FAC Explorer

Audit 346753

FY End
2024-06-30
Total Expended
$1.54M
Findings
2
Programs
7
Organization: Froedtert Health, Inc. and Affiliates (WI)
Year: 2024 Accepted: 2025-03-18
Auditor: Kpmg LLP

Organization Exclusion Status:

Findings

ID Ref Severity Repeat Requirement
528722 2024-001 Significant Deficiency - A
1105164 2024-001 Significant Deficiency - A

Programs

ALN Program Spent Major Findings
93.268 Immunization Cooperative Agreements $688,344 Yes 1
21.027 Coronavirus State and Local Fiscal Recovery Funds $250,699 - 0
93.912 Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement $198,234 - 0
93.399 Cancer Control $68,401 - 0
93.301 Small Rural Hospital Improvement Grant Program $38,750 - 0
93.426 The National Cardiovascular Health Program $15,056 - 0
93.241 State Rural Hospital Flexibility Program $6,273 - 0

Contacts

Name Title Type
KYSEBY3LV4G9 David Dirksmeyer Auditee
4148525548 Charles Klescewski Auditor
No contacts on file

Notes to SEFA

Title: (1) Basis of Pesentation Accounting Policies: (1) Basis of Presentation The schedule of expenditures of federal awards (the Schedule) includes all grants, contracts and similar agreements, loans, and loan guarantee agreements entered into directly between Froedtert Theda Care Health, Inc. and Affiliates (FTCH) and agencies and departments of the federal government, as well as awards from pass through entities, and should be read in conjunction with the FTCH’s consolidated financial statements. For the year ended June 30, 2024, FTCH had no expenditures in the form of noncash assistance, no federally provided insurance in effect during the year, and no loans or loan guarantees outstanding. The accompanying 2024 Schedule is prepared on the accrual basis of accounting. Expenditures consist of direct and indirect costs. Direct costs are those that can be easily identified with an individual federally sponsored project; whereas, indirect costs cannot be easily identified with an individual sponsored project. Indirect costs are the costs of services and resources that benefit many sponsored projects as well as non-sponsored projects and activities. The information in this 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 (Uniform Guidance). FTCH and federal agencies use an indirect cost rate to charge indirect costs to individual sponsored projects. In 2024, FTCH applied a Negotiated Indirect Cost Rate Agreement rate of 45.1% if eligible under an award, and the de minimus 10% or less if capped by the award or other purpose. De Minimis Rate Used: Y Rate Explanation: FTCH applied a Negotiated Indirect Cost Rate Agreement rate of 45.1% if eligible under an award, and the de minimus 10% or less if capped by the award or other purpose. The schedule of expenditures of federal awards (the Schedule) includes all grants, contracts and similar agreements, loans, and loan guarantee agreements entered into directly between Froedtert Theda Care Health, Inc. and Affiliates (FTCH) and agencies and departments of the federal government, as well as awards from pass through entities, and should be read in conjunction with the FTCH’s consolidated financial statements. For the year ended June 30, 2024, FTCH had no expenditures in the form of noncash assistance, no federally provided insurance in effect during the year, and no loans or loan guarantees outstanding. The accompanying 2024 Schedule is prepared on the accrual basis of accounting. Expenditures consist of direct and indirect costs. Direct costs are those that can be easily identified with an individual federally sponsored project; whereas, indirect costs cannot be easily identified with an individual sponsored project. Indirect costs are the costs of services and resources that benefit many sponsored projects as well as non-sponsored projects and activities. The information in this 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 (Uniform Guidance). FTCH and federal agencies use an indirect cost rate to charge indirect costs to individual sponsored projects. In 2024, FTCH applied a Negotiated Indirect Cost Rate Agreement rate of 45.1% if eligible under an award, and the de minimus 10% or less if capped by the award or other purpose.
Title: (2) Employer Identification Numbers Accounting Policies: (1) Basis of Presentation The schedule of expenditures of federal awards (the Schedule) includes all grants, contracts and similar agreements, loans, and loan guarantee agreements entered into directly between Froedtert Theda Care Health, Inc. and Affiliates (FTCH) and agencies and departments of the federal government, as well as awards from pass through entities, and should be read in conjunction with the FTCH’s consolidated financial statements. For the year ended June 30, 2024, FTCH had no expenditures in the form of noncash assistance, no federally provided insurance in effect during the year, and no loans or loan guarantees outstanding. The accompanying 2024 Schedule is prepared on the accrual basis of accounting. Expenditures consist of direct and indirect costs. Direct costs are those that can be easily identified with an individual federally sponsored project; whereas, indirect costs cannot be easily identified with an individual sponsored project. Indirect costs are the costs of services and resources that benefit many sponsored projects as well as non-sponsored projects and activities. The information in this 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 (Uniform Guidance). FTCH and federal agencies use an indirect cost rate to charge indirect costs to individual sponsored projects. In 2024, FTCH applied a Negotiated Indirect Cost Rate Agreement rate of 45.1% if eligible under an award, and the de minimus 10% or less if capped by the award or other purpose. De Minimis Rate Used: Y Rate Explanation: FTCH applied a Negotiated Indirect Cost Rate Agreement rate of 45.1% if eligible under an award, and the de minimus 10% or less if capped by the award or other purpose. Grant Entity Name EIN HRSA - Small Healthcare Provider Quality Improvement ThedaCare Medical Center – Waupaca, Inc. 39-0871113 CDC - WI DHS - Chronic Disease Prevention Program Froedtert ThedaCare Health, Inc. 39-2014409 NIH - New Cohorts for Environmental Exposures and Cancer Risks ThedaCare, Inc. 39-1509362 HRSA - WORH - Small Rural Hospital Program (SHIP) ThedaCare Medical Center - Berlin, Inc. 39-0806359 HRSA - WORH - Small Rural Hospital Program (SHIP) ThedaCare Medical Center - New London, Inc. 39-0869788 CDC - WI DHS - WORH - Rural Health Equity Program ThedaCare, Inc. 39-1509362 HRSA - WORH - Rural Hospital Flexibility Program ThedaCare, Inc. 39-1509362 COVID-19 - American Rescue Plan Act - WI DHS - MCH Equity Froedtert Hospital Foundation, Inc. 39-1431192 COVID-19 - American Rescue Plan Act - WI DHS - UWSMPH - Healthy Wisconsin Families Froedtert Memorial Lutheran Hospital, Inc. 39-6105970

Finding Details

Finding 2024-001
(3)   Findings and Questioned Costs Relating to Federal Awards: Finding 2024 001 Lack of review and approval of Time and Effort Reporting Finding Type: Significant Deficiency Federal Program Name: Immunization Cooperative Agreements Federal Agency: U.S. Department of Health and Human Services ALN # and Program Expenditures: 93.268 ($688,344) Federal Award Year: N/A Questioned Costs: None Compliance Requirement: Activities Allowed or Unallowed Condition Found In performing the monthly time and effort reporting certification and sign-off, management had not established adequate internal controls to ensure the completeness of time and effort certification in accordance with federal regulations, resulting in 4 of 58 (6.9%) submissions missing staff attestations and 2 submissions missing attestation dates. Additionally, for February 2024 time and effort report, while the manager initialed the time and effort report spreadsheet for each attesting employee, their signature was missing to certify their review and approval of the overall monthly submission. Criteria Per 2 CFR 200.303, guidance requires non-Federal entities to, among other things, establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Effective internal controls should include establishing and maintaining adequate controls over the certification of time and effort reporting required for the program. Cause Management did not have appropriate and sufficient review controls in place during the fiscal year to ensure the completeness of time and effort reporting attestation and certification. Possible Asserted Effect Failure to properly review and approve time and effort reports may result in inaccurate time and effort allocations being charged to the program. In this particular case, this did not occur as the employees did record their own hours and were 100% allocated to the specific grant. Repeat Finding No similar finding was reported in prior year audits. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Recommendation We recommend management review its current process for ensuring time and effort reporting attestation and certifications are properly reviewed and approved by the manager/supervisor before they are submitted to the Grant office and Finance. Views of Responsible Officials FTCH recognizes the observations made by KPMG, and has drafted a Corrective Action response.
Finding 2024-001
(3)   Findings and Questioned Costs Relating to Federal Awards: Finding 2024 001 Lack of review and approval of Time and Effort Reporting Finding Type: Significant Deficiency Federal Program Name: Immunization Cooperative Agreements Federal Agency: U.S. Department of Health and Human Services ALN # and Program Expenditures: 93.268 ($688,344) Federal Award Year: N/A Questioned Costs: None Compliance Requirement: Activities Allowed or Unallowed Condition Found In performing the monthly time and effort reporting certification and sign-off, management had not established adequate internal controls to ensure the completeness of time and effort certification in accordance with federal regulations, resulting in 4 of 58 (6.9%) submissions missing staff attestations and 2 submissions missing attestation dates. Additionally, for February 2024 time and effort report, while the manager initialed the time and effort report spreadsheet for each attesting employee, their signature was missing to certify their review and approval of the overall monthly submission. Criteria Per 2 CFR 200.303, guidance requires non-Federal entities to, among other things, establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Effective internal controls should include establishing and maintaining adequate controls over the certification of time and effort reporting required for the program. Cause Management did not have appropriate and sufficient review controls in place during the fiscal year to ensure the completeness of time and effort reporting attestation and certification. Possible Asserted Effect Failure to properly review and approve time and effort reports may result in inaccurate time and effort allocations being charged to the program. In this particular case, this did not occur as the employees did record their own hours and were 100% allocated to the specific grant. Repeat Finding No similar finding was reported in prior year audits. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Recommendation We recommend management review its current process for ensuring time and effort reporting attestation and certifications are properly reviewed and approved by the manager/supervisor before they are submitted to the Grant office and Finance. Views of Responsible Officials FTCH recognizes the observations made by KPMG, and has drafted a Corrective Action response.