 ? Procurement and Suspension and DebarmentIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, and 93.853See Schedule of Findings and Questioned Costs for chart/tableSt. Joseph?s Hospital and Medical CenterCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR 200.318 (i) General Procurement Standards states, ?the non-Federal entity must maintain records sufficient to detail the history of procurement. These records will include, but are not necessarily limited to, the following: Rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price.?Criteria or specific requirement (including statutory, regulatory, orother citation) (continued) 2 CFR 200.320 (c) Noncompetitive procurement states, ?there are specific circumstances in which noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or more of the following circumstances apply:(1) The acquisition of property or services, the aggregate dollar amount of which does not exceed the micro-purchase threshold (see paragraph (a)(1) of this section);(2) The item is available only from a single source;(3) The public exigency or emergency for the requirement will not permit a delay resulting from publicizing a competitive solicitation;(4) The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive procurement in response to a written request from the non-Federal entity; or(5) After solicitation of a number of sources, competition is determined inadequate.?Condition St. Joseph?s Hospital and Medical Center did not prepare and retain documentation of sole source justification for three procurements over the micro-purchase threshold made without competition.Cause St. Joseph?s Hospital and Medical Center did not have effective internal controls over preparation and retention of the rationale of the method of procurement.Effect or potential effect Noncompliance with the procurement documentation requirements of 2 CFR 200.318 (i) and without adequate documentation of sole source justification there is greater potential for noncompliance with noncompetitive procurement requirements in 2 CFR 200.320 (c).Questioned costs None.Context For 3 of 5 procurements selected for testing, St. Joseph?s Hospital and Medical Center indicated the procurement was a noncompetitive procurement (sole source) but did not have documentation to support the rationale for the sole source procurement.We selected and tested five procurements with expenditures totaling $151,515 from a population of 6 procurements with expenditures totaling $161,960 charged to the St. Joseph?s Hospital and Medical Center during the year ended June 30, 2022. The three noncompetitive procurements tested totaled $43,356.Identification as a repeat finding, if applicable This is not a repeat finding.Recommendation St. Joseph?s Hospital and Medical Center should retain written documentation for procurements documenting the history of the procurement prior to the procurement of goods or services, including, but not limited to, the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price.Views of responsibleofficials Management agrees with the finding and will implement corrective action by April 2023.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-014 ? Allowable Costs/Cost Principles; Period of PerformanceIdentification of the federal program Department of TreasuryCoronavirus Relief FundAssistance Listing No. 21.019CHI MemorialCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At CHI Memorial, controls over the required allowability criteria and period of performance with regard to payroll expense were not performed and/or documented.Cause CHI Memorial did not perform the necessary procedures addressing the requirements of 2 CFR 200.303(a).Effect or potential effect Payroll expenditures which are unallowable, inaccurate and/or outside of the grant period of performance could becharged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Total federal expenditures for Assistance Listing 21.019 were $1.6 million for the year ended June 30, 2022, all of which were at CHI Memorial.Identification as a repeat finding, if applicable This is a repeat finding for CHI Memorial ? Finding 2021-015.Recommendation We recommend management execute and retain evidence of its internal controls over payroll expenditures.Views of responsible officials Management agrees with the finding and will implement corrective action by April 2023.
Finding 2022-004 ? Cash ManagementIdentification of the federal program U.S. Department of EducationOffice of Federal Student AidSFA ClusterAssistance Listing Nos. 84.007, 84.063, and 84.268Good Samaritan College of Nursing & Health ScienceCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303 requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition Per discussion with management, Good Samaritan College of Nursing & Health Science has processes and internal controls in place to ensure requests for funding are allowable under the terms of the grant agreement. These internal controls included validating the draw agreed between the G5 system, COD, and Good Samaritan College of Nursing & Health Science?s internal records for student financial need. However, management did not consistently retain documentation evidencing the performance of these internal controls.Cause Due to employee turnover, Good Samaritan College ofNursing & Health Science did not retain sufficient evidence of internal controls over the cash compliance requirement.Effect or potential effect There is no consistent documentation to support the performance of internal controls.Finding 2022-004 ? Cash Management (continued)Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Total federal expenditures for Good Samaritan College of Nursing & Health Science Assistance Listing Nos. 84.007, 84.063, and 84.268 were $2.6 million, representing 25% of total SFA Cluster expenditures of approximately $10.9 million.Identification as a repeat finding, if applicable This is a repeat finding ? finding 2021-004.Recommendation Good Samaritan College of Nursing & Health Science should refine its process and retain documentation to evidence performance of its internal controls over cash management.Views of responsibleofficials Management agrees with the finding and implemented corrective action in June 2022.
Finding 2022-005 ? Special Tests and Provisions ? Enrollment ReportingIdentification of the federal program U.S. Department of EducationOffice of Federal Student AidSFA ClusterAssistance Listing No. 84.007, 84.063, 84.268Good Samaritan College of Nursing & Health ScienceCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303 requires that a non-federal entity must ?(a) 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. These internal controls should be compliance with guidance in ?Standards for Internal Control the Federal Government? issued by the Comptroller General the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition Good Samaritan College of Nursing & Health Science did not have internal controls over enrollment reporting.Cause Due to employee turnover, Good Samaritan College ofNursing & Health Science did not perform a review of the monthly borrower data reconciliations for FY22.Effect or potential effect Discrepancies between the U.S. Department of Education?s systems and Good Samaritan College of Nursing & Health Science?s internal records may not be timely identified and resolved.Questioned costs None.Finding 2022-005 ? Special Tests and Provisions ? Enrollment Reporting (continued)Context We issued a significant deficiency related to internal controls in the prior year. The finding related to this internal control was not remediated for the period under audit. Good Samaritan College of Nursing & Health Science did not have evidence of whether the internal controls over enrollment reporting were operating effectively during the year.Good Samaritan College of Nursing & Health Science has SFA Cluster expenditures of approximately $2.7 million, which makes up 25% of total SFA Cluster expenditures of approximately $10.9 million.Identification as a repeat finding, if applicable This is a repeat finding ? finding 2021-006.Recommendation We recommend management implement a process to review enrollment reporting requirements and prepare a reconciliation of data in accordance with 2 CFR 200.303a.Views of responsibleofficials Management agrees with the finding and implemented corrective action in June 2022.
Finding 2022-005 ? Special Tests and Provisions ? Enrollment ReportingIdentification of the federal program U.S. Department of EducationOffice of Federal Student AidSFA ClusterAssistance Listing No. 84.007, 84.063, 84.268Good Samaritan College of Nursing & Health ScienceCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303 requires that a non-federal entity must ?(a) 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. These internal controls should be compliance with guidance in ?Standards for Internal Control the Federal Government? issued by the Comptroller General the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition Good Samaritan College of Nursing & Health Science did not have internal controls over enrollment reporting.Cause Due to employee turnover, Good Samaritan College ofNursing & Health Science did not perform a review of the monthly borrower data reconciliations for FY22.Effect or potential effect Discrepancies between the U.S. Department of Education?s systems and Good Samaritan College of Nursing & Health Science?s internal records may not be timely identified and resolved.Questioned costs None.Finding 2022-005 ? Special Tests and Provisions ? Enrollment Reporting (continued)Context We issued a significant deficiency related to internal controls in the prior year. The finding related to this internal control was not remediated for the period under audit. Good Samaritan College of Nursing & Health Science did not have evidence of whether the internal controls over enrollment reporting were operating effectively during the year.Good Samaritan College of Nursing & Health Science has SFA Cluster expenditures of approximately $2.7 million, which makes up 25% of total SFA Cluster expenditures of approximately $10.9 million.Identification as a repeat finding, if applicable This is a repeat finding ? finding 2021-006.Recommendation We recommend management implement a process to review enrollment reporting requirements and prepare a reconciliation of data in accordance with 2 CFR 200.303a.Views of responsibleofficials Management agrees with the finding and implemented corrective action in June 2022.
Finding 2022-003 ? Reporting ? Common Origination and Disbursement (COD) SystemIdentification of the federal program U.S. Department of EducationOffice of Federal Student AidSFA ClusterAssistance Listing Nos. 84.063Good Samaritan College of Nursing & Health ScienceCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303 requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition Good Samaritan College of Nursing & Health Science did not perform its internal control over the requirement to submit Pell payment data to the Department of Education through the COD system, which consists of monthly Pell COD reconciliations.Cause Due to employee turnover over the several years, Good Samaritan College of Nursing & Health Science did not perform its monthly control over the COD System reporting, where a monthly reconciliation is created between the G5 system, COD, and Good Samaritan College of Nursing & Health Science?s internal records for Pell Grants.Effect or potential effect Discrepancies between the U.S. Department of Education?s systems and Good Samaritan College of Nursing & Health Science?s internal records may not be identified and resolved in a timely manner.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Total Pell grant expenditures for Good Samaritan College of Nursing & Health Science were approximately $0.7 million, representing 26% of the SFA Cluster expenditures at Good Samaritan College of Nursing & Health Science of approximately $2.7 million, and 6% of total SFA Cluster expenditures of approximately $10.9 million.Identification as a repeat finding, if applicable This is a repeat finding ? findings 2021-003, 2020-004 and 2019-008.Recommendation Good Samaritan College of Nursing & Health Science should ensure that all monthly Pell grant reconciliations are being performed, reviewed, and approved, with documentation being retained in the College?s internal records. The accuracy of disbursement data should also be validated.Views of responsibleofficials Management agrees with the finding and implemented corrective action in June 2022.
Finding 2022-004 ? Cash ManagementIdentification of the federal program U.S. Department of EducationOffice of Federal Student AidSFA ClusterAssistance Listing Nos. 84.007, 84.063, and 84.268Good Samaritan College of Nursing & Health ScienceCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303 requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition Per discussion with management, Good Samaritan College of Nursing & Health Science has processes and internal controls in place to ensure requests for funding are allowable under the terms of the grant agreement. These internal controls included validating the draw agreed between the G5 system, COD, and Good Samaritan College of Nursing & Health Science?s internal records for student financial need. However, management did not consistently retain documentation evidencing the performance of these internal controls.Cause Due to employee turnover, Good Samaritan College ofNursing & Health Science did not retain sufficient evidence of internal controls over the cash compliance requirement.Effect or potential effect There is no consistent documentation to support the performance of internal controls.Finding 2022-004 ? Cash Management (continued)Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Total federal expenditures for Good Samaritan College of Nursing & Health Science Assistance Listing Nos. 84.007, 84.063, and 84.268 were $2.6 million, representing 25% of total SFA Cluster expenditures of approximately $10.9 million.Identification as a repeat finding, if applicable This is a repeat finding ? finding 2021-004.Recommendation Good Samaritan College of Nursing & Health Science should refine its process and retain documentation to evidence performance of its internal controls over cash management.Views of responsibleofficials Management agrees with the finding and implemented corrective action in June 2022.
Finding 2022-002 ? Special Tests and Provisions ? Borrower Data and Reconciliation (Direct Loan)Identification of the federal program U.S. Department of EducationOffice of Federal Student AidSFA ClusterAssistance Listing No. 84.268Good Samaritan College of Nursing & Health ScienceCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303 requires that a non-federal entity must ?(a) 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. These internal controls should be compliance with guidance in ?Standards for Internal Control the Federal Government? issued by the Comptroller General the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Under 34 CFR 685.300(b)(5), the program participation agreement states that a school must agree to ?on a monthly basis, reconcile institutional records with Direct Loan funds received from the Secretary and Direct Loan disbursement records submitted to and accepted by the Secretary.?Condition Good Samaritan College of Nursing & Health Science did not perform the direct loan monthly reconciliations for FY22. Therefore, we were unable to verify the controls and compliance with the borrower data and reconciliation compliance requirement related to the performance of a monthly reconciliation.Cause Due to employee turnover over the past several years, Good Samaritan College of Nursing & Health Science did not perform direct loan monthly reconciliations for FY22.Effect or potential effect Discrepancies between the U.S. Department of Education?s systems and Good Samaritan College of Nursing & Health Science?s internal records may not be timely identified and resolved, reasons for remaining cash balances may not be properly documented, and cash management and disbursement reporting timelines may not be met.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Total direct loans for Good Samaritan College of Nursing & Health Science are approximately $2.0 million, representing 74% of Good Samaritan College of Nursing & Health Science?s SFA Cluster expenditures of approximately $2.7 million, and 18% of total SFA Cluster expenditures of approximately $10.9 million.Identification as a repeat finding, if applicable This is a repeat finding ? findings 2021-002, 2020-003 and 2019-007.Recommendation Good Samaritan College of Nursing & Health Science should ensure that all monthly direct loan reconciliations are being performed, reviewed, and approved, with documentation being retained in the College?s internal records.Views of responsibleofficials Management agrees with the finding and implemented corrective action in June 2022.
Finding 2022-004 ? Cash ManagementIdentification of the federal program U.S. Department of EducationOffice of Federal Student AidSFA ClusterAssistance Listing Nos. 84.007, 84.063, and 84.268Good Samaritan College of Nursing & Health ScienceCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303 requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition Per discussion with management, Good Samaritan College of Nursing & Health Science has processes and internal controls in place to ensure requests for funding are allowable under the terms of the grant agreement. These internal controls included validating the draw agreed between the G5 system, COD, and Good Samaritan College of Nursing & Health Science?s internal records for student financial need. However, management did not consistently retain documentation evidencing the performance of these internal controls.Cause Due to employee turnover, Good Samaritan College ofNursing & Health Science did not retain sufficient evidence of internal controls over the cash compliance requirement.Effect or potential effect There is no consistent documentation to support the performance of internal controls.Finding 2022-004 ? Cash Management (continued)Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Total federal expenditures for Good Samaritan College of Nursing & Health Science Assistance Listing Nos. 84.007, 84.063, and 84.268 were $2.6 million, representing 25% of total SFA Cluster expenditures of approximately $10.9 million.Identification as a repeat finding, if applicable This is a repeat finding ? finding 2021-004.Recommendation Good Samaritan College of Nursing & Health Science should refine its process and retain documentation to evidence performance of its internal controls over cash management.Views of responsibleofficials Management agrees with the finding and implemented corrective action in June 2022.
Finding 2022-005 ? Special Tests and Provisions ? Enrollment ReportingIdentification of the federal program U.S. Department of EducationOffice of Federal Student AidSFA ClusterAssistance Listing No. 84.007, 84.063, 84.268Good Samaritan College of Nursing & Health ScienceCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303 requires that a non-federal entity must ?(a) 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. These internal controls should be compliance with guidance in ?Standards for Internal Control the Federal Government? issued by the Comptroller General the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition Good Samaritan College of Nursing & Health Science did not have internal controls over enrollment reporting.Cause Due to employee turnover, Good Samaritan College ofNursing & Health Science did not perform a review of the monthly borrower data reconciliations for FY22.Effect or potential effect Discrepancies between the U.S. Department of Education?s systems and Good Samaritan College of Nursing & Health Science?s internal records may not be timely identified and resolved.Questioned costs None.Finding 2022-005 ? Special Tests and Provisions ? Enrollment Reporting (continued)Context We issued a significant deficiency related to internal controls in the prior year. The finding related to this internal control was not remediated for the period under audit. Good Samaritan College of Nursing & Health Science did not have evidence of whether the internal controls over enrollment reporting were operating effectively during the year.Good Samaritan College of Nursing & Health Science has SFA Cluster expenditures of approximately $2.7 million, which makes up 25% of total SFA Cluster expenditures of approximately $10.9 million.Identification as a repeat finding, if applicable This is a repeat finding ? finding 2021-006.Recommendation We recommend management implement a process to review enrollment reporting requirements and prepare a reconciliation of data in accordance with 2 CFR 200.303a.Views of responsibleofficials Management agrees with the finding and implemented corrective action in June 2022.
Finding 2022-001 ? Special Tests and Provisions ? Disbursements to or on Behalf of StudentsIdentification of the federal program U.S. Department of EducationOffice of Federal Student AidSFA ClusterAssistance Listing No. 84.268Good Samaritan College of Nursing & Health ScienceCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303 requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?34 CFR 685.300(b)(9) requires institutions to ?Provide for the implementation of a quality assurance system, as established by the Secretary and developed in consultation with the school, to ensure that the school is complying with program requirements and meeting program objectives.?Condition Good Samaritan College of Nursing & Health Science did not have evidence of whether the quality assurance system was operating effectively during the fiscal year ended June 30, 2022 (FY22).Cause Due to employee turnover over the past several years, Good Samaritan College of Nursing & Health Science did not retain evidence of whether the quality assurance system was operating effectively during FY22. Effect or potential effect Good Samaritan College of Nursing & Health Science did not have effective controls in place for FY22 regarding the operation and review of its quality assurance system. Due to this, Good Samaritan College of Nursing & Health Science may not comply with program requirements and objectives.Questioned costs None.Context Good Samaritan College of Nursing & Health Science did not have evidence of whether the quality assurance system, including the performance of monthly reconciliations, was operating effectively during the year.Total direct loans for Good Samaritan College of Nursing & Health Science are approximately $2.0 million, representing 74% of Good Samaritan College of Nursing & Health Science?s SFA Cluster expenditures of approximately $2.7 million, and 18% of total SFA Cluster expenditures of approximately $10.9 million.Identification as a repeat finding, if applicable This is a repeat finding ? findings 2021-001, 2020-002, and 2019-006.Recommendation Good Samaritan College of Nursing & Health Science should update the documentation of its direct loan quality assurance system periodically and retain evidence of its evaluation and review and the quality assurance procedures performed during the year.Views of responsibleofficials Management agrees with the finding and implemented corrective action in June 2022.
Finding 2022-017 ? Special Tests and Provisions ? Disbursements to or on Behalf of StudentsIdentification of the federal program U.S. Department of EducationOffice of Federal Student AidSFA ClusterAssistance Listing No. 84.268Good Samaritan College of Nursing & Health ScienceCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303 requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?34 CFR 668.165 Notices, requires the following:(1) Before an institution disburses title IV, HEA program funds for any award year, the institution must notify a student of the amount of funds that the student or his or her parent can expect to receive under each title IV, HEA program, and how and when those funds will be disbursed. If those funds include Direct Loan program funds, the notice must indicate which funds are from subsidized loans, which are from unsubsidized loans, and which are from PLUS loans.Criteria or specific requirement (including statutory, regulatory, orother citation) (continued) (2) Except in the case of a post-withdrawal disbursement made in accordance with ? 668.22(a)(5), if an institution credits a student ledger account with Direct Loan, Federal Perkins Loan, or TEACH Grant program funds, the institution must notify the student or parent of ?(i) The anticipated date and amount of the disbursement;(ii) The student?s or parent?s right to cancel all or a portion of that loan, loan disbursement, TEACH Grant, or TEACH Grant disbursement and have the loan proceeds or TEACH Grant proceeds returned to the Secretary; and(iii) The procedures and time by which the student or parent must notify the institution that he or she wishes to cancel the loan, loan disbursement, TEACH Grant, or TEACH Grant disbursement.(3) The institution must provide the notice described in paragraph (a)(2) of this section in writing ?(i) No earlier than 30 days before, and no later than 30 days after, crediting the student?s ledger account at the institution, if the institution obtains affirmative confirmation from the student under paragraph (a)(6)(i) of this section; or(ii) No earlier than 30 days before, and no later than seven days after, crediting the student?s ledger account at the institution, if the institution does not obtain affirmative confirmation from the student under paragraph (a)(6)(i) of this section.Condition Good Samaritan College of Nursing & Health Science did not send loan notifications to 2 of 28 students selected for disbursement testing for direct loans.Cause Internal controls over direct loan notifications were not designed or operating effectively.Effect or potential effect Good Samaritan College of Nursing & Health Science is noncompliant with regards to loan notification requirements which could impact a student?s ability to cancel the loan timely.Questioned costs None.Context For 2 of 28 students selected for testing that received direct loans, notifications were not sent to the students for direct loan disbursements. The two disbursements were made in June 2022 and were for $1,979 and $50. Direct loans totaling $65,950 were disbursed to the 28 selected students during the year.Total direct loans for Good Samaritan College of Nursing & Health Science are approximately $2.0 million, representing 74% of Good Samaritan College of Nursing & Health Science?s SFA Cluster expenditures of approximately $2.7 million, and 18% of total SFA Cluster expenditures of approximately $10.9 million.Identification as a repeat finding, if applicable This is not a repeat finding.Recommendation Good Samaritan College of Nursing & Health Science should establish procedures to ensure that loan notifications are sent for all loan disbursements, as required.Views of responsibleofficials Management agrees with the finding and will implement corrective action by April 2023.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-018 ? Procurement and Suspension and DebarmentIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, and 93.853See Schedule of Findings and Questioned Costs for chart/tableSt. Joseph?s Hospital and Medical CenterCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR 200.318 (i) General Procurement Standards states, ?the non-Federal entity must maintain records sufficient to detail the history of procurement. These records will include, but are not necessarily limited to, the following: Rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price.?Criteria or specific requirement (including statutory, regulatory, orother citation) (continued) 2 CFR 200.320 (c) Noncompetitive procurement states, ?there are specific circumstances in which noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or more of the following circumstances apply:(1) The acquisition of property or services, the aggregate dollar amount of which does not exceed the micro-purchase threshold (see paragraph (a)(1) of this section);(2) The item is available only from a single source;(3) The public exigency or emergency for the requirement will not permit a delay resulting from publicizing a competitive solicitation;(4) The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive procurement in response to a written request from the non-Federal entity; or(5) After solicitation of a number of sources, competition is determined inadequate.?Condition St. Joseph?s Hospital and Medical Center did not prepare and retain documentation of sole source justification for three procurements over the micro-purchase threshold made without competition.Cause St. Joseph?s Hospital and Medical Center did not have effective internal controls over preparation and retention of the rationale of the method of procurement.Effect or potential effect Noncompliance with the procurement documentation requirements of 2 CFR 200.318 (i) and without adequate documentation of sole source justification there is greater potential for noncompliance with noncompetitive procurement requirements in 2 CFR 200.320 (c).Questioned costs None.Context For 3 of 5 procurements selected for testing, St. Joseph?s Hospital and Medical Center indicated the procurement was a noncompetitive procurement (sole source) but did not have documentation to support the rationale for the sole source procurement.We selected and tested five procurements with expenditures totaling $151,515 from a population of 6 procurements with expenditures totaling $161,960 charged to the St. Joseph?s Hospital and Medical Center during the year ended June 30, 2022. The three noncompetitive procurements tested totaled $43,356.Identification as a repeat finding, if applicable This is not a repeat finding.Recommendation St. Joseph?s Hospital and Medical Center should retain written documentation for procurements documenting the history of the procurement prior to the procurement of goods or services, including, but not limited to, the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price.Views of responsibleofficials Management agrees with the finding and will implement corrective action by April 2023.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-016 ? Subrecipient MonitoringIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.853, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s subrecipient monitoring tracking document, while designed appropriately, is not being maintained effectively and includes errors, since line items on the tracking document for several subrecipients appear to be incorrect with regards to audit findings. Findings appear to have been left off of the tracking document or added incorrectly for a particular subrecipient or may not apply to the subrecipient but to a different subrecipient.Cause St. Joseph?s Hospital and Medical Center did not have internal controls and policies and procedures in place to effectively maintain its subrecipient monitoring tracking document.Effect or potential effect If the subrecipient monitoring tracking document includes errors, St. Joseph?s Hospital and Medical Center may not appropriately modify its ongoing monitoring and risk assessment procedures based on any findings noted in a subrecipients report.Questioned costs None.Context St. Joseph?s Hospital and Medical Center?s subrecipient expenditures totaled $4.7 million during the period, which represented 37% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million and 6% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is not a repeat finding.Recommendation We recommend St. Joseph?s Hospital and Medical Center implement controls over the maintenance of the subrecipient monitoring tracking document to ensure the tracking document is accurately representing the findings for each subrecipient so that the subrecipients may be effectively monitored.Views of responsibleofficials Management agrees with the finding and will implement corrective action by June 2023.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-013 ? Activities Allowed or UnallowedIdentification of the federal program U.S. Department of Health and Human ServicesCOVID-19 ? HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance FundAssistance Listing No. 93.461Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CRF Section 200.303 of the Uniform Guidance states the following regarding internal control: ?The non-Federal entity must: (a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework,? issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?There were two matters noted during our testing of the Uninsured Program:1) Per the Health Resources and Services and Administrative (HRSA), HRSA COVID-19 Uninsured Award Terms and Conditions and further clarified in the HRSA FAQs for COVID- 19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration, the FAQ states the following:?If a provider tests for COVID-19 as part of pre-operative or other medical treatment unrelated to COVID-19, is the test eligible for reimbursement?Criteria or specific requirement (including statutory, regulatory, orother citation) (continued) For the HRSA COVID-19 Uninsured Program, COVID-19 testing is eligible for reimbursement if one of the following diagnoses codes is included in any position on the claim:Z03.818 ? Encounter for observation for suspected exposure to other biological agents ruled out (possible exposure to COVID 19)Z11.59 ? Encounter for screening for other viral diseases (asymptomatic)Z20.828 ? Contact with and (suspected) exposure to other viral communicable (confirmed exposure to COVID-19)Z11.52 ? Encounter for screening for COVID-19 (asymptomatic)Z20.822 ? Contact with and (suspected) exposure to COVID 19Z86.16 ? Personal history of COVID-19Related treatment visits and services are not eligible for reimbursement given the primary reason for treatment is not COVID-19.?The Terms and Conditions for the program provide guidance on when the Recipient plans to submit claims for reimbursement for COVID-19 Testing and/or Testing-Related Items and Services provided to individuals who did not have any health care coverage at the time the services were provided. The Recipient acknowledges that each time the Recipient submits such claims for reimbursement, each claim must be in full compliance with these Terms and Conditions, and submission of those claims confirms the Recipient?s ongoing compliance with these Terms and Conditions.Criteria or specific requirement (including statutory, regulatory, orother citation) (continued) Testing-Related Items and Services means items and services furnished to an individual during health care provider office visits, including, for example, in-person visits and telehealth visits, urgent care center visits, and emergency room visits that result in an order for or administration of COVID-19 testing but only to the extent such items and services relate to the furnishing or administration of such product or to the evaluation of such individual for purposes of determining the need of such individual for such product.2) Any treatment without a COVID-19 primary diagnosis, except for pregnancy when the COVID-19 code may be listed as secondary, is not eligible for reimbursement.Condition 1) CommonSpirit Health did not have controls in place to limit the claims being submitted for Testing-Related Items and Services to include items and services related to furnishing or administering the COVID-19 test or for the evaluation of such individuals to determine the need for a COVID-19 test.2) CommonSpirit Health did not have controls in place to ensure that claims were not submitted for reimbursement when COVID-19 was not the primary diagnosis.Cause 1) Management interpreted the guidance as allowing all amounts for the encounter when a test was provided to be submitted for reimbursement regardless of whether COVID-19 was the primary diagnosis and the procedures were not directly related to administering the test or determining whether a test was needed.2) A mistake was made by the coder when coding the medical record.Effect or potential effect Certain claims submitted to the COVID-19 Uninsured Program were for unallowable activities and were not eligible for reimbursement under the COVID-19 Uninsured Program.Questioned costs $4,035Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.1) We identified 4 ($3,488) out of 62 ($122,450) claims selected for testing which included services that were unallowed because, although the episode had a COVID-19 test in the medical record, other non-COVID-19 treatment services were submitted for various emergency room visits when the primary diagnosis for the visit was not COVID-19. There were no subsequent repayments to HRSA or recoupments from HRSA related to these 4 claims.2) We identified 1 ($547) out of 62 ($122,450) claims selected for testing, where COVID-19 was not listed as the primary diagnosis. Total federal expenditures for Assistance Listing 93.461 were $23.9 million for the year ended June 30, 2022.Identification as a repeat finding, if applicable This is a repeat finding for CommonSpirit Health ? Finding 2021-014, with the exception of the one coding error identified, as this is a new aspect in the current year.Finding 2022-013 ? Activities Allowed or Unallowed (continued)Recommendation CommonSpirit Health should implement internal controls to review claims submitted to the COVID-19 Uninsured Program to ensure it is administering the program in compliance with the COVID-19 Uninsured Program regulations, specifically as it relates to the COVID-19 testing aspect of the program and only billing when COVID-19 is listed as the primary diagnosis in the medical record.Views of responsibleofficials 1) Management believes that CommonSpirit Health has the necessary controls in place to support accurate and compliant billing. In addition, Management believes CommonSpirit Health followed the HRSA COVID-19 Uninsured Program (Program) guidelines and frequently asked questions (FAQs) related to diagnostic testing and testing-related visits eligible for reimbursement, which were published from time to time after the introduction of this program.Although CommonSpirit Health continues to dispute the findings (REFERENCE 2021-014), CommonSpirit Health is refunding the Questioned Cost of $10,998 in order to resolve this finding. The refunds will be completed by April 30, 2023. In addition, the Program stopped accepting claims for testing and treatment on March 22, 2022, and claims for vaccine administration on April 5, 2022, due to lack of sufficient funds. CommonSpirit Health has not submitted claims to the Program since the Program was discontinued. In the event that CommonSpirit Health, through its proactive compliance efforts, identifies any additional claims submitted to the Program where reimbursement may not have been appropriate, CommonSpirit Health will refund such claims.2)Management believes that CommonSpirit Health has the necessary controls in place to support accurate and compliant billing. With respect to this one claim where COVID-19 was incorrectly listed in the primary diagnosis position, CommonSpirit Health will refund the claim amount of $547 by April 30, 2023.Conclusion Despite management?s response in the preceding section, we still conclude that a finding is warranted based on the items noted in our Condition and Context sections based on the Criteria or Specific Requirement section above.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-012 ? EligibilityIdentification of the federal program U.S. Department of Health and Human ServicesMedical Assistance Program (Medicaid Cluster)Assistance Listing No. 93.778Passed through Department of Health and Human Services ? State of California and California Department of Health Care ServicesDignity Health Medical FoundationDignity Health Connected LivingCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition The Dignity Health Medical Foundation and Dignity Health Connected Living did not retain evidence of Medicaid eligibility being reviewed prior to patient services being provided.Cause Dignity Health Medical Foundation management did not retain evidence of Medicaid eligibility being reviewed prior to patient services being provided due to lack of understanding of the documentation retention needed.Dignity Health Connected Living management did not retain evidence of Medicaid eligibility being reviewed prior to patient services being provided due to employee turnover.Effect or potential effect Ineligible individuals may be provided services.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Dignity Health Medical Foundation and Dignity Health Connected Living account for $3.5 million and $0.4 million, respectively, or 82% combined, of the $4.7 million total Medicaid Cluster expenditures.Identification as a repeat finding, if applicable This is a repeat finding for Dignity Health Medical Foundation and Dignity Health Connected Living ? Finding 2021-013.Recommendation We recommend management implement a process and internal controls to retain appropriate documentation that participants are eligible to receive services prior to providing services under the Medical Assistance Program.Views of responsibleofficials Management agrees with the finding and implemented corrective action in July 2022.
Finding 2022-012 ? EligibilityIdentification of the federal program U.S. Department of Health and Human ServicesMedical Assistance Program (Medicaid Cluster)Assistance Listing No. 93.778Passed through Department of Health and Human Services ? State of California and California Department of Health Care ServicesDignity Health Medical FoundationDignity Health Connected LivingCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition The Dignity Health Medical Foundation and Dignity Health Connected Living did not retain evidence of Medicaid eligibility being reviewed prior to patient services being provided.Cause Dignity Health Medical Foundation management did not retain evidence of Medicaid eligibility being reviewed prior to patient services being provided due to lack of understanding of the documentation retention needed.Dignity Health Connected Living management did not retain evidence of Medicaid eligibility being reviewed prior to patient services being provided due to employee turnover.Effect or potential effect Ineligible individuals may be provided services.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Dignity Health Medical Foundation and Dignity Health Connected Living account for $3.5 million and $0.4 million, respectively, or 82% combined, of the $4.7 million total Medicaid Cluster expenditures.Identification as a repeat finding, if applicable This is a repeat finding for Dignity Health Medical Foundation and Dignity Health Connected Living ? Finding 2021-013.Recommendation We recommend management implement a process and internal controls to retain appropriate documentation that participants are eligible to receive services prior to providing services under the Medical Assistance Program.Views of responsibleofficials Management agrees with the finding and implemented corrective action in July 2022.
Finding 2022-015 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of Health and Human ServicesMedical Assistance Program (Medicaid Cluster)Assistance Listing No. 93.778Passed through California Department of Health Care ServicesDignity Health Connected LivingCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by theCriteria or specific requirement (including statutory, regulatory, orother citation) (continued) Non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition At Dignity Health Connected Living, internal controls over the required allowability criteria with regard to payroll expense were not performed for 1 of 25 employees selected for testing.Cause Dignity Health Connected Living did not consistently perform the necessary internal control procedures addressing the requirements of 2 CFR 200.303(a) and 2 CFR 200.430.Effect or potential effect Unallowable and/or inaccurate payroll expenditures could becharged to the federal program.Questioned costs None.Context For 1 of 25 payroll expenditures selected for testing, Dignity Health Connected Living did not properly approve an employee timecard for time charged to the grant in accordance with the practices of Dignity Health Connected Living.Total payroll expenditures for Dignity Health Connected Living were $0.2 million and represent 5% of the total Medicaid Cluster expenditures of $4.7 million.Identification as a repeat finding, if applicable This is not a repeat finding.Recommendation We recommend management execute its processes to properly approve all time charged to federal grants in accordance with 2 CFR 200.430. Additionally, we recommend management execute and retain evidence of its internal controls over the allowability of payroll expenditures.Views of responsibleofficials Management agrees with the finding and will implement corrective action by April 2023.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-016 ? Subrecipient MonitoringIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.853, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s subrecipient monitoring tracking document, while designed appropriately, is not being maintained effectively and includes errors, since line items on the tracking document for several subrecipients appear to be incorrect with regards to audit findings. Findings appear to have been left off of the tracking document or added incorrectly for a particular subrecipient or may not apply to the subrecipient but to a different subrecipient.Cause St. Joseph?s Hospital and Medical Center did not have internal controls and policies and procedures in place to effectively maintain its subrecipient monitoring tracking document.Effect or potential effect If the subrecipient monitoring tracking document includes errors, St. Joseph?s Hospital and Medical Center may not appropriately modify its ongoing monitoring and risk assessment procedures based on any findings noted in a subrecipients report.Questioned costs None.Context St. Joseph?s Hospital and Medical Center?s subrecipient expenditures totaled $4.7 million during the period, which represented 37% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million and 6% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is not a repeat finding.Recommendation We recommend St. Joseph?s Hospital and Medical Center implement controls over the maintenance of the subrecipient monitoring tracking document to ensure the tracking document is accurately representing the findings for each subrecipient so that the subrecipients may be effectively monitored.Views of responsibleofficials Management agrees with the finding and will implement corrective action by June 2023.
Finding 2022-018 ? Procurement and Suspension and DebarmentIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, and 93.853See Schedule of Findings and Questioned Costs for chart/tableSt. Joseph?s Hospital and Medical CenterCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR 200.318 (i) General Procurement Standards states, ?the non-Federal entity must maintain records sufficient to detail the history of procurement. These records will include, but are not necessarily limited to, the following: Rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price.?Criteria or specific requirement (including statutory, regulatory, orother citation) (continued) 2 CFR 200.320 (c) Noncompetitive procurement states, ?there are specific circumstances in which noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or more of the following circumstances apply:(1) The acquisition of property or services, the aggregate dollar amount of which does not exceed the micro-purchase threshold (see paragraph (a)(1) of this section);(2) The item is available only from a single source;(3) The public exigency or emergency for the requirement will not permit a delay resulting from publicizing a competitive solicitation;(4) The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive procurement in response to a written request from the non-Federal entity; or(5) After solicitation of a number of sources, competition is determined inadequate.?Condition St. Joseph?s Hospital and Medical Center did not prepare and retain documentation of sole source justification for three procurements over the micro-purchase threshold made without competition.Cause St. Joseph?s Hospital and Medical Center did not have effective internal controls over preparation and retention of the rationale of the method of procurement.Effect or potential effect Noncompliance with the procurement documentation requirements of 2 CFR 200.318 (i) and without adequate documentation of sole source justification there is greater potential for noncompliance with noncompetitive procurement requirements in 2 CFR 200.320 (c).Questioned costs None.Context For 3 of 5 procurements selected for testing, St. Joseph?s Hospital and Medical Center indicated the procurement was a noncompetitive procurement (sole source) but did not have documentation to support the rationale for the sole source procurement.We selected and tested five procurements with expenditures totaling $151,515 from a population of 6 procurements with expenditures totaling $161,960 charged to the St. Joseph?s Hospital and Medical Center during the year ended June 30, 2022. The three noncompetitive procurements tested totaled $43,356.Identification as a repeat finding, if applicable This is not a repeat finding.Recommendation St. Joseph?s Hospital and Medical Center should retain written documentation for procurements documenting the history of the procurement prior to the procurement of goods or services, including, but not limited to, the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price.Views of responsibleofficials Management agrees with the finding and will implement corrective action by April 2023.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-016 ? Subrecipient MonitoringIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.853, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s subrecipient monitoring tracking document, while designed appropriately, is not being maintained effectively and includes errors, since line items on the tracking document for several subrecipients appear to be incorrect with regards to audit findings. Findings appear to have been left off of the tracking document or added incorrectly for a particular subrecipient or may not apply to the subrecipient but to a different subrecipient.Cause St. Joseph?s Hospital and Medical Center did not have internal controls and policies and procedures in place to effectively maintain its subrecipient monitoring tracking document.Effect or potential effect If the subrecipient monitoring tracking document includes errors, St. Joseph?s Hospital and Medical Center may not appropriately modify its ongoing monitoring and risk assessment procedures based on any findings noted in a subrecipients report.Questioned costs None.Context St. Joseph?s Hospital and Medical Center?s subrecipient expenditures totaled $4.7 million during the period, which represented 37% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million and 6% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is not a repeat finding.Recommendation We recommend St. Joseph?s Hospital and Medical Center implement controls over the maintenance of the subrecipient monitoring tracking document to ensure the tracking document is accurately representing the findings for each subrecipient so that the subrecipients may be effectively monitored.Views of responsibleofficials Management agrees with the finding and will implement corrective action by June 2023.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-007 ? Allowable Costs/Cost PrinciplesIdentification of the federal program Health Resources and Services AdministrationHIV Emergency Relief Project GrantsAssistance Listing No. 93.914See Schedule of Findings and Questioned Costs for chart/tableSt. Mary?s Medical Center ? San FranciscoVirginia MasonCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by theSection III ? Federal Award Findings and Questioned Costs (continued)Finding 2022-007 ? Allowable Costs/Cost Principles (continued)Criteria or specific requirement (including statutory, regulatory, orother citation) (continued) Non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition At St. Mary?s Medical Center ? San Francisco and Virginia Mason, controls over the required allowability criteria with regard to payroll expense were not performed and/or documented throughout the year.Cause St. Mary?s Medical Center ? San Francisco and Virginia Mason did not perform the necessary procedures addressing the requirements of 2 CFR 200.303(a) and 2 CFR 200.430.Effect or potential effect Unallowable and/or inaccurate payroll expenditures could becharged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.St. Mary?s Medical Center ? San Francisco expenditures of approximately $0.2 million represent 6% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.Virginia Mason expenditures of approximately $1.2 million represent 35% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Mary?s Medical Center ? San Francisco ? Finding 2020-006 and 2021-008.This is a repeat finding for Virginia Mason ? Finding 2021-008.Recommendation We recommend management execute its processes toproperly approve time charged to federal grants in accordance with 2 CFR 200.430. Additionally, we recommend management execute and retain evidence of its internal controls over the allowability of payroll expenditures.Views of responsibleofficials Management agrees with the finding and implemented corrective action in April 2022.
Finding 2022-006 ? EligibilityIdentification of the federal program Health Resources and Services AdministrationHIV Emergency Relief Project GrantsAssistance Listing No. 93.914See Schedule of Findings and Questioned Costs for chart/tableSt. Mary Medical Center ? Long BeachSt. Mary?s Medical Center ? San FranciscoCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco did not consistently retain evidence of their internal controls over the requirement to review eligibility requirements prior to administering services in accordance with the grant agreements.Cause At St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco, controls over the required eligibility criteria were not performed and/or documented for each participant.Effect or potential effect St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco could have provided services to ineligible individuals.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.St. Mary Medical Center ? Long Beach expenditures of approximately $1.9 million represent 52% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.St. Mary?s Medical Center ? San Francisco expenditures of approximately $0.2 million represent 6% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Mary?s Medical Center ? Long Beach ? Finding (2021-007).This is a repeat finding for St. Mary?s Medical Center ? San Francisco ? Finding (2021-007 and 2020-005).Recommendation St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco should perform and retain evidence of their review of patient eligibility as defined by the grant agreement to support the internal control environment.Views of responsibleofficials Management agrees with the finding and implemented corrective action in April 2022.
Finding 2022-007 ? Allowable Costs/Cost PrinciplesIdentification of the federal program Health Resources and Services AdministrationHIV Emergency Relief Project GrantsAssistance Listing No. 93.914See Schedule of Findings and Questioned Costs for chart/tableSt. Mary?s Medical Center ? San FranciscoVirginia MasonCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by theSection III ? Federal Award Findings and Questioned Costs (continued)Finding 2022-007 ? Allowable Costs/Cost Principles (continued)Criteria or specific requirement (including statutory, regulatory, orother citation) (continued) Non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition At St. Mary?s Medical Center ? San Francisco and Virginia Mason, controls over the required allowability criteria with regard to payroll expense were not performed and/or documented throughout the year.Cause St. Mary?s Medical Center ? San Francisco and Virginia Mason did not perform the necessary procedures addressing the requirements of 2 CFR 200.303(a) and 2 CFR 200.430.Effect or potential effect Unallowable and/or inaccurate payroll expenditures could becharged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.St. Mary?s Medical Center ? San Francisco expenditures of approximately $0.2 million represent 6% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.Virginia Mason expenditures of approximately $1.2 million represent 35% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Mary?s Medical Center ? San Francisco ? Finding 2020-006 and 2021-008.This is a repeat finding for Virginia Mason ? Finding 2021-008.Recommendation We recommend management execute its processes toproperly approve time charged to federal grants in accordance with 2 CFR 200.430. Additionally, we recommend management execute and retain evidence of its internal controls over the allowability of payroll expenditures.Views of responsibleofficials Management agrees with the finding and implemented corrective action in April 2022.
Finding 2022-006 ? EligibilityIdentification of the federal program Health Resources and Services AdministrationHIV Emergency Relief Project GrantsAssistance Listing No. 93.914See Schedule of Findings and Questioned Costs for chart/tableSt. Mary Medical Center ? Long BeachSt. Mary?s Medical Center ? San FranciscoCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco did not consistently retain evidence of their internal controls over the requirement to review eligibility requirements prior to administering services in accordance with the grant agreements.Cause At St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco, controls over the required eligibility criteria were not performed and/or documented for each participant.Effect or potential effect St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco could have provided services to ineligible individuals.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.St. Mary Medical Center ? Long Beach expenditures of approximately $1.9 million represent 52% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.St. Mary?s Medical Center ? San Francisco expenditures of approximately $0.2 million represent 6% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Mary?s Medical Center ? Long Beach ? Finding (2021-007).This is a repeat finding for St. Mary?s Medical Center ? San Francisco ? Finding (2021-007 and 2020-005).Recommendation St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco should perform and retain evidence of their review of patient eligibility as defined by the grant agreement to support the internal control environment.Views of responsibleofficials Management agrees with the finding and implemented corrective action in April 2022.
Finding 2022-006 ? EligibilityIdentification of the federal program Health Resources and Services AdministrationHIV Emergency Relief Project GrantsAssistance Listing No. 93.914See Schedule of Findings and Questioned Costs for chart/tableSt. Mary Medical Center ? Long BeachSt. Mary?s Medical Center ? San FranciscoCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco did not consistently retain evidence of their internal controls over the requirement to review eligibility requirements prior to administering services in accordance with the grant agreements.Cause At St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco, controls over the required eligibility criteria were not performed and/or documented for each participant.Effect or potential effect St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco could have provided services to ineligible individuals.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.St. Mary Medical Center ? Long Beach expenditures of approximately $1.9 million represent 52% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.St. Mary?s Medical Center ? San Francisco expenditures of approximately $0.2 million represent 6% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Mary?s Medical Center ? Long Beach ? Finding (2021-007).This is a repeat finding for St. Mary?s Medical Center ? San Francisco ? Finding (2021-007 and 2020-005).Recommendation St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco should perform and retain evidence of their review of patient eligibility as defined by the grant agreement to support the internal control environment.Views of responsibleofficials Management agrees with the finding and implemented corrective action in April 2022.
Finding 2022-006 ? EligibilityIdentification of the federal program Health Resources and Services AdministrationHIV Emergency Relief Project GrantsAssistance Listing No. 93.914See Schedule of Findings and Questioned Costs for chart/tableSt. Mary Medical Center ? Long BeachSt. Mary?s Medical Center ? San FranciscoCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco did not consistently retain evidence of their internal controls over the requirement to review eligibility requirements prior to administering services in accordance with the grant agreements.Cause At St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco, controls over the required eligibility criteria were not performed and/or documented for each participant.Effect or potential effect St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco could have provided services to ineligible individuals.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.St. Mary Medical Center ? Long Beach expenditures of approximately $1.9 million represent 52% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.St. Mary?s Medical Center ? San Francisco expenditures of approximately $0.2 million represent 6% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Mary?s Medical Center ? Long Beach ? Finding (2021-007).This is a repeat finding for St. Mary?s Medical Center ? San Francisco ? Finding (2021-007 and 2020-005).Recommendation St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco should perform and retain evidence of their review of patient eligibility as defined by the grant agreement to support the internal control environment.Views of responsibleofficials Management agrees with the finding and implemented corrective action in April 2022.
Finding 2022-006 ? EligibilityIdentification of the federal program Health Resources and Services AdministrationHIV Emergency Relief Project GrantsAssistance Listing No. 93.914See Schedule of Findings and Questioned Costs for chart/tableSt. Mary Medical Center ? Long BeachSt. Mary?s Medical Center ? San FranciscoCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco did not consistently retain evidence of their internal controls over the requirement to review eligibility requirements prior to administering services in accordance with the grant agreements.Cause At St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco, controls over the required eligibility criteria were not performed and/or documented for each participant.Effect or potential effect St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco could have provided services to ineligible individuals.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.St. Mary Medical Center ? Long Beach expenditures of approximately $1.9 million represent 52% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.St. Mary?s Medical Center ? San Francisco expenditures of approximately $0.2 million represent 6% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Mary?s Medical Center ? Long Beach ? Finding (2021-007).This is a repeat finding for St. Mary?s Medical Center ? San Francisco ? Finding (2021-007 and 2020-005).Recommendation St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco should perform and retain evidence of their review of patient eligibility as defined by the grant agreement to support the internal control environment.Views of responsibleofficials Management agrees with the finding and implemented corrective action in April 2022.
Finding 2022-006 ? EligibilityIdentification of the federal program Health Resources and Services AdministrationHIV Emergency Relief Project GrantsAssistance Listing No. 93.914See Schedule of Findings and Questioned Costs for chart/tableSt. Mary Medical Center ? Long BeachSt. Mary?s Medical Center ? San FranciscoCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco did not consistently retain evidence of their internal controls over the requirement to review eligibility requirements prior to administering services in accordance with the grant agreements.Cause At St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco, controls over the required eligibility criteria were not performed and/or documented for each participant.Effect or potential effect St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco could have provided services to ineligible individuals.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.St. Mary Medical Center ? Long Beach expenditures of approximately $1.9 million represent 52% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.St. Mary?s Medical Center ? San Francisco expenditures of approximately $0.2 million represent 6% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Mary?s Medical Center ? Long Beach ? Finding (2021-007).This is a repeat finding for St. Mary?s Medical Center ? San Francisco ? Finding (2021-007 and 2020-005).Recommendation St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco should perform and retain evidence of their review of patient eligibility as defined by the grant agreement to support the internal control environment.Views of responsibleofficials Management agrees with the finding and implemented corrective action in April 2022.
Finding 2022-006 ? EligibilityIdentification of the federal program Health Resources and Services AdministrationHIV Emergency Relief Project GrantsAssistance Listing No. 93.914See Schedule of Findings and Questioned Costs for chart/tableSt. Mary Medical Center ? Long BeachSt. Mary?s Medical Center ? San FranciscoCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco did not consistently retain evidence of their internal controls over the requirement to review eligibility requirements prior to administering services in accordance with the grant agreements.Cause At St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco, controls over the required eligibility criteria were not performed and/or documented for each participant.Effect or potential effect St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco could have provided services to ineligible individuals.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.St. Mary Medical Center ? Long Beach expenditures of approximately $1.9 million represent 52% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.St. Mary?s Medical Center ? San Francisco expenditures of approximately $0.2 million represent 6% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Mary?s Medical Center ? Long Beach ? Finding (2021-007).This is a repeat finding for St. Mary?s Medical Center ? San Francisco ? Finding (2021-007 and 2020-005).Recommendation St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco should perform and retain evidence of their review of patient eligibility as defined by the grant agreement to support the internal control environment.Views of responsibleofficials Management agrees with the finding and implemented corrective action in April 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-016 ? Subrecipient MonitoringIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.853, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s subrecipient monitoring tracking document, while designed appropriately, is not being maintained effectively and includes errors, since line items on the tracking document for several subrecipients appear to be incorrect with regards to audit findings. Findings appear to have been left off of the tracking document or added incorrectly for a particular subrecipient or may not apply to the subrecipient but to a different subrecipient.Cause St. Joseph?s Hospital and Medical Center did not have internal controls and policies and procedures in place to effectively maintain its subrecipient monitoring tracking document.Effect or potential effect If the subrecipient monitoring tracking document includes errors, St. Joseph?s Hospital and Medical Center may not appropriately modify its ongoing monitoring and risk assessment procedures based on any findings noted in a subrecipients report.Questioned costs None.Context St. Joseph?s Hospital and Medical Center?s subrecipient expenditures totaled $4.7 million during the period, which represented 37% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million and 6% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is not a repeat finding.Recommendation We recommend St. Joseph?s Hospital and Medical Center implement controls over the maintenance of the subrecipient monitoring tracking document to ensure the tracking document is accurately representing the findings for each subrecipient so that the subrecipients may be effectively monitored.Views of responsibleofficials Management agrees with the finding and will implement corrective action by June 2023.
Finding 2022-018 ? Procurement and Suspension and DebarmentIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, and 93.853See Schedule of Findings and Questioned Costs for chart/tableSt. Joseph?s Hospital and Medical CenterCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR 200.318 (i) General Procurement Standards states, ?the non-Federal entity must maintain records sufficient to detail the history of procurement. These records will include, but are not necessarily limited to, the following: Rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price.?Criteria or specific requirement (including statutory, regulatory, orother citation) (continued) 2 CFR 200.320 (c) Noncompetitive procurement states, ?there are specific circumstances in which noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or more of the following circumstances apply:(1) The acquisition of property or services, the aggregate dollar amount of which does not exceed the micro-purchase threshold (see paragraph (a)(1) of this section);(2) The item is available only from a single source;(3) The public exigency or emergency for the requirement will not permit a delay resulting from publicizing a competitive solicitation;(4) The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive procurement in response to a written request from the non-Federal entity; or(5) After solicitation of a number of sources, competition is determined inadequate.?Condition St. Joseph?s Hospital and Medical Center did not prepare and retain documentation of sole source justification for three procurements over the micro-purchase threshold made without competition.Cause St. Joseph?s Hospital and Medical Center did not have effective internal controls over preparation and retention of the rationale of the method of procurement.Effect or potential effect Noncompliance with the procurement documentation requirements of 2 CFR 200.318 (i) and without adequate documentation of sole source justification there is greater potential for noncompliance with noncompetitive procurement requirements in 2 CFR 200.320 (c).Questioned costs None.Context For 3 of 5 procurements selected for testing, St. Joseph?s Hospital and Medical Center indicated the procurement was a noncompetitive procurement (sole source) but did not have documentation to support the rationale for the sole source procurement.We selected and tested five procurements with expenditures totaling $151,515 from a population of 6 procurements with expenditures totaling $161,960 charged to the St. Joseph?s Hospital and Medical Center during the year ended June 30, 2022. The three noncompetitive procurements tested totaled $43,356.Identification as a repeat finding, if applicable This is not a repeat finding.Recommendation St. Joseph?s Hospital and Medical Center should retain written documentation for procurements documenting the history of the procurement prior to the procurement of goods or services, including, but not limited to, the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price.Views of responsibleofficials Management agrees with the finding and will implement corrective action by April 2023.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-014 ? Allowable Costs/Cost Principles; Period of PerformanceIdentification of the federal program Department of TreasuryCoronavirus Relief FundAssistance Listing No. 21.019CHI MemorialCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At CHI Memorial, controls over the required allowability criteria and period of performance with regard to payroll expense were not performed and/or documented.Cause CHI Memorial did not perform the necessary procedures addressing the requirements of 2 CFR 200.303(a).Effect or potential effect Payroll expenditures which are unallowable, inaccurate and/or outside of the grant period of performance could becharged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Total federal expenditures for Assistance Listing 21.019 were $1.6 million for the year ended June 30, 2022, all of which were at CHI Memorial.Identification as a repeat finding, if applicable This is a repeat finding for CHI Memorial ? Finding 2021-015.Recommendation We recommend management execute and retain evidence of its internal controls over payroll expenditures.Views of responsible officials Management agrees with the finding and will implement corrective action by April 2023.
Finding 2022-004 ? Cash ManagementIdentification of the federal program U.S. Department of EducationOffice of Federal Student AidSFA ClusterAssistance Listing Nos. 84.007, 84.063, and 84.268Good Samaritan College of Nursing & Health ScienceCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303 requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition Per discussion with management, Good Samaritan College of Nursing & Health Science has processes and internal controls in place to ensure requests for funding are allowable under the terms of the grant agreement. These internal controls included validating the draw agreed between the G5 system, COD, and Good Samaritan College of Nursing & Health Science?s internal records for student financial need. However, management did not consistently retain documentation evidencing the performance of these internal controls.Cause Due to employee turnover, Good Samaritan College ofNursing & Health Science did not retain sufficient evidence of internal controls over the cash compliance requirement.Effect or potential effect There is no consistent documentation to support the performance of internal controls.Finding 2022-004 ? Cash Management (continued)Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Total federal expenditures for Good Samaritan College of Nursing & Health Science Assistance Listing Nos. 84.007, 84.063, and 84.268 were $2.6 million, representing 25% of total SFA Cluster expenditures of approximately $10.9 million.Identification as a repeat finding, if applicable This is a repeat finding ? finding 2021-004.Recommendation Good Samaritan College of Nursing & Health Science should refine its process and retain documentation to evidence performance of its internal controls over cash management.Views of responsibleofficials Management agrees with the finding and implemented corrective action in June 2022.
Finding 2022-005 ? Special Tests and Provisions ? Enrollment ReportingIdentification of the federal program U.S. Department of EducationOffice of Federal Student AidSFA ClusterAssistance Listing No. 84.007, 84.063, 84.268Good Samaritan College of Nursing & Health ScienceCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303 requires that a non-federal entity must ?(a) 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. These internal controls should be compliance with guidance in ?Standards for Internal Control the Federal Government? issued by the Comptroller General the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition Good Samaritan College of Nursing & Health Science did not have internal controls over enrollment reporting.Cause Due to employee turnover, Good Samaritan College ofNursing & Health Science did not perform a review of the monthly borrower data reconciliations for FY22.Effect or potential effect Discrepancies between the U.S. Department of Education?s systems and Good Samaritan College of Nursing & Health Science?s internal records may not be timely identified and resolved.Questioned costs None.Finding 2022-005 ? Special Tests and Provisions ? Enrollment Reporting (continued)Context We issued a significant deficiency related to internal controls in the prior year. The finding related to this internal control was not remediated for the period under audit. Good Samaritan College of Nursing & Health Science did not have evidence of whether the internal controls over enrollment reporting were operating effectively during the year.Good Samaritan College of Nursing & Health Science has SFA Cluster expenditures of approximately $2.7 million, which makes up 25% of total SFA Cluster expenditures of approximately $10.9 million.Identification as a repeat finding, if applicable This is a repeat finding ? finding 2021-006.Recommendation We recommend management implement a process to review enrollment reporting requirements and prepare a reconciliation of data in accordance with 2 CFR 200.303a.Views of responsibleofficials Management agrees with the finding and implemented corrective action in June 2022.
Finding 2022-005 ? Special Tests and Provisions ? Enrollment ReportingIdentification of the federal program U.S. Department of EducationOffice of Federal Student AidSFA ClusterAssistance Listing No. 84.007, 84.063, 84.268Good Samaritan College of Nursing & Health ScienceCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303 requires that a non-federal entity must ?(a) 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. These internal controls should be compliance with guidance in ?Standards for Internal Control the Federal Government? issued by the Comptroller General the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition Good Samaritan College of Nursing & Health Science did not have internal controls over enrollment reporting.Cause Due to employee turnover, Good Samaritan College ofNursing & Health Science did not perform a review of the monthly borrower data reconciliations for FY22.Effect or potential effect Discrepancies between the U.S. Department of Education?s systems and Good Samaritan College of Nursing & Health Science?s internal records may not be timely identified and resolved.Questioned costs None.Finding 2022-005 ? Special Tests and Provisions ? Enrollment Reporting (continued)Context We issued a significant deficiency related to internal controls in the prior year. The finding related to this internal control was not remediated for the period under audit. Good Samaritan College of Nursing & Health Science did not have evidence of whether the internal controls over enrollment reporting were operating effectively during the year.Good Samaritan College of Nursing & Health Science has SFA Cluster expenditures of approximately $2.7 million, which makes up 25% of total SFA Cluster expenditures of approximately $10.9 million.Identification as a repeat finding, if applicable This is a repeat finding ? finding 2021-006.Recommendation We recommend management implement a process to review enrollment reporting requirements and prepare a reconciliation of data in accordance with 2 CFR 200.303a.Views of responsibleofficials Management agrees with the finding and implemented corrective action in June 2022.
Finding 2022-003 ? Reporting ? Common Origination and Disbursement (COD) SystemIdentification of the federal program U.S. Department of EducationOffice of Federal Student AidSFA ClusterAssistance Listing Nos. 84.063Good Samaritan College of Nursing & Health ScienceCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303 requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition Good Samaritan College of Nursing & Health Science did not perform its internal control over the requirement to submit Pell payment data to the Department of Education through the COD system, which consists of monthly Pell COD reconciliations.Cause Due to employee turnover over the several years, Good Samaritan College of Nursing & Health Science did not perform its monthly control over the COD System reporting, where a monthly reconciliation is created between the G5 system, COD, and Good Samaritan College of Nursing & Health Science?s internal records for Pell Grants.Effect or potential effect Discrepancies between the U.S. Department of Education?s systems and Good Samaritan College of Nursing & Health Science?s internal records may not be identified and resolved in a timely manner.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Total Pell grant expenditures for Good Samaritan College of Nursing & Health Science were approximately $0.7 million, representing 26% of the SFA Cluster expenditures at Good Samaritan College of Nursing & Health Science of approximately $2.7 million, and 6% of total SFA Cluster expenditures of approximately $10.9 million.Identification as a repeat finding, if applicable This is a repeat finding ? findings 2021-003, 2020-004 and 2019-008.Recommendation Good Samaritan College of Nursing & Health Science should ensure that all monthly Pell grant reconciliations are being performed, reviewed, and approved, with documentation being retained in the College?s internal records. The accuracy of disbursement data should also be validated.Views of responsibleofficials Management agrees with the finding and implemented corrective action in June 2022.
Finding 2022-004 ? Cash ManagementIdentification of the federal program U.S. Department of EducationOffice of Federal Student AidSFA ClusterAssistance Listing Nos. 84.007, 84.063, and 84.268Good Samaritan College of Nursing & Health ScienceCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303 requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition Per discussion with management, Good Samaritan College of Nursing & Health Science has processes and internal controls in place to ensure requests for funding are allowable under the terms of the grant agreement. These internal controls included validating the draw agreed between the G5 system, COD, and Good Samaritan College of Nursing & Health Science?s internal records for student financial need. However, management did not consistently retain documentation evidencing the performance of these internal controls.Cause Due to employee turnover, Good Samaritan College ofNursing & Health Science did not retain sufficient evidence of internal controls over the cash compliance requirement.Effect or potential effect There is no consistent documentation to support the performance of internal controls.Finding 2022-004 ? Cash Management (continued)Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Total federal expenditures for Good Samaritan College of Nursing & Health Science Assistance Listing Nos. 84.007, 84.063, and 84.268 were $2.6 million, representing 25% of total SFA Cluster expenditures of approximately $10.9 million.Identification as a repeat finding, if applicable This is a repeat finding ? finding 2021-004.Recommendation Good Samaritan College of Nursing & Health Science should refine its process and retain documentation to evidence performance of its internal controls over cash management.Views of responsibleofficials Management agrees with the finding and implemented corrective action in June 2022.
Finding 2022-002 ? Special Tests and Provisions ? Borrower Data and Reconciliation (Direct Loan)Identification of the federal program U.S. Department of EducationOffice of Federal Student AidSFA ClusterAssistance Listing No. 84.268Good Samaritan College of Nursing & Health ScienceCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303 requires that a non-federal entity must ?(a) 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. These internal controls should be compliance with guidance in ?Standards for Internal Control the Federal Government? issued by the Comptroller General the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Under 34 CFR 685.300(b)(5), the program participation agreement states that a school must agree to ?on a monthly basis, reconcile institutional records with Direct Loan funds received from the Secretary and Direct Loan disbursement records submitted to and accepted by the Secretary.?Condition Good Samaritan College of Nursing & Health Science did not perform the direct loan monthly reconciliations for FY22. Therefore, we were unable to verify the controls and compliance with the borrower data and reconciliation compliance requirement related to the performance of a monthly reconciliation.Cause Due to employee turnover over the past several years, Good Samaritan College of Nursing & Health Science did not perform direct loan monthly reconciliations for FY22.Effect or potential effect Discrepancies between the U.S. Department of Education?s systems and Good Samaritan College of Nursing & Health Science?s internal records may not be timely identified and resolved, reasons for remaining cash balances may not be properly documented, and cash management and disbursement reporting timelines may not be met.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Total direct loans for Good Samaritan College of Nursing & Health Science are approximately $2.0 million, representing 74% of Good Samaritan College of Nursing & Health Science?s SFA Cluster expenditures of approximately $2.7 million, and 18% of total SFA Cluster expenditures of approximately $10.9 million.Identification as a repeat finding, if applicable This is a repeat finding ? findings 2021-002, 2020-003 and 2019-007.Recommendation Good Samaritan College of Nursing & Health Science should ensure that all monthly direct loan reconciliations are being performed, reviewed, and approved, with documentation being retained in the College?s internal records.Views of responsibleofficials Management agrees with the finding and implemented corrective action in June 2022.
Finding 2022-004 ? Cash ManagementIdentification of the federal program U.S. Department of EducationOffice of Federal Student AidSFA ClusterAssistance Listing Nos. 84.007, 84.063, and 84.268Good Samaritan College of Nursing & Health ScienceCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303 requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition Per discussion with management, Good Samaritan College of Nursing & Health Science has processes and internal controls in place to ensure requests for funding are allowable under the terms of the grant agreement. These internal controls included validating the draw agreed between the G5 system, COD, and Good Samaritan College of Nursing & Health Science?s internal records for student financial need. However, management did not consistently retain documentation evidencing the performance of these internal controls.Cause Due to employee turnover, Good Samaritan College ofNursing & Health Science did not retain sufficient evidence of internal controls over the cash compliance requirement.Effect or potential effect There is no consistent documentation to support the performance of internal controls.Finding 2022-004 ? Cash Management (continued)Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Total federal expenditures for Good Samaritan College of Nursing & Health Science Assistance Listing Nos. 84.007, 84.063, and 84.268 were $2.6 million, representing 25% of total SFA Cluster expenditures of approximately $10.9 million.Identification as a repeat finding, if applicable This is a repeat finding ? finding 2021-004.Recommendation Good Samaritan College of Nursing & Health Science should refine its process and retain documentation to evidence performance of its internal controls over cash management.Views of responsibleofficials Management agrees with the finding and implemented corrective action in June 2022.
Finding 2022-005 ? Special Tests and Provisions ? Enrollment ReportingIdentification of the federal program U.S. Department of EducationOffice of Federal Student AidSFA ClusterAssistance Listing No. 84.007, 84.063, 84.268Good Samaritan College of Nursing & Health ScienceCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303 requires that a non-federal entity must ?(a) 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. These internal controls should be compliance with guidance in ?Standards for Internal Control the Federal Government? issued by the Comptroller General the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition Good Samaritan College of Nursing & Health Science did not have internal controls over enrollment reporting.Cause Due to employee turnover, Good Samaritan College ofNursing & Health Science did not perform a review of the monthly borrower data reconciliations for FY22.Effect or potential effect Discrepancies between the U.S. Department of Education?s systems and Good Samaritan College of Nursing & Health Science?s internal records may not be timely identified and resolved.Questioned costs None.Finding 2022-005 ? Special Tests and Provisions ? Enrollment Reporting (continued)Context We issued a significant deficiency related to internal controls in the prior year. The finding related to this internal control was not remediated for the period under audit. Good Samaritan College of Nursing & Health Science did not have evidence of whether the internal controls over enrollment reporting were operating effectively during the year.Good Samaritan College of Nursing & Health Science has SFA Cluster expenditures of approximately $2.7 million, which makes up 25% of total SFA Cluster expenditures of approximately $10.9 million.Identification as a repeat finding, if applicable This is a repeat finding ? finding 2021-006.Recommendation We recommend management implement a process to review enrollment reporting requirements and prepare a reconciliation of data in accordance with 2 CFR 200.303a.Views of responsibleofficials Management agrees with the finding and implemented corrective action in June 2022.
Finding 2022-001 ? Special Tests and Provisions ? Disbursements to or on Behalf of StudentsIdentification of the federal program U.S. Department of EducationOffice of Federal Student AidSFA ClusterAssistance Listing No. 84.268Good Samaritan College of Nursing & Health ScienceCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303 requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?34 CFR 685.300(b)(9) requires institutions to ?Provide for the implementation of a quality assurance system, as established by the Secretary and developed in consultation with the school, to ensure that the school is complying with program requirements and meeting program objectives.?Condition Good Samaritan College of Nursing & Health Science did not have evidence of whether the quality assurance system was operating effectively during the fiscal year ended June 30, 2022 (FY22).Cause Due to employee turnover over the past several years, Good Samaritan College of Nursing & Health Science did not retain evidence of whether the quality assurance system was operating effectively during FY22. Effect or potential effect Good Samaritan College of Nursing & Health Science did not have effective controls in place for FY22 regarding the operation and review of its quality assurance system. Due to this, Good Samaritan College of Nursing & Health Science may not comply with program requirements and objectives.Questioned costs None.Context Good Samaritan College of Nursing & Health Science did not have evidence of whether the quality assurance system, including the performance of monthly reconciliations, was operating effectively during the year.Total direct loans for Good Samaritan College of Nursing & Health Science are approximately $2.0 million, representing 74% of Good Samaritan College of Nursing & Health Science?s SFA Cluster expenditures of approximately $2.7 million, and 18% of total SFA Cluster expenditures of approximately $10.9 million.Identification as a repeat finding, if applicable This is a repeat finding ? findings 2021-001, 2020-002, and 2019-006.Recommendation Good Samaritan College of Nursing & Health Science should update the documentation of its direct loan quality assurance system periodically and retain evidence of its evaluation and review and the quality assurance procedures performed during the year.Views of responsibleofficials Management agrees with the finding and implemented corrective action in June 2022.
Finding 2022-017 ? Special Tests and Provisions ? Disbursements to or on Behalf of StudentsIdentification of the federal program U.S. Department of EducationOffice of Federal Student AidSFA ClusterAssistance Listing No. 84.268Good Samaritan College of Nursing & Health ScienceCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303 requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?34 CFR 668.165 Notices, requires the following:(1) Before an institution disburses title IV, HEA program funds for any award year, the institution must notify a student of the amount of funds that the student or his or her parent can expect to receive under each title IV, HEA program, and how and when those funds will be disbursed. If those funds include Direct Loan program funds, the notice must indicate which funds are from subsidized loans, which are from unsubsidized loans, and which are from PLUS loans.Criteria or specific requirement (including statutory, regulatory, orother citation) (continued) (2) Except in the case of a post-withdrawal disbursement made in accordance with ? 668.22(a)(5), if an institution credits a student ledger account with Direct Loan, Federal Perkins Loan, or TEACH Grant program funds, the institution must notify the student or parent of ?(i) The anticipated date and amount of the disbursement;(ii) The student?s or parent?s right to cancel all or a portion of that loan, loan disbursement, TEACH Grant, or TEACH Grant disbursement and have the loan proceeds or TEACH Grant proceeds returned to the Secretary; and(iii) The procedures and time by which the student or parent must notify the institution that he or she wishes to cancel the loan, loan disbursement, TEACH Grant, or TEACH Grant disbursement.(3) The institution must provide the notice described in paragraph (a)(2) of this section in writing ?(i) No earlier than 30 days before, and no later than 30 days after, crediting the student?s ledger account at the institution, if the institution obtains affirmative confirmation from the student under paragraph (a)(6)(i) of this section; or(ii) No earlier than 30 days before, and no later than seven days after, crediting the student?s ledger account at the institution, if the institution does not obtain affirmative confirmation from the student under paragraph (a)(6)(i) of this section.Condition Good Samaritan College of Nursing & Health Science did not send loan notifications to 2 of 28 students selected for disbursement testing for direct loans.Cause Internal controls over direct loan notifications were not designed or operating effectively.Effect or potential effect Good Samaritan College of Nursing & Health Science is noncompliant with regards to loan notification requirements which could impact a student?s ability to cancel the loan timely.Questioned costs None.Context For 2 of 28 students selected for testing that received direct loans, notifications were not sent to the students for direct loan disbursements. The two disbursements were made in June 2022 and were for $1,979 and $50. Direct loans totaling $65,950 were disbursed to the 28 selected students during the year.Total direct loans for Good Samaritan College of Nursing & Health Science are approximately $2.0 million, representing 74% of Good Samaritan College of Nursing & Health Science?s SFA Cluster expenditures of approximately $2.7 million, and 18% of total SFA Cluster expenditures of approximately $10.9 million.Identification as a repeat finding, if applicable This is not a repeat finding.Recommendation Good Samaritan College of Nursing & Health Science should establish procedures to ensure that loan notifications are sent for all loan disbursements, as required.Views of responsibleofficials Management agrees with the finding and will implement corrective action by April 2023.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-018 ? Procurement and Suspension and DebarmentIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, and 93.853See Schedule of Findings and Questioned Costs for chart/tableSt. Joseph?s Hospital and Medical CenterCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR 200.318 (i) General Procurement Standards states, ?the non-Federal entity must maintain records sufficient to detail the history of procurement. These records will include, but are not necessarily limited to, the following: Rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price.?Criteria or specific requirement (including statutory, regulatory, orother citation) (continued) 2 CFR 200.320 (c) Noncompetitive procurement states, ?there are specific circumstances in which noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or more of the following circumstances apply:(1) The acquisition of property or services, the aggregate dollar amount of which does not exceed the micro-purchase threshold (see paragraph (a)(1) of this section);(2) The item is available only from a single source;(3) The public exigency or emergency for the requirement will not permit a delay resulting from publicizing a competitive solicitation;(4) The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive procurement in response to a written request from the non-Federal entity; or(5) After solicitation of a number of sources, competition is determined inadequate.?Condition St. Joseph?s Hospital and Medical Center did not prepare and retain documentation of sole source justification for three procurements over the micro-purchase threshold made without competition.Cause St. Joseph?s Hospital and Medical Center did not have effective internal controls over preparation and retention of the rationale of the method of procurement.Effect or potential effect Noncompliance with the procurement documentation requirements of 2 CFR 200.318 (i) and without adequate documentation of sole source justification there is greater potential for noncompliance with noncompetitive procurement requirements in 2 CFR 200.320 (c).Questioned costs None.Context For 3 of 5 procurements selected for testing, St. Joseph?s Hospital and Medical Center indicated the procurement was a noncompetitive procurement (sole source) but did not have documentation to support the rationale for the sole source procurement.We selected and tested five procurements with expenditures totaling $151,515 from a population of 6 procurements with expenditures totaling $161,960 charged to the St. Joseph?s Hospital and Medical Center during the year ended June 30, 2022. The three noncompetitive procurements tested totaled $43,356.Identification as a repeat finding, if applicable This is not a repeat finding.Recommendation St. Joseph?s Hospital and Medical Center should retain written documentation for procurements documenting the history of the procurement prior to the procurement of goods or services, including, but not limited to, the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price.Views of responsibleofficials Management agrees with the finding and will implement corrective action by April 2023.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-016 ? Subrecipient MonitoringIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.853, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s subrecipient monitoring tracking document, while designed appropriately, is not being maintained effectively and includes errors, since line items on the tracking document for several subrecipients appear to be incorrect with regards to audit findings. Findings appear to have been left off of the tracking document or added incorrectly for a particular subrecipient or may not apply to the subrecipient but to a different subrecipient.Cause St. Joseph?s Hospital and Medical Center did not have internal controls and policies and procedures in place to effectively maintain its subrecipient monitoring tracking document.Effect or potential effect If the subrecipient monitoring tracking document includes errors, St. Joseph?s Hospital and Medical Center may not appropriately modify its ongoing monitoring and risk assessment procedures based on any findings noted in a subrecipients report.Questioned costs None.Context St. Joseph?s Hospital and Medical Center?s subrecipient expenditures totaled $4.7 million during the period, which represented 37% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million and 6% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is not a repeat finding.Recommendation We recommend St. Joseph?s Hospital and Medical Center implement controls over the maintenance of the subrecipient monitoring tracking document to ensure the tracking document is accurately representing the findings for each subrecipient so that the subrecipients may be effectively monitored.Views of responsibleofficials Management agrees with the finding and will implement corrective action by June 2023.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-013 ? Activities Allowed or UnallowedIdentification of the federal program U.S. Department of Health and Human ServicesCOVID-19 ? HRSA COVID-19 Claims Reimbursement for the Uninsured Program and the COVID-19 Coverage Assistance FundAssistance Listing No. 93.461Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CRF Section 200.303 of the Uniform Guidance states the following regarding internal control: ?The non-Federal entity must: (a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework,? issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?There were two matters noted during our testing of the Uninsured Program:1) Per the Health Resources and Services and Administrative (HRSA), HRSA COVID-19 Uninsured Award Terms and Conditions and further clarified in the HRSA FAQs for COVID- 19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration, the FAQ states the following:?If a provider tests for COVID-19 as part of pre-operative or other medical treatment unrelated to COVID-19, is the test eligible for reimbursement?Criteria or specific requirement (including statutory, regulatory, orother citation) (continued) For the HRSA COVID-19 Uninsured Program, COVID-19 testing is eligible for reimbursement if one of the following diagnoses codes is included in any position on the claim:Z03.818 ? Encounter for observation for suspected exposure to other biological agents ruled out (possible exposure to COVID 19)Z11.59 ? Encounter for screening for other viral diseases (asymptomatic)Z20.828 ? Contact with and (suspected) exposure to other viral communicable (confirmed exposure to COVID-19)Z11.52 ? Encounter for screening for COVID-19 (asymptomatic)Z20.822 ? Contact with and (suspected) exposure to COVID 19Z86.16 ? Personal history of COVID-19Related treatment visits and services are not eligible for reimbursement given the primary reason for treatment is not COVID-19.?The Terms and Conditions for the program provide guidance on when the Recipient plans to submit claims for reimbursement for COVID-19 Testing and/or Testing-Related Items and Services provided to individuals who did not have any health care coverage at the time the services were provided. The Recipient acknowledges that each time the Recipient submits such claims for reimbursement, each claim must be in full compliance with these Terms and Conditions, and submission of those claims confirms the Recipient?s ongoing compliance with these Terms and Conditions.Criteria or specific requirement (including statutory, regulatory, orother citation) (continued) Testing-Related Items and Services means items and services furnished to an individual during health care provider office visits, including, for example, in-person visits and telehealth visits, urgent care center visits, and emergency room visits that result in an order for or administration of COVID-19 testing but only to the extent such items and services relate to the furnishing or administration of such product or to the evaluation of such individual for purposes of determining the need of such individual for such product.2) Any treatment without a COVID-19 primary diagnosis, except for pregnancy when the COVID-19 code may be listed as secondary, is not eligible for reimbursement.Condition 1) CommonSpirit Health did not have controls in place to limit the claims being submitted for Testing-Related Items and Services to include items and services related to furnishing or administering the COVID-19 test or for the evaluation of such individuals to determine the need for a COVID-19 test.2) CommonSpirit Health did not have controls in place to ensure that claims were not submitted for reimbursement when COVID-19 was not the primary diagnosis.Cause 1) Management interpreted the guidance as allowing all amounts for the encounter when a test was provided to be submitted for reimbursement regardless of whether COVID-19 was the primary diagnosis and the procedures were not directly related to administering the test or determining whether a test was needed.2) A mistake was made by the coder when coding the medical record.Effect or potential effect Certain claims submitted to the COVID-19 Uninsured Program were for unallowable activities and were not eligible for reimbursement under the COVID-19 Uninsured Program.Questioned costs $4,035Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.1) We identified 4 ($3,488) out of 62 ($122,450) claims selected for testing which included services that were unallowed because, although the episode had a COVID-19 test in the medical record, other non-COVID-19 treatment services were submitted for various emergency room visits when the primary diagnosis for the visit was not COVID-19. There were no subsequent repayments to HRSA or recoupments from HRSA related to these 4 claims.2) We identified 1 ($547) out of 62 ($122,450) claims selected for testing, where COVID-19 was not listed as the primary diagnosis. Total federal expenditures for Assistance Listing 93.461 were $23.9 million for the year ended June 30, 2022.Identification as a repeat finding, if applicable This is a repeat finding for CommonSpirit Health ? Finding 2021-014, with the exception of the one coding error identified, as this is a new aspect in the current year.Finding 2022-013 ? Activities Allowed or Unallowed (continued)Recommendation CommonSpirit Health should implement internal controls to review claims submitted to the COVID-19 Uninsured Program to ensure it is administering the program in compliance with the COVID-19 Uninsured Program regulations, specifically as it relates to the COVID-19 testing aspect of the program and only billing when COVID-19 is listed as the primary diagnosis in the medical record.Views of responsibleofficials 1) Management believes that CommonSpirit Health has the necessary controls in place to support accurate and compliant billing. In addition, Management believes CommonSpirit Health followed the HRSA COVID-19 Uninsured Program (Program) guidelines and frequently asked questions (FAQs) related to diagnostic testing and testing-related visits eligible for reimbursement, which were published from time to time after the introduction of this program.Although CommonSpirit Health continues to dispute the findings (REFERENCE 2021-014), CommonSpirit Health is refunding the Questioned Cost of $10,998 in order to resolve this finding. The refunds will be completed by April 30, 2023. In addition, the Program stopped accepting claims for testing and treatment on March 22, 2022, and claims for vaccine administration on April 5, 2022, due to lack of sufficient funds. CommonSpirit Health has not submitted claims to the Program since the Program was discontinued. In the event that CommonSpirit Health, through its proactive compliance efforts, identifies any additional claims submitted to the Program where reimbursement may not have been appropriate, CommonSpirit Health will refund such claims.2)Management believes that CommonSpirit Health has the necessary controls in place to support accurate and compliant billing. With respect to this one claim where COVID-19 was incorrectly listed in the primary diagnosis position, CommonSpirit Health will refund the claim amount of $547 by April 30, 2023.Conclusion Despite management?s response in the preceding section, we still conclude that a finding is warranted based on the items noted in our Condition and Context sections based on the Criteria or Specific Requirement section above.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-012 ? EligibilityIdentification of the federal program U.S. Department of Health and Human ServicesMedical Assistance Program (Medicaid Cluster)Assistance Listing No. 93.778Passed through Department of Health and Human Services ? State of California and California Department of Health Care ServicesDignity Health Medical FoundationDignity Health Connected LivingCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition The Dignity Health Medical Foundation and Dignity Health Connected Living did not retain evidence of Medicaid eligibility being reviewed prior to patient services being provided.Cause Dignity Health Medical Foundation management did not retain evidence of Medicaid eligibility being reviewed prior to patient services being provided due to lack of understanding of the documentation retention needed.Dignity Health Connected Living management did not retain evidence of Medicaid eligibility being reviewed prior to patient services being provided due to employee turnover.Effect or potential effect Ineligible individuals may be provided services.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Dignity Health Medical Foundation and Dignity Health Connected Living account for $3.5 million and $0.4 million, respectively, or 82% combined, of the $4.7 million total Medicaid Cluster expenditures.Identification as a repeat finding, if applicable This is a repeat finding for Dignity Health Medical Foundation and Dignity Health Connected Living ? Finding 2021-013.Recommendation We recommend management implement a process and internal controls to retain appropriate documentation that participants are eligible to receive services prior to providing services under the Medical Assistance Program.Views of responsibleofficials Management agrees with the finding and implemented corrective action in July 2022.
Finding 2022-012 ? EligibilityIdentification of the federal program U.S. Department of Health and Human ServicesMedical Assistance Program (Medicaid Cluster)Assistance Listing No. 93.778Passed through Department of Health and Human Services ? State of California and California Department of Health Care ServicesDignity Health Medical FoundationDignity Health Connected LivingCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition The Dignity Health Medical Foundation and Dignity Health Connected Living did not retain evidence of Medicaid eligibility being reviewed prior to patient services being provided.Cause Dignity Health Medical Foundation management did not retain evidence of Medicaid eligibility being reviewed prior to patient services being provided due to lack of understanding of the documentation retention needed.Dignity Health Connected Living management did not retain evidence of Medicaid eligibility being reviewed prior to patient services being provided due to employee turnover.Effect or potential effect Ineligible individuals may be provided services.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Dignity Health Medical Foundation and Dignity Health Connected Living account for $3.5 million and $0.4 million, respectively, or 82% combined, of the $4.7 million total Medicaid Cluster expenditures.Identification as a repeat finding, if applicable This is a repeat finding for Dignity Health Medical Foundation and Dignity Health Connected Living ? Finding 2021-013.Recommendation We recommend management implement a process and internal controls to retain appropriate documentation that participants are eligible to receive services prior to providing services under the Medical Assistance Program.Views of responsibleofficials Management agrees with the finding and implemented corrective action in July 2022.
Finding 2022-015 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of Health and Human ServicesMedical Assistance Program (Medicaid Cluster)Assistance Listing No. 93.778Passed through California Department of Health Care ServicesDignity Health Connected LivingCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by theCriteria or specific requirement (including statutory, regulatory, orother citation) (continued) Non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition At Dignity Health Connected Living, internal controls over the required allowability criteria with regard to payroll expense were not performed for 1 of 25 employees selected for testing.Cause Dignity Health Connected Living did not consistently perform the necessary internal control procedures addressing the requirements of 2 CFR 200.303(a) and 2 CFR 200.430.Effect or potential effect Unallowable and/or inaccurate payroll expenditures could becharged to the federal program.Questioned costs None.Context For 1 of 25 payroll expenditures selected for testing, Dignity Health Connected Living did not properly approve an employee timecard for time charged to the grant in accordance with the practices of Dignity Health Connected Living.Total payroll expenditures for Dignity Health Connected Living were $0.2 million and represent 5% of the total Medicaid Cluster expenditures of $4.7 million.Identification as a repeat finding, if applicable This is not a repeat finding.Recommendation We recommend management execute its processes to properly approve all time charged to federal grants in accordance with 2 CFR 200.430. Additionally, we recommend management execute and retain evidence of its internal controls over the allowability of payroll expenditures.Views of responsibleofficials Management agrees with the finding and will implement corrective action by April 2023.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-016 ? Subrecipient MonitoringIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.853, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s subrecipient monitoring tracking document, while designed appropriately, is not being maintained effectively and includes errors, since line items on the tracking document for several subrecipients appear to be incorrect with regards to audit findings. Findings appear to have been left off of the tracking document or added incorrectly for a particular subrecipient or may not apply to the subrecipient but to a different subrecipient.Cause St. Joseph?s Hospital and Medical Center did not have internal controls and policies and procedures in place to effectively maintain its subrecipient monitoring tracking document.Effect or potential effect If the subrecipient monitoring tracking document includes errors, St. Joseph?s Hospital and Medical Center may not appropriately modify its ongoing monitoring and risk assessment procedures based on any findings noted in a subrecipients report.Questioned costs None.Context St. Joseph?s Hospital and Medical Center?s subrecipient expenditures totaled $4.7 million during the period, which represented 37% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million and 6% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is not a repeat finding.Recommendation We recommend St. Joseph?s Hospital and Medical Center implement controls over the maintenance of the subrecipient monitoring tracking document to ensure the tracking document is accurately representing the findings for each subrecipient so that the subrecipients may be effectively monitored.Views of responsibleofficials Management agrees with the finding and will implement corrective action by June 2023.
Finding 2022-018 ? Procurement and Suspension and DebarmentIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, and 93.853See Schedule of Findings and Questioned Costs for chart/tableSt. Joseph?s Hospital and Medical CenterCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR 200.318 (i) General Procurement Standards states, ?the non-Federal entity must maintain records sufficient to detail the history of procurement. These records will include, but are not necessarily limited to, the following: Rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price.?Criteria or specific requirement (including statutory, regulatory, orother citation) (continued) 2 CFR 200.320 (c) Noncompetitive procurement states, ?there are specific circumstances in which noncompetitive procurement can be used. Noncompetitive procurement can only be awarded if one or more of the following circumstances apply:(1) The acquisition of property or services, the aggregate dollar amount of which does not exceed the micro-purchase threshold (see paragraph (a)(1) of this section);(2) The item is available only from a single source;(3) The public exigency or emergency for the requirement will not permit a delay resulting from publicizing a competitive solicitation;(4) The Federal awarding agency or pass-through entity expressly authorizes a noncompetitive procurement in response to a written request from the non-Federal entity; or(5) After solicitation of a number of sources, competition is determined inadequate.?Condition St. Joseph?s Hospital and Medical Center did not prepare and retain documentation of sole source justification for three procurements over the micro-purchase threshold made without competition.Cause St. Joseph?s Hospital and Medical Center did not have effective internal controls over preparation and retention of the rationale of the method of procurement.Effect or potential effect Noncompliance with the procurement documentation requirements of 2 CFR 200.318 (i) and without adequate documentation of sole source justification there is greater potential for noncompliance with noncompetitive procurement requirements in 2 CFR 200.320 (c).Questioned costs None.Context For 3 of 5 procurements selected for testing, St. Joseph?s Hospital and Medical Center indicated the procurement was a noncompetitive procurement (sole source) but did not have documentation to support the rationale for the sole source procurement.We selected and tested five procurements with expenditures totaling $151,515 from a population of 6 procurements with expenditures totaling $161,960 charged to the St. Joseph?s Hospital and Medical Center during the year ended June 30, 2022. The three noncompetitive procurements tested totaled $43,356.Identification as a repeat finding, if applicable This is not a repeat finding.Recommendation St. Joseph?s Hospital and Medical Center should retain written documentation for procurements documenting the history of the procurement prior to the procurement of goods or services, including, but not limited to, the rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price.Views of responsibleofficials Management agrees with the finding and will implement corrective action by April 2023.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-016 ? Subrecipient MonitoringIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.853, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s subrecipient monitoring tracking document, while designed appropriately, is not being maintained effectively and includes errors, since line items on the tracking document for several subrecipients appear to be incorrect with regards to audit findings. Findings appear to have been left off of the tracking document or added incorrectly for a particular subrecipient or may not apply to the subrecipient but to a different subrecipient.Cause St. Joseph?s Hospital and Medical Center did not have internal controls and policies and procedures in place to effectively maintain its subrecipient monitoring tracking document.Effect or potential effect If the subrecipient monitoring tracking document includes errors, St. Joseph?s Hospital and Medical Center may not appropriately modify its ongoing monitoring and risk assessment procedures based on any findings noted in a subrecipients report.Questioned costs None.Context St. Joseph?s Hospital and Medical Center?s subrecipient expenditures totaled $4.7 million during the period, which represented 37% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million and 6% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is not a repeat finding.Recommendation We recommend St. Joseph?s Hospital and Medical Center implement controls over the maintenance of the subrecipient monitoring tracking document to ensure the tracking document is accurately representing the findings for each subrecipient so that the subrecipients may be effectively monitored.Views of responsibleofficials Management agrees with the finding and will implement corrective action by June 2023.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-008 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866See Schedule of Findings and Questioned Costs for chart/tableCriteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR Part 200 Section 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition St. Joseph?s Hospital and Medical Center used budgeted costs to determine the amount of expenses allocated to the grant and failed to reconcile these amounts to actual payroll costs at year-end. Additionally, certain payroll expenditures were not reviewed and approved.Cause Management did not review payroll expenditures to support allowable costs/cost principles nor did it reconcile budgeted costs to actual costs incurred for certain payroll expenses.Effect or potential effect Unallowable and inaccurate payroll expenditures could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-009.Recommendation We recommend management implement a process to record time charged to federal grants in accordance with 2 CFR 200.430 and implement effective internal controls to review and approve payroll expenditures charged to the grant.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-009 ? Allowable Costs/Cost PrinciplesIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that a non-federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States and the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition At St. Joseph?s Hospital and Medical center, internal controls over allowability criteria with regard to indirect expenditures were not performed throughout the entire period.Cause Management did not have a process in place for the entire fiscal year to evaluate if indirect costs charged to the grant exceeded the amount allowed under the grant agreement.Effect or potential effect Unallowable and inaccurate indirect expenditures could be charged to the federal program.Questioned costs None.Context We issued a significant deficiency related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding.Starting in January 2022, management began reconciling the costs for all grants and made adjusting entries to correct the amount of indirect costs previously charged to the award that were in excess of amounts allowed.The total indirect expenses make up $2.7 million or 22% of the $12.6 million research and development expenditures for St. Joseph?s Hospital and Medical Center, which represent 16% of the total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-010.Recommendation We recommend management implement and retain evidence of internal controls over indirect expenses charged to the grant to ensure that the rates used are in accordance with the federally negotiated rate or grant agreement and the total expenditures do not exceed the allowable limit.Views of responsibleofficials Management agrees with the finding and implemented corrective action in January 2022.
Finding 2022-010 ? Allowable Costs/Cost Principles (Salary Cap)Identification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.837, 93.838, 93.847, 93.853, 93.855, 93.865, and 93.866St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center did not retain evidence of review of the NIH salary cap requirement.Cause Management did not retain evidence of review and approval of NIH salary cap limited employees to support allowable costs/cost principles.Effect or potential effect Unallowable and inaccurate payroll expenditures surpassing the NIH salary cap could be charged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Payroll expenditures of $4.1 million represent 33% of St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million, which represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-011.Recommendation St. Joseph?s Hospital and Medical Center should retain evidence of its review to ensure the NIH salary cap is not exceeded.Views of responsibleofficials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-011 ? Special Tests and Provisions ? Key PersonnelIdentification of the federal program U.S. Department of DefenseU.S. Department of Health and Human ServicesResearch and Development ClusterAssistance Listing Nos.12.420, 93.279, 93.103, 93.121, 93.279, 93.286, 93.310, 93.350, 93.361, 93,394, 93.396, 93.650, 93.830, 93.838, 93.847, 93.853, 93.856, 93.865, 93.866, 93.880, and 98.837St. Joseph?s Hospital and Medical Center ? All Research and Development Cluster awards listed in Finding 2022-008 above.Criteria or specific requirement (including statutory, regulatory, or other citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Joseph?s Hospital and Medical Center?s internal controls over key personnel were not designed and operating effectively since level of effort certifications were not completed and signed timely by key personnel on grants.Cause St. Joseph?s Hospital and Medical Center did not complete certifications and sign level of effort certifications during the year or shortly thereafter.Effect or potential effect Prior approvals for change in key personnel specified in the application or the federal award; and the disengagement of key personnel from the project for more than three months, or a 25% reduction in time devoted to the project by the approved project director or principal investigator may not be adequately reported to the federal awarding agencies.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.Although, St. Joseph?s Hospital and Medical Center did have completed and signed level-of-effort certifications for 17 key personnel selected for compliance testing, we noted the certifications were not prepared and signed during the year ended June 30, 2022 or prior to 6 months after year-end.St. Joseph?s Hospital and Medical Center?s total research and development expenditures of $12.6 million represent 16% of total research and development cluster expenditures of $77.5 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Joseph Hospital and Medical Center ? Finding 2021-012.Recommendation St. Joseph?s Hospital and Medical Center should design internal controls over key personnel to ensure that certifications of level of effort by key personnel are completed and signed in a timely manner. Monitoring of the level of effort spent by key personnel should be performed throughout the year to ensure that the minimum requirements are being met.Views of responsible officials Management agrees with the finding and implemented corrective action in September 2022.
Finding 2022-007 ? Allowable Costs/Cost PrinciplesIdentification of the federal program Health Resources and Services AdministrationHIV Emergency Relief Project GrantsAssistance Listing No. 93.914See Schedule of Findings and Questioned Costs for chart/tableSt. Mary?s Medical Center ? San FranciscoVirginia MasonCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by theSection III ? Federal Award Findings and Questioned Costs (continued)Finding 2022-007 ? Allowable Costs/Cost Principles (continued)Criteria or specific requirement (including statutory, regulatory, orother citation) (continued) Non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition At St. Mary?s Medical Center ? San Francisco and Virginia Mason, controls over the required allowability criteria with regard to payroll expense were not performed and/or documented throughout the year.Cause St. Mary?s Medical Center ? San Francisco and Virginia Mason did not perform the necessary procedures addressing the requirements of 2 CFR 200.303(a) and 2 CFR 200.430.Effect or potential effect Unallowable and/or inaccurate payroll expenditures could becharged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.St. Mary?s Medical Center ? San Francisco expenditures of approximately $0.2 million represent 6% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.Virginia Mason expenditures of approximately $1.2 million represent 35% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Mary?s Medical Center ? San Francisco ? Finding 2020-006 and 2021-008.This is a repeat finding for Virginia Mason ? Finding 2021-008.Recommendation We recommend management execute its processes toproperly approve time charged to federal grants in accordance with 2 CFR 200.430. Additionally, we recommend management execute and retain evidence of its internal controls over the allowability of payroll expenditures.Views of responsibleofficials Management agrees with the finding and implemented corrective action in April 2022.
Finding 2022-006 ? EligibilityIdentification of the federal program Health Resources and Services AdministrationHIV Emergency Relief Project GrantsAssistance Listing No. 93.914See Schedule of Findings and Questioned Costs for chart/tableSt. Mary Medical Center ? Long BeachSt. Mary?s Medical Center ? San FranciscoCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco did not consistently retain evidence of their internal controls over the requirement to review eligibility requirements prior to administering services in accordance with the grant agreements.Cause At St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco, controls over the required eligibility criteria were not performed and/or documented for each participant.Effect or potential effect St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco could have provided services to ineligible individuals.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.St. Mary Medical Center ? Long Beach expenditures of approximately $1.9 million represent 52% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.St. Mary?s Medical Center ? San Francisco expenditures of approximately $0.2 million represent 6% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Mary?s Medical Center ? Long Beach ? Finding (2021-007).This is a repeat finding for St. Mary?s Medical Center ? San Francisco ? Finding (2021-007 and 2020-005).Recommendation St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco should perform and retain evidence of their review of patient eligibility as defined by the grant agreement to support the internal control environment.Views of responsibleofficials Management agrees with the finding and implemented corrective action in April 2022.
Finding 2022-007 ? Allowable Costs/Cost PrinciplesIdentification of the federal program Health Resources and Services AdministrationHIV Emergency Relief Project GrantsAssistance Listing No. 93.914See Schedule of Findings and Questioned Costs for chart/tableSt. Mary?s Medical Center ? San FranciscoVirginia MasonCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?2 CFR 200.430 (i) states ?Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federally assisted and all other activities compensated by theSection III ? Federal Award Findings and Questioned Costs (continued)Finding 2022-007 ? Allowable Costs/Cost Principles (continued)Criteria or specific requirement (including statutory, regulatory, orother citation) (continued) Non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity?s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.?Condition At St. Mary?s Medical Center ? San Francisco and Virginia Mason, controls over the required allowability criteria with regard to payroll expense were not performed and/or documented throughout the year.Cause St. Mary?s Medical Center ? San Francisco and Virginia Mason did not perform the necessary procedures addressing the requirements of 2 CFR 200.303(a) and 2 CFR 200.430.Effect or potential effect Unallowable and/or inaccurate payroll expenditures could becharged to the federal program.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.St. Mary?s Medical Center ? San Francisco expenditures of approximately $0.2 million represent 6% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.Virginia Mason expenditures of approximately $1.2 million represent 35% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Mary?s Medical Center ? San Francisco ? Finding 2020-006 and 2021-008.This is a repeat finding for Virginia Mason ? Finding 2021-008.Recommendation We recommend management execute its processes toproperly approve time charged to federal grants in accordance with 2 CFR 200.430. Additionally, we recommend management execute and retain evidence of its internal controls over the allowability of payroll expenditures.Views of responsibleofficials Management agrees with the finding and implemented corrective action in April 2022.
Finding 2022-006 ? EligibilityIdentification of the federal program Health Resources and Services AdministrationHIV Emergency Relief Project GrantsAssistance Listing No. 93.914See Schedule of Findings and Questioned Costs for chart/tableSt. Mary Medical Center ? Long BeachSt. Mary?s Medical Center ? San FranciscoCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco did not consistently retain evidence of their internal controls over the requirement to review eligibility requirements prior to administering services in accordance with the grant agreements.Cause At St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco, controls over the required eligibility criteria were not performed and/or documented for each participant.Effect or potential effect St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco could have provided services to ineligible individuals.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.St. Mary Medical Center ? Long Beach expenditures of approximately $1.9 million represent 52% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.St. Mary?s Medical Center ? San Francisco expenditures of approximately $0.2 million represent 6% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Mary?s Medical Center ? Long Beach ? Finding (2021-007).This is a repeat finding for St. Mary?s Medical Center ? San Francisco ? Finding (2021-007 and 2020-005).Recommendation St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco should perform and retain evidence of their review of patient eligibility as defined by the grant agreement to support the internal control environment.Views of responsibleofficials Management agrees with the finding and implemented corrective action in April 2022.
Finding 2022-006 ? EligibilityIdentification of the federal program Health Resources and Services AdministrationHIV Emergency Relief Project GrantsAssistance Listing No. 93.914See Schedule of Findings and Questioned Costs for chart/tableSt. Mary Medical Center ? Long BeachSt. Mary?s Medical Center ? San FranciscoCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco did not consistently retain evidence of their internal controls over the requirement to review eligibility requirements prior to administering services in accordance with the grant agreements.Cause At St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco, controls over the required eligibility criteria were not performed and/or documented for each participant.Effect or potential effect St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco could have provided services to ineligible individuals.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.St. Mary Medical Center ? Long Beach expenditures of approximately $1.9 million represent 52% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.St. Mary?s Medical Center ? San Francisco expenditures of approximately $0.2 million represent 6% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Mary?s Medical Center ? Long Beach ? Finding (2021-007).This is a repeat finding for St. Mary?s Medical Center ? San Francisco ? Finding (2021-007 and 2020-005).Recommendation St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco should perform and retain evidence of their review of patient eligibility as defined by the grant agreement to support the internal control environment.Views of responsibleofficials Management agrees with the finding and implemented corrective action in April 2022.
Finding 2022-006 ? EligibilityIdentification of the federal program Health Resources and Services AdministrationHIV Emergency Relief Project GrantsAssistance Listing No. 93.914See Schedule of Findings and Questioned Costs for chart/tableSt. Mary Medical Center ? Long BeachSt. Mary?s Medical Center ? San FranciscoCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco did not consistently retain evidence of their internal controls over the requirement to review eligibility requirements prior to administering services in accordance with the grant agreements.Cause At St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco, controls over the required eligibility criteria were not performed and/or documented for each participant.Effect or potential effect St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco could have provided services to ineligible individuals.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.St. Mary Medical Center ? Long Beach expenditures of approximately $1.9 million represent 52% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.St. Mary?s Medical Center ? San Francisco expenditures of approximately $0.2 million represent 6% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Mary?s Medical Center ? Long Beach ? Finding (2021-007).This is a repeat finding for St. Mary?s Medical Center ? San Francisco ? Finding (2021-007 and 2020-005).Recommendation St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco should perform and retain evidence of their review of patient eligibility as defined by the grant agreement to support the internal control environment.Views of responsibleofficials Management agrees with the finding and implemented corrective action in April 2022.
Finding 2022-006 ? EligibilityIdentification of the federal program Health Resources and Services AdministrationHIV Emergency Relief Project GrantsAssistance Listing No. 93.914See Schedule of Findings and Questioned Costs for chart/tableSt. Mary Medical Center ? Long BeachSt. Mary?s Medical Center ? San FranciscoCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco did not consistently retain evidence of their internal controls over the requirement to review eligibility requirements prior to administering services in accordance with the grant agreements.Cause At St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco, controls over the required eligibility criteria were not performed and/or documented for each participant.Effect or potential effect St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco could have provided services to ineligible individuals.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.St. Mary Medical Center ? Long Beach expenditures of approximately $1.9 million represent 52% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.St. Mary?s Medical Center ? San Francisco expenditures of approximately $0.2 million represent 6% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Mary?s Medical Center ? Long Beach ? Finding (2021-007).This is a repeat finding for St. Mary?s Medical Center ? San Francisco ? Finding (2021-007 and 2020-005).Recommendation St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco should perform and retain evidence of their review of patient eligibility as defined by the grant agreement to support the internal control environment.Views of responsibleofficials Management agrees with the finding and implemented corrective action in April 2022.
Finding 2022-006 ? EligibilityIdentification of the federal program Health Resources and Services AdministrationHIV Emergency Relief Project GrantsAssistance Listing No. 93.914See Schedule of Findings and Questioned Costs for chart/tableSt. Mary Medical Center ? Long BeachSt. Mary?s Medical Center ? San FranciscoCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco did not consistently retain evidence of their internal controls over the requirement to review eligibility requirements prior to administering services in accordance with the grant agreements.Cause At St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco, controls over the required eligibility criteria were not performed and/or documented for each participant.Effect or potential effect St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco could have provided services to ineligible individuals.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.St. Mary Medical Center ? Long Beach expenditures of approximately $1.9 million represent 52% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.St. Mary?s Medical Center ? San Francisco expenditures of approximately $0.2 million represent 6% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Mary?s Medical Center ? Long Beach ? Finding (2021-007).This is a repeat finding for St. Mary?s Medical Center ? San Francisco ? Finding (2021-007 and 2020-005).Recommendation St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco should perform and retain evidence of their review of patient eligibility as defined by the grant agreement to support the internal control environment.Views of responsibleofficials Management agrees with the finding and implemented corrective action in April 2022.
Finding 2022-006 ? EligibilityIdentification of the federal program Health Resources and Services AdministrationHIV Emergency Relief Project GrantsAssistance Listing No. 93.914See Schedule of Findings and Questioned Costs for chart/tableSt. Mary Medical Center ? Long BeachSt. Mary?s Medical Center ? San FranciscoCriteria or specific requirement (including statutory, regulatory, orother citation) 2 CFR 200.303(a) requires that the non-Federal entity must ?(a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).?Condition St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco did not consistently retain evidence of their internal controls over the requirement to review eligibility requirements prior to administering services in accordance with the grant agreements.Cause At St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco, controls over the required eligibility criteria were not performed and/or documented for each participant.Effect or potential effect St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco could have provided services to ineligible individuals.Questioned costs None.Context We issued a material weakness related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding.St. Mary Medical Center ? Long Beach expenditures of approximately $1.9 million represent 52% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.St. Mary?s Medical Center ? San Francisco expenditures of approximately $0.2 million represent 6% of total HIV Emergency Relief Project Grants expenditures of approximately $3.6 million.Identification as a repeat finding, if applicable This is a repeat finding for St. Mary?s Medical Center ? Long Beach ? Finding (2021-007).This is a repeat finding for St. Mary?s Medical Center ? San Francisco ? Finding (2021-007 and 2020-005).Recommendation St. Mary Medical Center ? Long Beach and St. Mary?s Medical Center ? San Francisco should perform and retain evidence of their review of patient eligibility as defined by the grant agreement to support the internal control environment.Views of responsibleofficials Management agrees with the finding and implemented corrective action in April 2022.