Audit 321917

FY End
2023-12-31
Total Expended
$12.04M
Findings
18
Programs
29
Year: 2023 Accepted: 2024-09-27

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
499140 2023-001 Material Weakness Yes I
499141 2023-001 Material Weakness Yes I
499142 2023-001 Material Weakness Yes I
499143 2023-002 Material Weakness Yes I
499144 2023-002 Material Weakness Yes I
499145 2023-002 Material Weakness Yes I
499146 2023-003 Material Weakness Yes ABCL
499147 2023-005 Material Weakness - L
499148 2023-004 Significant Deficiency - AB
1075582 2023-001 Material Weakness Yes I
1075583 2023-001 Material Weakness Yes I
1075584 2023-001 Material Weakness Yes I
1075585 2023-002 Material Weakness Yes I
1075586 2023-002 Material Weakness Yes I
1075587 2023-002 Material Weakness Yes I
1075588 2023-003 Material Weakness Yes ABCL
1075589 2023-005 Material Weakness - L
1075590 2023-004 Significant Deficiency - AB

Programs

ALN Program Spent Major Findings
21.027 Coronavirus State and Local Fiscal Recovery Funds $7.00M Yes 2
93.493 Congressional Directives $2.00M Yes 4
93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response $1.89M Yes 3
16.575 Crime Victim Assistance $251,186 - 0
93.213 Research and Training in Complementary and Integrative Health $154,423 - 0
93.991 Preventive Health and Health Services Block Grant $124,843 - 0
93.395 Cancer Treatment Research $61,974 - 0
93.889 National Bioterrorism Hospital Preparedness Program $60,920 - 0
20.600 State and Community Highway Safety $50,121 - 0
93.994 Maternal and Child Health Services Block Grant to the States $48,914 - 0
93.558 Temporary Assistance for Needy Families $44,168 - 0
93.732 Mental and Behavioral Health Education and Training Grants $33,304 - 0
93.855 Allergy, Immunology and Transplantation Research $25,912 - 0
93.080 Blood Disorder Program: Prevention, Surveillance, and Research $19,818 - 0
93.778 Medical Assistance Program $18,617 - 0
93.110 Maternal and Child Health Federal Consolidated Programs $16,941 - 0
93.837 Cardiovascular Diseases Research $12,449 - 0
93.838 Lung Diseases Research $12,095 - 0
93.360 Biomedical Advanced Research and Development Authority (barda), Biodefense Medical Countermeasure Development $10,683 - 0
93.865 Child Health and Human Development Extramural Research $7,934 - 0
93.853 Extramural Research Programs in the Neurosciences and Neurological Disorders $6,456 - 0
93.350 National Center for Advancing Translational Sciences $5,867 - 0
93.846 Arthritis, Musculoskeletal and Skin Diseases Research $5,814 - 0
93.839 Blood Diseases and Resources Research $5,291 - 0
93.439 State Physical Activity and Nutrition (span $4,981 - 0
93.867 Vision Research $4,907 - 0
93.070 Environmental Public Health and Emergency Response $1,701 - 0
93.361 Nursing Research $845 - 0
93.242 Mental Health Research Grants $259 - 0

Contacts

Name Title Type
F8WWSS8ECES3 Alicia Lamancusa Auditee
3305438171 Susan Flaherty Auditor
No contacts on file

Notes to SEFA

Title: Significant Accounting Policies Used in Preparing the Schedule of Expenditures of Federal Awards Accounting Policies: The schedule of expenditures of federal awards (Schedule) includes the federal grant activity of Children’s Hospital Medical Center of Akron and Affiliates, d.b.a. Akron Children’s, Employer Identification Number 34-0714357, and is presented on the accrual basis of accounting. The information in the Schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards. De Minimis Rate Used: N Rate Explanation: Indirect costs are charged to grants only when allowed and using specific agreed rates. The accompanying schedule of expenditures of federal awards (Schedule) includes the federal grant activity of Children’s Hospital Medical Center of Akron and Affiliates, d.b.a. Akron Children’s, Employer Identification Number 34-0714357, and is presented on the accrual basis of accounting. The information in the Schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards.
Title: 10% De Minimis Cost Rat Accounting Policies: The schedule of expenditures of federal awards (Schedule) includes the federal grant activity of Children’s Hospital Medical Center of Akron and Affiliates, d.b.a. Akron Children’s, Employer Identification Number 34-0714357, and is presented on the accrual basis of accounting. The information in the Schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards. De Minimis Rate Used: N Rate Explanation: Indirect costs are charged to grants only when allowed and using specific agreed rates. Akron Children’s has not elected to use the 10% de minimis indirect cost rate as allowed under the Uniform Guidance.
Title: Ohio Department of Health Payments Accounting Policies: The schedule of expenditures of federal awards (Schedule) includes the federal grant activity of Children’s Hospital Medical Center of Akron and Affiliates, d.b.a. Akron Children’s, Employer Identification Number 34-0714357, and is presented on the accrual basis of accounting. The information in the Schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards. De Minimis Rate Used: N Rate Explanation: Indirect costs are charged to grants only when allowed and using specific agreed rates. The table below outlines the payments Akron Children’s has received from the Ohio Department of Health for programs.

Finding Details

Identification of the federal program: Federal Agencies: U.S. Department of Health and Human Services Pass-Through Entities: Ohio Department of Health Assistance Listing No: 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response, 93.493 Congressional Directives, and 21.027 COVID-19 Coronavirus State and Local Recovery Funds Award Period: 2023 Criteria or specific requirement (including statutory, regulatory or other citation): 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).” Section 200.318(i) of the Uniform Guidance states the following regarding general procurement standards: “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.” Section 200.320(a)(1)(iii) of the Uniform Guidance states the following regarding formal procurement methods to be followed: “The non-Federal entity is responsible for determining and documenting an appropriate micro-purchase threshold based on internal controls, an evaluation of risk, and its documented procurement procedures.” Section 200.320(a)(2)(i) refers to small purchases as: “The acquisition of property or services, the aggregate dollar amount of which is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold. If small purchase procedures are used, price or rate quotations must be obtained from an adequate number of qualified sources as determined appropriate by the non-Federal entity.” Condition: For most of 2023, Akron Children’s Procurement Policy for Federal Grant Agreements and Contracts did not align with the Uniform Guidance requirements within Section 200.320 in that the requirements for price or rate quotations from an adequate number of sources for small purchases between the micro purchase and simplified acquisition thresholds are not defined. Akron Children’s updated the procurement policy to align with the Uniform Guidance requirements in November 2023. Cause: The small purchase procurement threshold within Akron Children’s Procurement Policy for Federal Grant Agreements and Contracts did not align with the procurement thresholds established under Uniform Guidance Section 200.320, until the policy was updated in November 2023. Effect or potential effect: Akron Children’s procurement policies were not designed in accordance with Section 2.00.320(a). As such, Akron Children’s purchases may not have been in accordance with the Uniform Guidance procurement standards. Questioned costs: None Context: Akron Children’s updated its procurement policy in November 2023. Procurements prior to this date may not have followed the required Uniform Guidance. Total Federal expenditures for the programs were $10,888,195 for the year ended December 31, 2023. Identification as a repeat finding, if applicable: The finding is a repeat finding from the prior year – 2022-001, as it relates to 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response. Recommendation: Akron Children’s should review and update its federal procurement policies to align with the procurement standards. Views of responsible officials: Akron Children's remediated this finding in November 2023 with the update and issuance of a modified Procurement Policy for Federal Grant Agreements and Contracts that aligns with the standards of Uniform Guidance.
Identification of the federal program: Federal Agencies: U.S. Department of Health and Human Services Pass-Through Entities: Ohio Department of Health Assistance Listing No: 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response, 93.493 Congressional Directives, and 21.027 COVID-19 Coronavirus State and Local Recovery Funds Award Period: 2023 Criteria or specific requirement (including statutory, regulatory or other citation): 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).” Section 200.318(i) of the Uniform Guidance states the following regarding general procurement standards: “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.” Section 200.320(a)(1)(iii) of the Uniform Guidance states the following regarding formal procurement methods to be followed: “The non-Federal entity is responsible for determining and documenting an appropriate micro-purchase threshold based on internal controls, an evaluation of risk, and its documented procurement procedures.” Section 200.320(a)(2)(i) refers to small purchases as: “The acquisition of property or services, the aggregate dollar amount of which is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold. If small purchase procedures are used, price or rate quotations must be obtained from an adequate number of qualified sources as determined appropriate by the non-Federal entity.” Condition: For most of 2023, Akron Children’s Procurement Policy for Federal Grant Agreements and Contracts did not align with the Uniform Guidance requirements within Section 200.320 in that the requirements for price or rate quotations from an adequate number of sources for small purchases between the micro purchase and simplified acquisition thresholds are not defined. Akron Children’s updated the procurement policy to align with the Uniform Guidance requirements in November 2023. Cause: The small purchase procurement threshold within Akron Children’s Procurement Policy for Federal Grant Agreements and Contracts did not align with the procurement thresholds established under Uniform Guidance Section 200.320, until the policy was updated in November 2023. Effect or potential effect: Akron Children’s procurement policies were not designed in accordance with Section 2.00.320(a). As such, Akron Children’s purchases may not have been in accordance with the Uniform Guidance procurement standards. Questioned costs: None Context: Akron Children’s updated its procurement policy in November 2023. Procurements prior to this date may not have followed the required Uniform Guidance. Total Federal expenditures for the programs were $10,888,195 for the year ended December 31, 2023. Identification as a repeat finding, if applicable: The finding is a repeat finding from the prior year – 2022-001, as it relates to 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response. Recommendation: Akron Children’s should review and update its federal procurement policies to align with the procurement standards. Views of responsible officials: Akron Children's remediated this finding in November 2023 with the update and issuance of a modified Procurement Policy for Federal Grant Agreements and Contracts that aligns with the standards of Uniform Guidance.
Identification of the federal program: Federal Agencies: U.S. Department of Health and Human Services Pass-Through Entities: Ohio Department of Health Assistance Listing No: 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response, 93.493 Congressional Directives, and 21.027 COVID-19 Coronavirus State and Local Recovery Funds Award Period: 2023 Criteria or specific requirement (including statutory, regulatory or other citation): 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).” Section 200.318(i) of the Uniform Guidance states the following regarding general procurement standards: “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.” Section 200.320(a)(1)(iii) of the Uniform Guidance states the following regarding formal procurement methods to be followed: “The non-Federal entity is responsible for determining and documenting an appropriate micro-purchase threshold based on internal controls, an evaluation of risk, and its documented procurement procedures.” Section 200.320(a)(2)(i) refers to small purchases as: “The acquisition of property or services, the aggregate dollar amount of which is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold. If small purchase procedures are used, price or rate quotations must be obtained from an adequate number of qualified sources as determined appropriate by the non-Federal entity.” Condition: For most of 2023, Akron Children’s Procurement Policy for Federal Grant Agreements and Contracts did not align with the Uniform Guidance requirements within Section 200.320 in that the requirements for price or rate quotations from an adequate number of sources for small purchases between the micro purchase and simplified acquisition thresholds are not defined. Akron Children’s updated the procurement policy to align with the Uniform Guidance requirements in November 2023. Cause: The small purchase procurement threshold within Akron Children’s Procurement Policy for Federal Grant Agreements and Contracts did not align with the procurement thresholds established under Uniform Guidance Section 200.320, until the policy was updated in November 2023. Effect or potential effect: Akron Children’s procurement policies were not designed in accordance with Section 2.00.320(a). As such, Akron Children’s purchases may not have been in accordance with the Uniform Guidance procurement standards. Questioned costs: None Context: Akron Children’s updated its procurement policy in November 2023. Procurements prior to this date may not have followed the required Uniform Guidance. Total Federal expenditures for the programs were $10,888,195 for the year ended December 31, 2023. Identification as a repeat finding, if applicable: The finding is a repeat finding from the prior year – 2022-001, as it relates to 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response. Recommendation: Akron Children’s should review and update its federal procurement policies to align with the procurement standards. Views of responsible officials: Akron Children's remediated this finding in November 2023 with the update and issuance of a modified Procurement Policy for Federal Grant Agreements and Contracts that aligns with the standards of Uniform Guidance.
Identification of the federal program: Federal Agencies: U.S. Department of Health and Human Services Pass-Through Entities: Ohio Department of Health Assistance Listing No: 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response, 93.493 Congressional Directives, and 21.027 COVID-19 Coronavirus State and Local Recovery Funds Award Period: 2023 Criteria or specific requirement (including statutory, regulatory or other citation): 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).” The Uniform Guidance 2 CFR Section 200.213 states, “Non-federal entities are subject to the non-procurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR Part 180. These regulations restrict awards, subawards, and contracts with certain parties that are debarred, suspended or otherwise excluded from or ineligible for participation in Federal assistance programs or activities”. Condition: We identified the following matters during our testing of suspension and debarment control processes: a) A third-party vendor performed the suspension and debarment validation process for Akron Children’s. The third-party vendor does not have a SOC 1 (System and Organization Controls) Report. For most of 2023, Akron Children’s relied on the suspension and debarment checks performed by the third-party vendor for results concluding no match without completing a validation control to ensure the results provided by the third party were accurate. b) Akron Children’s did not retain the supporting documentation of the reconciliation of the vendor list that is received from the third-party vendor that is used to perform the suspension and debarment checks after the suspension and debarment checks are performed to ensure the listing is complete and agrees to the vendor list provided by Akron Children’s to the third-party vendor. Cause: Akron Children’s did not have policies and procedures that require a validation of the third-party’s controls be performed to ensure that the suspension and debarment checks performed by the third-party vendor aligned with the governmental suspension and debarment database when the search resulted in no match. In addition, Akron Children’s did not have policies and procedures in place to require that documentation is retained to support the reconciliations performed between the vendor list sent to the third-party vendor and the results provided by the third-party vendor. Effect or potential effect: Akron Children’s screening for suspension and debarment through the third-party vendor results may not be accurate. By failing to retain the documentation of the reconciliation of vendor files to the third-party vendor search results, sufficient evidence was not retained to prove that the reconciliation took place. As a result, there was not sufficient evidence to validate the appropriate internal controls took place to prevent Akron Children’s from transacting with a vendor that was suspended or debarred, which was ultimately charged to a federal program. Questioned costs: None. Context: The federal portion of expenditures subject to suspension and debarment represents approximately 84% of total federal expenditures for the programs of $10,888,195 for the year ended December 31, 2023. Identification as a repeat finding, if applicable: The finding is a repeat finding from the prior year – 2022-002, as it relates to 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response. Recommendation: Management should add controls to validate the accuracy of the suspension and debarment search results performed by the third-party vendor when the search results in no match. Views of responsible officials: Akron Children's remediated these findings in the fourth quarter of 2023 by: 1) Implementing a periodic independent review of a sample of vendors sent to the third-party vendor to ensure that the processes employed by third-party vendor are accurate. 2) Developing a retention process for all vendor searches and file submissions to evidence compliance with the Federal regulations, including an independent review of the accuracy of file submissions. Further, a contract management system was installed in 2023 that holds the validation of new vendors as acceptable for federal procurements.
Identification of the federal program: Federal Agencies: U.S. Department of Health and Human Services Pass-Through Entities: Ohio Department of Health Assistance Listing No: 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response, 93.493 Congressional Directives, and 21.027 COVID-19 Coronavirus State and Local Recovery Funds Award Period: 2023 Criteria or specific requirement (including statutory, regulatory or other citation): 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).” The Uniform Guidance 2 CFR Section 200.213 states, “Non-federal entities are subject to the non-procurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR Part 180. These regulations restrict awards, subawards, and contracts with certain parties that are debarred, suspended or otherwise excluded from or ineligible for participation in Federal assistance programs or activities”. Condition: We identified the following matters during our testing of suspension and debarment control processes: a) A third-party vendor performed the suspension and debarment validation process for Akron Children’s. The third-party vendor does not have a SOC 1 (System and Organization Controls) Report. For most of 2023, Akron Children’s relied on the suspension and debarment checks performed by the third-party vendor for results concluding no match without completing a validation control to ensure the results provided by the third party were accurate. b) Akron Children’s did not retain the supporting documentation of the reconciliation of the vendor list that is received from the third-party vendor that is used to perform the suspension and debarment checks after the suspension and debarment checks are performed to ensure the listing is complete and agrees to the vendor list provided by Akron Children’s to the third-party vendor. Cause: Akron Children’s did not have policies and procedures that require a validation of the third-party’s controls be performed to ensure that the suspension and debarment checks performed by the third-party vendor aligned with the governmental suspension and debarment database when the search resulted in no match. In addition, Akron Children’s did not have policies and procedures in place to require that documentation is retained to support the reconciliations performed between the vendor list sent to the third-party vendor and the results provided by the third-party vendor. Effect or potential effect: Akron Children’s screening for suspension and debarment through the third-party vendor results may not be accurate. By failing to retain the documentation of the reconciliation of vendor files to the third-party vendor search results, sufficient evidence was not retained to prove that the reconciliation took place. As a result, there was not sufficient evidence to validate the appropriate internal controls took place to prevent Akron Children’s from transacting with a vendor that was suspended or debarred, which was ultimately charged to a federal program. Questioned costs: None. Context: The federal portion of expenditures subject to suspension and debarment represents approximately 84% of total federal expenditures for the programs of $10,888,195 for the year ended December 31, 2023. Identification as a repeat finding, if applicable: The finding is a repeat finding from the prior year – 2022-002, as it relates to 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response. Recommendation: Management should add controls to validate the accuracy of the suspension and debarment search results performed by the third-party vendor when the search results in no match. Views of responsible officials: Akron Children's remediated these findings in the fourth quarter of 2023 by: 1) Implementing a periodic independent review of a sample of vendors sent to the third-party vendor to ensure that the processes employed by third-party vendor are accurate. 2) Developing a retention process for all vendor searches and file submissions to evidence compliance with the Federal regulations, including an independent review of the accuracy of file submissions. Further, a contract management system was installed in 2023 that holds the validation of new vendors as acceptable for federal procurements.
Identification of the federal program: Federal Agencies: U.S. Department of Health and Human Services Pass-Through Entities: Ohio Department of Health Assistance Listing No: 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response, 93.493 Congressional Directives, and 21.027 COVID-19 Coronavirus State and Local Recovery Funds Award Period: 2023 Criteria or specific requirement (including statutory, regulatory or other citation): 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).” The Uniform Guidance 2 CFR Section 200.213 states, “Non-federal entities are subject to the non-procurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR Part 180. These regulations restrict awards, subawards, and contracts with certain parties that are debarred, suspended or otherwise excluded from or ineligible for participation in Federal assistance programs or activities”. Condition: We identified the following matters during our testing of suspension and debarment control processes: a) A third-party vendor performed the suspension and debarment validation process for Akron Children’s. The third-party vendor does not have a SOC 1 (System and Organization Controls) Report. For most of 2023, Akron Children’s relied on the suspension and debarment checks performed by the third-party vendor for results concluding no match without completing a validation control to ensure the results provided by the third party were accurate. b) Akron Children’s did not retain the supporting documentation of the reconciliation of the vendor list that is received from the third-party vendor that is used to perform the suspension and debarment checks after the suspension and debarment checks are performed to ensure the listing is complete and agrees to the vendor list provided by Akron Children’s to the third-party vendor. Cause: Akron Children’s did not have policies and procedures that require a validation of the third-party’s controls be performed to ensure that the suspension and debarment checks performed by the third-party vendor aligned with the governmental suspension and debarment database when the search resulted in no match. In addition, Akron Children’s did not have policies and procedures in place to require that documentation is retained to support the reconciliations performed between the vendor list sent to the third-party vendor and the results provided by the third-party vendor. Effect or potential effect: Akron Children’s screening for suspension and debarment through the third-party vendor results may not be accurate. By failing to retain the documentation of the reconciliation of vendor files to the third-party vendor search results, sufficient evidence was not retained to prove that the reconciliation took place. As a result, there was not sufficient evidence to validate the appropriate internal controls took place to prevent Akron Children’s from transacting with a vendor that was suspended or debarred, which was ultimately charged to a federal program. Questioned costs: None. Context: The federal portion of expenditures subject to suspension and debarment represents approximately 84% of total federal expenditures for the programs of $10,888,195 for the year ended December 31, 2023. Identification as a repeat finding, if applicable: The finding is a repeat finding from the prior year – 2022-002, as it relates to 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response. Recommendation: Management should add controls to validate the accuracy of the suspension and debarment search results performed by the third-party vendor when the search results in no match. Views of responsible officials: Akron Children's remediated these findings in the fourth quarter of 2023 by: 1) Implementing a periodic independent review of a sample of vendors sent to the third-party vendor to ensure that the processes employed by third-party vendor are accurate. 2) Developing a retention process for all vendor searches and file submissions to evidence compliance with the Federal regulations, including an independent review of the accuracy of file submissions. Further, a contract management system was installed in 2023 that holds the validation of new vendors as acceptable for federal procurements.
Identification of the federal program: Federal Agencies: U.S. Department of Health and Human Services Pass-Through Entities: Ohio Department of Health Assistance Listing No: 93.354, Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response Award Periods: 2023 Criteria or specific requirement (including statutory, regulatory or other citation): 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).” Condition: There was a lack of sufficient internal controls documentation evidencing management’s review and approval of the amounts submitted on the monthly financial and quarterly performance reports required by the Ohio Department of Health (ODH). Cause: Internal controls over the review of the reports were not documented sufficiently to evidence there were no errors in the reporting of the data. Effect or potential effect: Reports submitted to ODH may contain errors and not be supported by the books and records of Akron Children’s. Questioned costs: None Context: Akron Children’s submitted twelve monthly financial reports and four quarterly reports to the ODH in 2023. Management did not retain sufficient evidence supporting the review and approval of the financial reports prior to submission to ODH. Identification as a repeat finding, if applicable: The finding is a repeat finding from the prior year, 2022-003. Recommendation: When executing the established controls over the review and approval of the reports, management should document and retain evidence of the control procedures performed for all reports submitted. Views of responsible officials: Akron Children’s implemented a review checklist and sign-off process to document controls for the review of the monthly financial reports submitted to the granting agency in 2023. This checklist and sign-off process will be extended to all federal grants with periodic performance reporting in 2024.
Identification of the federal program: Federal Agencies: Department of Health, Health Resources and Services Administration (HRSA) Pass-Through Entities: None Assistance Listing No: 93.493 Congressional Directives Award Periods: 2023 Criteria or specific requirement (including statutory, regulatory or other citation): 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).” Condition: There was a lack of internal controls over management’s review and approval of documents submitted to the HRSA portal prior to submission. Cause: Akron Children’s did not have internal controls over the review of the documents submitted to HRSA to ensure the documentation uploaded was complete and accurate. Effect or potential effect: Reports submitted to HRSA may contain errors and not be supported by the books and records of Akron Children’s. Questioned costs: None Context: Akron Children’s submitted five reports to HRSA in 2023. Management did not retain sufficient evidence supporting the review and approval of the reports prior to submission to HRSA. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: When executing the established controls over the review and approval of the reports, management should document and retain evidence of the control procedures performed for all reports submitted. Views of responsible officials: Akron Children's will implement a review and sign-off process for all documentation to be submitted for federal grant requirements.
Identification of the federal program: Federal Agencies: Department of Health, Health Resources and Services Administration (HRSA) Pass-Through Entities: None Assistance Listing No: 93.493 Congressional Directives Award Periods: 2023 Criteria or specific requirement (including statutory, regulatory or other citation): 2 CFR 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).” Condition: Management did not have a formal, documented internal control in place to review the allowability of the expenses to be allocated to the grant. Cause: Management did not have in place a formal, documented internal control to review the allowability of expenses to be charged to the grant. Effect or potential effect: A lack of internal controls over the review and approval of expenditures could result in unallowable expenses being charged to the federal award. Questioned costs: None. Context: We obtained email communication among Akron Children’s personnel discussing the types of costs to be submitted (construction costs) and that the general contractor expenses could be used. However, once these costs had been identified to be charged to the grant, management did not document a review of the allowability of these transactions. Total expenditures reported on the Schedule of Expenditures of Federal Awards for the year ended December 31, 2023 were $2,000,000. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: Akron Children’s should put in place internal control procedures and retain evidence of review of expenditures charged to the grant to ensure the expenses are allowable. Views of responsible officials: Akron Children's will implement a more detailed review and documentation process for allowable expenses prior to determining expenses that are eligible for federal grant reimbursement.
Identification of the federal program: Federal Agencies: U.S. Department of Health and Human Services Pass-Through Entities: Ohio Department of Health Assistance Listing No: 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response, 93.493 Congressional Directives, and 21.027 COVID-19 Coronavirus State and Local Recovery Funds Award Period: 2023 Criteria or specific requirement (including statutory, regulatory or other citation): 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).” Section 200.318(i) of the Uniform Guidance states the following regarding general procurement standards: “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.” Section 200.320(a)(1)(iii) of the Uniform Guidance states the following regarding formal procurement methods to be followed: “The non-Federal entity is responsible for determining and documenting an appropriate micro-purchase threshold based on internal controls, an evaluation of risk, and its documented procurement procedures.” Section 200.320(a)(2)(i) refers to small purchases as: “The acquisition of property or services, the aggregate dollar amount of which is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold. If small purchase procedures are used, price or rate quotations must be obtained from an adequate number of qualified sources as determined appropriate by the non-Federal entity.” Condition: For most of 2023, Akron Children’s Procurement Policy for Federal Grant Agreements and Contracts did not align with the Uniform Guidance requirements within Section 200.320 in that the requirements for price or rate quotations from an adequate number of sources for small purchases between the micro purchase and simplified acquisition thresholds are not defined. Akron Children’s updated the procurement policy to align with the Uniform Guidance requirements in November 2023. Cause: The small purchase procurement threshold within Akron Children’s Procurement Policy for Federal Grant Agreements and Contracts did not align with the procurement thresholds established under Uniform Guidance Section 200.320, until the policy was updated in November 2023. Effect or potential effect: Akron Children’s procurement policies were not designed in accordance with Section 2.00.320(a). As such, Akron Children’s purchases may not have been in accordance with the Uniform Guidance procurement standards. Questioned costs: None Context: Akron Children’s updated its procurement policy in November 2023. Procurements prior to this date may not have followed the required Uniform Guidance. Total Federal expenditures for the programs were $10,888,195 for the year ended December 31, 2023. Identification as a repeat finding, if applicable: The finding is a repeat finding from the prior year – 2022-001, as it relates to 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response. Recommendation: Akron Children’s should review and update its federal procurement policies to align with the procurement standards. Views of responsible officials: Akron Children's remediated this finding in November 2023 with the update and issuance of a modified Procurement Policy for Federal Grant Agreements and Contracts that aligns with the standards of Uniform Guidance.
Identification of the federal program: Federal Agencies: U.S. Department of Health and Human Services Pass-Through Entities: Ohio Department of Health Assistance Listing No: 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response, 93.493 Congressional Directives, and 21.027 COVID-19 Coronavirus State and Local Recovery Funds Award Period: 2023 Criteria or specific requirement (including statutory, regulatory or other citation): 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).” Section 200.318(i) of the Uniform Guidance states the following regarding general procurement standards: “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.” Section 200.320(a)(1)(iii) of the Uniform Guidance states the following regarding formal procurement methods to be followed: “The non-Federal entity is responsible for determining and documenting an appropriate micro-purchase threshold based on internal controls, an evaluation of risk, and its documented procurement procedures.” Section 200.320(a)(2)(i) refers to small purchases as: “The acquisition of property or services, the aggregate dollar amount of which is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold. If small purchase procedures are used, price or rate quotations must be obtained from an adequate number of qualified sources as determined appropriate by the non-Federal entity.” Condition: For most of 2023, Akron Children’s Procurement Policy for Federal Grant Agreements and Contracts did not align with the Uniform Guidance requirements within Section 200.320 in that the requirements for price or rate quotations from an adequate number of sources for small purchases between the micro purchase and simplified acquisition thresholds are not defined. Akron Children’s updated the procurement policy to align with the Uniform Guidance requirements in November 2023. Cause: The small purchase procurement threshold within Akron Children’s Procurement Policy for Federal Grant Agreements and Contracts did not align with the procurement thresholds established under Uniform Guidance Section 200.320, until the policy was updated in November 2023. Effect or potential effect: Akron Children’s procurement policies were not designed in accordance with Section 2.00.320(a). As such, Akron Children’s purchases may not have been in accordance with the Uniform Guidance procurement standards. Questioned costs: None Context: Akron Children’s updated its procurement policy in November 2023. Procurements prior to this date may not have followed the required Uniform Guidance. Total Federal expenditures for the programs were $10,888,195 for the year ended December 31, 2023. Identification as a repeat finding, if applicable: The finding is a repeat finding from the prior year – 2022-001, as it relates to 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response. Recommendation: Akron Children’s should review and update its federal procurement policies to align with the procurement standards. Views of responsible officials: Akron Children's remediated this finding in November 2023 with the update and issuance of a modified Procurement Policy for Federal Grant Agreements and Contracts that aligns with the standards of Uniform Guidance.
Identification of the federal program: Federal Agencies: U.S. Department of Health and Human Services Pass-Through Entities: Ohio Department of Health Assistance Listing No: 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response, 93.493 Congressional Directives, and 21.027 COVID-19 Coronavirus State and Local Recovery Funds Award Period: 2023 Criteria or specific requirement (including statutory, regulatory or other citation): 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).” Section 200.318(i) of the Uniform Guidance states the following regarding general procurement standards: “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.” Section 200.320(a)(1)(iii) of the Uniform Guidance states the following regarding formal procurement methods to be followed: “The non-Federal entity is responsible for determining and documenting an appropriate micro-purchase threshold based on internal controls, an evaluation of risk, and its documented procurement procedures.” Section 200.320(a)(2)(i) refers to small purchases as: “The acquisition of property or services, the aggregate dollar amount of which is higher than the micro-purchase threshold but does not exceed the simplified acquisition threshold. If small purchase procedures are used, price or rate quotations must be obtained from an adequate number of qualified sources as determined appropriate by the non-Federal entity.” Condition: For most of 2023, Akron Children’s Procurement Policy for Federal Grant Agreements and Contracts did not align with the Uniform Guidance requirements within Section 200.320 in that the requirements for price or rate quotations from an adequate number of sources for small purchases between the micro purchase and simplified acquisition thresholds are not defined. Akron Children’s updated the procurement policy to align with the Uniform Guidance requirements in November 2023. Cause: The small purchase procurement threshold within Akron Children’s Procurement Policy for Federal Grant Agreements and Contracts did not align with the procurement thresholds established under Uniform Guidance Section 200.320, until the policy was updated in November 2023. Effect or potential effect: Akron Children’s procurement policies were not designed in accordance with Section 2.00.320(a). As such, Akron Children’s purchases may not have been in accordance with the Uniform Guidance procurement standards. Questioned costs: None Context: Akron Children’s updated its procurement policy in November 2023. Procurements prior to this date may not have followed the required Uniform Guidance. Total Federal expenditures for the programs were $10,888,195 for the year ended December 31, 2023. Identification as a repeat finding, if applicable: The finding is a repeat finding from the prior year – 2022-001, as it relates to 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response. Recommendation: Akron Children’s should review and update its federal procurement policies to align with the procurement standards. Views of responsible officials: Akron Children's remediated this finding in November 2023 with the update and issuance of a modified Procurement Policy for Federal Grant Agreements and Contracts that aligns with the standards of Uniform Guidance.
Identification of the federal program: Federal Agencies: U.S. Department of Health and Human Services Pass-Through Entities: Ohio Department of Health Assistance Listing No: 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response, 93.493 Congressional Directives, and 21.027 COVID-19 Coronavirus State and Local Recovery Funds Award Period: 2023 Criteria or specific requirement (including statutory, regulatory or other citation): 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).” The Uniform Guidance 2 CFR Section 200.213 states, “Non-federal entities are subject to the non-procurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR Part 180. These regulations restrict awards, subawards, and contracts with certain parties that are debarred, suspended or otherwise excluded from or ineligible for participation in Federal assistance programs or activities”. Condition: We identified the following matters during our testing of suspension and debarment control processes: a) A third-party vendor performed the suspension and debarment validation process for Akron Children’s. The third-party vendor does not have a SOC 1 (System and Organization Controls) Report. For most of 2023, Akron Children’s relied on the suspension and debarment checks performed by the third-party vendor for results concluding no match without completing a validation control to ensure the results provided by the third party were accurate. b) Akron Children’s did not retain the supporting documentation of the reconciliation of the vendor list that is received from the third-party vendor that is used to perform the suspension and debarment checks after the suspension and debarment checks are performed to ensure the listing is complete and agrees to the vendor list provided by Akron Children’s to the third-party vendor. Cause: Akron Children’s did not have policies and procedures that require a validation of the third-party’s controls be performed to ensure that the suspension and debarment checks performed by the third-party vendor aligned with the governmental suspension and debarment database when the search resulted in no match. In addition, Akron Children’s did not have policies and procedures in place to require that documentation is retained to support the reconciliations performed between the vendor list sent to the third-party vendor and the results provided by the third-party vendor. Effect or potential effect: Akron Children’s screening for suspension and debarment through the third-party vendor results may not be accurate. By failing to retain the documentation of the reconciliation of vendor files to the third-party vendor search results, sufficient evidence was not retained to prove that the reconciliation took place. As a result, there was not sufficient evidence to validate the appropriate internal controls took place to prevent Akron Children’s from transacting with a vendor that was suspended or debarred, which was ultimately charged to a federal program. Questioned costs: None. Context: The federal portion of expenditures subject to suspension and debarment represents approximately 84% of total federal expenditures for the programs of $10,888,195 for the year ended December 31, 2023. Identification as a repeat finding, if applicable: The finding is a repeat finding from the prior year – 2022-002, as it relates to 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response. Recommendation: Management should add controls to validate the accuracy of the suspension and debarment search results performed by the third-party vendor when the search results in no match. Views of responsible officials: Akron Children's remediated these findings in the fourth quarter of 2023 by: 1) Implementing a periodic independent review of a sample of vendors sent to the third-party vendor to ensure that the processes employed by third-party vendor are accurate. 2) Developing a retention process for all vendor searches and file submissions to evidence compliance with the Federal regulations, including an independent review of the accuracy of file submissions. Further, a contract management system was installed in 2023 that holds the validation of new vendors as acceptable for federal procurements.
Identification of the federal program: Federal Agencies: U.S. Department of Health and Human Services Pass-Through Entities: Ohio Department of Health Assistance Listing No: 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response, 93.493 Congressional Directives, and 21.027 COVID-19 Coronavirus State and Local Recovery Funds Award Period: 2023 Criteria or specific requirement (including statutory, regulatory or other citation): 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).” The Uniform Guidance 2 CFR Section 200.213 states, “Non-federal entities are subject to the non-procurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR Part 180. These regulations restrict awards, subawards, and contracts with certain parties that are debarred, suspended or otherwise excluded from or ineligible for participation in Federal assistance programs or activities”. Condition: We identified the following matters during our testing of suspension and debarment control processes: a) A third-party vendor performed the suspension and debarment validation process for Akron Children’s. The third-party vendor does not have a SOC 1 (System and Organization Controls) Report. For most of 2023, Akron Children’s relied on the suspension and debarment checks performed by the third-party vendor for results concluding no match without completing a validation control to ensure the results provided by the third party were accurate. b) Akron Children’s did not retain the supporting documentation of the reconciliation of the vendor list that is received from the third-party vendor that is used to perform the suspension and debarment checks after the suspension and debarment checks are performed to ensure the listing is complete and agrees to the vendor list provided by Akron Children’s to the third-party vendor. Cause: Akron Children’s did not have policies and procedures that require a validation of the third-party’s controls be performed to ensure that the suspension and debarment checks performed by the third-party vendor aligned with the governmental suspension and debarment database when the search resulted in no match. In addition, Akron Children’s did not have policies and procedures in place to require that documentation is retained to support the reconciliations performed between the vendor list sent to the third-party vendor and the results provided by the third-party vendor. Effect or potential effect: Akron Children’s screening for suspension and debarment through the third-party vendor results may not be accurate. By failing to retain the documentation of the reconciliation of vendor files to the third-party vendor search results, sufficient evidence was not retained to prove that the reconciliation took place. As a result, there was not sufficient evidence to validate the appropriate internal controls took place to prevent Akron Children’s from transacting with a vendor that was suspended or debarred, which was ultimately charged to a federal program. Questioned costs: None. Context: The federal portion of expenditures subject to suspension and debarment represents approximately 84% of total federal expenditures for the programs of $10,888,195 for the year ended December 31, 2023. Identification as a repeat finding, if applicable: The finding is a repeat finding from the prior year – 2022-002, as it relates to 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response. Recommendation: Management should add controls to validate the accuracy of the suspension and debarment search results performed by the third-party vendor when the search results in no match. Views of responsible officials: Akron Children's remediated these findings in the fourth quarter of 2023 by: 1) Implementing a periodic independent review of a sample of vendors sent to the third-party vendor to ensure that the processes employed by third-party vendor are accurate. 2) Developing a retention process for all vendor searches and file submissions to evidence compliance with the Federal regulations, including an independent review of the accuracy of file submissions. Further, a contract management system was installed in 2023 that holds the validation of new vendors as acceptable for federal procurements.
Identification of the federal program: Federal Agencies: U.S. Department of Health and Human Services Pass-Through Entities: Ohio Department of Health Assistance Listing No: 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response, 93.493 Congressional Directives, and 21.027 COVID-19 Coronavirus State and Local Recovery Funds Award Period: 2023 Criteria or specific requirement (including statutory, regulatory or other citation): 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).” The Uniform Guidance 2 CFR Section 200.213 states, “Non-federal entities are subject to the non-procurement debarment and suspension regulations implementing Executive Orders 12549 and 12689, 2 CFR Part 180. These regulations restrict awards, subawards, and contracts with certain parties that are debarred, suspended or otherwise excluded from or ineligible for participation in Federal assistance programs or activities”. Condition: We identified the following matters during our testing of suspension and debarment control processes: a) A third-party vendor performed the suspension and debarment validation process for Akron Children’s. The third-party vendor does not have a SOC 1 (System and Organization Controls) Report. For most of 2023, Akron Children’s relied on the suspension and debarment checks performed by the third-party vendor for results concluding no match without completing a validation control to ensure the results provided by the third party were accurate. b) Akron Children’s did not retain the supporting documentation of the reconciliation of the vendor list that is received from the third-party vendor that is used to perform the suspension and debarment checks after the suspension and debarment checks are performed to ensure the listing is complete and agrees to the vendor list provided by Akron Children’s to the third-party vendor. Cause: Akron Children’s did not have policies and procedures that require a validation of the third-party’s controls be performed to ensure that the suspension and debarment checks performed by the third-party vendor aligned with the governmental suspension and debarment database when the search resulted in no match. In addition, Akron Children’s did not have policies and procedures in place to require that documentation is retained to support the reconciliations performed between the vendor list sent to the third-party vendor and the results provided by the third-party vendor. Effect or potential effect: Akron Children’s screening for suspension and debarment through the third-party vendor results may not be accurate. By failing to retain the documentation of the reconciliation of vendor files to the third-party vendor search results, sufficient evidence was not retained to prove that the reconciliation took place. As a result, there was not sufficient evidence to validate the appropriate internal controls took place to prevent Akron Children’s from transacting with a vendor that was suspended or debarred, which was ultimately charged to a federal program. Questioned costs: None. Context: The federal portion of expenditures subject to suspension and debarment represents approximately 84% of total federal expenditures for the programs of $10,888,195 for the year ended December 31, 2023. Identification as a repeat finding, if applicable: The finding is a repeat finding from the prior year – 2022-002, as it relates to 93.354 Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response. Recommendation: Management should add controls to validate the accuracy of the suspension and debarment search results performed by the third-party vendor when the search results in no match. Views of responsible officials: Akron Children's remediated these findings in the fourth quarter of 2023 by: 1) Implementing a periodic independent review of a sample of vendors sent to the third-party vendor to ensure that the processes employed by third-party vendor are accurate. 2) Developing a retention process for all vendor searches and file submissions to evidence compliance with the Federal regulations, including an independent review of the accuracy of file submissions. Further, a contract management system was installed in 2023 that holds the validation of new vendors as acceptable for federal procurements.
Identification of the federal program: Federal Agencies: U.S. Department of Health and Human Services Pass-Through Entities: Ohio Department of Health Assistance Listing No: 93.354, Public Health Emergency Response: Cooperative Agreement for Emergency Response: Public Health Crisis Response Award Periods: 2023 Criteria or specific requirement (including statutory, regulatory or other citation): 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).” Condition: There was a lack of sufficient internal controls documentation evidencing management’s review and approval of the amounts submitted on the monthly financial and quarterly performance reports required by the Ohio Department of Health (ODH). Cause: Internal controls over the review of the reports were not documented sufficiently to evidence there were no errors in the reporting of the data. Effect or potential effect: Reports submitted to ODH may contain errors and not be supported by the books and records of Akron Children’s. Questioned costs: None Context: Akron Children’s submitted twelve monthly financial reports and four quarterly reports to the ODH in 2023. Management did not retain sufficient evidence supporting the review and approval of the financial reports prior to submission to ODH. Identification as a repeat finding, if applicable: The finding is a repeat finding from the prior year, 2022-003. Recommendation: When executing the established controls over the review and approval of the reports, management should document and retain evidence of the control procedures performed for all reports submitted. Views of responsible officials: Akron Children’s implemented a review checklist and sign-off process to document controls for the review of the monthly financial reports submitted to the granting agency in 2023. This checklist and sign-off process will be extended to all federal grants with periodic performance reporting in 2024.
Identification of the federal program: Federal Agencies: Department of Health, Health Resources and Services Administration (HRSA) Pass-Through Entities: None Assistance Listing No: 93.493 Congressional Directives Award Periods: 2023 Criteria or specific requirement (including statutory, regulatory or other citation): 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).” Condition: There was a lack of internal controls over management’s review and approval of documents submitted to the HRSA portal prior to submission. Cause: Akron Children’s did not have internal controls over the review of the documents submitted to HRSA to ensure the documentation uploaded was complete and accurate. Effect or potential effect: Reports submitted to HRSA may contain errors and not be supported by the books and records of Akron Children’s. Questioned costs: None Context: Akron Children’s submitted five reports to HRSA in 2023. Management did not retain sufficient evidence supporting the review and approval of the reports prior to submission to HRSA. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: When executing the established controls over the review and approval of the reports, management should document and retain evidence of the control procedures performed for all reports submitted. Views of responsible officials: Akron Children's will implement a review and sign-off process for all documentation to be submitted for federal grant requirements.
Identification of the federal program: Federal Agencies: Department of Health, Health Resources and Services Administration (HRSA) Pass-Through Entities: None Assistance Listing No: 93.493 Congressional Directives Award Periods: 2023 Criteria or specific requirement (including statutory, regulatory or other citation): 2 CFR 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).” Condition: Management did not have a formal, documented internal control in place to review the allowability of the expenses to be allocated to the grant. Cause: Management did not have in place a formal, documented internal control to review the allowability of expenses to be charged to the grant. Effect or potential effect: A lack of internal controls over the review and approval of expenditures could result in unallowable expenses being charged to the federal award. Questioned costs: None. Context: We obtained email communication among Akron Children’s personnel discussing the types of costs to be submitted (construction costs) and that the general contractor expenses could be used. However, once these costs had been identified to be charged to the grant, management did not document a review of the allowability of these transactions. Total expenditures reported on the Schedule of Expenditures of Federal Awards for the year ended December 31, 2023 were $2,000,000. Identification as a repeat finding, if applicable: The finding is not a repeat finding from the prior year. Recommendation: Akron Children’s should put in place internal control procedures and retain evidence of review of expenditures charged to the grant to ensure the expenses are allowable. Views of responsible officials: Akron Children's will implement a more detailed review and documentation process for allowable expenses prior to determining expenses that are eligible for federal grant reimbursement.